Every finding on record at Monument Healthcare Canyon Rim

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 28 sampled residents, the facility failed to implement new interventions after every fall. This resulted in a finding of harm for resident 72. Resident identifiers: 6 and 72.Findings included:HARM1. Resident 72 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, generalized weakness, weakness, fracture of mandible, other abnormalities of gait and mobility, other lack of coordination, and unsteadiness on feet.On 8/3/26 at 8:45 AM, an interview was conducted with resident 72. Resident 72 stated that she had fallen several times while at the facility and had gotten injured.A review of resident 72's Minimum Data Set (MDS) section GG functional abilities dated 4/17/26 revealed that she was dependent for bathing/showering, dependent for transferring, and a substantial/maximum assist for rolling.A review of resident 72's progress notes revealed:a. On 1/6/26 at 10:49 AM, a fall review note documented, Resident sustained a fall on 01/05/2026 5:00 PM with no injury. Observed on floor next to bed and wheelchair. Resident was attempting to change herself.The intervention for this fall was to place a call don't fall sign in resident 72's room.b. On 4/29/26 at 3:43 PM, a note documented, CNA [Certified Nursing Assistant] reported that during shower, resident had a near fall. CNA had to catch resident and place resident into w/c [wheelchair]. CNA observed blood on L [left] hip, notified nurse. Surgical incision dehiscence was discovered upon assessment. New dressing applied to L hip. Resident states she fell. Small, superficial abrasion present on forehead. Raised bump/ light discoloration present on center of forehead. EMS [Emergency Medical Services] called to send resident out for eval [evaluation]/ treatment.There was no intervention for this fall.c. On 5/8/26 at 11:10 PM, a note documented, The resident reportedly had a fall on 05/08/2026 when she tried going to use the restroom by herself, The resident did not use the call light. the resident fell and her right hip sutures opened and the resident was sent to the hospital, wound was sutured and the resident was sent back to the facility. bed time meds was [sic] administered, The resident is resting in bed.The intervention for this fall was to encourage resident 72 to spend time in her wheelchair outside of her room to discourage impulsive attempts to transfer herself and increase staff supervision.d. On 5/22/26 at 1:12 PM, a fall review note documented, Resident sustained a fall on 05/21/2026 4:20 AM with major injury: MAJOR ~4cm [centimeter] laceration w [with]/ slight swelling to chin. Upon hospital evaluation, residents jaw is fractured. On 5/21 at approximately 4:20 in the morning, the nurse was in the room next door and heard the resident calling for help. The nurse responded to the resident and found the resident sitting on her buttocks. Blood was visible from the front of the gown, and a few spots of blood on the floor. The nurse asked the residentwhat [sic] had happened, to which the resident responded she was trying to get up and get a drink as well as go to the bathroom. The resident was assisted back to bed and the nurse did a further skin assessment to which a ~4cm laceration w/ slight swelling tochin [sic], no other skin issues found. The nurse asked the resident if she felt any pain, to which she responded to jaw and pain when she swallows. The resident was sent to the hospital for further evaluation.The intervention for this fall was to post signs in the residents bedroom to call staff for help when wanting to get up.e. On 6/10/26 at 5:56 AM, a note documented, This RN [Registered Nurse] heard patient fall against the wall. When entering the room, patient was lying on her back. Stated she was turning off the light and slipped. Stated she hit her head. No bump or open area noted. Blood was coming from the incision site on the lefthip [sic]. 911 was called and patient was taken to the hospital. She returned around 2:30 am. Her incision site had a new dressing in place.The intervention for this fall was to leave the foot rests on the wheelchair as a visible cue to call for help.f. On 6/18/26 at 11:00 AM, a note documented, Witnessed patient Fall from wheelchair to bathroom floor. Pt said she hit her head and both elbows. PRN [as needed] pain meds administered per MAR [Medication Administration Record] .The intervention for this fall was to maintain resident 72's wheelchair legs while she occupied the wheelchair to serve as a visual cue for her to not self-transfer.g. On 6/23/26 at 11:59 PM, a note documented, LN [licensed nurse] heard a resident yell and cry; ran out into hallway to chase noise. LN observed resident door closed, entered room, resident on floor, prone position w/ her head supported by LFA [left forearm]; WC [wheelchair] next to resident on L [left]-side, brakes engaged. Resident stated she was attempting to get up and stated she was going to walk to her bed .The intervention for this fall was to add a repositioning bar to resident 72's bed.h. On 7/4/26 at 5:10 AM, a note documented, the resident had a fall in her room and was seen crawling out by herself without using the call button or calling for help. the resident was assessed, the resident sustained a hematoma on her occipital lobe, a skin tear on her left elbow of about 1cm long. the resident was assisted onto her wheel chair. the nurse asked the resident what she was trying to do before she had a fall, the resident was unable to answer, the resident stated that she had a fall and bumped her head on the floor and that she wants to go to the hospital. the nurse called the [local ambulance company] and sent the resident to the hospital.The intervention for this fall was to add a sleep aide to promote a better quality of sleep.i. On 7/11/26 at 10:22 PM, a fall review note documented, On 7/10 at approximately 1758 [5:58 PM], the resident was found on the floor in front of her wheelchair by a staff member rounding. Nurse was called to resident room where resident was assessed, the resident denied any pain and no injuries were noted. Upon investigation, it was determined that the resident was attempting to go to the bathroom at the time of the fall.The intervention for this fall was to encourage resident 72 to toilet during scheduled rounds to minimize unassisted toileting attempts.j. On 7/13/26 at 12:49 AM, a note documented, Resident found lying on the floor in her room. Fall was unwitnessed. Room light was off upon entry. No water, clutter, or other environmental hazards noted on the floor. Call light was within reach. Roommate reported hearing the fall and stated the resident may have struck her head on the floor.The intervention for this fall was to relocate resident 72 to a closer room near the nurse's station to increase monitoring.On 8/5/26 at 8:30 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 72 was a fall risk and wanted to transfer herself. CNA 1 stated that resident 72 required checks every 2 hours. CNA 1 stated that resident 72 was a one person assist and had to ask for help because she would fall transferring herself.On 8/5/26 at 8:35 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. ADON 1 stated that the facility participated in a falling leaf program that alerted staff that those residents required extra care and more frequent rounding. ADON 1 stated that residents were put on this program to help manage falls better. ADON 1 stated that resident 72 was not on the falling leaf program. ADON 1 stated that as a clinical team staff would meet and look through a resident's care plan after a fall and review the incident report to come up with an intervention that would fit best for the residents. ADON 1 stated that residents required interventions after every fall. ADON 1 stated that resident 72 was pleasantly confused most of the time, but very impulsive. On 8/6/26 at 10:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there were no notes or interventions for the fall on 4/29/26. The DON stated there was not a rationale from the Medical Director as to why a sleeping aid was implemented on 7/4/26 to prevent falls. POTENTIAL FOR HARM2. Resident 6 was admitted to the facility on [DATE] with diagnoses which included, acquired absence of right leg below knee, acquired absence of left leg below knee, generalized muscle weakness, and other abnormalities of gait and mobility.On 8/3/26 at 10:59 AM, an interview and concurrent observation was conducted with resident 6. Resident 6 stated that he had fallen yesterday and had multiple scrapes on his hands from the fall. Resident 6 was observed to have multiple scrapes and purple discolorations to his hands and upper arms. Resident 6 was observed to have a 1/4 bar to the upper right side of the resident's bed. Resident 6 was observed to be on a bolstered mattress. There was a grabber located on a chair to the left of the bed that was behind curtains that were closed. A review of resident 6's progress notes revealed:a. On 6/19/26 at 4:56 AM, a note documented, The resident had a fall at 2200 [10:00 PM] on 6/19/26 [sic]. the resident was assessed and helped back into his bed.The intervention for this fall was to add a bolster mattress to avoid the resident from slipping out of bed.b. On 7/2/26 at 7:06 AM, a note documented, the resident had a fall this morning at 0530 am. the resident stated that his pillow fell on the floor and he was trying to pick it up. the resident was accessed and assisted back into his bed.The intervention for this fall was to lower resident 6's bed while occupied at night to minimize the risk of injury related to rolling off the edge.c. On 7/6/26 at 4:42 AM, a note documented, The resident was observed lying on the floor next to his bed in a supine position . the resident reported minimal pain on his tail bone area and denied pain on his head.The intervention for this fall was to provide resident 6 with a grabber arm to minimize risk of him over-reaching and losing balance.d. On 7/15/26 at 11:03 AM, an interdisciplinary team (IDT) fall review note documented, Resident sustained a fall on 07/14/2026 11:00 AM with no injury. NONE Fall (1) details: On 7/14/26 at approximately 1100 [11:00 AM], resident was seated in his wheelchair at the nurses' station holding a bottle of coke. While attempting to open the bottle, resident dropped it on the floor. Staff attempted to assist in retrieving the item; resident became agitated and refused staff assistance. Resident subsequently fell from his wheelchair to the floor. A CNA was at next [sic] to the resident and assisted resident to thefloor [sic], preventing further injury. Resident was assessed following the fall; no injuries or complaints of pain noted at that time. [It should be noted that there was no progress note regarding this fall]The intervention for this fall was a referral to rehabilitation services.e. On 7/27/26 at 11:21 AM, an IDT fall review note documented, .The patient was observed on the floor at approximately 14:55 [2:55 PM] in a supine. When asked what had happened, he stated he rolled off the bed when he was repositioning himself. [It should be noted that there were no progress notes regarding this fall.]The intervention for this fall was to place reposition bars bilaterally to the bed to assist with transfers, repositioning, and bed mobility. [It should be noted that there was only one reposition bar to the right side of resident 6's bed.]f. On 8/2/26 at 11:15 AM, a note documented, Resident had a fall outside in the smoking area at 1100 [11:00 AM], he was found on the ground on the corner of the building, back of head was bleeding with large bump.The intervention for this fall was to encourage the smoking aide to wheel resident 6 back and forth from the smoking break patio.g. On 8/3/26 at 5:23 PM, a note documented, At approximately 1440 [2:40 PM] resident was in the smoking patio for the smoking break. Aide was helping having [sic] the residents all set up for the smoking. She reported hearing a noise but did not see the fall. Resident fell from his wheelchair when propelling himself. This RN [Registered Nurse] was called. Resident was observed on his back with his limps [sic] up in his wheelchair and his back and head on the floor. When asked how it happened, resident stated he lost balance in his chair, hit another resident, and fell. Abrasion from previous fall, the scab was reopened. Resident is being referred to physical therapy to have his wheelchair evaluated and for strengthening.The intervention for this fall was to have maintenance/therapy evaluate resident 6's wheelchair for safety and to have therapy evaluate resident 6 for strengthening.On 8/4/26 at 11:28 AM an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated that the therapy department received notifications for physical therapy and occupational therapy evaluations through their telehealth website. The PTA stated that physical therapy and occupational therapy had not received an order for an evaluation for resident 6 and he had never been a patient receiving their services.On 8/5/26 at 8:27 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 6 was a fall risk and he had fallen multiple times while at the facility. CNA 1 stated that resident 6 had recently fallen while outside. CNA 1 stated that the only intervention that she knew of for resident 6 was increased supervision. On 8/5/26 at 9:02 AM, an interview was conducted with ADON 1. ADON 1 stated that interventions that included a referral to therapy were made during the clinical morning meeting and physical therapy staff were present and a whole team decision was made if a resident should be evaluated for therapy. ADON 1 stated that she thought resident 6 had bilateral reposition bars.On 8/6/26 at 10:11 AM, an interview was conducted with the DON. The DON stated that resident 6's bilateral reposition bars had been rectified and he now had two. The DON stated that the intervention on 7/14/26 for therapy to evaluate was not done. The DON stated that the team discussed this in an IDT meeting and decided that this was not an ideal intervention and a new intervention was not implemented.

