Every finding on record at Monument Healthcare Brigham City

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 20 sampled residents, the facility failed to implement new or revised interventions after consecutive falls. In addition, the locked unit was left without nursing staff supervision for multiple periods of time and a resident wandered into other resident's rooms. Resident identifiers: 13 and 21.Findings included:1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, muscle weakness, other abnormalities of gait and mobility, and unspecified dementia.The following observations of resident 13 were made:a. On 6/29/26 at 10:17 AM, resident 13 was observed to be in bed. The bed was in an elevated position.b. On 6/29/26 at 11:09 AM, resident 13 was observed in bed. The bed was observed in an elevated position and the call light was out of reach of the resident hanging upon the wall. c. On 6/29/26 at 12:07 PM, resident 13 was up in his wheelchair and leaning to the left side. A Certified Nursing Assistant (CNA) asked resident 13 if he was okay and to sit up in his chair. Resident 13 had his eyes closed and appeared sleepy. The CNA repeatedly asked resident 13 if he was okay. The CNA continued to assist with feeding another resident.d. On 6/29/26 at 1:23 PM, resident 13 was in bed in an elevated position watching television. The call light was pinned up on the wall and was not accessible by resident 13. e. On 6/29/26 at 1:48 PM, resident 13 was in bed sleeping. The bed was in an elevated position and the call light was not accessible by resident 13. A review of resident 13's progress notes revealed:a. On 1/10/25 at 2:48 PM, a nursing note documented, At approx 1350 [1:50 PM], nurse was alerted to pt [patient] having fallen. Upon arrival to pt's room, pt was observed to be sitting on floor, next to bed, with right arm on mattress. Asked pt what happened but got no response. ROM [range of motion] to all extremities performed. Good ROM without facial grimacing. No observed injuries. Assisted pt into w/c [wheelchair] via 2 person assist.The intervention implemented for this fall was to re-educate staff to lower the bed after cares.b. On 8/23/25 at 9:30 AM, an incident note documented, Nurse was walking past residents room and saw a CNA with [resident 13]. [Resident 13] was sitting on his foot rests watching television. He was fully clothed and wearing socks. Nurse assessed resident for injury. [Resident 13] was assisted back into wheelchair by staff. He was able to help with his feet. [Resident 13] was unable to state what happened, he just smiled. Assessed resident for injury. The intervention implemented for this fall was to follow the falling leaf program.c. On 9/4/25 at 10:20 PM, a health status note documented, At 2015 [8:15 PM], designated CNA alerted this nurse regarding 'resident being on the floor'. This nurse immediately ran to assess, with resident noted sitting on buttocks anterior to wheelchair, proximal to TV [television]. Resident displaying happy affect, unable to answer questions rendered by this nurse. Resident shook their head in a 'no' motion when prompted regarding pain. Resident slowly lifted up off of floor via 3 person assist. The intervention implemented for this fall was staff educated to lay patient down after meals.d. On 9/8/25 at 9:18 PM, a progress note documented, Resident had a fall at 2100 [9:00 PM] from wheelchair to floor. Slid between foot rests and was found by CNA's when attempting to assist resident to bed.The intervention implemented for this fall was to place a foam cushion to wheelchair.e. On 11/19/25 at 11:22 AM, a progress note documented, Nurse was notified that resident had fallen from their wheelchair to the floor, unwitnessed. Nurse immediately went to assess the situation. Resident was found on his knees, crouched in the fetal position. Resident was moved back to his chair with three staff members and a gait belt. Then resident was transferred via hoyer to his bed.Visible injuries noted on both his knees, small superficial scrapes. Redness noted on his chest/abdomen and upper arms.The intervention implemented for this fall was to follow PT (physical therapy) recommendations. PT evaluated and recommended resident be laid down in bed after meals or when not with family or receiving direct care. It should be noted that this intervention was used for the fall that occurred on 9/4/25.f. On 12/18/25 at 9:08 PM, a progress note documented, Called to room by aide stating resident was on the floor. Entered room to find resident lying in front of his wheelchair on his left side. Appears he was pulling on the other bed stead and pulled wheelchair over. He is nonverbal and unable to state what happened. The intervention implemented for this fall was to move the resident to a shared room after Christmas per his mother's request due to falls from fidgeting or boredom. g. On 2/15/26 at 7:04 PM, a progress note documented, This nurse was notified at 1855 [6:55 PM] that resident had a witnessed fall. CNA walked by resident room and he was leaning on bedside table. Bedside table moved forward and resident fell forward to the floor on his knees and hands. CNA assisted resident to the floor from kneeling position and stated resident did not hit his head. Slight redness noted on his abdomen, mainly on left hip/ribs area.The intervention implemented for this fall was to post a sign in the resident's room that stated, Help me to bed right after meals to prevent me from falling. It should be noted that placing the resident in bed after meals was used as an intervention for the falls on 9/4/25 and 11/19/25.On 6/30/26 at 2:21 PM, an interview was conducted with CNA 7. CNA 7 stated that resident 13 was dependent on staff with all transfers and used a Hoyer lift. CNA 7 stated that resident 13 was a fall risk anytime he was in his wheelchair. CNA 7 stated that right after meals resident 13 had to be laid down in bed so he didn't fall out of his wheelchair. CNA 7 stated that resident 13's bed should be in the lowest position. CNA 7 stated that resident 13 was not able to use a call light to call for help and relied on staff to monitor him frequently. 2. Resident 21 was admitted to the facility on [DATE] with diagnoses which included unsteadiness on feet, history of falling, and Alzheimer's disease. The following observations were made of resident 21:a. On 6/29/26 at 9:21 AM, resident 21 was observed in his wheelchair pushing against an exit door in the locked unit. No staff were observed to be around resident 21 at this time.b. On 6/29/26 at 9:34 AM, resident 21 was observed to enter another resident's room and stood up from his wheelchair. Resident 21 was observed to ambulate with a shuffling gait into the bathroom of a resident. c. On 6/29/26 at 9:37 AM, a CNA was observed to get resident 21 out of the bathroom and wheel him into his room. d. On 6/29/26 at 9:39 AM, resident 21 was observed trying to exit through the east door in the locked unit. e. On 6/29/26 at 9:41 AM, the unit nurse exited the locked unit.f. On 6/29/26 at 9:49 AM, resident 21 was observed to ambulate with a shuffling gait into his bathroom. No staff were observed to assist the resident. It should be noted that the unit nurse was out of the locked unit and the unit CNA was in a resident room transferring a resident with a Hoyer. g. On 6/29/26 at 10:29 AM, resident 21 was observed to be laying on the fall mat of his room. No nursing staff were observed in the hallways or at the nurse's station in the locked unit.h. On 6/29/2026 at 10:32 AM, the unit nurse returned to the locked unit. i. On 6/29/26 at 10:34 AM, resident 21 was assisted up off the floor by the nurse and placed back into bed. j. On 6/29/26 at 11:17 AM, resident 21 was observed to get out of bed unassisted and ambulate with a shuffling gait to his bathroom unassisted by staff. k. On 6/29/26 at 11:32 AM, resident 21 was observed to wheel into a resident's room and began to go through the other resident's belongings. No nursing staff were observed in the hallways or at the nurse's station in the locked unit.l. On 6/29/26 at 11:34 AM, resident 21 was observed to try and open the fire extinguisher cover and attempted to remove the fire extinguisher from the wall. No nursing staff were observed in the hallways or at the nurse's station in the locked unit.m. On 6/29/26 at 11:35 AM, resident 21 was observed to enter a resident's bathroom and proceeded to urinate on the floor of the resident's bathroom. No nursing staff were observed in the hallways or at the nurse's station in the locked unit.n. On 6/30/26 at 10:50 AM, resident 21 was observed to be lying sideways in bed with his lower body and legs on the floor mat. A review of resident 21's progress notes revealed:a. On 1/23/26 at 10:38 AM, a progress note documented, Nurse observed resident falling while transferring himself from couch to chair in lounge area witnessed. Nurse immediately went to assess resident. Resident was found in sitting position on the floor. Nurse assisted resident back into chair.Nurse asked resident what happened resident stated 'I was transferring myself and I got dizzy and fell.' Nurse took VS [vital signs] of resident, Resident complained of right arm pain. The intervention implemented for the fall was to place resident 21 on the falling leaf program.b. On 1/26/26 at 6:53 PM, a progress note documented, pt was found on his knees by CNAs, pt is stable.Hospice nurse aware of faulty wheelchair, new wheelchair ordered for pt.The intervention implemented for the fall was to have hospice provide a new wheelchair.c. On 2/2/26 at 11:50 PM, a progress note documented, Resident had witnessed fall. Fall witnessed by CNA and occurred in front of dementia hall nurses' desk. CNA had resident seated on sofa and told him she was going to get him food. Resident stood up from sofa, stated 'goodbye' and proceeded to ambulate usings [sic] his wheelchair as a walker. Resident moved quickly, went in a circular motion, lost balance, and feel [sic] to ground hitting right side. Resident did not hit head. Resident did not lose consciousness. RN [Registered Nurse] was called to assist. RN assessed resident noting that resident's right elbow had a bruising, swelling, and a small bump. RN noticed that left ankle alsohad [sic] bruising, swelling, and a small bump.The intervention implemented for the fall was for resident 21 to use the recreation cart.d. On 3/21/26 at 3:11 AM, a progress note documented, Aide and nurse were standing at nurses station when resident stood up to self transfer from a recliner into his wheelchair. His right knee buckled and he fell down on his knees. Landing on the right knee and hitting his right elbow on the arm of the chair. Assisted him to a sitting position to assess the body. He was then assisted back up into the chair. He was rubbing his elbow and knee. He originally stated he didn't want anything for pain then changed his mind.The intervention for the fall was to administer as needed pain medications. It should be noted that this was a treatment and not an intervention to prevent future falls.e. On 4/24/26 at 4:49 PM, a progress note documented, Fall charting: Resident on alert charting r/t [related to] recent unwitnessed fall.The intervention for the fall was to treat resident 21's urinary tract infection. f. On 5/5/26 at 5:14 PM, a progress note documented, this nurse continues to check neurological status after fall this afternoon. Resident baseline. No injuries from fall noted during assessments.The intervention for the fall was to remove the rugs from the memory care unit.g. On 5/16/26 at 2:58 PM, a progress note documented, CNA was walking past res [resident] room and saw res on floor. Res was lying on his right side, w/c [wheelchair] was folded and on it's [sic] side behind his back. Floor mat was in place and res was lying on part of it, hips and legs were on it, shoulders were not. Res lifted with hoyer into bed without c/o [complaints of] pain. The intervention for the fall was to place bright colored tape on wheelchair brakes.h. On 6/16/26 at 10:28 AM, a progress note documented, [Resident 21] found lying beside bed stating he fell OOB [out of bed]. Assisted into WC with CNA assistance.The intervention for this was to complete a medication review. i. On 6/17/26 at 3:55 AM, a general note documented, Resident found on hands and knees with his forehead resting on the floor. Resident is unable to explain what he was doing as well as unable to state whether he hit his head. Resident assessed for injuries with none found and neurochecks completed. Resident is unable to state whether he is in pain and is currently oriented to name only.There was no intervention implemented after this fall.j. On 6/23/26 at 10:17 AM, a progress note documented, Resident found on the floor in the bathroom, no injuries, neurological status assessed and resident baseline. Resident up in wheelchair stating no pain from fall.The intervention for the fall was to perform neurological checks. It should be noted that neurological checks are a response to a fall, and not an intervention to prevent further falls. On 6/30/26 at 2:27 PM, an interview was conducted with CNA 7. CNA 7 stated that resident 21 would go into other resident's rooms and wandered around the locked unit all day long. CNA 7 stated that there had to be a staff member on the unit at all times and if staff were not located at the nurse's station then they were usually in a resident's room. CNA 7 stated that if she had to shower a resident then she would let nursing staff know that she was unable to observe the residents. CNA 7 stated that resident 21 was a fall risk and fell a lot. CNA 7 stated that she would walk past his room often and made sure that she took him to the bathroom every 2 hours. CNA 7 stated that there were some aggressive residents in the locked unit that did not like resident 21 entering their rooms and going through their belongings. CNA 7 stated that resident 21 required supervision at all times and assistance with transfers. On 7/1/26 at 8:07 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the locked unit contained residents with diagnoses of prior elopements, dementia residents, residents that wandered and were actively exit seeking. The DON stated that a CNA should be on the locked unit at all times and the north nurse was off and on the locked unit intermittently doing medication pass. The DON stated that CNAs should be doing their regular 2 hour rounding and there did not need to be any one to one supervision of residents. The DON stated that resident 21 was an active wanderer and she expected nursing staff to keep an eye on him. The DON stated that the recreation cart was used for resident 21 to give him activities and puzzles to keep him occupied. The DON stated that neurological checks were an intervention after falls because they increased supervision for 3 days. The DON stated that the falling leaf program was to let staff know that the resident had falls and the resident needed to have closer supervision. The DON stated that falls required new interventions after every fall.

Based on observation and interviews, for 4 of 20 sampled residents, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident had a clothing protector placed on her by another resident as she said she was headed to the bathroom. The resident was observed to enter her bathroom and return to eat with the same clothing protector. Another resident's oxygen tubing was on the floor in the dining room and staff placed the tubing on her face and nasal cannula in her nose. In addition, the Hoyer lift was not sanitized between residents' use. Resident identifiers: 4, 6, 26, and 29.Findings included:1. On 6/29/26 at 11:46 AM, resident 29 was observed to pass out clothing protectors. Resident 6 was observed to wheel herself toward the exit of the dining room when resident 29 placed the clothing protector on her. Resident 6 stated she had to go to the bathroom. Resident 6 was observed to enter her bathroom with her clothing protector and exited the bathroom with the clothing protector. At 11:50 AM, Resident 6 was observed to wheel herself back to the dining room and eat with the same clothing protector. 2. On 6/29/26 at 11:58 AM, an observation was made of resident 4. Resident 4 was wheeled into the dining room by 2 Certified Nursing Assistants, including (CNA) 5. CNA 5 was observed to pick up resident 4's nasal cannula off the floor of the dining room and placed it in the resident's nose. CNA 5 did not sanitize the equipment that was on the ground in the dining room prior to placing it on resident 4's face. On 7/1/26 at 10:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated staff should have replaced the oxygen tubing and not placed it on resident 4's face after being on the floor. The DON stated resident 6 should have been provided a new clothing protector prior to eating. 3. On 7/1/26 at 7:30 AM, an observation was made of 2 CNAs entering resident 26's room with the Hoyer lift. At 7:35 AM, the CNAs exited resident 26's room with the Hoyer lift and entered resident 29's room. On 7/1/26 at 7:42 AM, an observation was made of a CNA exiting resident 29's room with the Hoyer lift and placing the Hoyer lift in the hallway. It should be noted that the Hoyer lift was not sanitized in between resident 26's use and resident 29's use. On 7/1/26 at 7:48 AM, an interview was conducted with CNA 6. CNA 6 stated that she had not sanitized the Hoyer lift in between resident use and that she should have. On 7/1/26 at 9:03 AM, an interview was conducted with the DON. The DON stated that staff should be wiping down the Hoyer lift with a sanitizer cloth in between resident use.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, hand hygiene was not done according to professional standards and there were soiled areas in the kitchen. Findings include:1. On 6/29/26 at 10:00 AM, an initial tour was conducted of the kitchen. The following was observed:a. The vents above the grill were observed to have dust on them.b. There were large bins labeled oatmeal, powdered sugar, flour and sugar that were observed to be soiled on the outside. c. Celery Seed and Mediterranean style ground oregano spices were open to air. d. The juice machine compressor had crumbs and debris on it. The compressor was on a tray that had crumbs and debris. 2. On 7/1/26 at 10:35 AM, a follow up observation of the kitchen was conducted. The following was observed:a. The vents above the grill were observed to have dust on them.b. There were large bins labeled oatmeal, powdered sugar, flour and sugar that were observed to be soiled on the outside. c. The juice machine compressor had crumbs and debris on it. The compressor was on a tray that had crumbs and debris. d. The Dietary Manager (DM) was observed to perform hand hygiene by placing soap on his hands and rubbing his hands together under water for less than 20 seconds. The DM was observed to put his hand in the glove box and removed 2 gloves which he placed on his hands. The DM was observed to cut pie, touch the pie and plate the pies with gloved hands. e. The DM was observed to remove his gloves, touch certificates on the wall, and then donned gloves. The DM was observed to continue plating pies and touching the pie with his gloved hand. No hand hygiene was performed prior to donning the gloves. f. The DM was observed to perform hand hygiene by placing soap on his hands, and rubbing his hands together under water for 4 seconds. g. [NAME] 1 was observed to perform hand hygiene. [NAME] 1 placed soap in her hands, and rubbed her hands together under water for less than 4 seconds. h. [NAME] 1 was observed to perform hand hygiene. [NAME] 1 placed soap in her hands, and rubbed her hands together under water for 10 seconds. A hand washing sign above the hand washing sink revealed to rinse hands, lather soap, rub hands together palm to palm, rub back of hands, rub fingers interlaced, base of thumbs, rub fingers, wash wrist, rinse hand well, dry with clean towel, turn faucet off with paper towel. Perform hand washing for at least 20 seconds under running water that is at least 110 degrees. On 7/1/26 at 10:49 AM, an interview was conducted with the DM. The DM stated washing hands under water should take as long as singing happy birthday 3 times really fast. The DM stated scrub, dry and then reglove was the procedure. The DM stated the vents above the grill and ovens were cleaned at least monthly by running them through the dishmachine. The DM stated it was not dust on the vents but it was build up from running them through the dish machine. The DM stated the juice machine compressor and tray were cleaned weekly. The DM stated there was a lot of debris on the compressor.