Based on interview and record review, it was determined that for 1 of 28 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene. Specifically, a resident did not receive a shower until 9 days after her admission to the facility per the available documentation at the facility. Resident identifier: 87.Findings Included:Resident 87 was admitted [DATE] and discharged on 3/3/26 with diagnoses that included, extradural and subdural abscess unspecified, meningitis unspecified, infection following a procedure other surgical site subsequent encounter, morbid (severe) obesity due to excess calories, and aphasia following cerebral infarction.Resident 87's medical record was reviewed from 8/3/26 through 8/5/26. Resident 87's shower sheets were requested from the facility and reviewed. The shower sheets documented that Resident 87 received showers on the following dates: 2/11/26, 2/16/26, 2/25/26, 3/2/26, and 3/3/26. Resident 87's certified nursing assistant (CNA) charting was reviewed. There was no documentation that the resident received a shower during her stay at the facility. Resident 87's admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident 87 was dependent on others for showering and bathing. On 8/5/26 at 12:41 PM, an interview was conducted with the shower certified nursing assistant (SCNA). The SCNA stated that when a resident received a shower, it was documented on a shower sheet and in the resident's CNA charting. The SCNA stated that these would be the only two places a shower would be documented. The SCNA stated that residents at the facility received 2-3 showers per week depending on the resident's preference.On 8/5/26 at 12:55 PM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. ADON 1 stated that when a resident received a shower, it should be documented on a shower sheet and in the resident's CNA charting. ADON 1 stated that while resident 87 was staying at the facility, the facility was only documenting showers on shower sheets, and that was why resident 87 did not have any CNA charting for showers.

Based on interview and record review, it was determined that in response to allegations of abuse, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 10 sampled residents and prevent further potential abuse while an investigation was being processed for 1 of 10 sampled residents. Specifically, the facility did not have evidence that abuse allegations were thoroughly investigated and allowed an alleged perpetrator to continue to have access to the alleged victim and other vulnerable residents. This was determined to have occurred at an Immediate Jeopardy level for resident 5. Resident identifiers: 1 and 5. On 12/12/2024, a finding of Immediate Jeopardy (IJ) (immediate threat to the health and safety of patients) was identified in the area of 483.12 Freedom from Abuse, Neglect, and Exploitation. The facility was notified of this finding verbally and in writing on 12/12/2024 at 10:20 AM. The facility submitted an IJ removal plan on 12/12/2024 at 3:41 PM, alleging removal as of 12/12/2024 at 2:30 PM. The plan was accepted, and the facility was notified at 5:36 PM on 12/12/2024. An onsite visit was conducted on 12/16/2024, and surveyors determined that the IJ had been removed on 12/12/2024 based on the steps the facility had taken. The facility was notified of this finding at 10:30 AM on 12/16/2024. Findings Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, suicidal ideation, muscle weakness, and dysphagia. On 12/11/2024 at 2:00 pm, an interview was conducted with resident 5, who stated that he had experienced verbal and sexual abuse from the Certified Nurse Assistant (CNA) 1. Resident 5 stated that at the end of the week before the interview, resident 5 had diarrhea and needed assistance from CNA 1 to help clean up. The resident stated that CNA 1 instructed the resident to hold their penis while the CNA used wet wipes to clean the resident's penis and scrotum. The resident stated they were having difficulty holding it up as the CNA instructed, and the CNA said, You're being stupid again, aren't you? and smacked my hands away. CNA 1 then Grabbed my penis between [CNA 1's] fingers and pulled on it as hard as [CNA 1] could and proceeded to scrub my penis on the sides while holding it up. When the resident complained about the rough treatment, the resident stated CNA 1 said, All men like to have that done to them and All men like to have it hurt like that. The resident then stated that when CNA 1 was finished cleaning them up, the CNA said, I hope when I go to college to be a nurse, I find a boyfriend who is as big as you are. The resident stated that they complained about the treatment to another CNA, CNA 2. The resident also said that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated that CNA 6 talked with them the next day about the incident, but according to the resident, nothing was ever done about it. During the interview, resident 5 was tangential and perseverated on various complaints, requiring frequent redirection, but was consistent in their retelling of events throughout questioning. Note: CNA 1 was observed in the building providing direct care to residents on 12/12/2024. Resident 5's medical record was reviewed on 12/11/2024. On 11/27/2024, a quarterly Minimum Data Set (MDS) assessment was completed for resident 5. It was documented that resident 5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident 5 was cognitively intact. On 12/13/2024, a psychiatric evaluation for Resident 5 was completed by a physician. The physician documented Resident 5's horrible experience with the CNA, CNA 1, and how Resident 5 felt they had been sexually assaulted big time. The following narrative was documented, He reports that when the CNA entered the room, she said, Ew, you stink, took his shirt off, pulled his pants down, and said, You are such a mess. He reports that she then took her gloves off, looked at him and it (referring to his penis), and told him, Hold it up like this as hard as you can . just hold it there. He reports that his hand slipped, and she got upset, told him she wanted him to hold it a certain way, then smacked his hand away and moved her hand up his penis to hold it. He reports that he told her it hurt, and she responded, Good. It is supposed to. All men want their penis to hurt like that. He reports that she held his penis and squeezed it tight while cleaning him and stated, Doesn't it feel good? while she wiped him with wipes. He reports that he was black and blue down there from cleaning so hard and that he thinks he needed a shower because he could have been cleaner. He reported that she told him, I am leaving Sandstone next week. I hope my next boyfriend or husband is as big as you. It should be noted that resident 5's progress notes and care plan were reviewed, and no documentation was located to indicate resident 5 had sexual behaviors. On 12/11/2024 at 3:00 pm, the DON was interviewed. The DON stated that they did talk with Resident 5 on Friday, 12/6/2024, the day after the incident, but did not have anyone else present during the conversation. When asked whether they were aware of the resident's complaint, the DON stated, Sure, I guess now that you say it, he told me about a CNA making like, swearing at him, touching him. He was saying that one CNA was swearing at him, saying 'you're covered in shit' and holding his anatomy while she was changing him. The DON also said that during their interview with the resident, they stated, [Resident 5] was talking about a brief change, and the CNA was making him do all the motions. [Resident 5] was trying to indicate that the CNA was wanting him to, I don't want to add words, [Resident 5] was trying to make it like [CNA 1] was trying to do something sexual. The DON stated that CNA 1 had no prior complaints about their performance of peri-care and that it was not normal practice for the resident to be asked to hold themselves while the CNA performed peri-care. The DON stated that they told the administrator about the incident the next day in the morning meeting. The DON was asked if an incident report was completed or if a note in the electronic medical record, or anywhere else, was made, to which they said: I don't know, I would have to double check, but I'd have to backtrack and look. The DON was asked to provide any documentation that was made concerning the incident but did not provide any. On 12/11/2024, at 3:30 PM, the Administrator (ADMN)/abuse coordinator was interviewed. The ADMN stated that they were not aware of the abuse allegation made by resident 5 and subsequently did not complete an investigation. On 12/12/2024 at 9:08 AM, an interview was conducted with the ADON. The ADON stated they recently had to be a witness for the DON while they talked to Resident 5 about inappropriate patient care. The ADON stated the situation had been reported by CNA 2. The ADON stated resident 5 informed them CNA 1 had been using profanity and was talking inappropriately about their anatomy. The ADON stated resident 5 had complained to CNA 2 about what had occurred earlier in the day. The ADON stated resident 5 was told by CNA 1 they had a large penis. Resident 5's penis was then grasped tightly by CNA 1, and they did not relinquish their grip after Resident 5 voiced being in pain. The ADON stated Resident 5 was told they were a piece of shit and lazy. The ADON stated they interviewed CNA 1 the following morning. The ADON stated that CNA 1 said resident 5 had been moaning during the brief change. CNA 1 informed Resident 5 that those noises were inappropriate and that Resident 5 had never complained of any pain throughout the brief change. CNA 1 stated they felt awkward and uncomfortable with how resident 5 made them feel. The ADON stated they had switched CNA 1's assignment, so they no longer worked with resident 5. The ADON stated that this situation had been discussed in the morning meeting and that the Administrator had been made aware. The ADON stated the DON made notes of the incident Note: The facility provided no evidence that this allegation was thoroughly investigated. 2. Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, cirrhosis of the liver, pressure ulcer of unspecified site, altered mental status, mood disorder, bipolar disorder, hallucinations, and post-traumatic stress disorder. On 9/5/2024, an MDS assessment was completed for resident 1. It was documented that resident 1 had a BIMS score of 10, which indicated moderate cognitive impairment. A care plan focus area initiated on 6/24/2024 and revised on 12/5/2024 documented that resident 1 had an alteration in their thought process due to moderate cognitive impairment. It should be noted resident 1's progress notes were reviewed, and there was no documentation located to indicate resident 1 had sexual behaviors or had been involved in a resident-to-staff interaction. On 12/10/2024 at 11:37 am, an interview was conducted with Resident 1. Resident 1 stated they required a lot of help from staff and needed to have their brief changed often due to diarrhea. Resident 1 stated they had no issues with staff being inappropriate with them. Resident 1 stated they had memory problems, which did not allow them to answer questions well. Resident 1 stated their memory was bad. On 12/10/2024 at 12:00 PM, an interview was conducted with RN 1. RN 1 stated Resident 1 was completely dependent on care and occasionally refused his care. RN stated resident 1 had cognitive deficits, dementia, and exhibited negative symptoms of schizophrenia. RN 1 stated that resident 1 sometimes forgot who they were and often said they were missing certain body parts, such as their mouth, head, and legs. RN 1 stated resident 1 was not aware of what was going on. On 12/10/2024 at 1:35 PM, an interview was conducted with the DON. The DON stated they recently had a resident come to them and inform them about concerns with a nighttime aide and suggestive conversations that had been going on. The DON stated that resident 1's roommate had informed them on the morning of 11/16/24 about the nighttime care concern that occurred on 11/15/24. Resident 1's roommate had been adamant that there had been a suggestive conversation between the night aid and resident 1 during a brief change. The DON stated they believed resident 1's roommate interpreted resident 1 and the night aide's interaction as something sexual. The DON stated resident 1's roommate could hear parts of the conversation that occurred but was unable to confirm the entire conversation and any actions due to the curtain being closed. The DON stated after they had spoken to resident 1's roommate and then asked resident 1 about any concerns they had with recent cares approximately within 12 hours of the incident. The DON stated resident 1 shrugged their shoulders after being asked if they could recall any incidents about the night before and were unable to get anything. The DON stated resident 1 did not seem distressed or upset. The DON stated resident 1's cognition fluctuates daily, and they had cognitive deficits. The DON stated there were times when resident 1 complained about a missing limb or body part. Resident 1 mentioned they were satisfied with the care they had been receiving. The DON stated once this had been reported to them, they immediately talked to the staff involved. The survey team requested all documentation gathered throughout the investigation. The DON stated they had a soft file that included resident and staff interviews. The DON stated that a soft file was created due to significant concerns resident 1's roommate had. The DON stated it had been hard to determine if the situation happened due to the varying responses during the interviews with staff, resident 1, and resident 1's roommate. The survey team immediately requested the soft file documentation. Note: On 12/10/2024, the soft file for the allegation made by resident 1 ' s roommate was provided to the survey team. The soft file included brief interviews with resident 1, resident 6, CNA 1, and CNA 2. It was documented that during Resident 6 ' s interview, they stated that an inappropriate conversation had occurred, but they had not witnessed anything. There was no clarification as to what was said to make resident 6 think the conversation was inappropriate. Per the documentation, Resident 1, who had cognitive deficits, was asked if any abuse or neglect had occurred with their care and if anyone had been inappropriate with them. Resident 1 denied any concerns. In the documentation of the interview with CNA 1, they stated resident 1 believed they were missing limbs and needed to be re-oriented. Per the documentation of CNA 2 ' s interview, CNA 2 stated resident 1 had been inappropriate and had made suggestive comments. It should be noted no further details were included to indicate what was said between CNA 2 and resident 1 and what limbs resident 1 believed to be missing. The DON stated a soft file was a simple document that helped them track patterns, behaviors, and performance. On 12/10/2024 at 1:55 PM, an interview was conducted with resident 6. Resident 6 stated that something inappropriate had happened to his roommate, resident 1, and one- or two-night aides. Resident 6 stated the staff involved had crossed a boundary and had taken advantage of resident 1. Resident 6 stated it occurred about 1 month ago during a nighttime brief change, but they could not recall what had been said and did not want to accuse a staff member of something due to their memory. Resident 6 stated they had informed the DON of what had occurred. On 12/10/2024 at 2:52 PM, an interview was conducted with CNA 1. CNA 1 stated they had received abuse training during their orientation. They had only heard of two abuse allegations in the six months they had been here. CNA 1 stated the first one occurred a month ago with resident 1. CNA 1 stated resident 1 often stated they did not have certain body parts such as a mouth or head. CNA 1 stated they had received a report from CNA 2, who informed them at that time resident 1 had stated they did not have a penis during one of the brief changes. CNA 2 stated they held up resident 1's penis for them to see it themselves. CNA 1 stated they reported the incident to the DON after resident 1 had brought up the situation multiple times throughout the day. CNA 1 stated they assumed CNA 2 had informed the nurses about what happened because it had occurred during their shift. CNA 1 stated resident 1's roommate also brought up the situation. CNA 1 stated they reported what happened to resident 1 to RN 1 sometime in the morning. CNA 1 stated the DON had interviewed them about the incident the same day. On 12/11/2024 at 12:28 PM, a follow up interview was conducted with RN 1. RN 1 stated there was no logic when resident 1 informed staff they did not have a mouth, legs, or head and they were difficult to reorient. RN 1 stated they were aware of a situation where resident 1 had informed a nighttime aid they did not have a penis. RN 1 stated the night aid had shown resident 1 their penis in an attempt to re-orient resident 1. RN 1 stated they were made aware of the situation by resident 1's roommate, who stated a weird conversation had occurred during a brief change. RN 1 stated resident 1's roommate reported this 24 hours after it had occurred. RN 1 stated they immediately notified the DON of the situation, and the DON later interviewed CNA 1 of what they had been told. On 12/11/2024 at 3:30 PM, an interview was conducted with the ADMN. The ADMN stated they were the abuse coordinator. The ADMN stated once they were alerted of an allegation of abuse, they conducted an initial investigation to verify if there was any evidence of abuse and to gather information to rule out hearsay or speculation. The ADMN stated during the investigation process, they conducted interviews with the residents and staff involved and did chart reviews. The ADMN stated they also look to see if a resident has had a change in behavior and see if there was any derogatory outcome from the event. The ADMN stated the investigation was a collaborative effort. The ADMN stated they had not conducted any abuse investigations in November or December 2024. The ADMN stated they were informed resident 1 stated they did not have a penis, and the CNA assured the resident they did have one. The ADMN stated that when resident 1 was interviewed, they denied anything had occurred and that the staff had not witnessed a change in behavior. The ADMN stated resident 1's roommate had speculated what had occurred. The ADMN stated they did not believe it was an allegation of abuse because of resident 1's roommate's mental history. Based upon the evidence provided by the DON, the ADMN did not believe it was a substantial event because what had been perceived was not accurate to what the caregiver did. The ADMN stated they were alerted very timely by the DON. Note: The ADMN did not complete an investigation. On 12/11/2024 at 4:03 PM, an interview was conducted with CNA 2. CNA 2 stated during their second rounds, resident 1 informed them they did not have a penis. CNA 2 stated they informed resident 1 it had been there last time they changed their brief and was pretty sure it was still there. CNA 2 opened resident 1's brief and stated, look it's right there. CNA 2 stated resident 1 lifted their head up and started pulling at their penis in their direction. CNA 2 stated resident 1 then asked them what they would do if they wanted to kiss them. CNA 2 informed resident 1 that was not an appropriate thing to talk about, and resident 1 kept pulling at his penis. CNA 2 informed resident 1 they did not need to pull at their penis, and then resident 1 stated CNA 2 needed a man. CNA 2 told resident 1 they did not need a man and were not going to go there. CNA 2 informed resident 1 they needed to finish their brief change and left the room after completion. CNA 2 stated they informed the nurse of what had occurred and charted that resident 1 was sexually inappropriate. CNA 2 stated that it had been unusual behavior for resident 1. CNA 2 stated they had been contacted by the DON the following day and was notified that resident 1's roommate had stated that something different had occurred. CNA 2 stated that resident 1's roommate had twisted what had occurred. Note: There was no evidence that CNA 2 documented that resident 1 was sexually inappropriate in resident 1 ' s medical record or that the allegation of abuse that was made on 11/15/2024 had been reported to the SSA, APS, or Law Enforcement. 19354 A review of the facility's policy and procedure for abuse prevention was conducted. The policy defined verbal abuse as the use of oral, written or gestured language that expresses disparaging and derogatory terms to residents within their hearing/seeing distance and sexual abuse as non-consensual sexual contact of any type with a resident. It was further documented that the facility would, .1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. 2. Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety. 3. Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses . 5. Take actions related to resolving resident and family issues/concerns/allegations, educating staff, communicating with families and others (as relevant) and record .