Based on observation, interview, and record review, for 1 of 20 sampled residents, the facility did not ensure that pain management services were provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals. Specifically, a nurse failed to timely assess and administer a prescribed as-needed (PRN) opioid pain medication to a resident experiencing pain after repeated requests from the resident and alerts from multiple certified nursing assistants (CNAs). The resident experienced pain, which was described by the resident as agony, for more than four hours. Resident identifier: 33. Findings included:Resident 33 was admitted to the facility on [DATE] with diagnoses which included: Muscular Dystrophy, Unspecified; Other Specified Disorders of Teeth and Supporting Structures; Major Depressive Disorder, Recurrent, Moderate; Unspecified Dementia, Moderate, Without Behavioral Disturbance; and Personality Disorder, Unspecified. On 6/29/26 at 9:28 AM, the surveyor observed resident 33 in her room with CNA 4. Resident 33 and CNA 4 were observed teasing and joking with each other. Resident 33 stated to the surveyor that she liked to joke around but that some people could not take a joke. Resident 33 stated that an agency nurse refused to provide her PRN pain medication until approximately 4:00 AM a few nights before (June 25, 2026) despite her repeatedly asking for it. Resident 33 stated she had been joking with two CNAs about using a BB gun, paint gun, or water gun, to kill people and explained to them why those items would not work. Resident 33 stated the nurse threatened to call the police on her and refused to give her the medication. Resident 33 stated she was in agony for hours due to the pain and receiving no relief until she finally told a CNA she would call Adult Protective Services (APS) in the morning. Resident 33's care plan initiated on 5/8/26 and revised on 6/26/26, revealed a Focus area that indicated resident 33: has chronic pain and is on an Opiate medication. Resident 33, regularly rates pain as severe when requesting pain medication. The documented Goal was : I will remain free from pain or at a level of discomfort acceptable to me through the review date. A listed intervention included: Administer medication as ordered. A physician order dated 5/28/26 revealed Oxycodone-Acetaminophen Oral Tablet 7.5-325 MG [milligrams]; Give 1 tablet by mouth every 6 hours as needed for moderate pain. A second order dated 4/29/26 revealed, Acetaminophen tab [tablet] 325 mg; give 2 tablets by mouth every 8 hours as needed for pain. A progress note dated 6/19/26 indicated Mouth pain is reported almost constantly, frequently interfering with sleep, therapy, and daily activities, with pain scores fluctuating between 0 and 10 over the past month. Oxycodone-acetaminophen PRN dosing was changed from every 8 hours to every 6 hours as needed on 05/28/2026 due to increased pain . will likely need to have extractions of her teeth. The June 2026 Medication Administration Record (MAR) and the narcotic record book were reviewed. Resident 33 was administered a PRN dose of Oxycodone-Acetaminophen 7.5-325 mg on 6/25/26, at 9:29 AM, with a documented follow-up pain scale rating of 3. [Note: The pain scale was 0-10 with 0 being no pain and 10 being excruciating pain.]No pain medications were administered to resident 33 until 6/26/26 at 4:09 AM when Oxycodone-Acetaminophen was administered. It should be noted resident 33 was not administered pain medication for over 18 hours and over 4 hours after the initial request for pain medication. A progress note dated 6/25/26 at 11:40 PM by Registered Nurse (RN) 1 revealed This nurse was alerted by two CNAs that had just left the pt [patients] room stating that the pt was making comments regarding killing people with guns. This nurse inquired with the pt why she was making the statements . This nurse reiterated that the staff takes statements such as this very seriously and that the police will be called if she makes further statements regarding threatening other peoples safety and lives . The pt then demanded that the nurse leave her room and not come back, this nurse agreed and left her room. Review of this note revealed no documentation that RN 1 conducted a pain assessment, addressed the resident's request for pain medication, or contacted the provider or facility management.A progress note dated 6/26/26 at 4:11 AM by RN 1 revealed, At med [medication] pass for pain med this pt was calling this nurse profanities, yelling and screaming at her, and threw her med cup at her. She went on to say to give her her pain medication and to 'get the hell out of my room!' . She took her medication and demanded that this nurse perform cares .On 6/30/26 at 5:29 PM, RN 1 provided a written statement to the facility Administrator regarding the incident with resident 33 on 6/25/26. RN 1 stated that on 6/26/26 at approximately 2:00 AM, she was approached by two CNAs who were concerned because resident 33 had been making repeated statements expressing a desire to kill staff and residents within the facility. They reported that she stated she intended to shoot everyone in the building and described the types of firearms she would use. They further reported that, earlier during the day shift, she had spoken with another resident regarding obtaining an automatic rifle and had allegedly asked him to acquire one for her so she could carry out these statements. RN 1 stated that she entered resident 33's room at approximately 2:15 to 2:30 AM to discuss the issue, but that the resident became increasingly hostile. RN 1 stated that at approximately 3:00 to 3:15 AM, she was informed by a CNA that resident 33 was requesting pain medication and that this was the first time I had been notified during my shift that she was requesting pain medication. Upon entering the resident's room to administer the pain medication, the resident began complaining that she had been waiting all night for her pain medications, and later threw a cup of water at RN 1 telling the nurse to get out of her room while yelling things such as This is abuse! Review of the June 2026 Medication Administration Record (MAR) revealed that when resident 33 was administered her pain medication on 6/26/26 at 4:09 AM, the resident's pain level was documented as a 1. On 7/1/26 at 11:41 AM, CNA 1 was interviewed. CNA 1 stated that she and CNA 3 assisted resident 33 into bed between 11:30 PM and midnight on 6/25/26. CNA 1 stated she observed resident 33 to be crying because no one knew her routine, and she began talking about killing people at the facility with a BB gun, a paint gun, and a water gun. CNA 1 stated that resident 33 requested her pain medication once she was in bed. CNA 1 stated she was with CNA 3 when CNA 3 informed RN 1 of the statements and told her resident 33 was requesting her pain medication. CNA 1 stated RN 1 went to speak to resident 33 and when she left resident 33's room, the resident informed CNA 1 that the nurse refused to give her the pain pill. CNA 1 stated she then asked RN 1 to give the resident the medication, but RN 1 stated she would not provide it due to the statements the resident had made. CNA 1 stated approximately 5 minutes later, resident 33 activated her call light again and CNA 2 answered the call light and told RN 1 resident 33 needed a pain pill. CNA 1 stated RN 1 called out down the hallway, She is not getting it. CNA 1 stated that resident 33 activated her call light multiple times, threatened to call the police, and requested her pain medication a total of 4 times before RN 1 finally administered it before the morning shift arrived.On 7/1/26, the surveyor reviewed a written statement from CNA 3 dated June 26, 2026. The statement noted that at approximately 12:30 AM, resident 33 requested assistance getting ready for bed and talked about using a BB gun, paint gun, or squirt gun to kill people. CNA 3 wrote: She asked for her night medication. We let the nurse know about the medication, and also told her about the remarks she was making. The nurse then told us that she can not give her opioids with her having/saying those things.On 7/1/26 at 10:31 AM, CNA 2 was interviewed. CNA 2 stated that she answered resident 33's call light after the two CNA's had gotten her to bed for the night. CNA 2 stated resident 33 was crying, sad, and complaining that RN 1 refused to provide her pain medication, stating she felt the nurse was bullying resident 33. CNA 2 stated she informed RN 1 that the resident wanted her pain medication, and RN 1 responded that she would get to her when she had time.On 7/1/26, at 9:47 AM, RN 1 was interviewed. RN 1 stated she worked the night shift on 6/25/26, through 6/26/26, from 6:00 PM to 6:00 AM. RN 1 stated that around 2:00 AM, two CNAs reported that resident 33 was making threats about harming residents and staff with an assault rifle. RN 1 stated she spoke with the resident at 2:15 AM, and when she asked the resident if she wanted to harm people, the resident said yes. Resident 33 tried to play off her threats by saying she was joking. When RN 1 said this is serious, the resident went into a rage, called her the worst nurse ever, and told her to leave. RN 1 stated that around 3:15 AM, a CNA informed her that the resident wanted pain medication. RN 1 checked the MAR and debated whether it was safe to give an opioid medication to a resident making threats. RN 1 provided the medication just after 4:00 AM on 6/26/26, as the resident had not received pain medication since 6/25/26 at 9:29 AM. When asked if she obtained a specific pain level rating before administering the medication, RN 1 stated the resident's response was broad, and that the Resident said, It is always a 10! RN 1 denied that the resident was joking.On 7/1/26, the surveyor reviewed documentation provided to the Administrator by Registered Nurse (RN) 2 who spoke with resident 33 on 6/26/26. Resident 33 was upset and sad about an incident during the night shift. The note specified resident 33 reported she repeated her request for a pain pill, but the nurse said, 'I am not giving pain medication to someone who is threatening people to kill people.' Resident 33 reported she tried to explain to RN 1 that it was a joke but RN 1 said it was not funny. Resident 33 said she again asked for pain medication and rated her pain a 10/10 but the nurse just left. The resident continued to request medication a few times an hour but was not given relief until 4:00am.On 6/30/25 at 1:04 PM, the Administrator was interviewed. The Administrator stated that resident 33 had a dark sense of humor and was severely depressed. The Administrator stated that the night nurse made a decision to hold the resident's opioid medication so that behaviors would not worsen. The Administrator confirmed that the resident felt the nurse withheld her medication to punish her, that the resident did not receive her medication until 4:00 AM, and that the nurse had since been suspended pending the investigation.On 7/1/26 at 12:30 PM, the Director of Nursing (DON) was interviewed. The DON stated that pain must be treated subjectively based on the resident's report. The DON stated that if a CNA reported a resident was in pain, the nurse must assess the resident and treat the pain quickly as a priority. The DON acknowledged the medication was not provided until 4:09 AM. The DON stated that there was no documentation of a pain assessment prior to the 4:09 AM administration. The DON stated that if a nurse had safety concerns regarding administering a prescribed narcotic due to a resident's behaviors or threats, the nurse must contact the on-call medical provider or facility clinical leadership for guidance.

Based on interview and record review, the facility must ensure that a resident's physician was immediately consulted when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, a nurse failed to immediately consult with the resident's physician following a significant change in a resident's psychosocial and behavioral status involving homicidal threats and the subsequent withholding of ordered pain medication. Resident identifier: 33. Findings included:Resident 33 was admitted to the facility on [DATE] with diagnoses which included muscular dystrophy, disorders of teeth and supporting structures; major depressive disorder, dementia, and personality disorder.On 6/29/26 at 9:28 AM, resident 33 was interviewed. Resident 33 stated that an agency nurse refused to provide her PRN (as needed) pain medication until approximately 4:00 AM a few nights before (June 25, 2026) despite her repeatedly asking for it. Resident 33 stated she had been joking with two CNAs (Certified Nursing Assistants) about using a BB gun, paint gun, or water gun, to kill people and explained to them why those items would not work. Resident 33 stated the nurse threatened to call the police on her and refused to give her pain medication. Resident 33 stated she was in agony for hours due to the pain and receiving no relief until she finally told a CNA she would call Adult Protective Services (APS) in the morning.Review of the physician orders dated 5/28/26 for Oxycodone-Acetaminophen 7.5-325 mg (milligram), to be administered by mouth every 6 hours as needed for moderate pain.A progress note dated 6/19/26 indicated that resident 33 reported almost constant mouth pain that frequently interfered with sleep, therapy, and daily activities, with pain scores fluctuating between 0 and 10 over the past month.Review of the resident's care plan, revised on 6/26/26, indicated an intervention to administer pain medications as ordered for chronic pain. The documented goal was for the resident to remain free from pain or at an acceptable level of discomfort.A facility progress note by Registered Nurse (RN) 1 on 6/25/26, at 11:40 PM indicated that two nursing assistants informed RN 1 that resident 33 was making comments regarding killing people with guns. RN 1 documented she entered the room and reiterated to the resident that threats were taken seriously and that the police would be called if further statements were made. The resident then demanded that RN 1 leave the room.A written statement by CNA 3 dated 6/26/26, indicated that at approximately 12:30 AM, Resident 33 asked for their night medication. CNA 3 informed RN 1 of the request and the remarks the resident was making. CNA 3 documented that RN 1 stated they could not give opioids to the resident while they were saying those things.It should be noted there was no documentation in the progress notes by RN 1 that she consulted with the Director of Nursing or the physician regarding the statements made by resident 33 or the resident's request for pain medication.On 6/30/26 at 5:29 PM, RN 1 provided a written statement to the facility Administrator regarding the incident with resident 33 on 6/25/26. RN 1 stated that on 6/26/26 at approximately 2:00 AM, she was approached by two CNAs who were concerned because resident 33 had been making repeated statements expressing a desire to kill staff and residents within the facility. They reported that she stated she intended to shoot everyone in the building and described the types of firearms she would use. They further reported that, earlier during the day shift, she had spoken with another resident regarding obtaining an automatic rifle and had allegedly asked him to acquire one for her so she could carry out these statements. RN 1 stated that she entered resident 33's room at approximately 2:15 to 2:30 AM to discuss the issue, but that the resident became increasingly hostile. RN 1 stated that at approximately 3:00 to 3:15 AM, she was informed by a CNA that resident 33 was requesting pain medication and that this was the first time I had been notified during my shift that she was requesting pain medication. Upon entering the resident's room to administer the pain medication, the resident began complaining that she had been waiting all night for her pain medications, and later threw a cup of water at RN 1 telling the nurse to get out of her room while yelling things such as This is abuse! On 7/1/26 at 9:47 AM, RN 1 was interviewed. RN 1 stated that around 2:00 AM, CNA's reported that resident 33 was making threats about harming people in the building. RN 1 stated they spoke with the resident at 2:15 AM to hear their side, and the resident confirmed wanting to harm people. RN 1 reported resident 33 tried to play off her threats as a joke and when RN 1 indicated the statements were serious, resident 33's behaviors escalated and she screamed at RN 1 to leave her room. RN 1 stated that around 3:15 AM, a CNA requested pain medication for the resident. RN 1 stated they were concerned about whether it was safe to administer an opioid medication while the resident was making threats, but decided to give them to her after reviewing the MAR and noting she had not received pain medication for several hours. RN 1 confirmed they administered the pain medication at 4:09 AM.Review of the June 2026 Medication Administration Record (MAR) revealed that when resident 33 was administered her pain medication on 6/26/26 at 4:09 AM, the resident's pain level was documented as a 1. On 7/1/26, at 11:41 AM, CNA 1 was interviewed. CNA 1 stated that while getting resident 33 ready for bed on the night of 6/25/26 with CNA 3, the resident began talking about killing people with water and paint guns. CNA 1 stated resident 33 mentioned she asked another resident what weapon to use. CNA 1 stated that she and CNA 3 informed RN 1 of the remarks and told RN 1 that the resident requested a pain pill. CNA 1 stated that RN 1 refused to give the resident the pain medication due to the threats she made. CNA 1 stated that the resident asked for the pain pill four times throughout the night, that RN 1 was informed of the pain medication requests, and that RN 1 did not call the doctor.On 7/1/26 at 12:30 PM, the DON (Director of Nursing) was interviewed. The DON stated that if a resident was in pain, the nurse must assess the resident and treat the pain. The DON stated that if an ordered medication was withheld or delayed due to behavioral concerns, the nurse must immediately notify the on-call provider for guidance. The DON confirmed that RN 1 failed to notify the physician or facility administration during the shift regarding resident 33's homicidal statements and the subsequent delay in pain management. The DON verified the physician was not notified until the morning of 6/26/26.Review of the facility's internal investigation report dated 6/26/26 confirmed that the medical provider was not timely notified by the nurse until the morning after report that the resident was having concerning behavior that poses a safety risk to others, and that the nurse did not feel comfortable administering the opiate medication until she was able to speak with the resident about her threats. The facility noted, This is a process and customer service issue that all nursing staff will be trained on. The facility's internal investigation also acknowledged the nurse did not fully document a thorough pain assessment when administering the opiate medication to the patient. The policy titled 001 - Resident Rights/Dignity: Abuse and Neglect - Clinical Protocol (effective date February 1, 2024) revealed under the Assessment and Recognition protocol, the policy specified:The nurse will assess the individual and document related findings. Assessment data will include: . B. Pain assessment.C. Current behavior . The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, for 1 out of 20 sampled residents, a resident taking an antidepressant medication for insomnia did not have hours of sleep monitored. Resident identifier: 21.Findings included:Resident 21 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder, insomnia, and Alzheimer's. Resident 21 had a physician order started on 11/4/25 for traZODone HCI [hydrochloride] Oral Tablet (Trazodone HCI) Give 100 mg [milligrams] by mouth at bedtime related to INSOMNIAA review of resident 21's Medication Administration Record and Treatment Administration Record for May and June 2026 revealed that resident 21 was not being monitored for hours of sleep.On 7/1/26 at 8:26 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that trazodone required monitoring for antidepressant use and hours of sleep, unless a resident was just taking the medication for depression. The DON stated that resident 21 was taking trazodone for insomnia and sleep. The DON stated that resident 21 did not have his hours of sleep monitored.

Based on interview and record review, it was determined that for 1 out of 13 sampled residents, the facility did not ensure residents had a right to be free from neglect. Specifically, a resident was left in a wet brief for an extended period of time and sustained a rash and excoriation to the groin. This resulted in a finding of harm for the resident. Resident identifier: 9.Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, unspecified urinary incontinence, mild cognitive impairment of uncertain or unknown etiology, and cognitive communication deficit.Resident 9's medical record was reviewed on 12/3/25.On 3/13/25 at 10:00 PM, a progress note documented, Oncoming aides rounded on resident and discovered excoriated peri-area [perineum] with a split open area at the left waist approx [approximately] 3 inches long. There is also an area on her left shoulder that appears to be a rash approx 4x 4 without any open areas. Antifungal powder was applied to peri area. Collagen and dressing was applied to split open area. Monitor rash on shoulder for improvement vs [versus] worsening.It should be noted that a skin assessment dated [DATE] for resident 9 showed no skin abnormalities.The facility Incident Report Form was reviewed. The facility reported that staff found (resident 9) had not been changed for a long period. (Certified Nursing Assistant 5) discovered (resident 9) saturated with dried and wet urine up to her shoulders and notified the nurse (Registered Nurse 1) who confirmed the condition. (Certified Nursing Assistant 4), assigned to the room, claimed she had changed (resident 9), but the resident's condition indicated otherwise. (Registered Nurse 1) assessed (resident 9), noted a rash, excoriation, and a yeast area, and applied barrier cream. The Director of Nursing was notified, and the facility immediately suspended (Certified Nursing Assistant 4) pending investigation. The RNC (Regional Nurse Consultant) ordered psychosocial checks for 72 hours and two-hour nurse checks. The facility began an investigation and planned staff education on the bowel and bladder program.The facility Follow-up Investigation Report was reviewed. Resident 9 had severe dementia so staff interviews provided most of the information. (Certified Nursing Assistant 4) gave conflicting accounts and admitted she had not performed the required two hour checks. Oncoming staff found the resident heavily soiled and appeared to have lain in urine for about eight hours. The nurse assessed resident 9 and documented a rash, excoriation, and a yeast area, then provided treatment. Staff also reported that (Certified Nursing Assistant 4) yelled at (Certified Nursing Assistant 5).A review of Registered Nurse (RN) 1's initial interview documented, RN 1 reported that around 10:00 PM, she heard Certified Nursing Assistant (CNA) 4 yelling, you're not going to ruin my reputation, while blocking CNA 5 from entering resident 9's room. After RN 1 knocked, CNA 4 allowed her in. CNA 4 first claimed she had changed resident 9 multiple times, then changed her story and admitted she had not changed the resident since 2:30 PM. RN 1 observed that the resident appeared to have been sitting in urine for at least 8 hours, with urine up to her shoulders, despite typically staying dry and not tolerating being wet. RN 1 also noted that CNA 4 had repeatedly stated over the radio that she was all caught up during her shift.A review of CNA 6's initial interview documented, Upon arriving at work CNA 4 attempted to give CNA 6 report of her residents and she informed CNA 4 to give report to CNA 5. CNA 6 overheard CNA 5 say the situation was unacceptable and CNA 4 began to yell at CNA 5. CNA 4 blocked the door, but opened it when the nurse intervened. CNA 6 observed that CNA 5 remained calm while CNA 4 yelled. CNA 6 noted that CNA 4's outburst was unusual but that care issues with CNA 4 had occurred on previous shifts, often requiring additional work from the next shift.A review of CNA 5's initial interview documented, When CNA 5 arrived for her shift, CNA 4 admitted she had not given resident 9 her scheduled shower and that the resident needed a full bed change. CNA 5 saw that resident 9 had urine up to her shoulders and appeared to have been in that state for some time. CNA 5 handed supplies to CNA 4 refusing to participate, but CNA 4 yelled at her, slammed the door, and blocked her from re-entering the room. RN 1 had to knock on the door to gain access to the room. CNA 4 told RN 1 that the resident was last changed around 2:30 PM and this had occurred at shift change around 10:00 PM.A review of the alleged perpetrator CNA 4's initial interview documented, CNA 4 reported that CNA 5 yelled at her for not changing resident 9's brief. She initially claimed she had changed the resident around 5:30-6:00 PM. CNA 4 admitted she likely had not checked the resident for 2-3 hours and acknowledged she should have followed the two hour check policy. CNA 4 blocked the door briefly to compose herself but let RN 1 in, who also questioned her. CNA 4 said she did a quick check around 8:00 PM and discovered the resident's condition at 9:45 PM. CNA 4 admitted she handled the situation poorly by yelling at CNA 5 and expressed that she did not want to work with CNA 5 again. CNA 4 reported that she had not noticed any skin issues on resident 9 during her shift.The facility verified the allegation and terminated the employee. A review of the facility's abuse and neglect policy revealed: 001 - Resident Rights/Dignity: Abuse and Neglect - Clinical Protocol. 2. Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Assessment and Recognition 5. Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example, inadequate prevention or care of pressure ulcers, inattention to advance directives and resident wishes, inappropriate management of problematic behavior, recurrent failure to provide incontinence care, failure to report or evaluate significant weight loss, repeated failure to check for correct application of restraints, etc. On 12/3/25 at 10: 43 AM, an interview was conducted with CNA 7. CNA 7 stated that she performed bed checks on residents at least every 60 minutes. CNA 7 stated that during bed checks she would see if a resident required a brief change or needed to use the toilet. CNA 7 stated that a resident should only be left in a wet brief for a maximum of seven minutes because a resident could develop an infection or a skin condition. CNA 7 stated that she always changed a wet brief immediately when a resident was found to have one. On 12/3/25 at 10:48 AM, an interview was conducted with CNA 8. CNA 8 stated that skin breakdown could occur if a resident was left in a wet brief for any period of time and it was best to change the resident immediately. On 12/3/25 at 10:56 AM, an interview was conducted with CNA 1. CNA 1 stated that he rounded on residents at least every 2 hours and checked for any resident with a soiled brief. CNA 1 stated that when he checked on residents he would always check to see if their bed linens were damp and would change those if they were. CNA 1 stated that he would never leave a resident in a wet brief and if he saw that a resident had one then he would change it and not wait. CNA 1 stated that he would never go more than 2 hours without checking on residents. On 12/3/25 at 11:04 AM, an interview was conducted with RN 2. RN 2 stated that skin checks were done on residents weekly. RN 2 stated that CNAs were responsible for checking on residents and if the resident was incontinent checking on the resident's brief. RN 2 stated that if a resident had a wet brief then they should be changed immediately because skin breakdown or urinary tract infections could occur.On 12/3/25 at 12:57 PM, a phone interview was conducted with CNA 6. CNA 6 stated that on 3/13/25 she was coming on shift at 10:00 PM and CNA 4 walked up to her and tried to pass off her residents. CNA 6 stated that she was not taking the hall CNA 4 had and instructed her to wait until CNA 5 came. CNA 6 stated that she was taking the batteries out of the hoyer lift and could hear CNA 5 tell CNA 4 that leaving resident 9 like she had was unacceptable and that CNA 5 was going to go get the nurse. CNA 6 stated that she heard CNA 4 start screaming that she had changed resident 9. CNA 6 stated that CNA 4 barricaded herself in resident 9's room and would not let any one enter the room. CNA 6 stated that RN 1 came to resident 9's room and knocked on the door and told CNA 4 to let her in. CNA 6 stated that RN 1 went into the room and told CNA 4 that you could not leave a resident in this state. CNA 6 stated that resident 9 was very incontinent and there were standing orders to check on the resident every 2 hours and resident 9 never refused care.On 12/3/25 at 1:25 PM, an interview was conducted with RN 3. RN 3 stated that CNAs performed checks on the residents and this should occur every 2 hours. RN 3 stated that skin breakdown could occur on a resident in a matter of minutes if they were left in a wet or soiled brief and barrier cream had not been applied. On 12/3/25 at 1:47 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that CNAs should be rounding on residents at least every 2 hours and that included checking for wet briefs. The ADON stated that resident 9 was alert to self and sometimes place. The ADON stated that resident 9 was very incontinent and did not use a toilet. The ADON stated that resident 9 was unable to tell staff when she had been incontinent. The ADON stated that she had not been working at the facility at the time of the incident. On 12/3/25 at 3:30 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated rounding on residents was a case by case basis and best practice would be to round on them every 2 to 4 hours. On 12/3/25 at 4:49 PM, a phone interview was conducted with CNA 4. CNA 4 stated she was employed to transport, change, and shower patients. CNA 4 stated that she had to check on residents every 2 hours. CNA 4 stated that if she didn't have to disturb a resident then she would not go into their room and check on them. CNA 4 stated that she had made a faux pas where she had a room and both the residents were memory care and she had to check on them every 2 hours. CNA 4 stated that she got caught up performing a resident shower and got busy with other things and didn't check on the residents as often as she should have. CNA 4 stated that in this instance the resident was soaking wet and she went to tell the CNA that was taking over that the resident needed everything changed. CNA 4 stated that the other CNA yelled at her and she went into the room and held the door closed and would not let staff in. CNA 4 stated she let the nurse in and the nurse told her that she had not done her job well. CNA 4 stated that she knew this was imprisonment by holding the door shut. CNA 4 stated that she decided to quit the job and not admit her guilt. CNA 4 stated that she changed resident 9 at 6:45 PM and was not sure if she had charted that. CNA 4 stated that all of this happened over a year ago and she could not remember anything else.It should be noted that when the surveyor asked CNA 4 about the inconsistencies with her statements to the facility, her initial interview, and the interview she had just provided, CNA 4 stated that she had to go and did not want to discuss this any further. On 12/3/25 at 5:09 PM, a phone interview was conducted with RN 1. RN 1 stated that on 3/13/25 CNA 4 was on the radio all night long announcing that she was all caught up with her work. RN 1 stated that the night shift aides came in and began doing their rounds. RN 1 stated that resident 9 had been lying in filth and there were multiple color striations of the dried urine on the sheets. RN 1 stated that it was a lot of urine and that resident 9 had not had her brief changed since 2:30 PM. RN 1 stated that the on-coming CNA called her and asked her to come down to the room and in the process CNA 4 had barricaded herself in the room to prevent anyone from seeing the resident or her bed linens. RN 1 stated she told CNA 4 to open the door and let them in so they could fix the issue. RN 1 stated that CNA 4 finally opened the door and was yelling at CNA 5 that she hadn't done anything wrong and continued yelling. RN 1 stated that CNA 4 left the building after that. It should be noted that RN 1 could not recall if resident 9 had any skin issues when asked by the surveyor. RN 1 stated that if she documented that there were skin issues then it was true.