Based on interview and record review, it was determined for 2 out of 10 sampled residents that in response to allegations of abuse, the facility failed to report allegations immediately. Specifically, allegations of abuse were not reported to the State Survey Agency (SSA), Adult Protective Services (APS), or the police. This was determined to have occurred at an Immediate Jeopardy level for resident 5. Resident identifiers: 1 and 5. On 12/12/2024, a finding of Immediate Jeopardy (IJ) (immediate threat to the health and safety of patients) was identified in the area of 483.12 Freedom from Abuse, Neglect, and Exploitation. The facility was notified of this finding verbally and in writing on 12/12/2024 at 10:20 AM. The facility submitted an IJ removal plan on 12/12/2024 at 3:41 PM, alleging removal as of 12/12/2024 at 2:30 PM. The plan was accepted, and the facility was notified at 5:36 PM on 12/12/2024. An onsite visit was conducted on 12/16/2024, and surveyors determined that the IJ had been removed on 12/12/2024 based on the steps the facility had taken. The facility was notified of this finding at 10:30 AM on 12/16/2024. Findings Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, suicidal ideation, muscle weakness, and dysphagia. On 12/11/2024 at 2:00 pm, an interview was conducted with resident 5, who stated that he had experienced verbal and sexual abuse from the Certified Nurse Assistant (CNA) 1. Resident 5 stated that at the end of the week before the interview, resident 5 had diarrhea and needed assistance from CNA 1 to help clean up. The resident stated that CNA 1 instructed the resident to hold their penis while the CNA used wet wipes to clean the resident's penis and scrotum. The resident stated they were having difficulty holding it up as the CNA instructed, and the CNA said, You're being stupid again, aren't you? and smacked my hands away. CNA 1 then Grabbed my penis between [CNA 1's] fingers and pulled on it as hard as [CNA 1] could and proceeded to scrub my penis on the sides while holding it up. When the resident complained about the rough treatment, the resident stated CNA 1 said, All men like to have that done to them and All men like to have it hurt like that. The resident then stated that when CNA 1 was finished cleaning them up, the CNA said, I hope when I go to college to be a nurse, I find a boyfriend who is as big as you are. The resident stated that they complained about the treatment to another CNA, CNA 2. The resident also said that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated that CNA 6 talked with them the next day about the incident, but according to the resident, nothing was ever done about it. During the interview, resident 5 was tangential and perseverated on various complaints, requiring frequent redirection, but was consistent in their retelling of events throughout questioning. Resident 5's medical record was reviewed on 12/11/2024. On 11/27/2024, a quarterly Minimum Data Set (MDS) assessment was completed for resident 5. It was documented that resident 5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated resident 5 was cognitively intact. On 12/13/2024, a psychiatric evaluation for Resident 5 was completed by a physician. The physician documented what Resident 5 relayed as a horrible experience with the CNA, CNA 1, and how Resident 5 felt they had been sexually assaulted big time. The following narrative was documented, He reports that when the CNA entered the room, she said Ew, you stink, took his shirt off, pulled his pants down, and said, You are such a mess. He reports that she then took her gloves off, looked at him and it (referring to his penis), and told him, Hold it up like this as hard as you can . just hold it there. He reports that his hand slipped, and she got upset, told him she wanted him to hold it a certain way, then smacked his hand away and moved her hand up his penis to hold it. He reports that he told her it hurt, and she responded, ' Good. ' It is supposed to. All men want their penis to hurt like that. He reports that she held his penis and squeezed it tight while cleaning him and stated, Doesn't it feel good? while she wiped him with wipes. He reports that he was black and blue down there from cleaning so hard and that he thinks he needed a shower because he could have been cleaner. He reported that she told him, I am leaving Sandstone next week. I hope my next boyfriend or husband is as big as you. It should be noted that resident 5's progress notes and care plan were reviewed, and no documentation was located to indicate resident 5 had sexual behaviors. On 12/11/2024 at 3:00 pm, the DON was interviewed. The DON stated that they did talk with Resident 1 on Friday, 12/6/2024, the day after the incident, but did not have anyone else present during the conversation. When asked whether they were aware of the resident's complaint, the DON stated, Sure, I guess now that you say it, he told me about a CNA making like, swearing at him, touching him. He was saying that one CNA was swearing at him, saying 'you're covered in shit' and holding his anatomy while she was changing him. The DON also said that during their interview with the resident, they stated, [Resident 5] was talking about a brief change, and the CNA was making him do all the motions. [Resident 5] was trying to indicate that the CNA was wanting him to, I don't want to add words, [Resident 5] was trying to make it like [CNA 1] was trying to do something sexual. The DON stated that CNA 1 had no prior complaints about their performance of peri-care and that it was not normal practice for the resident to be asked to hold themselves while the CNA performed peri-care. The DON stated that they told the administrator about the incident the next day in the morning meeting but did not know if they reported it to the state or other agencies. On 12/11/2024, at 3:30 PM, the Administrator (ADMN)/abuse coordinator was interviewed. The ADMN stated that they were not aware of the abuse allegation made by resident 5 and stated that when they receive information of suspected abuse, they immediately contact the regional nurse, director of operations, family, notify the Department of Health on form 358, contact adult protective services, the long term care ombudsman and police if necessary. ADMN stated that the last abuse incident they were aware of and reported occurred on 10/10/2024 as a resident-to-resident incident. On 12/12/2024 at 9:08 AM, an interview was conducted with the ADON. The ADON stated they recently had to be a witness for the DON while they talked to Resident 5 about inappropriate patient care. The ADON stated the situation had been reported by CNA 2. The ADON stated resident 5 informed them CNA 1 had been using profanity and was talking inappropriately about their anatomy. The ADON stated resident 5 had complained to CNA 2 about what had occurred earlier in the day. The ADON stated resident 5 was told by CNA 1 they had a large penis. Resident 5's penis was then grasped tightly by CNA 1, and they did not relinquish their grip after Resident 5 voiced being in pain. The ADON stated Resident 5 was told they were a piece of shit and lazy. The ADON stated they interviewed CNA 1 the following morning. The ADON stated that CNA 1 said resident 5 had been moaning during the brief change. CNA 1 informed Resident 5 that those noises were inappropriate and that Resident 5 had never complained of any pain throughout the brief change. CNA 1 stated they felt awkward and uncomfortable with how resident 5 made them feel. The ADON stated they had switched CNA 1's assignment, so they no longer worked with resident 5. The ADON stated that this situation had been discussed in the morning meeting and that the Administrator had been made aware of it. The ADON stated the DON made notes of the incident, but to their knowledge, no notification had been made to any agency. It should be noted this allegation was made on 12/06/2024 and was not reported to the SSA, APS, or Law Enforcement. 2. Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, cirrhosis of the liver, pressure ulcer of unspecified site, altered mental status, mood disorder, bipolar disorder, hallucinations, and post-traumatic stress disorder. On 9/5/2024, an MDS assessment was completed for resident 1. It was documented resident 1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. A care plan focus area initiated on 6/24/2024 and revised on 12/5/2024 documented that resident 1 had an alteration in their thought process due to moderate cognitive impairment. It should be noted resident 1's progress notes were reviewed, and there was no documentation located to indicate resident 1 had sexual behaviors or had been involved in a resident-to-staff interaction. On 12/10/2024 at 11:37 am, an interview was conducted with Resident 1. Resident 1 stated they required a lot of help from staff and needed to have their brief changed often due to diarrhea. Resident 1 stated they had no issues with staff being inappropriate with them. Resident 1 stated they had memory problems, which did not allow them to answer questions well. Resident 1 stated their memory was bad. On 12/10/2024 at 12:00 PM, an interview was conducted with RN 1. RN 1 stated Resident 1 was completely dependent on care and occasionally refused his care. RN stated resident 1 had cognitive deficits, dementia, and exhibited negative symptoms of schizophrenia. RN 1 stated that resident 1 sometimes forgot who they were and often said they were missing certain body parts, such as their mouth, head, and legs. RN 1 stated resident 1 was not aware of what was going on. On 12/10/2024 at 1:35 PM, an interview was conducted with the DON. The DON stated they recently had a resident come to them and inform them about concerns with a nighttime aide and suggestive conversations that had been going on. The DON stated that resident 1's roommate had informed them on the morning of 11/16/24 about the nighttime care concern that occurred on 11/15/24. Resident 1's roommate had been adamant that there had been a suggestive conversation between the night aide and resident 1 during a brief change. The DON stated they believed resident 1's roommate interpreted resident 1 and the night aide's interaction as something sexual. The DON stated resident 1's roommate could hear parts of the conversation that occurred but was unable to confirm the entire conversation and any actions due to the curtain being closed.The DON stated after they had spoken to resident 1's roommate and then asked resident 1 about any concerns they had with recent cares approximately within 12 hours of the incident. The DON stated resident 1 shrugged their shoulders after being asked if they could recall any incidents about the night before and were unable to get anything. The DON stated resident 1 did not seem distressed or upset. The DON stated resident 1's cognition fluctuates daily, and they had cognitive deficits. The DON stated there were times when resident 1 complained about a missing limb or body part. Resident 1 mentioned they were satisfied with the care they had been receiving. The DON stated once this had been reported to them, they immediately talked to the staff involved. On 12/10/2024 at 1:55 PM, an interview was conducted with resident 6. Resident 6 stated that something inappropriate had happened to his roommate with one- or two-night aides. Resident 6 stated the staff involved had crossed a boundary and had taken advantage of resident 1. Resident 6 stated it occurred about 1 month ago during a nighttime brief change, but they could not recall what had been said and did not want to accuse a staff member of something due to their memory. Resident 6 stated they had informed the DON of what had occurred. On 12/10/2024 at 2:52 PM, an interview was conducted with CNA 1. CNA 1 stated they had received abuse training during their orientation. They had only heard of two abuse allegations in the six months they had been here. CNA 1 stated the first one occurred a month ago with resident 1. CNA 1 stated resident 1 often stated they did not have certain body parts such as a mouth or head. CNA 1 stated they had received a report from CNA 2, who informed them at that time resident 1 had stated they did not have a penis during one of the brief changes. CNA 2 stated they held up resident 1's penis for them to see it themselves. CNA 1 stated they reported the incident to the DON after resident 1 had brought up the situation multiple times throughout the day. CNA 1 stated they assumed CNA 2 had informed the nurses about what happened because it had occurred during their shift. CNA 1 stated resident 1's roommate also brought up the situation. CNA 1 stated they reported what happened to resident 1 to RN 1 sometime in the morning. CNA 1 stated the DON had interviewed them about the incident the same day. On 12/11/2024 at 12:28 PM, a follow up interview was conducted with RN 1. RN 1 stated there was no logic when resident 1 informed staff they did not have a mouth, legs, or head, and they were difficult to reorient. RN 1 stated they were aware of a situation where resident 1 had informed a nighttime aide they did not have a penis. RN 1 stated the night aide had shown resident 1 their penis in an attempt to re-orient resident 1. RN 1 stated they were made aware of the situation by resident 1's roommate, who stated a weird conversation had occurred during a brief change. RN 1 stated resident 1's roommate reported this 24 hours after it had occurred. RN 1 stated they immediately notified the DON of the situation, and the DON later interviewed CNA 1. On 12/11/2024 at 3:30 PM, an interview was conducted with the ADMN. The ADMN stated they were the abuse coordinator. The ADMN stated that anytime abuse was identified, it was reported to the regional nurse consultant, regional operations, Adult Protective Services (APS), Ombudsman, and law enforcement. The ADMN stated they submitted a 358 form within 2 hours to the state survey agency. The ADMN stated they had not conducted any abuse investigations in November or December 2024. The ADMN stated they were informed resident 1 stated they did not have a penis, and the CNA assured the resident, they did have one. The ADMN stated when resident 1 was interviewed, they denied anything had occurred, and staff had not witnessed a change in behavior. The ADMN stated resident 1's roommate had speculated what had occurred. The ADMN stated they did not believe it was an allegation of abuse because of resident 1's roommate's mental history. Based upon the evidence provided by the DON, the ADMN did not believe it was a substantial event because what had been perceived was not accurate to what the caregiver did. The ADMN stated they were alerted very timely by the DON. On 12/11/2024 at 4:03 PM, an interview was conducted with CNA 2. CNA 2 stated during their second rounds, resident 1 informed them they did not have a penis. CNA 2 stated they informed resident 1 it had been there last time they changed their brief and was pretty sure it was still there. CNA 2 opened resident 1's brief and stated, look it's right there. CNA 2 stated resident 1 lifted their head up and started pulling at their penis in their direction. CNA 2 stated resident 1 then asked them what they would do if they wanted to kiss them. CNA 2 informed resident 1 that was not an appropriate thing to talk about, and resident 1 kept pulling at his penis. CNA 2 informed resident 1 they did not need to pull at their penis, and then resident 1 stated CNA 2 needed a man. CNA 2 told resident 1 they did not need a man and were not going to go there. CNA 2 informed resident 1 they needed to finish their brief change and left the room after completion. CNA 2 stated they informed the nurse of what had occurred and charted that resident 1 was sexually inappropriate. CNA 2 stated that it had been unusual behavior for resident 1. CNA 2 stated they had been contacted by the DON the following day and was notified that resident 1's roommate had stated that something different had occurred. CNA 2 stated that resident 1's roommate had twisted what had occurred. It should be noted there was no evidence that CNA 2 documented that resident 1 was sexually inappropriate in resident 1 ' s medical record or that the allegation of abuse that was made on 11/15/2024 had been reported to the SSA, APS, or Law Enforcement. 19354 A review of the facility's policy and procedure for abuse prevention was conducted. The policy defined verbal abuse as the use of oral, written or gestured language that expresses disparaging and derogatory terms to residents within their hearing/seeing distance and sexual abuse as non-consensual sexual contact of any type with a resident. It was further documented that the facility would, 2. Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety 6. Notify law enforcement authorities and press charges, if indicated. 7. Report the investigation findings to the appropriate State Agencies, as required by law .