Based on interview and record review, the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 1 out of 27 sampled residents, staff were unable to locate a resident for a period of time. There was an area of the facility that was locked an unaccessable to staff. There was a facility staff member in the locked area that the resident was observed to exit from. The resident made statements that the staff member engaged in sexual actions with her. In addition, the staff member had been talked to about not remaining in the facility after dinner time. This example was cited at Immediate Jeopardy. Resident identifiers: 4, 6, 12, 23, 28, 31, 36, 90 and 141. Findings included: Notice: On 4/11/24 at 12:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally and in writing to the facility Administrator, Chief Operating Officer, [NAME] President of Clinical Services, Director of Nursing (DON), and Regional Nurse Consultant (RNC). On 4/11/24 at 3:02 PM, the facility Administrator provided the following abatement plan for the removal of the IJ effective on 4/11/24 at 4:00 PM. [Facility name] is providing the following information to demonstrate that the immediacy of the cited deficiency F600 has been removed. Summary of Actions Take: Resident: Resident [31] Resident and staff member were separated immediately Police contacted immediately upon suspicion Resident assessed; no injury noted Notification to Physicians, POA [Power of Attorney] Incident reported by administrator to DHS [Department of Health Services], APS [Adult Protective Services], Ombudsman Resident interviewed with administrator Hospital evaluation completed, no trauma noted Resident care plan reviewed and updated as needed Provider to assess/evaluate residents including medication review SS [Social Services] wellness visits to be completed for resident x 2 and PRN [as needed] Behavioral health visit requested with [local mental health] provider Therapy: Therapy Staff Member (ST) Therapy staff member was immediately placed on administrative leave, facility keys/badge provided to administrator Therapy staff member was questioned and released by the police, pending potential charges Employee file was reviewed Therapy staff member will not return to the facility RDO [Regional Director of Operations] spoke to Therapy Regional Director and informed him that staff are not to stay in the facility after normal business hours without the approval of the facility administrator Facility will ensure the therapy staff working in the facility have background checks (DACS) [Direct Access Clearance System] that are connected to the facility. Other Residents at Potential Risk: All residents interviewed by administrator/designee to assess potential for abuse/neglect allegations Systemic Changes and Education Facility will ensure all staff working in the facility have background checks (DACS) that are connected to the facility. Locks will be removed from all doors and/or Master Key accessible to charge nurse on medication cart Staff Members will not remain in the facility after normal business hours without the approval of the facility administrator Administrator, DON and RNC reviewed Abuse & Neglect Policy Administrator, DON and IDT [Interdisciplinary team] were educated by RNC regarding Abuse & Neglect Policy Administrator/DON/designee will complete Abuse & Neglect education with all staff Education including post-test initiated immediately for all facility staff on Abuse/Neglect All employees will be educated at start of their next shift or if no scheduled shift by all staff meeting on 4/16/24 Monitoring and Quality Improvement Measures: The DON/designee will review incidents of sexually inappropriate behavior weekly x 4 weeks then monthly x3 months to ensure appropriate interventions are implemented and no trends are noted The Administrator/designee will conduct 5 random resident & staff interviews weekly x 4 weeks and then monthly thereafter x 3 months to ensure the Abuse & Neglect Policy have been followed and allegations have been investigated and reported timely The facility administrator/designee will do random facility visits during off hours 2x/week x 4 weeks and then monthly thereafter x 3 months to ensure that only staff clocked in and assigned to be working are in the facility and that the charge nurse has a Master Key to all locked doors in the facility The Administrator/designee will review 5 employee files (including contracted therapist) weekly x 4 weeks and then monthly thereafter times 3 months to ensure they have completed abuse training, verification of license and background checks (DACS) is connected to the facility. Medical Director was informed of the incident and QAA [Quality Assurance and Assessment] Review & Recommendations Results will be reported to the QAA committee from monitoring and follow-up The administrator is responsible for substantial compliance of this Plan of Action. The facility alleges the immediacy with deficient practice has been removed on April 11, 2024 by 4:00 PM. Findings included: Immediate Jeopardy Resident 31 was admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis, muscle weakness, dementia of unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, protein-calorie malnutrition, immunodeficiency, and chronic respiratory failure with hypoxia. On 4/9/24, between 9:50 AM and 10:05 AM, separate interviews were held with Licensed Practical Nurse (LPN) 1 and resident 4. During these interviews, LPN 1 informed the surveyor that late the previous evening, resident 31 had gone missing. LPN 1 reported that as staff searched for the resident, they noticed the therapy gym doors were locked. LPN 1 stated the therapy gym was the only location in the facility staff were unable to access to search for the resident. LPN 1 stated staff had been searching for resident 31 for about 20 minutes, when resident 31 was observed walking in the hall with therapy paperwork. LPN 1 stated resident 31 had vomited and had been incontinent of stool. Resident 4 informed the surveyor that on the evening of 4/8/24, there were five police officers in the facility. The resident stated she was uncertain why law enforcement was in the facility. On 4/9/24 an interview was conducted with resident 31. Resident 31 stated that she knew why police were at the facility last night but did not want to say anything. On 4/9/24 at approximately 11:00 AM, an interview was conducted with the Administrator. The Administrator stated that there was an allegation of abuse on 4/8/24, that she reported to the State Survey Agency (SSA). The Administrator provided the 358 report to surveyors. The 358 revealed on 4/8/24 at 9:40 PM, staff became aware that resident 31 stated that she wanted to have sex with a male staff member, but she did not have sex. A Physical Therapist was identified on the form as the alleged perpetrator. The steps taken immediately to ensure residents were protected revealed [Resident 31] was brought to her room by staff members. When resident stated that she wanted to have sex with a male staff member, the only male staff member on shift was placed on administrative leave pending investigation. RN [Registered Nurse] performed full body assessment and noted no injuries. BIMS [Brief Interview of Mental Status] was performed showing 14/15 cognitively intact. Physician notified, family notified. The incident was reported to law enforcement, APS, and Ombudsman. Resident 31's medical record was reviewed 4/8/24 through 4/11/24. On 8/18/23, a hospital History and Physical from the local hospital revealed resident 31 had a diagnosis of dementia. It was documented that resident 31 was oriented to person and place but not time, she knew it was August but thought it was the year 2080. Resident 31 was told the story from the St. Louis Mental Status testing, she was unable to recall any details. The assessment/plan for dementia revealed that resident 31 had significant dementia that had progressed. On 1/8/24, a state optional Minimum Data Set (MDS) assessment revealed resident 31 had a BIMS score of 15. The MDS further revealed resident 31 required supervision with bed mobility, transfers, and toilet use. A care plan dated 8/22/23 and revised on 9/4/23, revealed The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia and cognitive communication deficit. The goal was The resident will be able to communicate basic needs on a daily basis through the review date. Interventions included Communicate with the resident/family/caregivers regarding residents capabilities and needs and COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. A care plan dated 9/4/23, revealed The resident has a communication problem and does not always understand others d/t [due to] dementia and cognitive communication deficit. The goal was The resident will be able to make basic needs known on a daily basis through the review date. Interventions included Anticipate and meet needs; Be conscious of resident position when in groups, activities, dining room to promote proper communication with others; and COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. A progress note dated 3/26/24 at 4:02 PM, revealed Patient requires help with the following ADLs [activities of daily living]: dressing up to extensive assistance and showers up to extensive assistance. Patient has a diagnosis of dementia. At times patient can be very forgetful and need cueing and reminders. Patient has a history of falling and fell at home prior to coming to our facility r/t confusion and trying to do things on her own. Patient has a history of hallucinating and reports seeing dogs and cats doing various things around her. Patient takes medications to help with hallucinations and medications are managed by [local behavioral health company]. A progress note dated 4/8/24 at 9:40 PM, revealed Nursing staff found resident standing in the hallway with her walker. Resident was pale and nauseated. Full body assessment performed. No injuries noted. Resident was assisted to the bathroom and had a large BM [bowel movement]. She was assisted back to bed where she vomited x1 into her garbage can. MD [Medical Doctor], Administrator and family notified. A progress note dated 4/9/24 at 5:49 PM, revealed Admin [Administrator] had several interactions with resident this day. Resident joking and conversing with staff throughout shift. Resident denies any pain or emotional distress. Resident alert and oriented x 4 [person, place, time, and situation] with ability to recall facts and participate in conversations appropriately. On 4/9/24 at 3:25 PM, an observation was made of resident 31. Resident 31 was observed to be assisted by staff members into the facility van. On 4/9/24 at 3:46 PM, an interview was conducted with the DON. The DON stated resident 31 requested to go to the emergency room (ER). The DON stated she was unable to tell anyone why resident 31 was going to the ER. The DON stated it was still under investigation and she needed to talk to the Administrator prior to sharing information. On 4/9/24 at 4:17 PM, an interview was conducted with the Administrator. The Administrator stated that the facility was in the middle of an investigation with PTA [Physical Therapy Assistant] 1 and resident 31. The Administrator stated she talked to resident 31's family and the family wanted resident 31 evaluated at the emergency room . The Administrator stated resident 31's family stated to the Administrator that if anything happened between resident 31 and PTA 1 it would have been consensual from resident 31. The Administrator stated resident 31 had a history of dementia but her BIMS score on 4/8/24, was 14 out of 15. The Administrator stated she was not sure if resident 31 had a Montreal Cognitive Assessment test completed. The Administrator stated she was made aware of the situation at 9:42 PM on 4/8/24. The Administrator stated RN 1 informed her that facility staff found resident 31 in the hallway and that staff took resident 31 back to her room. The Administrator stated that RN 1 told her that resident 31 stated she wanted to have sex with someone but had not had sex with anyone. The Administrator stated she was not aware of any other statements made by resident 31. The Administrator stated there was no history of allegations against PTA 1. The Administrator stated she completed the exhibit 358 form to report to the allegation to the SSA. The Administrator stated she wrote that the alleged perpetrator was a Physical Therapist but it was actually a Physical Therapy Assistant. The Administrator stated PTA 1 worked four hours per day Monday through Friday, usually in the mid afternoon. The Administrator stated after talking to the Therapy Coordinator (TC), the TC reported she had a complaint last week that residents would rather do therapy earlier. The Administrator stated PTA 1 worked at another building first and then came to the facility later in the day. On 4/10/24 at 11:19 AM, a telephone interview was held with a facility medication aide certified, who was also Certified Nursing Assistant (CNA) 2. This staff member stated she had worked in the facility more than nine years and that she was very familiar with all the residents. CNA 2 stated on the evening of 4/8/24, she was completing the medication pass on the North end of the building when RN 1 approached her and stated she was unable to locate resident 31. CNA 2 stated six staff members began searching for resident 31, looking in all rooms, bathrooms, the family room, and shower rooms. CNA 2 stated a nursing student, precepting at the facility, searched outside the facility, as did CNA 1 and CNA 2. CNA 2 stated PTA 1's motorcycle was still parked at the facility. CNA 2 stated all staff then went to the two doors of the therapy room, which were locked and the lights in the room were off. CNA 2 stated the therapy room were usually unlocked and open. CNA 2 stated a light in an office within the therapy room was on, but the door was closed to the office area. CNA 2 stated she first observed resident 31 as she came back in through the south door and walked toward the east hallway. CNA 2 stated resident 31 looked sick, clammy, and like she was going to pass out. CNA 2 stated resident 31 told staff she did not want to talk about it. CNA 2 stated that she and CNA 1 stayed with resident 31 in her room, as they had established a rapport with her. CNA 2 stated resident 31 said she was sick to her stomach and she had spit up mucus two times in the trash. CNA 2 stated resident 31 said she had a crush on someone but did not want to say who because she did not want him to lose his job. CNA 2 stated she and CNA 1 asked resident 31 what had happened and resident 31 replied that they, resident 31 and the male staff member, wanted to try something. CNA 2 stated she asked resident 31 if her clothes were off, to which CNA 2 stated the resident replied they were off, for the most part. CNA 2 stated she asked resident 31 if the male staff member's clothes were off. CNA 2 stated resident 31 responded, yes. CNA 2 stated resident 31 told CNA 2 and CNA 1 that resident 31 and the male staff member were trying to have sex and it did not work. CNA 2 stated she asked resident 31 what she meant. CNA 2 stated resident 31 replied that it was like her crotch was sewn shut because it had been [AGE] years since she did something and pointed to her pelvic area. CNA 2 stated resident 31 further replied that they could not get it in. CNA 2 stated RN 1 was outside the room with a medication cart and CNA 2 told RN 1 to call the cops. CNA 2 stated resident 31 told her this was not the first time it had happened, but that resident 31 did not say when it had happened before. On 4/9/24 at 6:58 PM, a telephone interview was conducted with CNA 1. CNA 1 stated she worked in the facility since 2017 and was familiar with all the residents. CNA 1 stated she started a shift at 6:00 PM on 4/8/24, and should have been off at 10:00 PM. CNA 1 stated she left the facility between 12:00 AM and 12:30 AM on 4/9/24. CNA 1 stated on the evening of 4/8/24, she was working on the South end of the building and there were three other CNA's on duty. CNA 1 stated there was a nursing student who asked if she knew where resident 31 was. CNA 1 stated she had seen resident 31 about 30 minutes before which was about 8:30 PM, because she rubbed lotion on the resident's feet. CNA 1 stated it was common for resident 31 to walk around the facility with a walker in the evening. CNA 1 stated that the Student Nurse stated she must have missed her in the hallway. CNA 1 stated that the Student Nurse made another lap around the facility and stated to CNA 1 she could not find her. CNA 1 stated resident 31 had moved rooms a few times and had dementia, so she thought maybe resident 31 was in an old room or bathroom. CNA 1 stated she began looking through her previous rooms and bathrooms. CNA 1 stated the search expanded to every room and bathroom. CNA 1 stated the only area staff were unable to get into was the therapy gym. CNA 1 stated she looked into the therapy gym through the window on the door and it was dark. CNA 1 stated she thought resident 31 was in there, so she banged on the door and no one opened the door and did not see anyone in the gym. CNA 1 stated staff looked downstairs, even though that area had been locked. CNA 1 stated she had come upstairs and by the East entrance and turned the corner to the East hallway and saw resident 31 in the hallway. CNA 1 stated she went up to resident 31 and stood in front of her walker and asked where she was and what happened. CNA 1 stated resident 31 appeared white in color and was disoriented. CNA 1 stated resident 31 stated she did not want to talk to her. CNA 1 stated resident 31 pushed by her and sat down on her bed. CNA 1 stated resident 31 stated she was getting sick and then observed resident 31 vomit. CNA 1 stated resident 31 looked at the staff members in her room, because everyone was there at that time. CNA 1 stated she asked for everyone to step out of the room except for CNA 2. CNA 1 stated she and CNA 2 remained with resident 31 to discuss what had occurred. CNA 1 stated resident 31 told them she had a crush on someone but stated she did not want that person to be fired. CNA 1 stated resident 31 explained that she and a male staff member tried to have sex but he could not get it in. CNA 1 stated resident 31 pointed toward her private area. CNA 1 stated CNA 2 asked resident 31 if her clothing was off, to which resident 31 replied yes. CNA 1 stated CNA 2 asked resident 31 if the male staff member's clothing was off, to which resident 31 replied yes. CNA 1 stated resident 31 explained the male staff member was very gentle with her. CNA 1 stated resident 31 explained she and the male staff member had tried before and could not get it in before either. CNA 1 stated that resident 31 told her it was consensual. CNA 1 stated resident 31 did not have cognition to understand what had happened. CNA 1 stated PTA 1 was at the facility after 8:00 PM, at night sometimes and he started being there later within the last few weeks. CNA 1 stated other staff members were concerned about him being at the facility later. CNA 1 stated she did not know exact times PTA 1 was at the facility because they were usually really busy working with residents. On 4/9/24 at 5:20 PM, a telephone interview was conducted with the Student Nurse (SN). The SN stated on 4/8/24 shortly after 9:00 PM, she was unable to locate resident 31 and asked other facility staff to assist in finding her. The SN stated there were alarms on the exit doors but staff looked outside anyway's thinking maybe the alarms had glitched. The SN stated staff checked all the resident rooms, empty rooms, and the bathrooms in the resident rooms. The SN stated resident 31 was not known to be a flight risk or go outside. The SN stated the lights were off in the therapy room. The SN stated there were windows on the doors to the therapy room. The SN stated that she was not familiar with the vehicles of the staff but a staff member mentioned that PTA 1's motorcycle was in the parking lot. The SN stated staff went back to the therapy room and she noticed the light in the therapy office was on. The SN stated staff had knocked and yelled resident 31's name thinking resident 31 was in the office or therapy room and had fallen. The SN stated there were codes to the basement but staff looked in the basement for resident 31. The SN stated staff had gone to the basement and she remained on the main floor looking for resident 31. The SN stated she was near resident room [ROOM NUMBER] and started walking toward the South side of the facility when she observed resident 31 come out of the therapy room through the East door. The SN stated she yelled resident 31's name and resident 31 turned her head and started walking towards the SN. The SN stated she knocked on the basement door and yelled that she found resident 31. The SN stated that resident 31 looked pale, confused, and altered. The SN stated resident 31 was usually bubbly and smiley and resident 31 had a look on her face like she did not know what was going on, like a deer in the headlights. The SN stated that resident 31 did not look like her usual self. The SN stated it was approximately 20 minutes that staff had been looking for resident 31. The SN stated they started looking for resident 31 at approximately 9:10 PM. The SN stated that she asked resident 31 where she was and resident 31 stated I am okay why do you want to know. The SN stated that she told resident 31 that everyone had been looking for her but resident 31 did not want to answer the questions. The SN stated that resident 31 looked overwhelmed, pale, and asked to sit down. The SN stated that resident 31 started to vomit when they got her to sit down. The SN stated that resident 31 was comfortable with CNA 1 and CNA 2. The SN stated that the CNA's stayed in the room with resident 31 and asked resident 31 where she was. The SN stated that CNA 1 came out of resident 31's room crying and stated that resident 31 told her everything and they needed to call the police. The SN stated we called the police and ran to the therapy gym to see if PTA 1 was still in the room. The SN stated that PTA 1 came out of the therapy room and was trying to leave. The SN stated that PTA 1 went back into the therapy gym and slammed the door. The SN stated the staff stood by the therapy doors so PTA 1 could not leave the facility. The SN stated when the police arrived at the facility PTA 1 left the therapy room with his motorcycle gear on. The SN stated the police put PTA 1 in handcuffs. The SN stated when the staff were confronting PTA 1, resident 31 came out of her room and defecated on herself in the hallway. On 4/9/24 at 3:00 PM, a telephone interview was conducted with RN 1. RN 1 stated on 4/8/24 at about 9:00 PM, she was looking for resident 31 to Administer her medications. RN 1 stated resident 31 had asked for pain medication about five minutes before that. RN 1 stated resident 31 was not in her room or bathroom. RN 1 stated resident 31's roommate said she went out in the hallway. RN 1 stated she had the SN with her and asked her to look for resident 31. RN 1 stated the SN was unable to locate resident 31 after about five to 10 minutes. RN 1 stated the SN had looked in hallways and rooms near resident 31's room. RN 1 stated she asked the CNA's to help them look for resident 31. RN 1 stated the staff looked in all of the resident rooms, even the empty ones, and all the bathrooms. RN 1 stated the staff looked in any room they could get into and then looked outside. RN 1 stated staff looked in the basement. RN 1 stated it was not like resident 31 to be gone that long. RN 1 stated resident 31 had dementia but had not tried to elope or leave the facility. RN 1 stated after not being able to find her, there were a couple rooms that were locked like the activity room, the social services room, and the therapy gym. RN 1 stated staff looking outside and noticed PTA 1's motorcycle was there. RN 1 stated that PTA 1 was usually at the facility from 6:00 PM to 8:30 or 9:00 PM. RN 1 stated the therapy gym was usually not locked and the office light would be on. RN 1 stated after about 30 minutes staff found resident 31 in the hallway by the therapy gym that was next to the family room. RN 1 stated resident 31 had therapy handouts in her hand. RN 1 stated resident 31 looked really pale and she said she had been in the family room. RN 1 stated resident 31 said she needed to sit down. RN 1 stated resident 31 sat down on the bed and threw-up. RN 1 stated at that point, resident 31 appeared overwhelmed with everyone. RN 1 stated CNA 1 and CNA 2 stayed with resident 31. RN 1 stated that resident 31 had a large bowel movement and her periarea was assessed and there were no concerns or redness. RN 1 stated CNA 1 and CNA 2 talked with resident 31 and exited resident 31's room and was told to call the police at about 9:30 PM. RN 1 stated resident 31 did not provide any information to her directly. RN 1 stated staff were banging on the therapy gym doors and there was no answer. RN 1 stated she contacted resident 31's family members, the physician, and the administrator. RN 1 stated resident 31 was not physically injured and was not in any pain. RN 1 stated resident 31 was not in distress but had a deer in the headlights look. RN 1 stated that the SN was the first person to find resident 31. RN 1 stated that the SN told her resident 31 came out of the therapy gym. RN 1 stated she was not sure if a sexual assault exam was completed. RN 1 stated she did not remember seeing PTA 1 with resident 31 in the past and did not know if she was receiving therapy services. RN 1 stated she saw PTA 1 working with resident 28 and resident 36. RN 1 stated PTA 1 was usually at the facility between 6:00 PM to 6:30 PM until 9:00 PM. RN 1 stated the therapy gym was never locked. RN 1 stated the Maintenance Director had a key to the therapy gym. RN 1 stated the light in the therapy office was visible around the door frame through the windows in the therapy gym door. RN 1 stated the lights were turned off when she looked in there. RN 1 stated she was not sure where therapy paperwork was stored. RN 1 stated she had not seen therapy paperwork before. RN 1 stated she completed a full body assessment on resident 31. RN 1 stated when she performed the assessment resident 31 stated he never forced himself on her. RN 1 stated the Administrator directed her to not be specific with her charting and to keep it very clinical in resident 31's nursing progress notes. RN 1 stated she was able to document that resident 31 was pale, had a large bowel movement, and threw-up once. RN 1 stated she was able to document there was no trauma. RN 1 stated she was able to document details in the incident report. On 4/10/24 at 8:30 AM, an interview was conducted with the TC. The TC stated PTA 1 had been suspended as of 4/8/24. The TC stated PTA 1 clocked in and out on the computer. The TC stated she had talked to PTA 1 about how he was coming in too late in the evenings on 3/15/24. The TC stated residents were refusing therapy because it was so late. The TC stated PTA 1 was coming in late about 3:10 PM, and left between 6:00 PM and 8:00 PM. The TC stated she reminded PTA 1 that they want him to leave before 7:00 PM. The TC stated she thought he was having long days at another facility but after talking to the director of the other facility, that was not the case. The TC stated she left the therapy room doors open and unlocked with the light out. The TC stated she came in the morning a few times and one of the doors was locked to the therapy room. On 4/10/24 at 9:56 AM, a follow-up interview was conducted with the TC. The TC stated she did not know why PTA 1 would clock out at 6:45 PM, and still be at the facility after 9:00 PM. The TC stated she was not aware PTA 1 had stayed later than he had when clocked out. On 04/10/24 at 12:39 PM, an interview was conducted with the TC. The TC stated she left the facility between 2:00 PM and 4:00 PM, and PTA 1 was usually not at the facility when she left. The TC stated the staff completed point of care documentation. The TC stated that documentation should be completed as therapy was provided to the resident. The TC stated when PTA 1 signed out then he should be done with his day. The TC stated if PTA 1 was not done with his day then he should stay on the clock and the time would go toward patient care. On 4/10/24 at 4:16 PM, a follow-up interview was conducted with the TC. The TC stated she was unable to find therapy notes from PTA 1 for treatments that should have been provided on 4/8/24, for four additional residents. The TC stated she was only able to locate therapy notes for resident 6. On 4/11/24 at 8:08 AM, an interview was conducted with the TC. The TC stated PTA 1 was only able to document therapy notes while at the facility. The TC stated the facility had three laptops that were available for therapy staff to document on and those laptops did not leave the facility. On 4/11/24 at 9:37 AM, a follow up interview was conducted with RN 1. RN 1 stated that she was in the middle of medication pass when the CNA reported that resident 31 had requested Tylenol. RN 1 stated she had an admission prior that took awhile to complete. RN 1 stated she pushed the medication cart over to resident 31's room because she was unsure if resident 31 wanted her other medications. RN 1 clarified she had not prepped any of resident 31's medications prior to moving the medication cart. RN 1 stated that after pushing the medication cart to resident 31's room was when she had discovered resident 31 was missing and she started searching for resident 31. RN 1 stated it was 11:30 PM, before resident 31 received her medications. On 4/11/24 at 2:39 PM, an interview was conducted with PTA 1. PTA 1 stated he had worked at the facility for about two months. PTA 1 stated he worked about 15 hours per week at the facility. PTA 1 stated he arrived between lunch and dinner and left the facility about 8:00 PM. PTA 1 stated sometimes he was there a little later to catch up on things. PTA 1 stated if he was trying to catch up on things, he was not paid for his time. PTA 1 stated there was a little work area inside the gym where he would think about things and add additional notes to resident medical records that he had forgotten about. PTA 1 stated on 4/8/24, he arrived at the facility about 3:00 PM. PTA 1 stated he went into the gym, closed the door, shut out the lights, and shut the office door. PTA 1 stated he played catch up, documented, collected himself, and got everything ready for the next day. PTA 1 stated he did discharge documentation for two residents. PTA 1 stated that he sometimes did not get everything done. PTA 1 stated there was regular preparing and then there was Me preparing that he was not paid for. PTA 1 stated he did not see any residents on 4/8/24, but he saw patients. PTA 1 stated the difference between the two were that patients he had treatments and residents did not. PTA 1 stated he [TRUNCATED]

Based on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature was not manufacture required temperature and there were no sanitizer strips available to test the solution. Findings included: 1. On 4/8/24 at 9:03 AM, an initial tour of the kitchen was conducted. The following observation was made of the dish machine [Note: All temperatures were in degrees Fahrenheit.] a. The washing temperature was 110 and the rinse temperature was 120. There were 11 plates, five cups, one dessert dish, and a lid that were in the dish machine. An observation was made of the Dietary Manager (DM) replacing the dishes with the clean dishes. b. The washing temperature was 110 and the rinse temperature was 120. The dish machine basket had seven trays in it and were replaced with clean dishes. An interview was immediately conducted with the DM. The DM stated the dish machine was between 100 and 200 degrees and was usually over 140. The DM stated that the dish machine needed to be run a few times. The DM stated that she had been running the dish machine and was finishing dishes. The DM stated with resident showers sometimes the temperature fluctuated. A log titled Dish Machine -PPM (Part Per Million) Sanitizer Record Log revealed the dish machine sanitizer was checked in the morning and afternoon. There were no temperatures on the log. The logs were reviewed for January 2024, February 2024, and April 2024. On 4/8/24, during the initial kitchen tour, an observation was made of the sanitizer buckets. The DM stated she had just changed the sanitizer solution. The DM was observed to put the sanitizer strip for quats into the solution and it did not change color. The DM stated she needed a new container of strips. The DM stated she was unable to locate strips. 2. On 4/16/24 at 9:57 AM, a follow-up tour of the kitchen was conducted. The following observation was made of the dish machine [Note: All temperatures were in degrees Fahrenheit.] a. The washing cycle temperature was 115 and the rinse cycle temperature was 119. Sanitizer was 100. b. The washing cycle temperature was 100 and the rinse cycle temperature was 115. c. The washing cycle temperature was 100 and the rinse cycle temperature was 119. A log titled Low Temperature Dish Machine Log for April 2024 revealed time, initials, wash temperature > (greater than) 120, rinse temperature > 120, sanitizer > 50 PPM for each day of April for breakfast, lunch, and dinner. The last temperature recorded was 4/14/24. On 4/16/24 at 9:52 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated the dish machine temperatures should be around 120. DA 1 was observed to look at the dish machine temperature and confirmed the washing cycle was 100 and the rinsing cycle was 115. DA 1 stated she checked the temperatures of the dish machine and sanitizer every morning. DA 1 stated it was the 16th but she documented the temperatures on the 14th. DA 1 stated she was not sure why the log changed for the dish machine. On 4/16/24 at 10:00 AM, an interview was conducted with the Vendor Consultant. The Vendor Consultant stated she was at the facility once a month to consult for the DM. The Vendor Consultant stated the DM was not working that day. The Vendor Consultant stated the dish machine log was changed because it needed to have breakfast, lunch, and dinner temperatures on the logs. The Vendor Consultant stated she suggested changing the logs for the dish machine. The Vendor Consultant stated she checked the dish machine on 4/15/24. The Vendor Consultant stated the washing cycle temperature should be 120 and the rinsing cycle temperature should be 120. The Vendor Consultant stated the dish machine needed to be run a few cycles to get to temperature above 120 for the wash and rinse.

Based on observation and interview, the facility failed to provide a suitable, nourishing alternate meals and snacks for residents wanting to eat at non-traditional times, or outside of scheduled meal service times. Specifically, for 5 out of 27 sampled residents, residents were only offered saltine crackers for snacks. Resident identifiers: 3, 4, 6, 31, and 141. Findings included: On 4/8/24 at 9:00 AM and 2:30 PM, an observation was made of a container at the south nurses station. There were saltine crackers in the container. On 4/8/24 at 9:15 AM and 2:35 PM, an observation was made of a container at the north nurses station. There were saltine cracker in the container and one of the saltine crackers was open to air. On 4/9/24 at 9:30 AM, an observation was made of the north nurses station. There were saltine crackers in a container on the counter and one of the saltine crackers was open to air. On 4/9/24 at 2:00 PM and 4:00 PM, an observation was made at the south nurses station. There were saltine crackers in a container on the counter. On 4/10/24 at 12:33 PM, an observation was made of the north nurses station. There was a container with a use by 4/10/24 label. In the container there were apples, crackers and peanut butter, pretzels, and saltine crackers. On 4/9/24 at 9:52 AM, an interview was conducted with resident 4. Resident 4 stated she was offered saltine crackers for snacks usually. Resident 4 stated sometimes there were oranges, pudding, apples, bananas, and cookies but the snacks were filled once a week at the nurses station. Resident 4 stated if the Dietary Manager knew someone important was coming to the facility she loaded up the snacks. Resident 4 stated the snacks were usually filled on Fridays. Resident 4 stated the south nurses station usually had better snacks. On 4/9/24 at 4:12 PM, an interview was conducted with resident 3. Resident 3 stated she was only offered crackers for snacks unless her family brought in snacks. Resident 3 stated she was not offered a snack on a regular basis unless her family had brought in a snack. Resident 3 stated she would like to have snacks offered at night because Who wants to go to bed hungry? On 4/16/24 at 11:12 AM, an interview was conducted with resident 141. Resident 141 stated if he went to the nurses station there were snacks available before bed. Resident 141 stated there were not to many snacks available at the nurses station. On 4/16/24 at 10:00 AM, an interview was conducted with a Vendor Consultant. The Vendor Consultant stated there were refrigerators at each nurses station for snacks and a basket on the counter. The Vendor Consultant stated the baskets were to be filled daily with crackers and other snacks. On 4/16/24 at 10:17 AM, an interview was conducted with [NAME] 1. [NAME] 1 stated the snacks were restocked during the evening shift. [NAME] 1 stated that he worked days and did not stock snacks. On 4/16/24 at 10:18 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated snacks were restocked during the evening shift so she did not stock snacks. 50200 On 4/16/24 at 11:13 AM, an interview was conducted with Resident 6 regarding food and snacks. Resident 6 stated that there were always saltines offered and there were other times fruit and other crackers were offered, but not on a consistent basis. Resident 6 stated that at bedtime she was sometimes asked if she would like a snack when the staff refill her water cup, but never on a regular basis. On 4/16/24 at 11:17 AM, an interview was conducted with Resident 31 regarding food and snacks. Resident 31 stated that she was not told when new snacks had been put out and that most of the snacks were taken by the time she walked around the facility. Resident 31 stated that she had gotten snacks at bedtime, but was uncertain if there was a routine regarding when snacks were given.