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 4 out of 28 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, 4, 7, and 32. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 32's medical record was reviewed on 8/17/22. Resident 32's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was 7/26/22. The quarterly MDS assessment was not completed, and the status was marked as In Progress. The quarterly MDS assessment documented that the assessment was to be complete by 8/9/22. On 8/17/22 at 1:22 PM, an interview was conducted with the Corporate Resource Nurse (CRN). Resident 32's quarterly MDS assessment was reviewed with the CRN. The CRN stated that resident 32's quarterly MDS assessment was late. 2. Resident 7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22 at 12:15 PM, resident 7's quarterly MDS assessment was reviewed. The ARD date was 7/13/22, and the completion date was 7/27/22. As of 8/15/22, the quarterly MDS assessment was still in process. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22, resident 4's medical record was reviewed. Resident 4's most recent quarterly MDS assessment was reviewed, and it revealed that the ARD target for completion was 7/12/22. The quarterly MDS assessment was completed on 8/9/22, which was 28 days late. 4. Resident 1 was admitted to the facility initially on 8/26/16 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22, resident 1's medical record was reviewed. Resident 1's most recent quarterly MDS assessment was reviewed, and it revealed that the ARD target for completion was 7/6/22. The quarterly MDS assessment was completed on 8/8/22, which was 33 days late. On 8/17/22 at 10:18 AM, an interview was conducted with the MDS coordinator. The MDS Coordinator stated that different staff members were involved with completing the annual and quarterly MDS assessments. The MDS Coordinator stated the staff members who participated in the care of the resident received notification on the computer system that an evaluation for an upcoming MDS was required. The MDS Coordinator stated staff members would then complete the evaluations and document the required information. The MDS Coordinator stated when MDS assessments were due to be completed, she would pull information from the staff evaluations to complete the MDS. The MDS Coordinator stated if she had any questions, she would interview the resident for clarification. The MDS Coordinator stated once the resident's MDS was due, there were 14 days to complete the assessment. The MDS Coordinator further stated that she received an alert if an assessment was overdue. The MDS Coordinator stated her employment at the facility started in February 2022. The MDS Coordinator stated that at the time, the position was already vacant, and she was unsure for how long. The MDS Coordinator stated she was working on getting the backlogged MDS assessments completed. On 8/17/22 at 1:22 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that the MDS Coordinator had 14 days after the ARD to complete the MDS assessment, and 14 days to submit the MDS. The CRN stated there would always be a completion date for the MDS assessment. The CRN stated if the MDS assessment had not been completed by the completion date the MDS was considered late.

Based on observation and interview it was determined the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, for 4 out of 28 sampled residents, staff referred to resident's who required dining assistance as feeders, a resident was told the location of where he needed to eat his meals, residents were observed to wait for their meal trays while their tablemate's ate, and a resident waited approximately 46 minutes for his lunch tray to be served. Resident identifiers: 12, 17, 37, and 49. Findings included: On 8/15/22 at 12:21 PM, a continuous observation was made of the assisted dining room on the third floor during the lunch meal service. The dining room was observed with 8 residents seated inside. 1. On 8/15/22 at 12:23 PM, the facility Administrator (ADM) and Assistant Director of Nursing (ADON) were observed to walk by the doorway to the assisted dining room. The ADON paused in the doorway to the dining room and told Certified Nurse Assistant (CNA) 1 that only feeders should be in the assisted dining room. The ADM was heard to correct the ADON and referred to the residents as assisted diners. At approximately 12:25 PM, an interview was conducted with the ADM. The ADM stated that the ADON felt horrible about calling the residents feeders, especially since she had been educating the staff on not to do that. 2. On 8/15/22 at 12:35 PM, an observation was made of the ADON telling resident 37 that he needed to eat downstairs. Resident 37 was seated in the assisted dining room. Resident 37 replied no, she said I could eat up here and pointed at CNA 1. The ADON told resident 37 that he needed to get back into the habit of eating downstairs. 3. On 8/15/22 at 12:38 PM, the lunch meal trays arrived on the third floor. The following observations were made of the assisted dining room: a. On 8/15/22 at 12:40 PM, the lunch tray was delivered to resident 15 by Licensed Practical Nurse (LPN) 1. Resident 15 was seated at the table with resident 49. b. On 8/15/22 at 12:40 PM, the lunch tray was delivered to resident 16 by LPN 1. Resident 16 was seated at the table with resident 37. c. On 8/15/22 at 12:41 PM, the lunch tray was delivered to resident 7 by LPN 1. At 12:48 PM, dining assistance was provided to resident 7 by CNA 2. Resident 7 was seated at the table with resident 17 and resident 41. d. On 8/15/22 at 12:46 PM, all the meal trays were delivered from the meal cart. Resident 49, 37, and 17 were not provided a meal tray. e. On 8/15/22 at 12:54 PM, the lunch tray was delivered to resident 37 by LPN 2. It should be noted that resident 37 waited 14 minutes for his meal tray after his tablemate, resident 16, was served. f. On 8/15/22 at 12:59 PM, an interview was conducted with CNA 2. CNA 2 stated that the meal trays normally came in two separate carts and that resident 49 and resident 17 were served from the second cart. g. On 8/15/22 at 1:03 PM, the second dining cart arrived to the third floor and was placed in the middle of the hallway. CNA 2 delivered the lunch tray to resident 17. It should be noted that resident 17 waited 22 minutes for her meal tray after her tablemate, resident 7, was served. h. On 08/15/22 at 1:10 PM, the lunch tray was delivered to resident 49 by CNA 2. At 1:12 PM, CNA 2 provided resident 49 his first bite of food. It should be noted that resident 49 waited 30 minutes for his meal tray after his tablemate, resident 15, was served. 4. On 8/15/22 at 1:18 PM, resident 12 was observed to ask CNA 2 for his meal tray. Both meal carts were observed empty. CNA 3 informed CNA 2 that resident 12 did not have a meal tray in his room or on the meal delivery cart. CNA 2 instructed CNA 3 to go to the kitchen and obtain a lunch tray for resident 12. An immediate interview was conducted with resident 12. Resident 12 stated that it sometimes took this long for his food to arrive. Resident 12 was observed to ask LPN 1 where his lunch tray was. Resident 12 was observed outside the assisted dining room drinking coffee since approximately 12:40 PM. At 1:26 PM, the lunch tray was delivered to resident 12's room by CNA 3. At 1:28 PM, the ADON was observed to bring resident 12's tray to CNA 3 and stated it was on her hallways meal cart. It should be noted that resident 12 was observed to wait for his lunch tray for approximately 46 minutes since the beginning of lunch service.

Based on interview and record review, it was determined, the facility did not ensure that each resident's 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, for 2 out of 28 sampled residents, a resident's beta blocker medication to treat tremors, anxiety, and possibly high blood pressure was not monitored according to the physician ordered parameters. In addition, the facility did not implement the Medical Director (MD) orders as they pertained to the pharmacist's recommendations. Resident identifiers: 12 and 35. Findings included: 1. Resident 35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 35's medical record was reviewed on 8/16/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] < [less than] 100 or HR [heart rate] <60. A review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the August 2022 Blood Pressure (BP) Summary and Pulse Summary documented the following blood pressure and pulse for resident 35. [Note: Resident 35's blood pressure and pulse were not monitored two times a day as ordered by the physician.] a. On 8/14/22 at 9:33 AM, BP 106/66 millimeters of mercury (mmHg) and HR 76 beats per minute (bpm). b. On 8/15/22 at 10:33 AM, BP 110/58 mmHg and HR 81 bpm. c. On 8/16/22 at 8:02 AM, BP 98/56 mmHg and HR 94 bpm. [Note: According to the August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .] On 8/17/22 at 11:13 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the physician would designate if he wanted the residents vital signs checked on a daily basis. LPN 1 stated the vital sign parameters ordered by the physician would trigger in the MAR. LPN 1 stated on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 1 stated if the vital signs were not on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 1 stated if the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 1 stated that she would not hold the medication unless the vital signs were concerning. On 8/17/22 at 12:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that typically the facility did not use parameters. The DON stated that resident 35 was on alert charting for the [MEDICATION(S)] since it was a new medication for resident 35. The DON stated if a resident had physician ordered parameters it would populate for additional information on the MAR. The DON stated that typically vital signs were obtained once a day unless the resident was skilled or the physician requested the vital signs be obtained more often. The DON stated that the nurses would enter the vital signs in the resident medical record. 2. Resident 12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22, resident 12's medical record was reviewed. Resident 12's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] Tablet 5 mg, give 10 mg by mouth one time a day. The order was initiated on 7/22/22. b. Omeprazole Tablet Delayed Release 20 mg, give 40 mg by mouth one time a day. The order was initiated on 5/14/22. c. Famotidine Tablet 20 mg, give 20 mg by mouth at bedtime. The order was initiated on 5/13/22 and discontinued on 7/21/22. d. [MEDICATION(S)] Solution 100 UNIT/milliliter (Insulin [MEDICATION(S)]), inject 6 unit intramuscularly before meals. The order was initiated on 6/15/22. On 8/6/22 at 5:00 PM, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pharmacy consultation reports revealed the following: a. On 5/1/22, the pharmacist recommended to consider a trial discontinuation of the [MEDICATION(S)] 5 mg daily. The MD accepted the recommendation and documented that it be implemented as written. The MD signed the form on 5/26/22. The form had a handwritten note that stated parameters were removed. Review of the May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 5 mg daily without parameters was initiated on 5/21/22, and discontinued on 7/21/22. On 7/22/22 the [MEDICATION(S)] was increased to 10 mg daily. It should be noted that the medication was never discontinued per the MD recommendation. b. On 5/1/22 the pharmacist recommended to consider discontinuing Omeprazole and changing Famotidine to 20 mg two times a day. The MD accepted the recommendation and documented that it be implemented. The MD signed the form on 5/26/22. Review of the May, June, July, and August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Omeprazole 40 mg daily was initiated on 5/14/22, and was a current active order. It should be noted that the Omeprazole was never discontinued per the MD recommendations and the Famotidine was not changed to 20 mg two times a day. On 8/17/22 at 9:15 AM, an interview was conducted with LPN 3. LPN 3 stated that if she received any physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 3 stated that if the unit manager (UM) received a verbal order or new order they would put it in or tell the floor nurse to enter it. LPN 3 stated that on one occasion she was present when the provider gave a new order by telephone to the UM and she entered the order. LPN 3 stated that for any parameters on orders they would have to enter that information in the computer. LPN 3 stated that typically they had parameters on blood pressure medications, or monitoring for effectiveness with a pain medication. LPN 3 stated that the computer would not automatically que the nurse for vital sign parameters but would automatically pop up for blood sugars and pain scores. On 8/17/22 at 10:00 AM, an interview was conducted with the DON and the Administrator. The DON stated that on 5/20/22, she received an order from the MD to discontinue the blood pressure parameters for the [MEDICATION(S)] 5 mg daily. The DON stated that it was after the parameters were discontinued that they received the pharmacy recommendation with the MD new order to discontinue the [MEDICATION(S)] medication all together. The DON stated that the [MEDICATION(S)] medication was not discontinued per the MD's order. The DON confirmed that the Omeprazole was not discontinued, and the Famotidine order was not changed per the MD orders. The DON stated that the pharmacy recommendation process was that the pharmacist would send the recommendations to the DON. The DON then placed each resident's pharmacy consultation report in each provider's box for review. The DON stated that the providers would return the consultation report with any medication changes and new orders to the DON, Assistant Director of Nursing (ADON), or the UM. The DON stated that it appeared to be an oversight and the medication changes were not implemented as ordered by the MD. The DON stated that the [MEDICATION(S)], Omeprazole, and Famotidine changes were not identified and only the ADON could make changes in the electronic medical records.

Based on interview, it was determined, the facility did not ensure that individual financial records were available to the residents through quarterly statements and upon request. Specifically, for 1 out of 28 sampled residents, a resident did not receive quarterly statements regarding his personal funds. Resident identifier: 12. Findings included: On 8/15/22 at 9:36 AM, an interview was conducted with resident 12. Resident 12 stated the facility held funds in a personal account for him. Resident 12 stated he did not receive a quarterly statement regarding his personal funds. Resident 12 stated he would like to receive a statement, so he was aware of the status of his personal funds. On 8/17/22 at 9:59 AM, an interview was conducted with the Business Office Manager (BOM). The BOM stated there were all kinds of statements that could be pulled from the Resident Funds Management System. The BOM stated residents did not automatically get a quarterly statement regarding their funds. The BOM stated if a resident requested a statement, a statement could be printed. The BOM stated a requested statement would show every withdrawal and deposit related to that resident's personal funds.