Based on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 4 out of 27 sampled resident, residents complained of food quality and a test tray was bland. Resident identifiers: 4, 9, 15, and 27. Findings included: On 4/8/24 at 10:44 AM, an interview was conducted with resident 27. Resident 27 stated the food was unappealing and unappetizing. On 4/8/24 at 9:32 AM, an interview was conducted with resident 15. Resident 15 stated she was sensitive to spices and strong flavors. Resident 15 stated lately the food had been pretty spicy. Resident 15 stated most foods had peppers of some kind added to them. On 4/8/24 at 10:24 AM, an interview was conducted with resident 9. Resident 9 stated the food was not good and there were no substitutes. On 4/8/24 at 10:49 AM, an interview was conducted with resident 4. Resident 4 stated we need better food. Resident 4 stated she was not allowed to have more than four ounces of juice per day. On 4/9/24 at 12:24 PM, an observation was made of the facility tray line. The last hall trays were plated at 12:24 PM. A test tray was requested at 12:25 PM. The Dietary Manager (DM) stated that she was out of Spaghetti. The DM stated if someone wanted seconds, sometimes they could get it. The DM stated she had pureed broccoli, turkey, and dessert. The DM was observed to put marinara sauce over the turkey and ham cubes. The test tray was observed to have cubes of ham and turkey with marinara sauce on top. There was pureed broccoli and a dessert dish with a yellow colored dessert. The pureed broccoli was bland and with chunks in it. The turkey and ham were bland to the taste with a slimy texture. The dessert had fruit on the bottom and raw cake on top of it. On 4/9/24 at 1:06 PM, an interview was conducted with the DM. The DM stated the ham and turkey were the alternative meal. The DM stated the alternate meal was not served to any residents and everyone was served Spaghetti. The DM stated the turkey and ham were served two to three days prior. The DM stated the dessert was a fruit crisp. The DM stated the turkey and ham should have had gravy on top. The DM stated three residents were served pureed food. The DM stated there was only one resident that wanted seconds of spaghetti and that resident was provided a sandwich because he was already served large portions. On 4/15/24 at 12:38 PM, the last lunch tray was served. Another test tray was requested. The residents were served meat, stuffing, cake, broccoli, and a roll. The temperatures were in degrees Fahrenheit. The pork was 116.5, the stuffing was 120.5, the broccoli was 119.4, the coffee was 114.2. The pork was tough to chew and bland to the taste. The stuffing was mushy and bland to the flavor. The chocolate cake was dry. The roll was sweet with a strong seasoning. On 4/16/24 at 10:00 AM, an interview was conducted with the Vendor Consultant. The Vendor Consultant stated she was at the facility monthly to consult for the DM. The Vendor Consultant stated the cook ran out of gravy for the pork and stuffing. The Vendor Consultant stated after the stuffing had been sitting on the steam table, the cook added water before serving the test tray. The Vendor Consultant stated she did not obtain a test tray with the pork so she did not know how it tasted.

Based on observation and interview, the facility did not provide a clean, comfortable, homelike environment. Specifically, there were odors throughout the facility. Findings included: On 4/8/24 at 8:57 AM, an observation was made in the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor. On 4/8/24 from 11:45 AM to 11:52 AM, an observation was made in the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor. On 4/9/24 at 9:08 AM, an observation was made in the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine, bowel movement, and body odor through the hallway. On 4/9/24 at 11:54 AM, an observation was made in the hallway outside room [ROOM NUMBER] and into the dining room. There was a strong urine odor. On 4/9/24 at 12:04 PM, an observation was made in the dining room and the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor. On 4/10/24 at 7:40 AM, an observation was made of a strong smell of urine in the north hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. On 4/10/24 at 8:26 AM, an observation was made in the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine and body odor. There were wheelchairs in the atrium observed. One of the wheelchairs was observed to have a brown substance on the seat and up the back of the seat. On 4/11/24 at 3:37 PM through 3:55 PM, there was an observation of the hallway outside room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor outside room [ROOM NUMBER] that increased in strength to room [ROOM NUMBER]. On 4/11/24 at 3:51 PM, an observation was made of a strong smell of urine in the north hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. On 4/15/24 at 11:47 AM, an observation was made in the hallway outside room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor in the hallway outside room [ROOM NUMBER], the urine odor was stronger outside rooms [ROOM NUMBERS]. The odor continued to room [ROOM NUMBER]. The urine odor was observed in the dining room. At 12:05 PM, an observation was made in the dining room and atrium. There was a strong urine odor. At 12:56 PM, there was a strong urine odor in the hallway outside room [ROOM NUMBER] to room [ROOM NUMBER] and in the dining room. On 4/15/24 at 11:48 AM, an observation was made of a strong smell of urine in the north hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. On 4/16/24 at 8:05 AM, an observation was made of a strong smell of urine in the north hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. On 4/16/24 at 9:49 AM, an observation was made outside room [ROOM NUMBER] in the hallway. There was a strong urine odor. On 4/16/24 at 9:42 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she noticed a urine odor that morning when she first got to the facility. RN 2 stated she had not noticed a urine odor any other day. RN 2 stated she did not look to find where the odor was coming from. On 4/16/24 at 9:44 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated there was usually an odor in the hallway from room [ROOM NUMBER] to room [ROOM NUMBER]. CNA 3 stated there was a resident with really stinky bowel movements that caused an odor through the hallway. CNA 3 stated staff tried to spray air freshener. CNA 3 stated there was a resident in room [ROOM NUMBER] with hemorrhoids that had a discharge that smelled through the hallway. On 4/16/24 at 9:47 AM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated there was normally an odor in room [ROOM NUMBER]. HK 1 stated there were certain rooms that had odors. HK 1 stated the urine odor came from room [ROOM NUMBER]. HK 1 stated the residents in room [ROOM NUMBER] had incontinent issues and refused to be changed at times so their beds and wheelchairs smelled of urine. HK 1 stated anytime the residents were out of their beds or wheelchairs the equipment was cleaned. HK 1 stated sometimes room [ROOM NUMBER] had urine odors. HK 1 stated if there was a urine odor it was usually a wet brief in the trash can in the bathroom. HK 1 stated some residents who were more self sufficient, put their briefs in the trash can. On 4/16/24 at 10:23 AM, an interview was conducted with CNA 5. CNA 5 stated she noticed odors outside room [ROOM NUMBER] because the resident refused to be changed. CNA 5 stated sometimes residents have commented, That's a little smelly. CNA 5 stated the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] had a urine odor at times. On 4/16/24 at 10:26 AM, an interview was conducted with CNA 6. CNA 6 stated Oh yeah when asked if she noticed odors in the hallways. CNA 6 stated she knew where the odor came from because a resident refused to get out of bed in room [ROOM NUMBER]. CNA 6 stated she thought the wheelchair in the atrium with the brown substance on the seat and up the back was from room [ROOM NUMBER]-2. CNA 6 stated Um yeah when she observed the brown substance on the wheelchair.

Based on interview and record review, the facility did not develop and implement written polices and procedures that prohibited and prevented abuse, neglect, and exploitation of residents. Specifically, a staff member was not connected to the facility through the Direct Access Clearance System (DACS). Findings included: Physical Therapy Assistant (PTA) 1's employee file was reviewed on 4/10/24. The file revealed an offer letter for another facility. There was no information regarding PTA 1 being employed with the facility being surveyed. The information provided was from a contract rehabilitation company. On 4/9/24 at 4:17 PM, an interview was conducted with the Administrator. The Administrator stated prior to a staff member working with residents a background screening was completed. The Administrator stated PTA 1 had a background screening completed and there were no problems. On 4/11/24 at 9:08 AM, an interview was conducted with the Background Processing Manager (BPM) at the State Survey Agency. The BPM checked PTA 1 in the DACS. The BPM stated that PTA 1 was eligible for work but PTA 1 had not been connected to the facility being surveyed. The BPM stated the employee should be linked upon engagement with the facility. The facility policy Freedom from Abuse, Neglect, and Exploitation Preventing and Prohibiting Abuse was dated 11/2017 and revised on 9/13/2022. The policy documented: PURPOSE: To keep residents free from abuse, neglect, and exploitation of residents and misappropriation of resident property. POLICY: The facility's policy is to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. The facility will establish procedures to investigation any such allegations. The facility will investigate and report such allegations and provides training on abuse, neglect, exploitation, and misappropriation of resident property for facility staff. The facility completes reporting of abuse allegations, including crimes occurring in the facility, in accordance with Federal regulation. Facility staff are educated and informed of their employee rights and reporting responsibilities and are protected from retaliation. The facility establishes methods to facilitate communication and coordination for situations of abuse, neglect, misappropriation of resident property, and exploitation with the Quality Assurance and Performance Improvement (QAPI) program. GUIDELINES: 1. The facility will maintain and implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property. 2. The policies and procedures will include the following components: a. Screening b. Training c. Prevention d. Identification e. Investigation f. Protection g. Reporting and response 3. The abuse prevention policies and procedures will be in coordination with the QAPI program. SCREENING 1. Potential employees should receive an interview prior to hire and employment history will be screened. 2. Potential employees will be screened with the appropriate licensing/certification boards, in various/multiple states when applicable. 3. When possible, previous and/or current employers should be contacted to obtain a reference for a potential employee. 4. Facility will conduct a criminal background check on potential employees who have been deemed qualified for hire. 5. The facility will not employ an individual whose pre-employment screening indicates a criminal or licensing/certification board history of abuse, neglect, or misappropriation of property. 6. The facility will report to the state nurse aide registry or other licensing authorities any knowledge of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. 7. Contracted staff, temporary staff and students will be screened by the third-party agency or academic institution according the same or substantially similar guidelines as stated above. 8. The facility screens prospective residents to determine if the facility has the capability and capacity to provide the necessary care and services for residents admitted to the facility. TRAINING 1. Staff will receive training related to: a. Prohibiting and preventing any form of abuse, neglect, misappropriation of resident property and exploitation b. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property c. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators d. Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources and when and to whom to report alleged violations without fear of reprisal e. Understanding behavioral symptoms of residents which may increase the risk of abuse and neglect and how to respond. PREVENTION 1. Staff will be informed of the individual residents' care needs and behavioral symptoms. 2. Staff will identify, assess, develop care plan interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as: a. Verbally aggressive behavior b. Physically aggressive behavior c. Sexually aggressive behavior d. Taking, touching, or rummaging through another's property e. Wandering into other's room/space f. History of self-injurious behaviors g. Communication disorders or language barriers h. Extensive nursing care needs or totally dependent residents 3. The facility will provide a safe environment that supports, as much as possible, a resident's desire to engage in a consensual sexual relationship between residents with the capacity to consent. 4. The facility will provide for the health and safety of residents regarding visitors. 5. The facility will provide residents and resident representatives information related to how and to whom they may report concerns, incidents, and grievances without fear of retribution. 6. Staff will be deployed in a manner to meet the needs of the residents. 7. Staff supervision will help to identify staff behaviors that may indicate potential for abuse or neglect. IDENTIFICATION 1. Facility staff will be trained to identify the different types of abuse. 2. Administration and staff will monitor for signs of abuse. These, include a. A suspicious injury b. Sudden or unexplained changes in the resident's behavior, such as fear of a person or place or feeling of guilt or shame. INVESTIGATION 1. Allegations of abuse, neglect, misappropriation and exploitation will be investigated, including: a. Identifying staff responsible for the investigation. b. Exercising caution in handling potential evidence. c. Identifying and interviewing involved persons, witnesses, and others who may have knowledge to the extent possible d. Determining whether abuse, neglect, exploitation and/or mistreatment occurred and, is so the extent and cause. e. Documenting the investigation. PROTECTION 1. During an investigation of alleged abuse, neglect, exploitation, and/or misappropriation, the facility will, to the extent possible, protect residents from harm during and after the investigation to include (as appropriate): a. Responding quickly to protect the alleged victim and integrity of the investigation. b. Examining the alleged victim for sign of injury if needed. c. increased supervision of the alleged victim and residents. d. Room or staff changes if necessary. e. Protection from retaliation. f. Providing emotional support and counseling to the resident, as needed REPORTING OF ALLEGATIONS OR SUSPICIONS 1. Staff will immediately report alleged violations to the Administrator, state agency, adult protective services, and other required agencies (i.e., law enforcement when applicable) within specified timeframes as required by law. 2. Reporters will not be subject to retaliation or reprisal, by the facility or any agent of the facility. 3. The facility will post a conspicuous notice informing employees of their rights. The facility will take necessary actions as a result of the investigation. 4. The facility will report to the State licensing and/or certification agencies any knowledge of any actions by a court of law which would indicate an employee is unfit for employment. 5. Staff will be trained regarding changes that are implemented. (Cross refer to F600)

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs. Specifically, for 1 out of 27 sampled residents, a resident did not have an intervention implemented from his care plan which resulted in multiple falls, a skin tear, and hip pain. Resident Identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, surgical amputation, diabetes mellitus, hyperlipidemia, hypertension, coronary artery disease, and chronic pain syndrome. Resident 9's medical record was reviewed on 4/9/24. A review of Resident 9's care plan initiated on 2/20/24, showed that the resident is at risk for falls and has had an actual fall r/t [related to] gait/balance problems. Resident 9's care plan was revised on 3/6/24, with interventions to include a bed change to a bariatric bed. On 3/6/24 at 6:33 AM, a Nursing Note documented Resident had an unwitnessed fall. No injuries noted. Neuro [neurological] checks started. Resident was angry with staff for wanting to assist him back into bed. He swore at staff, swatted staff away and stated 'I'm tired. Leave me alone.' Staff encouraged resident to allow staff to help him. Resident allowed staff to assist him back into bed using hoyer lift. Call light within reach, bed in low position, door left open. DON [Director of Nursing] and MD [Medical Doctor] notified. On 3/6/24 at 3:19 PM, a Nursing Note documented Patient reviewed in IDT [interdisciplinary team] meeting r/t fall on 3/6 [24]. Staff walked by patients room and noticed they were not in their bed. Staff walked into room and found patient on the ground in between their bed and the wall with a pillow under their head. Nurse assessed patient. No injuries noted. Patient reports not knowing how they fell and states they just woke up on the floor. Staff attempted to get patient back into bed and at first patient refused and swatted staff away. Eventually patient agreed to be hoyer liftedback [sic] into bed. Bed was put in lowest position and call light within reach. This nurse talked to patient about their fall later in the day and patient still reported they did not know what happened. Patient reports having a bigger bed may help prevent it in the future. Intervention: Bed changed from regular size to bariatric. On 4/1/24 at 7:15 AM, a Nursing Note documented this LN [licensed nurse] called into resident room due to resident being found sitting on the floor on the side of his bed. no clutter, or wet on floor. non skid socks not applicable as resident has bilat [bilateral] amputation. call light in use. resident states he was sleeping and rolled out of bed. skin assessment shows no new injuries. neuros and vitals [vital signs] implemented per facility policy. Md and DON notified. On 4/5/24 at 9:36 AM, a Nursing Note documented Patient reviewed in IDT meeting r/t unwitnessed fall. Staff found patient sitting on the ground next to their bed. Patient reports they just rolled out of bed in their sleep. Nurse assessed patient. No injuries noted. VSS [vital signs stable] Neuros WNL [within normal limits]. Staff assisted patient back into bed. Provider notified. Patient own responsible party. Intervention: Pharmacist to review medications. On 4/6/24 at 10:11 PM, a Nursing Note documented . had an unwitnessed fall where he obtained a pin sized abrasion to his right elbow. Cleansed with wound cleanser - steri strips applied. No other injuries observed. Neuro checks started. Resident was assisted back into bed. Bed in low position. Call light within reach. PRN [as needed] pain medication administered. He is alert and oriented x4 [person, place, time and event]. MD, DON notified. On 4/7/24 at 3:36 PM, a Nursing Note documented res [resident] had a recent fall, no latent injuries noted. continues to have pain in hip. PRN oxy [oxycodone] given with good effect. vitals and neuros WNL. On 4/7/24 at 11:09 PM, an Alert Note documented Continues on post fall charting. Res c/o [complaining of] Hip pain throughout shift. PRN oxycodone administered for pain with effective pain relief per resident. Res denies further concerns. Call light within reach. On 4/8/24 at 10:18 AM, a Nursing Note documented Pharmacist reviewed medications r/t falls. Recommended changing Prozac to Lexapro. In house provider reviewed recommendation and did not want to implement changes. States its [sic] too soon to contribute to medication side effects. On 4/8/24 at 12:54 PM, a Nursing Note documented Patient reviewed in IDT meeting r/t unwitnessed fall on 4/6 [24]. Patient reports he just rolled out of bed. Nurse assessed patient. Abrasion to R [right] elbow found. Nurse cleansed site and applied steri strips. Staff assisted patient back into bed. Patient given PRN pain meds [medications]. Provider notified. Patient own responsible party. Intervention: Fall matt placed next bed. On 4/8/24 at 10:26 AM, an interview was conducted with resident 9. Resident 9 stated that he had recently fallen out of bed a couple of times and cut his arm and hurt his left hip. Resident 9 stated that he refused to go to the hospital after the last fall. Resident 9 stated that he requested a bigger bed because he believed that was the reason that he kept falling or rolling out of bed. Resident 9 stated that he had not received a bigger bed. On 4/9/24 at 1:22 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that resident 9 did not have a bariatric bed. CNA 3 stated that resident 9 had a fall not too long ago and that a fall mat was placed on the floor next to the resident's bed. CNA 3 stated that if a resident was a fall risk, then the resident's bed was usually lowered closer to the floor. On 4/9/24 at 1:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was aware that resident 9 had a couple of falls in the past two weeks. LPN 1 stated that the last fall resident 9 sustained a skin tear to his right arm and had left hip pain. LPN 1 stated that the pharmacist was going to review resident 9's medications for a possible reason for the falls. LPN 1 stated that she was unaware of any interventions in place for resident 9 prior to the fall on 4/6/24. LPN 1 stated that after the fall on 4/6/24, a floor mat was placed on the floor next to the resident's bed. On 4/9/24 at 1:35 PM, an interview was conducted with the DON. The DON stated that resident 9 did receive a bariatric bed after his fall on 3/6/24. The DON stated that there were several interventions put in place for the resident which included the bariatric bed, pharmacy review of medications, and a floor mat. The DON stated that she would have maintenance check to see if the resident had a bariatric bed. On 4/16/24 at 8:11 AM, an interview was conducted with CNA 4 regarding care plans. CNA 4 stated that when she received report at the beginning of her shift she also received an update regarding changes in care plans for residents. CNA 4 stated that she reviewed the Kardex of residents every shift for any updated change in information. CNA 4 stated that she was not familiar with Resident 9's care plan. On 4/16/24 at 8:15 AM, an interview was conducted with LPN 1. LPN 1 stated that care plans got updated regularly by the nursing administration staff. LPN 1 stated that when changes were made to a resident's care plan she received those changes through a report from the previous nurse before beginning her shift. LPN 1 stated that the intervention for the bariatric bed for resident 9 was not known to her until questioned by survey member. On 4/16/24 at 8:20 AM, an interview was conducted with the DON. The DON stated that if there was a change in a resident's care plan then usually an inservice was done regarding the change and the Kardex would reflect the change. The DON stated that she reached out to maintenance regarding the intervention for the bariatric bed in March 2024, and was told that the resident had a bariatric bed. The DON stated that she found out the bed was not a bariatric bed during the survey.