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 2 out of 28 sampled residents, a residents comprehensive assessment was not completed at least once every 12 months. In addition, a residents admission Minimum Data Set (MDS) assessment was not completed within 14 days after admission. Resident identifiers: 40 and 105. Findings included: 1. Resident 105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 105's medical record was reviewed on 8/17/22. Resident 105's admission MDS assessment was reviewed, and it was revealed that the assessment reference date (ARD) target date for completion of the admission MDS assessment was 8/9/22. The admission MDS assessment was not completed, and the status was marked as In Progress. 2. Resident 40 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22, resident 40's medical record was reviewed. Resident 40's most recent annual MDS was reviewed, and it was revealed that the ARD target date for completion was 6/29/22. The completion date on the most recent annual MDS assessment was 7/26/22, 27 days late. On 8/17/22 at 10:18 AM, an interview was conducted with the MDS coordinator. The MDS Coordinator stated that different staff members were involved with completing the annual and quarterly MDS assessments. The MDS Coordinator stated the staff members who participated in the care of the resident received notification on the computer system that an evaluation for an upcoming MDS was required. The MDS Coordinator stated staff members would then complete the evaluations and document the required information. The MDS Coordinator stated when MDS assessments were due to be completed, she would pull information from the staff evaluations to complete the MDS. The MDS Coordinator stated if she had any questions, she would interview the resident for clarification. The MDS Coordinator stated once the resident's MDS was due, there were 14 days to complete the assessment. The MDS Coordinator further stated that she received an alert if an assessment was overdue. The MDS Coordinator stated her employment at the facility started in February 2022. The MDS Coordinator stated that at the time, the position was already vacant, and she was unsure for how long. The MDS Coordinator stated she was working on getting the backlogged MDS assessments completed. On 8/17/22 at 1:22 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that the MDS Coordinator had 14 days after the ARD to complete the MDS assessment, and 14 days to submit the MDS. The CRN stated there would always be a completion date for the MDS assessment. The CRN stated if the MDS assessment had not been completed by the completion date the MDS was considered late.

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 28 sampled residents, a resident's Minimum Data Set (MDS) annual assessment was coded incorrectly by indicating the resident was not on hospice when the resident was on hospice. Resident identifier: 40. Findings included: Resident 40 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22, resident 40's medical record was reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 40's medical record included multiple hospice visit documents dating back to 2016. Resident 40's medical record contained a Hospice Certification and Plan of Care that was dated 6/21/22, and included relevant diagnoses, medications, treatment orders, and interventions that were to be provided by hospice and facility staff. Resident 40's care plan, which was revised on 4/30/22, included a Hospice CNA [Certified Nursing Assistant] Plan that listed specific cares the hospice CNA would provide at regularly scheduled visits. The start date documented for the Hospice CNA Plan was 6/26/21. On 8/16/22 at 11:49 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 40 was receiving hospice services at least 3 times per week for her primary diagnosis. LPN 1 stated facility staff had regular communication with hospice staff regarding resident 40 at least 5 times per week. Resident 40's annual MDS assessment was completed on 7/26/22. Section O, Special Treatments, Procedures, and Programs documented that resident 40 was not receiving hospice services. On 8/17/22 at 9:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated floor nurses completed some of the information that was included in the MDS. The DON stated evaluations were triggered for staff members who needed to complete information for an upcoming MDS evaluation. The DON also stated information about residents was shared during morning meetings, Interdisciplinary Team Meetings, long term care meetings, and Prescription Drug Plan meetings. The DON stated the MDS Coordinator was the staff member who completed the MDS information for submission. The DON also stated she was unsure if the MDS Coordinator had been trained in using the Resident Assessment Instrument system. On 8/17/22 at 10:18 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated updates to the resident's MDS were required upon admission, annually, and quarterly. The MDS Coordinator stated she reviewed resident records to obtain much of the information included in the MDS. The MDS Coordinator stated staff who were familiar with each resident would complete relevant areas of the assessment that were triggered in the resident's medical record prior to the MDS being completed. The MDS Coordinator stated she would review the information and interview the resident for clarification if she had questions. The MDS Coordinator stated that she was responsible to complete the MDS in the system using the information other staff members had provided. On 8/17/22 at 1:30 PM, an interview was conducted with the Corporate Registered Nurse (CRN). The CRN stated she was familiar with resident 40 and that the resident was receiving hospice services. The CRN observed resident 40's annual MDS assessment documentation that stated resident 40 was not on hospice services. The CRN confirmed the MDS documentation was incorrect.

Based on interview and record review, it was determined, the facility did not ensure that the pharmacist's reported irregularities of a resident's drug regimen were reported to the Medical Director (MD) and the reports were acted upon. Specifically, for 1 out of 28 sampled residents, the facility did not implement the MD orders as they pertained to the pharmacist's recommendations. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of [CONDITION(S)] disorder, type 2 diabetes mellitus, major depressive disorder, obsessive-compulsive disorder (OCD), anxiety disorder, gastro-[CONDITION(S)] reflux, chronic [CONDITION(S)], [CONDITION(S)], obstructive and reflux [CONDITION(S)], retention of urine, dysphagia, [CONDITION(S)], [CONDITION(S)], hypertension, mild cognitive impairment, and [CONDITION(S)]. On 8/15/22, resident 12's medical record was reviewed. Resident 12's physician's orders revealed the following: a. [MEDICATION(S)] Tablet 5 milligrams (mg), give 10 mg by mouth one time a day. The order was initiated on 7/22/22. b. [MEDICATION(S)] Oral Tablet, give 50 mg by mouth two times a day. The order was initiated on 7/15/22. c. Omeprazole Tablet Delayed Release 20 mg, give 40 mg by mouth one time a day. The order was initiated on 5/14/22. d. Famotidine Tablet 20 mg, give 20 mg by mouth at bedtime. The order was initiated on 5/13/22 and discontinued on 7/21/22. e. [MEDICATION(S)] Tablet 5 mg, give 5 mg by mouth one time a day. The order was initiated on 5/14/22. f. [MEDICATION(S)] Tablet 10 mg, give 10 mg by mouth at bedtime. The order was initiated on 5/14/22. Review of the pharmacy consultation reports revealed the following: a. On 5/1/22, the pharmacist recommended to consider a trial discontinuation of the [MEDICATION(S)] 5 mg one time a day. The MD accepted the recommendation and documented that it be implemented as written. The MD signed the form on 5/26/22. The form had a hand written note that stated parameters were removed. Review of the May 2022 Medication Administration Record (MAR) revealed that the [MEDICATION(S)] 5 mg daily, hold if systolic blood pressure less than 110 was initiated on 5/14/22, and discontinued on 5/20/22. [MEDICATION(S)] 5 mg daily without parameters was initiated on 5/21/22, and discontinued on 7/21/22. On 7/22/22, the [MEDICATION(S)] was increased to 10 mg daily. It should be noted that the medication was never discontinued per the MD recommendation. b. On 5/1/22, the pharmacist recommended to consider discontinuing Omeprazole and changing Famotidine to 20 mg two times a day. The MD accepted the recommendation and documented that it be implemented. The MD signed the form on 5/26/22. Review of the May, June, July, and August 2022 MAR revealed that the Famotidine was initiated on 5/13/22, and discontinued on 7/21/22. The Omeprazole 40 mg daily was initiated on 5/14/22, and was a current active order. It should be noted that the Omeprazole was never discontinued per the MD recommendations and the Famotidine was not changed to 20 mg two times a day. c. On 5/17/22, the pharmacist documented that the resident received two antidepressants for OCD concomitantly: [MEDICATION(S)] 100 mg three times a day, and [MEDICATION(S)] 100 mg at bedtime. The recommendation was that if therapy could not be adjusted to provide a rationale for duplicate therapy. The MD accepted the recommendations with the following modifications: decrease [MEDICATION(S)] 100 mg to two times a day will continue to try to wean. The MD signed the form on 5/26/22. Review of the May, June, July, and August 2022 MAR revealed that the [MEDICATION(S)] 100 mg three times a day was initiated on 5/13/22, and discontinued on 6/30/22. On 6/30/22, the order was changed to [MEDICATION(S)] 100 mg two times a day for 7 days. It should be noted that it took 35 days to implement the taper per the MD recommendation. On 6/20/22, the Psychiatric-Mental Health Nurse Practitioner (PMHNP) documented a decline to the recommendations and did not want to implement any changes due to, Pt [patient] is stable at this time on both medications. He does not tolerate medication changes. It should be noted that the MD and the PMHNP had conflicting orders for the [MEDICATION(S)]. d. On 5/1/22, the pharmacist documented that the resident received two antipsychotics for [CONDITION(S)]: [MEDICATION(S)] Extended Release, and [MEDICATION(S)]. The recommendation was that if therapy could not be adjusted to provide a rationale for duplicate therapy. The MD response was to decrease the [MEDICATION(S)] to 5 mg two times a day. The MD signed the order on 5/26/22. It should be noted that the [MEDICATION(S)] was not decreased per the MD orders. On 6/3/22, the Assistant Director of Nursing (ADON) documented on the consultation report for antipsychotics, Spoke with [MD name removed] abt [about] all 4 pgs [pages] of recommends. Brief discussion in Pysch (sic) med [medication] mtg [meeting]- zero changes mentioned - still adjusting to new environment - Hold off till Tues [Tuesday 6/7/22] and he will review as there is multiple med changes. Review of the progress notes and physician notes revealed no other documentation from the MD related to the [MEDICATION(S)]. On 6/20/22, the PMHNP documented, Pt. is finally stable - do not recommend decreasing the dose of either medication. He does not tolerate medication changes. It should be noted that the MD and the PMHNP had conflicting orders for the [MEDICATION(S)]. On 8/17/22 at 10:00 AM, an interview was conducted with the Director of Nursing (DON) and the Administrator (ADM). The DON stated that the [MEDICATION(S)] 100 mg two times a day was not started until 7/1/22. The DON stated that the PMHNP ordered the [MEDICATION(S)] taper from 100 mg three times a day to 100 mg two times a day on 6/30/22. The ADM stated that the PMHNP started at the end of May 2022 and there was some confusion with conflicting orders from the MD and PMHNP. The DON confirmed that the MD ordered the [MEDICATION(S)] to be decreased from 100 mg three times a day to 100 mg two times a day, but they did not implement the change for 35 days. The ADM stated that at the end of June or the beginning of July they decided to have the PMHNP write the [CONDITION(S)] medication orders to eliminate any confusion with the medication management. The DON stated that on 5/20/22, she received an order from the MD to discontinue the blood pressure parameters for the [MEDICATION(S)] 5 mg daily. The DON stated that it was after the parameters were discontinued that they received the pharmacy recommendation with the MD new order to discontinue the [MEDICATION(S)] medication all together. The DON stated that the [MEDICATION(S)] medication was not discontinued per the MD's order. The DON confirmed that the Omeprazole was not discontinued and the Famotidine order was not changed per the MD orders. The DON stated that the pharmacy recommendation process was that the pharmacist would send the recommendations to the DON. The DON then placed each resident's pharmacy consultation report in each provider's box for review. The DON stated that the providers would return the consultation report with any medication changes and new orders to the DON, ADON, or the Unit Manager. The DON stated that it appeared to be an oversight and the medication changes were not implemented as ordered by the MD. The DON stated that the [MEDICATION(S)], Omeprazole, and Famotidine changes were not identified and only the ADON could make changes in the electronic medical records.

Based on interview and record review, it was determined, the facility did not ensure that residents who received [CONDITION(S)] drugs were not prescribed the medication unless necessary to treat a specific condition as diagnosed in the clinical record; and residents who used [CONDITION(S)] drugs received gradual dose reductions, monitoring, and behavioral interventions in an effort to discontinue the medication. Specifically, for 1 out of 28 sampled resident, the Medical Director (MD) ordered dose adjustments of [CONDITION(S)] medications that were not implemented and doses of [CONDITION(S)] medications were missed. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of [CONDITION(S)] disorder, type 2 diabetes mellitus, major depressive disorder, obsessive-compulsive disorder (OCD), anxiety disorder, gastro-[CONDITION(S)] reflux, chronic [CONDITION(S)], [CONDITION(S)], obstructive and reflux [CONDITION(S)], retention of urine, dysphagia, [CONDITION(S)], [CONDITION(S)], hypertension, mild cognitive impairment, and [CONDITION(S)]. On 8/15/22, resident 12's medical record was reviewed. Resident 12's physician's orders revealed the following: a. [MEDICATION(S)] Oral Tablet, give 50 milligrams (mg) by mouth two times a day. The order was initiated on 7/15/22. b. [MEDICATION(S)] Tablet 5 mg, give 5 mg by mouth one time a day. The order was initiated on 5/14/22. c. [MEDICATION(S)] Tablet 10 mg, give 10 mg by mouth at bedtime. The order was initiated on 5/14/22. d. [MEDICATION(S)] ([MEDICATION(S)]) Capsule 200 mg, give 200 mg by mouth one time a day. The order was initiated on 7/25/22. Review of resident 12's July 2022 Medication Administration Record (MAR) revealed that the [MEDICATION(S)] was initiated on 7/1/22, at a dosage of 50 mg daily and stopped on 7/7/22. On 7/9/22, the [MEDICATION(S)] dosage was increased to 100 mg daily and was discontinued on 7/15/22. On 7/17/22, the [MEDICATION(S)] dosage was increased to 150 mg daily and was discontinued on 7/23/22. On 7/25/22, the [MEDICATION(S)] dosage was increased to 200 mg daily and remained the current order. The [MEDICATION(S)] was documented as not administered on 7/8/22, 7/16/22, and 7/24/22, in between the dose adjustments. On 6/30/22 at 1:43 PM, resident 12's progress notes documented, resident's insurance will no longer cover his [MEDICATION(S)]. [Psychiatric-Mental Health Nurse Practitioner (PMHNP) name omitted] began taper- decreased [MEDICATION(S)] to 100mg BID [two times a day] x [times] 1 week, then 50mg BID x 1 week. To start [MEDICATION(S)] 50mg QAM [every morning] x 1 week, increase to 100mg QAM x 1 week, then 150mg QAM x 1 week, then 200mg PO [by mouth] QAM indefinitely for OCD. orders in computer and sent to pharmacy On 6/30/22, the PMHNP visit note documented, Taper down [MEDICATION(S)], start [MEDICATION(S)] per insurance denial. Decrease [MEDICATION(S)] to 100 mg BID x 1 week, then 50 mg BID x 1 week, then DC [discontinue]. Start [MEDICATION(S)] 50 mg QAM x 1 week, then 100 mg QAM x 1 week, then 150 mg QAM x 1 week, then 200 mg QAM. Review of the July and August 2022 MAR revealed that the [MEDICATION(S)] 50 mg two times a day order was still active and not discontinued. Review of the pharmacy consultation reports revealed the following: a. On 5/17/22, the pharmacist documented that the resident received two antidepressants for OCD concomitantly: [MEDICATION(S)] 100 mg three times a day, and [MEDICATION(S)] 100 mg at bedtime. The recommendation was that if therapy could not be adjusted to provide a rationale for duplicate therapy. The MD accepted the recommendations with the following modifications: decrease [MEDICATION(S)] 100 mg to two times a day will continue to try to wean. The MD signed the form on 5/26/22. Review of the May, June, July, and August 2022 MAR revealed that the [MEDICATION(S)] 100 mg three times a day was initiated on 5/13/22, and discontinued on 6/30/22. On 6/30/22, the order was changed to [MEDICATION(S)] 100 mg two times a day for 7 days. It should be noted that it took 35 days to implement the taper per the MD recommendation. On 6/20/22, the PMHNP documented a decline to the recommendations and did not want to implement any changes due to, Pt [patient] is stable at this time on both medications. He does not tolerate medication changes. It should be noted that the MD and the PMHNP had conflicting orders for the [MEDICATION(S)]. b. On 5/1/22, the pharmacist documented that the resident received two antipsychotics for [CONDITION(S)]: [MEDICATION(S)] Extended Release, and [MEDICATION(S)]. The recommendation was that if therapy could not be adjusted to provide a rationale for duplicate therapy. The MD response was to decrease the [MEDICATION(S)] to 5 mg two times a day. The MD signed the order on 5/26/22. It should be noted that the [MEDICATION(S)] was not decreased per the MD orders. On 6/3/22, the Assistant Director of Nursing (ADON) documented on the consultation report for antipsychotics, Spoke with [MD name omitted] abt [about] all 4 pgs [pages] of recommends. Brief discussion in Pysch (sic) med [medication] mtg [meeting]- zero changes mentioned - still adjusting to new environment - Hold off till Tues [Tuesday 6/7/22] and he will review as there is multiple med changes. Review of the progress notes and physician notes revealed no other documentation from the MD related to the [MEDICATION(S)]. On 6/20/22, the PMHNP documented Pt. is finally stable - do not recommend decreasing the dose of either medication. He does not tolerate medication changes. It should be noted that the MD and the PMHNP had conflicting orders for the [MEDICATION(S)]. On 8/17/22 at 9:15 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that if she received any physician's orders she would put it into the computer system. LPN 3 stated that if the unit manager (UM) received a verbal order or new order they would put it in or tell the floor nurse to enter it. LPN 3 stated that on one occasion she was present when the provider gave a new order by telephone to the UM and she entered the order. LPN 3 stated that for any parameters on orders they would have to enter that information in the computer. LPN 3 stated that typically they had parameters on blood pressure medications, or monitoring for effectiveness with a pain medication. LPN 3 stated that the computer would not automatically que the nurse for vital sign parameters but would automatically pop up for blood sugars and pain scores. On 8/17/22 at 10:00 AM, an interview was conducted with the Director of Nursing (DON) and the Administrator (ADM). The DON stated that if a medication was scheduled to be administered and no documentation was found in the MAR that she would look on an administration report to verify that the medication had been given. The DON stated she would then look at the progress notes to see if anything was documented about the medication administration. The DON stated that there was no documentation explaining why resident 12 did not receive the [MEDICATION(S)] on 7/8/22, 7/16/22, and 7/24/22. The DON stated that the resident's [CONDITION(S)] medications were discussed in the [CONDITION(S)] Quality Assurance and Performance Improvement meeting. The DON stated what we typically do was discuss the resident, look at the order, look at the notes and see if the provider ordered the medication the way that it was transcribed into the computer system. The DON stated that if the medication was discussed in the [CONDITION(S)] meeting then she would ensure the accuracy of the medication order. The DON stated that if a floor nurse received the new order then they would be responsible to enter the order in the computer system. The DON stated that in the case of the [MEDICATION(S)] order it was given to the floor nurse and they entered it into the electronic medical record. The DON stated that she verified the floor nurse received the [MEDICATION(S)] order by the audit feature and could verify the date that it was ordered to see if there was any special notes applied. The DON stated that the notes stated no missed dates were required. The DON stated that the order should have been entered so there were no missed days in between the dose adjustment. The DON stated that it was an oversight by the nurse and that the resident should not have missed days in between the dose adjustment. The DON stated that the [MEDICATION(S)] 100 mg two times a day was not started until 7/1/22. The DON stated that the PMHNP ordered the [MEDICATION(S)] taper from 100 mg three times a day to 100 mg two times a day on 6/30/22. The ADM stated that the PMHNP started at the end of May 2022 and there was some confusion with conflicting orders from the MD and PMHNP. The DON confirmed that the MD ordered the [MEDICATION(S)] to be decreased from 100 mg three times a day to 100 mg two times a day, but they did not implement the change for 35 days. The ADM stated that at the end of June or the beginning of July they decided to have the PMHNP write the [CONDITION(S)] medication orders to eliminate any confusion with the medication management. The DON stated that on 5/20/22, she received an order from the MD to discontinue the blood pressure parameters for the [MEDICATION(S)] 5 mg daily. The DON stated that it was after the parameters were discontinued that they received the pharmacy recommendation with the MD new order to discontinue the [MEDICATION(S)] medication all together. The DON stated that the [MEDICATION(S)] medication was not discontinued per the MD's order. The DON confirmed that the Omeprazole was not discontinued, and the Famotidine order was not changed per the MD orders. The DON stated that the pharmacy recommendation process was that the pharmacist would send the recommendations to the DON. The DON then placed each resident's pharmacy consultation report in each provider's box for review. The DON stated that the providers would return the consultation report with any medication changes and new orders to the DON, ADON, or the UM for them to implement the changes. The DON stated that it appeared to be an oversight and the medication changes were not implemented as ordered by the MD.

Based on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air, and food items in the walk-in refrigerator were open to air. Findings included: On 8/15/22 at 8:28 AM, an initial walk through of the kitchen was conducted. In the walk-in refrigerator, a box containing bacon was observed to be open with the bacon open to air. On 8/17/22 at 10:53 AM, a second walk through of the kitchen was conducted. In the walk-in refrigerator, a box containing bacon was observed to be open with the bacon open to air. In the walk-in freezer, a box of garden burgers was open with the patties open to air, a box of cookie dough was observed to be open with the dough open to air, and a box of frozen dinner rolls was open with the dough open to air. On 8/17/22 at 11:04 AM, an interview was conducted with the Dietary Manager (DM). The DM stated dietary staff were educated with training videos they were required to watch every month. The DM stated that she provided in-services to employees at the beginning of the shift if specific kitchen practices needed to be reviewed. The DM stated the facility Registered Dietitian conducted monthly audits of the kitchen to ensure the kitchen was clean and items were stored properly. The DM stated she was provided a report after the audit that she documented in the computer and sent to the corporate office.

Based on observation, interview, and record review, it was determined, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 28 sampled residents, a resident was administered the wrong medication during the medication administration task observation. Resident identifier: 41. Findings included: Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 10:22 AM, Licensed Practical Nurse (LPN) 1 was observed to prepare and administer a medication to resident 41. LPN 1 administered [MEDICATION(S)] 100 milligrams (mg) to resident 41. [Note: The [MEDICATION(S)] 100 mg was ordered by the physician to be administered at bedtime and in the morning.] Resident 41's medical record was reviewed for the reconciliation of medications. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [Note: A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 10:56 AM, an interview was conducted with LPN 1. LPN 1 stated that she had administered the [MEDICATION(S)] to resident 41. LPN 1 stated that she should have administered the [MEDICATION(S)] to resident 41. LPN 1 stated that she would need to contact the physician and the Director of Nursing (DON). On 8/17/22 at 11:14 AM, a follow up interview was conducted with LPN 1. LPN 1 stated that she contacted the physician and was instructed to keep an eye on resident 41 and obtain a set of vital signs. LPN 1 stated that resident 41 had been on higher doses of [MEDICATION(S)] in the past. LPN 1 stated that resident 41 would be on alert charting for the next three days which included monitoring. LPN 1 stated she had contacted the physician, DON, Corporate Resource Nurse, and resident 41's family. On 8/17/22 at 11:14 AM, LPN 1 was observed to prepare and administer [MEDICATION(S)] 100 mg to resident 41. LPN 1 was observed to explain the medication error to resident 41 and instructed resident 41 to watch for dizziness. LPN 1 stated she would need to complete an incident report. On 8/17/22 at 12:08 PM, an interview was conducted with the DON. The DON stated the resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that narcotics were stored in the the medication carts in a separate locked drawer. The DON stated the nurses were to compare the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the nurses were to verify the resident name if the nurses were not familiar with the resident and then administer the medications to the resident.