Based on observation, interview, and record review, the facility did not ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 27 sampled residents, a resident did not have an assistance device to prevent falls which resulted in multiple falls. Resident Identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, surgical amputation, diabetes mellitus, hyperlipidemia, hypertension, coronary artery disease, and chronic pain syndrome. Resident 9's medical record was reviewed on 4/9/24. A review of Resident 9's care plan initiated on 2/20/24, showed that the resident is at risk for falls and has had an actual fall r/t [related to] gait/balance problems. Resident 9's care plan was revised on 3/6/24, with interventions to include a bed change to a bariatric bed. On 3/6/24 at 6:33 AM, a Nursing Note documented Resident had an unwitnessed fall. No injuries noted. Neuro [neurological] checks started. Resident was angry with staff for wanting to assist him back into bed. He swore at staff, swatted staff away and stated 'I'm tired. Leave me alone.' Staff encouraged resident to allow staff to help him. Resident allowed staff to assist him back into bed using hoyer lift. Call light within reach, bed in low position, door left open. DON [Director of Nursing] and MD [Medical Doctor] notified. On 3/6/24 at 3:19 PM, a Nursing Note documented Patient reviewed in IDT [interdisciplinary team] meeting r/t fall on 3/6 [24]. Staff walked by patients room and noticed they were not in their bed. Staff walked into room and found patient on the ground in between their bed and the wall with a pillow under their head. Nurse assessed patient. No injuries noted. Patient reports not knowing how they fell and states they just woke up on the floor. Staff attempted to get patient back into bed and at first patient refused and swatted staff away. Eventually patient agreed to be hoyer liftedback [sic] into bed. Bed was put in lowest position and call light within reach. This nurse talked to patient about their fall later in the day and patient still reported they did not know what happened. Patient reports having a bigger bed may help prevent it in the future. Intervention: Bed changed from regular size to bariatric. On 4/1/24 at 7:15 AM, a Nursing Note documented this LN [licensed nurse] called into resident room due to resident being found sitting on the floor on the side of his bed. no clutter, or wet on floor. non skid socks not applicable as resident has bilat [bilateral] amputation. call light in use. resident states he was sleeping and rolled out of bed. skin assessment shows no new injuries. neuros and vitals [vital signs] implemented per facility policy. Md and DON notified. On 4/5/24 at 9:36 AM, a Nursing Note documented Patient reviewed in IDT meeting r/t unwitnessed fall. Staff found patient sitting on the ground next to their bed. Patient reports they just rolled out of bed in their sleep. Nurse assessed patient. No injuries noted. VSS [vital signs stable] Neuros WNL [within normal limits]. Staff assisted patient back into bed. Provider notified. Patient own responsible party. Intervention: Pharmacist to review medications. On 4/6/24 at 10:11 PM, a Nursing Note documented . had an unwitnessed fall where he obtained a pin sized abrasion to his right elbow. Cleansed with wound cleanser - steri strips applied. No other injuries observed. Neuro checks started. Resident was assisted back into bed. Bed in low position. Call light within reach. PRN [as needed] pain medication administered. He is alert and oriented x4 [person, place, time and event] MD, DON notified. On 4/7/24 at 3:36 PM, a Nursing Note documented res [resident] had a recent fall, no latent injuries noted. continues to have pain in hip. PRN oxy [oxycodone] given with good effect. vitals and neuros WNL. On 4/7/24 at 11:09 PM, an Alert Note documented Continues on post fall charting. Res c/o [complaining of] Hip pain throughout shift. PRN oxycodone administered for pain with effective pain relief per resident. Res denies further concerns. Call light within reach. On 4/8/24 at 10:18 AM, a Nursing Note documented Pharmacist reviewed medications r/t falls. Recommended changing Prozac to Lexapro. In house provider reviewed recommendation and did not want to implement changes. States its [sic] too soon to contribute to medication side effects. On 4/8/24 at 12:54 PM, a Nursing Note documented Patient reviewed in IDT meeting r/t unwitnessed fall on 4/6 [24]. Patient reports he just rolled out of bed. Nurse assessed patient. Abrasion to R [right] elbow found. Nurse cleansed site and applied steri strips. Staff assisted patient back into bed. Patient given PRN pain meds [medications]. Provider notified. Patient own responsible party. Intervention: Fall matt placed next bed. On 4/8/24 at 10:26 AM, an interview was conducted with Resident 9. Resident 9 stated that he had recently fallen out of bed a couple of times and cut his right arm and hurt his left hip. Resident 9 stated that he refused to go to the hospital after the fall. Resident 9 stated that he requested a bigger bed because he believed that this was the reason that he kept falling or rolling out of bed. Resident 9 stated that he had not received a bigger bed. On 4/9/24 at 1:22 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that resident 9 did not have a bariatric bed. CNA 3 stated that resident 9 had a fall not too long ago and that a fall mat was placed on the floor next to the resident's bed. CNA 3 stated that if a resident was a fall risk, then the resident's bed was usually lowered closer to the floor. On 4/9/24 at 1:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was aware that resident 9 had a couple of falls in the past two weeks. LPN 1 stated that with the last fall resident 9 sustained a skin tear to his right arm and had left hip pain. LPN 1 stated that the pharmacist was going to review resident 9's medications for a possible reason for the falls. LPN 1 stated that she was unaware of any interventions in place for resident 9 prior to the fall on 4/6/24. LPN 1 stated that after the fall on 4/6/24, a floor mat was placed on the floor next to the resident's bed. On 4/9/24 at 1:35 PM, an interview was conducted with the DON. The DON stated that resident 9 did receive a bariatric bed after his fall on 3/6/24. The DON stated that there were several interventions put in place for the resident which included the bariatric bed, pharmacy review of medications, and a floor mat. The DON stated that she would have maintenance check to see if the resident had a bariatric bed. On 4/9/24 at 1:55 PM, an observation was made of the DON and a member of the maintenance staff in resident 9's room measuring the resident's bed. On 4/9/24 at 1:58 PM, an interview was conducted with the DON. The DON stated that resident 9 did not have a bariatric bed and that maintenance would be getting one for the resident. On 4/10/24 at 7:40 AM, an observation was made of resident 9's old bed being removed from the room by the DON and Administrator. Resident 9 was observed in a bariatric bed.

Based on interview and record, it was determined, the facility did not encode discharge Minimum Data Set (MDS) assessment data within 7 days after a facility completes a resident's assessment. Specifically, for 3 out of 31 sampled residents, discharge assessments were not completed and transmitted. Resident identifiers: 5, 11, and 14. Findings included: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 5's medical record was reviewed. Resident 5's face sheet was reviewed, and revealed that resident 5 was discharged from the facility on 5/28/22. Resident 5's discharge Minimum Data Set (MDS) assessment was reviewed, and it was revealed that the target date for the completion of the discharge MDS assessment was 5/28/22. The discharge MDS assessment was not completed, and the status was marked as In Progress. 2. Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 11's medical record was reviewed. Resident 11's face sheet was reviewed, and revealed that resident 11 was discharged from the facility on 5/3/22. Resident 11's discharge MDS assessment was reviewed, and it was revealed that the target date for the completion of the discharge MDS assessment was 5/3/22. The discharge MDS assessment was not completed, and the status was marked as In Progress. 3. Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 14's medical record was reviewed. Resident 14's face sheet was reviewed, and revealed that resident 14 was discharged on [DATE]. Resident 14's discharge MDS assessment was reviewed, and it was revealed that the target date for the completion of the discharge MDS assessment was 5/1/22. The discharge MDS assessment was not completed, and the status was marked as In Progress. On 6/27/22 at 10:40 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that it was her responsibility to complete the MDS assessments. The ADON described her process of completing the MDS assessments. The ADON stated that the computer system the facility used created a list of resident names to indicate that the residents were due for an updated MDS assessment. The ADON stated that department heads in the facility entered information as needed in the resident's MDS assessment, and the ADON was the person responsible for finalizing the MDS assessment. Once the MDS assessments were updated and complete, the ADON stated that staff members from corporate would export the completed MDS assessments. The ADON acknowledged that the resident discharge MDS assessments were not completed and submitted.

Based on interview and record review, it was determined, the facility did not conduct comprehensive assessments of residents in accordance with the timeframe's specified. Specifically, for 3 out of 31 sampled residents, comprehensive assessments of residents were not completed at least once every 12 months. Resident identifiers: 13, 90, and 91. Findings included: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 13's medical record was reviewed. Resident 13's annual Minimum Data Set (MDS) assessment was reviewed, and it was revealed that the target date for completion of the most recent annual MDS assessment was 4/7/22. The annual MDS assessment was not completed, and the status was marked as In Progress. 2. Resident 91 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 91's medical record was reviewed. Resident 91's annual MDS assessment was reviewed, and it was revealed that the target date for the completion of the most recent annual MDS assessment was 6/6/22. The annual MDS assessment was not completed, and the status was marked as In Progress. 3. Resident 90 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/21/22, resident 90's medical record was reviewed. Resident 90's annual MDS assessment was reviewed, and it was revealed that the target date for completion of the annual MDS assessment was 6/3/22. The annual MDS assessment was not completed, and the status was marked as In Progress. On 6/27/22 at 10:40 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that it was her responsibility to complete the MDS assessments. The ADON described her process of completing the MDS assessments. The ADON stated that the computer system the facility used created a list of resident names to indicate that the residents were due for an updated MDS assessment. The ADON stated that department heads in the facility entered information as needed in the resident's MDS assessment, and the ADON was the person responsible for finalizing the MDS assessment. Once the MDS assessments were updated and complete, the ADON stated that staff members from corporate would export the completed MDS assessments. The ADON acknowledged that the resident comprehensive MDS assessments were overdue.

Based on interview and record review, it was determined, the facility did not assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare & Medicaid Services not less frequently than once every 3 months. Specifically, for 13 out of 31 sampled residents, quarterly Minimum Data Set (MDS) assessments were not completed every 3 months. In addition, quarterly MDS assessments were not completed no later than 14 days after the assessment reference date (ARD). Resident identifiers: 1, 2, 3, 4, 6, 9, 13, 16, 26, 30, 89, 90, and 142. Findings included: 1. Resident 89 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 89's medical record was reviewed. Resident 89's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 5/25/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. Resident 89's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 3/7/22. The quarterly MDS assessment was completed, and the status was marked as Export Ready. 2. Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 9's medical record was reviewed. Resident 9's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 5/13/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. 3. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 6's medical record was reviewed. Resident 6's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 4/15/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. 4. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 4's medical record was reviewed. Resident 4's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 4/26/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. 5. Resident 26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 26's medical record was reviewed. Resident 26's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 5/13/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. 6. Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/27/22, resident 16's medical record was reviewed. Resident 16's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 11/24/21. The quarterly MDS assessment was completed by facility staff on 12/15/21. [Note: The quarterly MDS assessment was completed 21 days after the ARD.] Resident 16's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 2/24/22. The quarterly MDS assessment was completed by facility staff on 4/12/22. [Note: The quarterly MDS assessment was completed 47 days after the ARD.] Resident 16's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 5/26/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. 7. Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/22/22, resident 2's medical record was reviewed. Resident 2's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 3/30/22. The quarterly MDS assessment was completed by facility staff on 6/21/22. [Note: The quarterly MDS assessment was completed 83 days after the ARD.] 8. Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/22/22, resident 30's medical record was reviewed. Resident 30's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 5/24/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. 9. Resident 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 3's medical record was reviewed. Resident 3's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 4/2/22. The quarterly MDS assessment was completed by facility staff on 6/21/22. [Note: The quarterly MDS assessment was completed 80 days after the ARD.] 10. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 1's medical record was reviewed. Resident 1's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 3/19/22. The quarterly MDS assessment was completed by facility staff on 6/21/22. [Note: The quarterly MDS assessment was completed 94 days after the ARD.] 11. Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 13's medical record was reviewed. Resident 13's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for the completion of the quarterly MDS assessment was 2/14/22. The quarterly MDS assessment was completed by facility staff on 4/12/22. [Note: The quarterly MDS assessment was completed 57 days after the ARD.] 12. Resident 142 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 142's medical record was reviewed. Resident 142's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for the completion of the quarterly MDS assessment was 3/14/22. The quarterly MDS assessment was completed by facility staff on 6/17/22. [Note: The quarterly MDS assessment was completed 95 days after the ARD.] 13. Resident 90 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 90's medical record was reviewed. Resident 90's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for the completion of the quarterly MDS assessment was 3/5/22. The quarterly MDS assessment was completed by staff on 6/14/22. [Note: The quarterly MDS assessment was completed 101 days after the ARD.] On 6/27/22 at 10:40 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that it was her responsibility to complete the MDS assessments. The ADON described her process of completing the MDS assessments. The ADON stated that the computer system the facility used created a list of resident names to indicate that the residents were due for an updated MDS assessment. The ADON stated that department heads in the facility entered information as needed in the resident's MDS assessment, and the ADON was the person responsible for finalizing the MDS assessment. Once the MDS assessments were updated and complete, the ADON stated that staff members from corporate would export the completed MDS assessments. The ADON acknowledged that the resident quarterly MDS assessments were overdue.

Based on interview and record review, it was determined, the facility assessments did not accurately reflect the resident's status. Specifically, for 1 out of 31 sampled residents, a resident's discharge Minimum Data Set (MDS) assessment was coded incorrectly by indicating that a resident was discharged to a hospital when the resident was actually discharged home. Resident Identifier: 40. Findings Included: Resident 40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/22, resident 40's medical record was reviewed, and it was revealed that the discharge MDS assessment indicated that resident 40 had been discharged to an acute hospital. A progress note dated 4/16/22 at 9:13 AM, was reviewed. The progress note documented, Discharge Summary: Pt [Patient] admitted to facility on 4-12-22. Pt's stay was largely uneventful and pt is discharging to home today. On 6/23/22 at 10:40 AM, an interview with the Social Services Director (SSD) was conducted. The SSD stated that resident 40 was discharged to his home and did not go to the hospital. On 6/23/22 at 10:55 AM, an interview with the Director of Nursing (DON) was conducted. The DON confirmed that resident 40 was discharged to home on 4/16/22. On 6/27/22 at 10:40 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that it was her responsibility to complete the MDS assessments. The ADON described her process of completing the MDS assessments. The ADON stated that the computer system the facility used created a list of resident names to indicate that the residents were due for an updated MDS assessment. The ADON stated that department heads in the facility entered information as needed in the resident's MDS assessment, and the ADON was the person responsible for finalizing the MDS assessment. Once the MDS assessments were updated and complete, the ADON stated that staff members from corporate would export the completed MDS assessments. The ADON acknowledged that residents 40's MDS assessment was incorrectly coded as being discharged to a hospital and that the assessment should have reflected that resident 40 was discharged to home.

Based on interview and record review, it was determined, the facility did not comprehensively assess a resident within 14 days after determining, or should have determined, that there has been a significant change in the resident's physical or mental condition. Specifically, for 1 out of 31 sampled residents, a resident that was discharged from Hospice services did not have a significant change Minimum Data Set (MDS) assessment completed. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's medical record was reviewed on 6/22/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's significant change MDS assessment was reviewed, and it was revealed that the target date for completion for the significant change MDS assessment was 6/15/22. The significant change MDS assessment was not completed, and the status was marked as In Progress. On 6/27/22 at 10:40 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that it was her responsibility to complete the MDS assessments. The ADON described her process of completing the MDS assessments. The ADON stated that the computer system the facility used created a list of resident names to indicate that the residents were due for an updated MDS assessment. The ADON stated that department heads in the facility entered information as needed in the resident's MDS assessment, and the ADON was the person responsible for finalizing the MDS assessment. Once the MDS assessments were updated and complete, the ADON stated that staff members from corporate would export the completed MDS assessments. The ADON acknowledged that resident 2 had a significant change MDS assessment that was overdue.

Based on interview and record review, it was determined that for 1 of 24 sample residents, the facility did not ensure that residents' drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, a resident receiving anti-coagulation medication did not receive timely monitoring and was subsequently hospitalized . In addition, a resident who was supposed to receive a taper of medication did not receive this in a timely manner. Resident identifier: 88. This deficiency was cited at past non-compliance. The facility, upon determining that a lab had been missed and a resident was hospitalized , determined the cause of the missed lab. They put a Four Step action plan into place, including audits, staff education, identifying other potential residents at risk, a process change for lab orders, and follow up in Quality Assurance meetings. The compliance date for this deficiency is 12/4/19. Findings include: 1. Resident 88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 88's medical record was reviewed on 2/19/20. Resident 88's admission orders [REDACTED]. Resident 88's (MONTH) 2019 Medication Administration Record [REDACTED]. Resident 88's physician orders [REDACTED]. The orders also indicated that resident 88's PT/INR was to be rechecked on 11/23/19. Resident 88's (MONTH) 2019 MAR indicated [REDACTED]. Neither the MAR indicated [REDACTED]. Physician orders [REDACTED]. Progress notes dated 11/28/19 indicated . Verbal order received for stat (immediate) INR. RN (Registered Nurse) preformed (sic) INR by finger stick with a result of (greater than) 8.0 This finding was also reported to (name of physician) new order received for venous draw to verify INR result. No indication could be found in resident 88's medical record that the follow up INR was completed. Progress notes dated 11/29/19 indicated that Resident had some blood clot (sic) produced in his nose and then stated he coughed up some blood on a tissue about the size of a nickel coin. Progress notes dated 12/2/19 at 11:24 AM indicated that Lab draw (PT/INR) was drawn this morning and taken to (name of local hospital) lab. (Name of physician) is aware that it wasn't drawn on the 28th and it was drawn this morning. He has no new orders at this time. laboratory results dated [DATE] indicated that the PT/INR was collected on 12/2/19 at 12:30 PM. The results also indicated that the INR was 30.2 and that the reference range was 1.5 to 3.5. The lab results revealed Panic result called to (name of Director of Nursing) at (3:09 PM). Any INR (greater) than 5.0 is considered a CRITICAL value and will be called to the Doctor. Resident 88's INR was 30.2 according to the lab results sheet. Progress notes dated 12/2/19 a 3:28 PM indicated that the local hospital called and reported critical high for the recent lab that was drawn this morning. INR 30.2 PT 246.7 (Name of physician) was called and gave order to ship to the (name of local hospital). Progress notes dated 12/3/19 indicated that resident 88 had been admitted to the hospital and was on telemetry, taking vit (Vitamin) K. On 2/19/20 at 1:30 PM, an interview was conducted with the facility Administrator (ADM) and Director of Nursing) DON. The ADM stated that the Monday after the resident was hospitalized , the DON had identified the missed lab on 11/28/19. The MD stated that a 4 step action plan had been put into place as part of a Quality Assurance Process Improvement (QAPI) initiative by the facility. The ADM provided a copy of the facility investigation, including the QAPI. The investigation confirmed that resident 88's follow up INR had not been drawn on 11/23/19 or 11/28/19, and the resident was subsequently hospitalized .

Based on observation, interview and record review it was determined that the facility did not ensure that 1 of 27 sample residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. In addition, a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, a resident was admitted with limited range of motion to his right upper extremity and received therapy services with a splint which improved his range of motion. After the resident had discharged from therapy services there was no follow up treatment and subsequently he was unable to apply his splint/brace and the contracture became worse. These findings were found to have occurred at a harm level. Resident identifier: 24. Findings include: Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/22/19 at 8:20 AM, an observation was made of resident 24. Resident 24 was observed to have a splint on his right foot and lower leg. Resident 24 was observed to have his right hand and wrist turned in toward his forearm. On 1/22/19 at approximately 3:30 PM, an interview was conducted with resident 24. Resident 24 stated that he needed a new splint for his right wrist and hand. Resident 24 stated that he would like therapy for his right wrist and hand but he was not currently receiving therapy. Resident 24 stated that staff were not providing range of motion services or applying his splint to his right hand and wrist. Resident 24's medical record was reviewed on 1/23/19. A Minimum Data Set ((MDS) dated [DATE] revealed that resident 24 had impaired mobility to upper and lower extremities on one side. The MDS further revealed resident 24 had a brief interview of mental status score of 12 which revealed resident 24 had mild cognitive impairment. Resident 24's care plan dated 11/22/17 and revised on 5/29/18 revealed a Focus of, ADL (activities of daily living) and FALLS: . He has impaired function and weakness on his R (right) side both upper and lower extremities. One of the goals developed was, (Resident 24) will maintain current level of function through the review date. One of the interventions developed to achieve the goal was, NURSING REHAB/RESTORATIVE: Splint/Brace Program #1 (resident 24) needs assistance with his brace/splint for his R arm. Help him apply remove it daily as ordered. Assist him with regaining ROM (range of motion) and strength as needed. A review of resident 24's physicians orders revealed the following: a. On 11/21/17, AFO (ankle foot orthoses) Brace every day and evening shift for support Apply to Right lower extremity when up out of bed. b. On 11/29/18, OT (Occupational Therapy) Clarification: 11/28: Patient to participate in skilled OT 10 (times) in 3 weeks for contracture management and education for patient and staff on correct application of RUE (right upper extremity) brace and safety precautions to increase functional use of RUE during transfers and ADLs with there (therapy) ex (exercises), neuromuscular re-ed (re-education), manual therapy, and orthotic management. (Note: There were no physician's orders regarding a splint/brace or ROM services for resident 24's upper extremity prior to 11/29/18.) Resident 24's Occupational Therapy notes revealed the following: a. On 12/5/17, OT Treatment .Pt (patient) has new resting hand splint for RUE wearing it two hours on one hour off to build up endurance to wearing it all the time. Pt tolerated well. b. On 12/29/17, . Patient trained on bed to w/c (wheelchair) transfer, completed with 1 person Max (maximum) A+ (assist), recommend having 2 persons to assist with transfer to prevent injury to patient and staff. c. On 1/2/18, .Discussed purpose of LUE (Left Upper Extremity) splint, including increased functionality; however, within brief educational session patient did not demonstrate adequate comprehension. (Note: Resident's right upper extremity required a splint not the left.) d. On 1/4/18, . w/c transfers requiring Max A, which was an improvement from previous transfer training. e. On 1/5/18, . Patient resting hand splint was placed on right upper extremity. Patient reported decreased complaint of pain with resting hand splint. f. On 1/8/18, .Pt was instructed in wearing resting hand splint to decrease contracture. Pt had c/o (complaint of) pain so therapist adjusted splint after nursing had applied the splint. g. On 1/9/18, .Pt required max A to apply resting hand splint to RUE to help with contractions. Pt tolerated with c/o pain in RUE. h. On 1/22/18, .Pt was instructed in w/c mobility to increase activity tolerance and strengthen UE (upper extremity) to improve performance in transfers and self care tasks. i. On 1/23/18, .Patient reported being willing to wear resting hand splint on right upper extremity. Patient was educated on the importance of continuous use of resting hand splint to improve the effectiveness of rest hand splint. Patient agreed to wear resting hand splint one hour on and one hour off until Monday (MONTH) 29. The week of (MONTH) 29 patient will increase wearing time to two hours on and one hour off. Therapist massage and stretched wrist and hand in preparation for placement of resting hand splint to decrease amount of pain when rest hand splint was placed. Pt tolerated well with little complaint. j. On 1/30/18, . Reassessed patient's RUE splint, more aggressive adjustments were made for MP (metacarpophalangeal) and PIP (proximal interphalangeal) joint flexion to reduce pain and increase compliance with wearing schedule. Brace reapplied 3 times with adjustments made to prevent pressure points and skin breakdown. Patient reported that, post-adjustment, his brace was comfortable enough to wear all night. k. On 1/31/18, .Patient reported that he was able to wear RUE brace all night due to decreased pain after yesterday's adjustments. l. On 2/5/18, .PROM (passive range of motion) stretches with right elbow, wrist, and digits completed and RUE brace applied to decrease flexor tone in order to improve functional use of RUE and prevent further contractures/musculoskeletal deformity. m. On 2/6/18, .Patient continues to report decreased pain and increased wearing duration following adjustments to brace. A form titled OT- Therapist Progress & Discharge Summary dated 2/14/18 revealed that, Patient has made significant functional gains throughout the course of occupational therapy. However, progress toward goals plateaued and patient discharged from therapy at this time. The form further revealed that resident 24, tolerates right resting hand splint for 90 minutes. (Note: There were no physician's orders or nursing progress notes that documented resident 24 was receiving treatments and application of his splint for right upper extremity from (MONTH) (YEAR) until (MONTH) (YEAR).) Resident 24 was re-evaluated for Occupational therapy on 11/28/18 and the following treatments were documented: a. On 11/29/18, . Manual therapy/PROM provided to RUE to improve tissue mobility and decrease pain in order for patient to improve ability to donn (sic) and wear wrist splint in order to increase safety and independence with transfers and self-care tasks. b. On 11/30/18, . Deviation and/or deformities at dominant RUE severely impacting functional performance of ADLs and transfers. PROM completed with right wrist and digits to elongate wrist and digit flexors to prepare for donning splint. Splint donned with difficulty, improvements in wrist mobility from previous OT sessions has been lost and patient is fully contracted again. c. On 12/5/18, .Manual therapy provided to right wrist and hand to improve tissue mobility and decrease pain in order for patient to improve ability to donn (sic) and wear wrist splint in order to increase safety with transfers. Moist heat was applied and extended PROM to right wrist and digits. Unable to donn (sic) splint without pain today and splint was not applied; digits are medially deviated and thumb is adducted too far for current splint to be effective and pain-free. Recommend fabrication of new resting hand splint to better fit the patient's current musculoskeletal condition. Discontinuing attempts to manipulate right hand into current splint to avoid soft tissue damage and pain. d. On 12/11/18, .Manual therapy provided to R shoulder, elbow, wrist and hand working from proximal to distal to improve tissue mobility and decrease pain in order for patient to decrease muscle tone and increase flexibility. Splint was not applied. Talked to OTR (Registered Occupational Therapist) and OTR has determined muscle tone is to (sic) high for splint. e. On 12/13/18, .Manual therapy provided to R shoulder, R wrist, and R hand, working from proximal to distal to improve tissue mobility, contracture mgt (management), and decrease pain in order for patient to decrease muscle tone and increase flexibility. Splint was not applied due (sic) improper fit. A form titled OT - Therapist Progress & Discharge Summary dated 12/18/18 revealed the Start of the Goal status as of 11/28/18 was The patient tolerates R UE resting hand splint for 60 minutes. The form further revealed, GOAL NOT MET. as of 12/18/18. The Explanation: Increased ulnar deviation of digits and thumb [DIAGNOSES REDACTED] prevented proper application of right resting hand splint. Staff training never attempted due to lack of progress. A nursing progress note revealed on 1/19/19 at 1:49 PM, . He received a score of 12/15 on his most recent cognitive assessment. (Resident 24) continues to require assistance with all of his ADL cares. On 1/23/19 at 1:32 PM, a follow up interview was conducted with resident 24. Resident 24 stated that he had not worn his RUE brace for 3 months because his brace was too small and he needed to get a new one. Resident 24 stated he wanted to wear the splint and do therapy because he wanted to be able to use his hand again. On 1/23/19 at 1:43 PM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that resident 24 had been receiving occupational therapy services in the past. The DOR stated that resident 24 had a rigid wrist splint when he was admitted to the facility and the splint was not comfortable. The DOR stated that he wore the splint about an hour per day and resident 24 had been refusing to wear the splint. The DOR stated that resident 24 had been refusing the splint for at least a month. The DOR stated that he called resident 24's daughter a couple of weeks ago regarding having another splint made. The DOR reported that resident 24's daughter stated she would find out where previous splint was made. The DOR stated that resident 24's contracture was about the same as when he was admitted and the contracture improved with therapy but had since regressed. On 1/23/19 at 3:00 PM, an interview was conducted with the Minimum Data Set (MDS) coordinator. The MDS coordinator stated that she had been managing the Restorative Nursing Assistant (RNA) program. The MDS coordinator stated that there was a weekly meeting with the DOR, Business Office Manager, MDS coordinator, Assistant Director of Nursing, and Director of Nursing. The MDS coordinator stated that residents with increased falls, increased ADL assistance, and residents who were experiencing a decline, were discussed in the meeting. The MDS coordinator stated that the RNA program was complex and there were specific parameters for the program. The MDS coordinator stated that there was not currently an RNA program at the facility. The MDS coordinator stated that resident 24 was discussed in the meeting and had recently restarted therapy for contractures and bed mobility. The MDS coordinator stated that resident 24 was not receiving RNA services since being discharged from therapy services in (MONTH) (YEAR). On 1/23/19 at 4:50 PM, an interview was conducted with Certified Occupational Therapy Assistant (COTA) 1. COTA 1 stated that measurements for contractures were documented on the original evaluation. COTA 1 stated that if the measurements were not documented then measurements were not completed. COTA 1 stated that OT 1 instructed her about a month ago not to use the splint for resident 24 because it did not fit. On 1/23/19 at 1:40 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she provided care to resident 24. CNA 2 stated that she helped resident 24 stretch his arm and elbow when resident 24 used the sit-to-stand lift. CNA 2 stated that she stretched his elbow out straight but that she did not move his hand or wrist. On 1/24/19 at 8:04 AM, an interview was conducted with CNA 3. CNA 3 stated that she had worked at the facility for a couple of months. CNA 3 stated that she thought there might be an RNA program but she was not sure. CNA 3 stated she never stretched resident 24's hand or provided range of motion exercises for his hand or wrist. On 1/24/19 at 8:07 AM, an interview was conducted with CNA 4. CNA 4 stated that she worked with resident 24 sometimes. CNA 4 stated that she had stretched out resident 24's arm when he was on the sit-to-stand lift. CNA 4 stated that she stretched his elbow only and did not do anything with his hand or wrist. CNA 4 stated that the facility did not have an RNA program since they had lost a lot of staff lately. On 1/24/19 at 10:29 AM, another follow up interview was conducted with resident 24. Resident 24 stated that his hand did not generally hurt but it felt better when staff were stretching it and putting the splint on. Resident 24 stated that he liked when staff worked with his hand, but staff had not worked with his hand since (YEAR). Resident 24 stated that CNAs did not perform range of motion or any other exercises for his hand and wrist. Resident 24 stated that he did not refuse to wear the splint after he was discharged from therapy. Resident 24 stated that staff did not teach him how to use the splint nor did staff apply the splint for him. On 1/24/19 at 10:06 AM, an interview was conducted with Occupational Therapist (OT) 1. OT 1 stated that resident 24 had a contracture upon admission to the facility. OT 1 stated that he worked with resident 24 after admission and readmitted him to therapy services again recently. OT 1 stated that the first time he received therapy, the therapy staff worked with general ADLs and transfers. OT 1 stated that he worked with resident 24's right arm and he had a splint that resident 24 brought from somewhere else. OT 1 stated that he was trying to increase resident 24's tolerance to the splint and originally the splint fit after stretches were performed on his hand and wrist. OT 1 stated that resident 24's splint was made of hard material and his hand and wrist fit in the straight splint with some manipulation during the original therapy services. OT 1 stated that the second time he evaluated resident 24 (November of (YEAR)) he focused on opening the hand. OT 1 stated that resident 24's hand/wrist had curled and the resident was unable to bear weight on his hand/wrist for transfers. OT 1 stated that resident 24 was able to bear weight on his hand when he was discharged from therapy in (MONTH) (YEAR). OT 1 stated that resident 24 was able to use his right hand and wrist a lot more using active motion than he could now. OT 1 stated that resident 24 could do more weight bearing exercises and was able to tolerate the splint for a couple of hours in (MONTH) (YEAR). OT 1 stated that resident 24's tolerance for the splint was low when he evaluated resident 24 in (MONTH) of (YEAR). OT 1 stated that resident 24 was more contracted and his fingers were turned in further so it took some doing to stretch out the resident's hand and wrist to put the splint on. OT 1 stated that he stopped trying to apply the splint because he did not want to cause soft tissue damage to resident 24. OT 1 stated that he was causing resident 24 pain when trying to stretch out the resident's hand and wrist to fit into the splint. OT 1 stated that he told the COTA to not use resident 24's splint because it did not fit. OT 1 stated that he thought he recommended RNA services when resident discharged from therapy in Februrary (YEAR). OT 1 stated that resident 24 required ROM exercises and the splint to be worn to prevent the contracture from becoming worse. OT 1 stated that he expected therapy to be effective with a better splint because the first therapy was effective in decreasing the contracture. OT 1 stated that resident 24 refused his splint at times but stated there were no other interventions or equipment offered. On 1/24/19 at 1:00 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that resident 24 was admitted with a contracture, and the resident's family took resident 24 to an appointment to get a splint and upon return to the facility there were no directions provided. The CRN stated that staff did not know where the splint was obtained from. The CRN stated that resident 24 was directed in applying his own splint from (MONTH) (YEAR) until (MONTH) (YEAR). The CRN stated that she did not know if the contracture had gotten worse. The CRN stated that after starting OT in (MONTH) (YEAR) the OT thought he needed a new splint so calls were made to the family to find out where the resident had received the splint. The CRN stated that resident 24's family had called back and there had been an appointment scheduled for 2/1/19. The CRN stated that she was now looking into an appropriate type of program for CNAs to manage contractures. The CRN stated that she did not know about the RNA program at the facility.

Based on interview and record review, it was determined that for 1 of 25 sample residents, the facility did not ensure that a resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, a resident who experienced a change of condition and who later expired, did not receive the necessary care and monitoring. Resident identifier: 48. Findings include: Resident 48 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE], resident 48's medical record was reviewed and revealed a Physician's Note dated [DATE]. The note documented that resident 48's lungs were clear and made no mention that resident 48 had lung problems. A Monthly assessment dated [DATE] documented that resident 48's oxygen saturations were 98% (percent) on room air and that her respiratory system was within normal limits. A physician's orders [REDACTED]. (Note: a Full Code indicates that the resident and/or resident's family desired the resident to be resuscitated if found without a pulse or breathing. Conversely, a No code or DNR (do not resuscitate) indicates that the resident and/or resident's family wish for no resuscitation in such a case.) A Nursing Note dated [DATE], documented that resident 48 had complained of nausea and vomiting during the day shift on [DATE]. The note documented that resident 48 complained of breathlessness before dinner time on [DATE]. The note documented that Licensed Practical Nurse (LPN) 1 had given resident 48 a nebulizer treatment with the medication [MEDICATION NAME]. The note documented that the resident verbalized relief after the treatment. The note also documented that the resident again became short of breath at approximately 10:15 PM and received an additional nebulizer treatment. The facility nurse documented that at approximately 11:25 PM, resident 48 verbalized relief. The note further documented that resident 48 was found at 12:05 AM on [DATE] to be cold and without a pulse or respirations. (Note: There was no documentation that the physician was notified of this change of condition or need for new medication. Additionally, there was no documentation that resident 48's vital signs were taken or that her lungs were assessed for abnormality.) LPN 1 further documented that upon being notified of resident 48 being found without a pulse, resident 48's family member had requested that resident 48 be taken to the hospital. The note stated that emergency medical service (EMS) staff arrived, analyzed resident 48's heart rhythm with an EKG (electrocardiogram), and pronounced resident 48 as deceased . (Note: no nurse's assessment or vital signs were documented in the medical record for this time period.) A Nursing Note dated [DATE], documented that LPN 1 was interviewed by the facility management. The note documented that LPN 1 stated the physician was not notified that resident 48 was short of breath or that she had administered the [MEDICATION NAME] breathing treatments. On [DATE] at 12:22 PM, the Director of Nursing (DON) was interviewed. The DON stated that resident 48's vital signs were taken on [DATE] at approximately 6:00 PM and were normal, according to her interview with LPN 1, whom had written them on her shift worksheet (Note: No such documentation of vital signs could be found in the medical record.) The DON stated that LPN 1 did not initiate CPR (cardiopulmonary resuscitation) because LPN 1, knew that she (resident 48) was gone. The DON stated that LPN 1 had called resident 48's family as well as several members of the facility management for guidance before emergency medical services were activated. The DON stated that EMS was called at approximately 12:20 AM. (Note: This was 15 minutes after resident 48 was found without a pulse.) The DON stated that the physician was later contacted after resident 48 had expired. On [DATE] at 1:24 PM, an attempt was made to contact LPN 1 via telephone. LPN 1 did not return survey staff's phone calls. On [DATE] at 1:55 PM, Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated that she had seen resident 48 right before her shift started at 10:00 PM on [DATE] and resident 48 had stated she was nauseous. CNA 1 stated she went to resident 48's room to test her oxygen saturations and found her at 12:05 AM on [DATE] with cold hands, sunken cheeks, and a yellow hue to her skin. CNA 1 stated that she alerted LPN 1 immediately, who checked for a pulse and commented that she was going to phone resident 48's family. CNA 1 stated that LPN 1 told resident 48's sister that sending her to the hospital wouldn't help and that the sister replied, Just do it. CNA 1 stated that LPN 1 told her and another CNA to get the backboard and LPN 1 called 911. CNA 1 stated that the EMS team arrived before the facility staff could commence CPR on resident 48. The facility administrator provided survey staff with a document entitled NURSES INSERVICE which was dated [DATE]. It read, CODE STATUS: Where do you find the code status in the resident chart? . Another document dated [DATE] entitled, NURSES INSERVICES read, The POLST (physician's orders [REDACTED]. On [DATE] at 2:04 PM, the DON and Administrator (ADM) were re-interviewed. The DON stated that the policy on residents who were a full code had always been to start CPR and continue until EMS arrived and took over. The ADM stated that the policy also documented that CPR was prohibited if there were,obvious signs of loss of life. The ADM provided a policy that documented, Emergency Procedure- Cardiopulmonary Resuscitation .Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [MEDICAL CONDITION] 5. Early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase changes of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: 7. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or 8. There are obvious signs of irreversible death (e.g., rigor mortis) . (Note: LPN 1 did not document that resident 48 had rigor mortis upon discovery at 12:05 AM.) On [DATE] at 2:33 PM, an observation was made of the facility crash cart. There was an automated external defibrillator (AED) located above the crash cart which was stocked with defibrillator pads. (Note: BLS certification teaches that an AED analyzes heart rhythms and delivers a shock of defibrillation if needed.) A follow up interview was conducted with the DON and ADM at 2:39 PM. The DON and ADM stated that the facility's AED was available for use on [DATE] and [DATE]. The DON stated that LPN 1 had not mentioned utilizing the AED during her interview. (Cross refer to F157)

Based on 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 for 2 of 32 sample residents. Specifically, (1) A resident had a significant change in condition with no cardiopulmonary resuscitation initiated and (2) A resident had documented pain after a suspected ankle fracture with no interventions for days, after an order was received to increase the resident's pain medications. Resident identifiers: 4 and 83. Findings include: 1. Resident 83 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:20 PM, a resident family member was interviewed. The family member stated that about a week ago a resident fell down in the bathroom between resident rooms [ROOM NUMBERS]. The family member stated that she pressed both call lights, including the one in room [ROOM NUMBER] and the one in the bathroom. The family member stated that she decided to go and get help as nobody responded to the call lights for about 5 minutes. The family member stated that she told a Certified Nursing Assistant (CNA) in the hallway that somebody had fallen in the bathroom. The family member stated that the CNA was texting on her phone at the time. The family member stated that she had to go out into the hallway a second time to ask for help, as nobody responded after pulling the call lights and telling a CNA that someone had fallen down in the bathroom. The family member stated that after going into the hallway to ask for help two separate times nursing staff arrived to help the resident who had fallen down in the bathroom. On [DATE] resident 83's medical record was reviewed. A nursing note dated [DATE] at 10:14 PM revealed the following: "Resident was found in bathroom by room [ROOM NUMBER]'s daughter this nurse was notified and went into bathroom with CNA. Resident was lying on the bathroom floor. Resident was assessed. This nurse and CNA applied a gait belt and got resident up and sitting on the toilet. Resident was very weak. We got resident into bed and he started complaining of SOB (shortness of breath). We raised the HOB (head of bed) and were getting a set of vital signs. Resident was cold to the touch and his skin was very clammy. Resident was very pale. No respirations or heart rate noted at 2130 (9:30 PM). Family and doctor both notified." (sic) A nursing note dated [DATE] at 3:09 AM revealed the following: "Resident has passed. His family visited and he was released to (the mortuary) in North Ogden. Doctor and management staff were notified." A Physician Telephone Order dated [DATE] revealed that resident 83's body was released to the mortuary on [DATE] at 12:48 AM. A nursing note dated [DATE] at 5:06 PM revealed the following: "L.E. (Late Entry) for [DATE]. Res. (resident) found laying on his back on bathroom floor with head up against the northern door of bathroom. Had brief still up, but pants pulled halfway down @ 2110 (9:10 PM). Res. had locked himself in the bathroom from his side. Went into adjoining room that shares a bathroom and able to get to him from there. Asked what happened and stated, 'Was coming into the bathroom and fell .' Had four wheeled walker in the bathroom with him which was still standing upright. Assessed ROM (range of motion) to all extremities and could MAE (move all extremities). Had full ROM and no pain in them. Asked if he hit his head and stated yes. Examined head and no bruising, bumps or bleeding present. No changes in LOC (level of consciousness) noted, able to answer questions appropriately. Eyes PERRLA (pupils equal, round, and reactive to light and accommodation). Grips equal bilat (bilaterally) and able to move legs with equal strength. Denied any pain when asked. 'I just want to get up.' Assisted to the toilet by nurse and CNA. Assisted w/ (with) changing pull-up, given pericare and brought w/c (wheelchair) in to Res. Noted weakness upon transfer to the toilet and kept stating tired and wanted to get into bed. Noticed some facial drooping to R (right) side of face while on toilet. Assisted w/ extensive assist of two, CNA and nurse, into bed. CNA attempted VS (vital signs) once in bed and unable to get BP (blood pressure). Nurse tried to get BP and continue with Neuro checks. Nurse in with Res. and called to this writer about unreadable BP and some chest pain. Checked for Advanced Directives/Living Will. Living Will stated DNR (Do Not Resuscitate). No Nitro (([MEDICATION NAME]) orders noted in chart. Called family to alert of situation. Granddaughter was primary contact did not call back after left message to please call facility. Called MD (Medical Doctor) listed and left page to call back for orders and if he had a h/o (history of) chest pain. Tried another granddaughter on list and left message for her to please call facility. No return call. Nurse communicated no resp (respirations)/no pulse, and MD called back at that point. Informed him Living Will stated DNR and MD called time of death 2130 (9:30 PM) r/t (related to) [MEDICAL CONDITION] Family stated, 'He just wanted to be with grandma who passed away two weeks ago.' Had (mortuary company) picked out, but granddaughter had to drive to alert Res's son and stated they might be in prior to mortuary coming." (sic) On [DATE] at 10:56 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that a resident's daughter came out and told nursing staff that someone had fallen. RN 2 stated that CNA 1 and RN 3 went in there to try and take care of everything while RN 2 was assisting another resident. On [DATE] at 12:25 PM, RN 3 was interviewed. RN 3 stated that a resident's daughter alerted facility staff that resident 83 had fallen in the bathroom. RN 3 stated that the door through resident 83's room was locked and the staff had to use the room next door to enter the bathroom. RN 3 stated that resident 83 was on the floor with his head to the north door. RN 3 stated that resident 83's pants were half-way down and that resident 83 was trying to get to the bathroom independently. RN 3 stated that resident 83 was assessed and there were no problems with range of motion or grips. RN 3 stated that the resident wanted to go back to bed. RN 3 stated that CNA 1 and RN 4 came in to get resident 83 back into bed. RN 3 stated that she then went to help another resident. RN 3 stated that she left the room at the point resident 83 was taken to bed. RN 3 stated that CNA 1 and RN 4 then called her on the radio and said they were unable to get a blood pressure on resident 83. RN 3 stated that they also reported over the radio that resident 83 was having chest pain at that point. RN 3 stated that she then checked orders for [MEDICATION NAME] and there were no orders. RN 3 stated that the physician was then called to obtain orders for [MEDICATION NAME]. RN 3 stated that it was communicated over the radio that resident 83's pulse was getting weaker. RN 3 stated that she checked resident 83's living will and it revealed that resident 83 did not want to be resuscitated. RN 3 stated that resident 83 passed away at about 9:30 PM. On [DATE] at 12:45 PM, CNA 1 was interviewed. CNA 1 stated that she helped RN 3 get resident 83 back onto the toilet from the bathroom floor. CNA 1 stated that resident 83 felt really clammy to her and she was not sure if the nurses had noticed it at that time. CNA 1 stated that the nursing staff then transferred the resident to bed. CNA 1 stated that resident 83 was gray, pale and had chest pain at the point of being transferred to bed. CNA 1 stated that the nurses were then checking to see if resident 83 had a history of [REDACTED]. CNA 1 stated that the RN 2 and RN 3 told her that the resident was a "DNR (Do Not Resuscitate)" and that she should not give CPR (Cardio [MEDICAL CONDITION] Resuscitation). On [DATE] resident 83's living will was reviewed. The living will for resident 83 revealed the following: "...2. I declare that if at any time I should have an injury, disease or illness which is certified in writing to be a terminal condition by two physicians who have personally examined me, and in the opinion of those physicians the application of life-sustaining procedures would serve only to unnaturally postpone or prolong the dying process, I direct that these procedures be withheld or withdrawn and my death be permitted to occur naturally." On [DATE] at 4:10 PM, the facility Physician was interviewed. The Physician stated that he was told that resident 83 was admitted to the facility and then died the next day. The Physician stated that he had not yet seen resident 83. When asked if resident 83 had any terminal diagnoses, the Physician stated that resident 83 just died suddenly. The Physician stated that resident 83's would indicate a [MEDICAL CONDITION]. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on [DATE]. On [DATE], the facility staff completed an annual Minimum Data Set (MDS) Assessment for resident 4. The facility staff assessed resident 4 having scheduled pain medications daily. Resident 4's pain assessment documented that resident 4 was nonverbal, vocalized pain, and had facial expressions and protective body movements which indicated that resident 4 was in pain daily. On [DATE], a "Generalized Pain" care plan was developed by the facility staff. The facility staff documented "(Resident 4) exhibited s/sx (signs or symptoms) of pain, crying out, repetitive vocalizations, grimacing." The goals that were developed included: (1) "(Resident 4) will have no unrepeated adverse side-effects r/t (related to) his/her pain management regimen. Through next review" and (2) "(Resident 4) will accept Hospice interventions and will be as pain free as possible each day through next review." The approaches that were developed to achieve those goals included: "(1) Observed for verbal and non-verbal s/sx of pain. Watch for grimacing, groaning, guarding, increased expression of anger, agitation, tearfulness, withdrawal, etc (et cetera); (2) Administer pain medications as ordered. Give prior to treatments, therapies or other activities identified to cause resident pain, as possible; (3) Ensure proper body alignment and position for comfort, as possible; (4) Provide calm, quiet environment for periods of increased pain; (5) Involve in activities that may divert attention from pain, such as music, reading and social interaction, as tolerated by resident; (6) Encourage resident to notify staff of pain; and (7) Reposition for for (sic) comfort of LLE (left lower extremity)." The [DATE] "physician's orders [REDACTED]. a. [MEDICATION NAME] 150 mcg (micrograms) patch that was to be changed every 2 days; b. [MEDICATION NAME] 10 mg (milligrams) three times a day; c. [MEDICATION NAME] 20 mg/ml (milligrams per milliliter) 0.5 ml - 2 ml every 2 hours as needed for pain; and d. [MEDICATION NAME] 10 mg every 8 hours as needed for muscle spasms/rigidity. Review of the "Physician's Telephone Orders" revealed an order written [REDACTED]." The electronic "Departmental Notes" were reviewed. The facility licensed nursing staff documented the following entries: 1. [DATE] at 10:19 AM: "CARE MEETING: (yearly) Behavior: Resident yells out at times while in the w/c (wheelchair). She appears to be more comfortable in bed resting. ...She is unable to make her needs known. ...Pain: She has a [MEDICATION NAME] 150 mcg that is changed q (every) 2 days, [MEDICATION NAME] 10 mg (10 mg) TID (three times a day) and also q 8 hours prn (as needed), [MEDICATION NAME] HCL 20 mg/ml 0.5 ml - 2 ml q 2 hours prn..." 2. [DATE] at 11:12 AM: "Unable to conduct resident interview d/t nonverbal responses. Interviewed, RN, LPN, and CNA regarding Cognitive status and pain. ...When asked staff about pain, staff stated she has daily nonverbal s/sx of pain, facial expressions, body movments (sic) that may be r/t pain during cares. Staff all state her body movements of hitting and nonverbal s/sx are heightened when a newer staff member is working with Res. (resident)." 3. [DATE] at 10:53 AM: "Monthly Summary: ...(Resident 4) has generalized pain and is administered [MEDICATION NAME] 150 mcg which is changed every 2 days. (Resident 4) also has [MEDICATION NAME] HCl 20 mg/Ml Sol 0.5 ml-2 ml PO (by mouth) q 2 h PRN..." 4. [DATE] at 8:15 AM: "CNA reported to floor nurse that resident's left ankle looks like something is wrong. The floor nurse came and got the DON (Director of Nursing) who then went down and assessed and found the left ankle to to (sic) swollen, red and hot. She instructed the floor nurse to contact hospice. Hospice nurse (name removed) came in and assessed and said there isn't much we can do with her ankle she isn't a candidate for surgery. She said she would call her daughter and let her know what it looks like. Talking with the staff they said that the hospice cna was in [DATE] and showered this resident and did report that the ankle looked different to the floor nurse this day (name removed). Our staff has reported that this CNA (name removed) transfers her by herself. Facility staff has been instructed that this resident is a two person transfer d/t (due to) her being so fragile. This hospice CNA has stated that she is tall and she is able to transfer this resident by herself. She has been talked with in the past about how the facility feels about that and that she needs to get help when she is here so that the resident is safe at all times. Hospice nurse left orders to ace wrap and apply ice pack as long as resident can tolerate it. Her daughter was called and she just stressed to all involved to please be more careful with her mother. Social services did call (the hospice company) and informed them about the incident and they said they would talk with their cna." 5. [DATE] at 2:28 PM: "Resident has ace bandage wrapped on left ankle for support. Resident continues to be in pain, tearful, r/t left ankle. [MEDICATION NAME] administered at 0900 (9:00 AM). this was effective. Pillows for positioning to left leg and ankle. Late Entry for [DATE]: Resident left ankle is wrapped with an ace bandage. Left foot and leg is red and warm to the touch. Resident cries out when leg and ankle is touched. Hospice CNA was informed not to shower resident today, but to provide her a bed bath and to leave her in bed d/t resident's pain level. Resident was administered [MEDICATION NAME] 1 ml at 1215 (12:15 PM) yesterday which seemed to help somewhat." 6. [DATE] at 7:28 PM: "Late entry [DATE] Resident was a two person extensive assist using draw (a draw sheet) with transfers. Resident was assisted with AM cares and propelled by staff to main dining room. Resident was observed in main dining room grunting and crying out loudly. This nurse administered PRN [MEDICATION NAME] 1 mL in hot chocolate. Resident consumed 100% of hot chocolate. She was assisted to her room and into bed. Resident was 1 person extensive assist with shower per (hospice aide). Skin check revealed that resident continued with some redness to sacral coccyx region and a new [MEDICATION NAME] dressing was applied as ordered. No other observations were made at that time. (Hospice) aide did report this nurse that resident was protecting her left side, but no observations of swelling, redness or areas of heat were observed and it was explained to hospice aide that resident was administered PRN [MEDICATION NAME] for increased calling out and crying. Resident attended lunch in the main dining room and then was propelled back to room and assisted to bed. No further grunting or call out was observed throughout the shift." (Note: The entry for the incident that occurred on [DATE] was not documented in the medical record until [DATE], after the survey began.) 7. [DATE] at 1:23 PM: "Resident continues with increased exhibitions of pain r/t left ankle. Affected area continues to be swollen and bruised, bruising has turned green/purple in color. Swelling has decreased since last week. Resident gaurds (sic) the extremity when staff is assisting with cares. Resident was showered by her hospice aide prior to lunch. This nurse assisted with transfers to and from shower bed using draw sheet and two person total assist. Resident showed increased agitation and exhibitions of pain. 1 ml of [MEDICATION NAME] administered at this time. [MEDICATION NAME] administration was effective. Hospice contacted about the possibility of getting a (sic) air splint or other spiliting (sic) device for left ankel (sic) to further protect it. Ace wrap reapplied and is intact at this time. WCTM (Will Continue To Monitor)." 8. [DATE] at 12:32 PM: "LATE ENTRY FOR [DATE]: Hospice nurse in today to assess resident. She felt that resident was exhibiting signs of increased pain and said that she would go back and ask MD (medical doctor) for an increase in the fenynal (sic) patch. It was also discussed that her daughter might benefit from the clergy/SS (social services) talking with her. Hospice nurse called back and said that the increase on the patch will not happen yet: her daughter feels that it isn't needed. Staff will continue to assess resident for s/s of increase pain." (Note: On [DATE], a new order was received to increase resident 4's [MEDICATION NAME] to 175 mcg. The order to increase the [MEDICATION NAME] was not initiated until [DATE], two days after it was received.) On [DATE], the facility DON completed a "Resident Incident Report." The DON documented "CNA was getting resident up for the day and noticed that the left ankle was swollen, red and warm to the touch. Left ankle swollen, red and warm." The DON further documented "Additional Follow-ups: [DATE] Resident was in w/c at nurses station and her ankle looked as if it could be fx (fractured). Hospice was called and they came in and assessed also and gave orders." The [DATE] and [DATE] electronic medication administration records were reviewed. The licensed nursing staff documented the following: a. [DATE] - [DATE]: The pain Score (using the Wong Baker Faces Pain Scale) at 6:00 AM and 6:00 PM was rated by the staff to be between ,[DATE]: i. The licensed nursing staff documented one pain score at a 4 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 4 was defined at "Hurts little more (moderate))." ii. The licensed nursing staff documented five pain scores at a 3 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 2 was defined as between, "Hurts little bit (mild pain) and "Hurts little more (moderate))." iii. The licensed nursing staff documented eight pain scores at a 2 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 2 was defined as "Hurts little bit (mild pain)). iv. The nursing staff documented nine pain scores at a 1 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 1 was defined as between, "No Hurt (No pain)" and "Hurts Little Bit (Mild Pain))." v. The nursing staff documented 30 pain scores at a 0 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 0 was defined as "No Hurt (No pain)." b. [DATE] through [DATE]: i. The nursing staff documented one pain score of 10 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 10 was defined as, "Hurts worst (Worst))." ii. The nursing staff documented six pain scores of 8 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 8 was defined as, "Hurts Whole Lot (Excruciating))." iii. The nursing staff documented five pain scores of 5 (According to the Wong-Baker FACES Pain Rating Scale, a pain rating of 5 was defined as being between, "Hurts Little More (Moderate)" and "Hurts Even More (Severe))." iv. The nursing staff documented administering [MEDICATION NAME] HCL 20 mg/ml 0.5 ml/2 ml every 2 hrs between [DATE] and [DATE] on:: a. [DATE] - two doses were administered. The licensed nursing staff did not document whether the [MEDICATION NAME] was effective or ineffective. b. [DATE] - two doses were administered. The licensed nursing staff did not document whether the [MEDICATION NAME] was effective or ineffective. c. [DATE] - one dose was administered. The licensed nursing staff did not document whether the [MEDICATION NAME] was effective or ineffective. d. [DATE] - one dose was administered. The licensed nursing staff did not document whether the [MEDICATION NAME] was effective or ineffective. e. [DATE] - one dose was administered. The licensed nursing staff did not document whether the [MEDICATION NAME] was effective or ineffective. (Note: Resident 4 did not receive [MEDICATION NAME] HCL prior to [DATE].) On [DATE] at approximately 3:00 PM, the facility DON was interviewed. The DON was unable to provide additional information as to why the order to increase the [MEDICATION NAME] Patch was not initiated until [DATE]. On [DATE] at approximately 9:30 AM, the facility Corporate Nurse Consultant (CNC) was interviewed. CNC stated that resident 4's hospice company had reported to the facility on [DATE], that resident 4's family did not think that resident 4 needed the [MEDICATION NAME] Patch increased. CNC stated that on [DATE], the hospice company reported to the facility that resident 4's family agreed to the increase in the [MEDICATION NAME] Patch, but that the patch was not increased until [DATE], despite the assessed pain levels above.