Based on interview and record review, it was determined the facility did not ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding. Specifically, for 2 of 5 sampled residents, the residents' tube feeding formulas were not administered in accordance with recommendations made by the Registered Dietitian (RD) or each of their calculated energy needs which resulted in significant weight losses. Resident identifiers: 1 and 2. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 12/16/20. A review of resident 1's physician's orders [REDACTED]. a. Initiated on 11/5/20 and discontinued on 11/25/20: Enteral Feed . every night shift Infuse overnight with [MEDICATION NAME] with fiber at 100 ml (milliliters)/ (per) hr (hour) . b. Initiated on 11/25/20 and discontinued on 11/20/20: Enteral Feed . every night shift Enteral Nutrition via Pump- [MEDICATION NAME] 1.5 at 100 ml per hour for 12 hours via pump per NG (nasogastric) tube . (Note: Resident 1 discharged from the facility on 11/29/20.) Resident 1's Nutritional Evaluation, dated 11/11/20, documented that her calculated daily energy needs were: 1662.5 - 1995 calories. The evaluation further documented the following recommendations: No diet order in place. RD recommends low residual diet with soft, bland foods. Receiving nocturnal EN (enteral nutrition) @ (at) 105 ml/hr x (for) 16 hrs (hours) provided by high protein formula of [MEDICATION NAME] with Fiber via NG tube . providing 1680 kcals (calories). The evaluation further documented that resident 1 experienced nausea, vomiting, and reflux, was not able to eat much food orally, and was mostly reliant on the tube feeding administration to meet nutrition needs. (Note: Resident 1's physician's orders [REDACTED]. Furthermore, no diet order was implemented for soft, bland foods.) A review of resident 1's progress notes documented the following entries related to tube feeding administration: a. On 11/3/20, a Skilled Nursing Note documented that resident 1 had a NG tube in place and tube feeding formula, specifically [MEDICATION NAME] with fiber, was administered at a rate of 100 ml/hr over the course of 12 hours in accordance with physician's orders [REDACTED].) b. On 11/11/20, a Nutrition/Dietary Note documented that there was no diet order in place and the RD recommended a low residual, soft and bland food diet. The note further documented resident 1 experienced a great deal of nausea, vomiting, and acid reflux resulting in a minimal oral intake of food. The note further documented resident 1 was mostly reliant on enteral nutrition and received [MEDICATION NAME] with fiber via NG tube at a rate of 105 ml/hr for 16 hours nocturnally, which provided a total of 1680 kcal. (Note: Resident 1's tube feeding administration was not changed from 100 ml/hr for 12 hours to 105 ml/hr for 16 hours. Furthermore, resident 1 remained without a diet order.) c. On 11/25/20, a Nutrition/Dietary Note documented that the RD recommended resident 1's tube feeding administration change to [MEDICATION NAME] 1.5 to better meet her needs, which were estimated to be 1600-1900 kcal per day. The note further documented that administration of [MEDICATION NAME] 1.5 at a rate of 100 ml/hr for 12 hours would provide 1800 kcal, and resident 1's nutritional needs were met entirely with enteral nutrition therapy because she did not eat orally. A review of resident 1's weight measurements revealed the following trend: a. On 11/13/20, resident 1 weighed 175.6 pounds. b. On 11/18/20, resident 1 weighed 159.8 pounds. (Note: This weight documented a 9% weight loss since 11/13/20.) c. On 11/24/20, resident 1 weighed 150.9 pounds. (Note: This weight documented a 14.07% weight loss since 11/13/20.) The facility's Tube Feeding Management / Restore Eating Skills policy and procedure, dated June 2018, documented the following information: . PURPOSE: Based upon a comprehensive assessment, the facility supports the resident receiving enteral feedings . 8. ENTERAL NUTRITION. Facility, in collaboration with the RD and Dietary Services, provides direction for . b. How to determine whether the tube feedings meet the resident's nutritional needs and when to adjust them accordingly . The facility's Nutrition and Hydration Maintenance policy and procedure, dated June 2018, documented the following information: . PURPOSE: Based upon a comprehensive assessment, the facility supports the resident in maintaining acceptable parameters of nutritional status, to the extent possible . 4. INTERVENTIONS. Interventions related to a resident's nutrition/hydration status are individualized to the specific needs of the resident . The policy and procedure provided the following suggested parameters for evaluating the significance of unplanned and undesired weight loss: a. Over the course of one month, a 5% weight loss was considered significant and a loss of greater than 5% was considered severe. (Note: Resident 1's weight loss of 14.07% within one month was considered a severe loss.) b. Over the course of three months, a 7.5% weight loss was considered significant and a loss of greater than 7.5% was considered severe. c. Over the course of six months, a 10% weight loss was considered significant and a loss of greater than 10% was considered severe. On 12/16/20 at 12:34 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she received residents' diet orders within the first day of admission. The DM further stated she was told resident 1 did not eat any food by mouth (NPO), she did not receive a diet order for resident 1, and meal trays were not provided for resident 1. On 12/16/20 at 12:43 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 1's tube feeding was administered over the course of 12 hours starting at 6:00 PM. RN 1 further stated weight changes were monitored by the RD, and skin and weight meetings were held to review weight changes. A Skin & (and) Nutrition Review, dated 11/20/20, documented that resident 1 experienced a significant weight loss, and was encouraged to eat soft foods with low residual orally in order to advance from nocturnal tube feeding administration. The review documented the following recommendations: RD Consult . Continue weekly weights. Offer soft diet PO (by mouth) and Boost in between. Monitor for [MEDICAL CONDITION] and continue to monitor weight weekly . (Note: According to resident 1's Medication Administration Record [REDACTED]. Furthermore, resident 1 remained without a diet order.) On 12/16/20 at 1:16 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated residents with tube feedings were weighed on a weekly basis, and the Director of Nursing (DON) and physician were notified of significant weight changes. LPN 1 further stated she was told resident 1 was NPO and while working with resident 1, she complained of severe constipation and bowel pain. On 12/16/20 at 1:33 PM, an interview was conducted with the Unit Manager (UM). The UM stated residents with tube feedings were weighed on a weekly basis and significant weight changes were monitored by herself, the RD, and the DON. The UM further stated resident 1 was fearful of eating, experienced nausea and vomiting, and was reliant on enteral nutrition. The UM stated resident 1 received tube feeding administration at a rate of 100 ml/hr nocturnally, and resident 1 did not have a diet order but was not NPO because she was encouraged to eat orally and worked with Speech Therapy (ST) on swallowing skills. The UM further stated resident 1's significant weight change was attributed to fluid loss. A ST Evaluation and Plan of Treatment, dated 11/17/20, documented that resident 1 presented with moderate oropharyngeal dysphagia, characterized by reluctance to take liquid or food orally related to a fear of vomiting, pharyngeal weakness related to no PO intake for the past four weeks, and decreased safety awareness. (Note: Without any PO intake for the past four weeks, resident 1 was provided with 1200 kcal solely via enteral nutrition which was approximately 460 kcal less than resident 1's estimated daily energy needs.) On 12/16/20 at 2:19 PM, an interview was conducted with the RD. The RD stated residents with tube feedings were reviewed every week for weight changes during a skin and weight meeting, and she communicated any order changes to the team as appropriate. The RD stated she tried to attend all skin and weight meetings but was sometimes unable to attend, and was currently working remotely due to the pandemic. The RD stated she was notified of significant weight changes and also reviewed residents for weight changes herself, and significant weight changes were automatically triggered for review within the electronic medical record. The RD stated following a significant weight change, she worked with the dietary department to implement extra portions, extra protein, or supplementation as appropriate. The RD stated resident 1 ate orally and had a tube feeding, but she was not eating enough orally to discontinue the tube feeding. The RD stated she waited on resident 1's diet order for a while and thought it was implemented, and resident 1 should have received meal trays. The RD further stated resident 1 admitted to the facility with an order for [REDACTED]. The RD stated Boost supplementation was initiated for resident 1, but was discontinued by the physician because resident 1 did not drink a lot of it. The RD further stated she was unsure why resident 1 was changed to [MEDICATION NAME]. The RD further stated resident 1 experienced a significant weight loss, but she was not notified because she had been out of the facility that week and had another RD filling in for her. On 12/17/20 at 10:34 AM, an interview was conducted with the DON. The DON stated skin and weight meetings were held on a weekly basis to review residents with tube feedings, and these meetings were attended by herself, the DM, the UM, and the RD by phone. The DON stated residents were reviewed for significant weight changes and when resident 1 experienced a significant weight loss, the RD was out of town and she was unable to speak with her until a few days later. The DON further stated a soft diet was recommended for resident 1 but she refused food. On 12/17/20 at 3:53 PM, a follow up interview was conducted with the DON. The DON stated resident 1 received tube feeding administration in accordance with discharge orders provided by the hospital, and the formula was changed from [MEDICATION NAME] to [MEDICATION NAME] upon admission to the facility after verifying with the physician that it was an appropriate substitution. The DON stated the RD recommended resident 1's tube feeding administration increase to 105 ml/hr for 16 hours and Boost supplementation be initiated on 11/11/20. The DON further stated Boost supplementation was implemented, but the tube feeding administration rate was not changed from 100 ml/hr for 12 hours to 105 ml/hr for 16 hours. 2. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 12/16/20. The hospital discharge physician's orders [REDACTED]. a. Feedings through a tube and nothing by mouth. b. Durable Medical Equipment Tube Feeding for clinical indication of malnutrition. Promote via pump 75 ml per hour 24 hours per day. Free water 360 ml per day. Tube type nasojejunal tube (NJ). A review of physician's orders [REDACTED]. a. A verbal order received on 11/13/20 at 7:07 PM, Enteral Feed Order every shift Enteral Nutrition via Pump - [MEDICATION NAME] 1.5 at 20ml per hour DHT (Dobhoff Tube). Increase 5ml every 2 hours till able tp (sic) tolerate 75ml per hour. b. Initiated on 11/14/20 at 6:00 AM and discontinued on 11/18/20 at 12:06 PM, Enteral Feed Order every shift Enteral Nutrition via Pump - [MEDICATION NAME] 1.5 at 20ml per hour DHT. Increase 5ml every 2 hours till able tp (sic) tolerate 75ml per hour. (Note: The feeding was documented as initiated on 11/14/20, at Night on the November 2020 MAR. Resident 2 was readmitted to the facility on [DATE] at 7:00 PM. Resident 2 went two days without a tube feeding.) c. Initiated on 11/18/20 at 6:00 PM, Enteral Feed Order every shift until 11/18/20 18:01 (6:01 PM) Enteral Nutrition via pump - Titrate [MEDICATION NAME] 1.5 up to 60ml per hour DHT. Increase 5ml every 2 hours till able t0 (sic) tolerate 60ml per hour. (Note: The feeding was documented as a one time initiation on the November 2020 MAR.) d. Initiated on 11/24/20 at 6:00 AM and discontinued on 12/7/20 at 11:54 AM, Enteral Feed Order every shift Enteral Nutrition via Pump - Titrate [MEDICATION NAME] 1.5 up to 60ml per hour DHT. Increase 5ml every 2 hours till able t0 (sic) tolerate 60ml per hour. (Note: Resident 2 did not have an Enteral Feed Order for 5 days.) A review of progress notes documented the following entries related to tube feeding administration: a. On 11/12/20 at 7:00 PM, a Nursing Note documented that resident 2 was a readmission. b. On 11/12/20 at 9:18 PM, a Nursing Note documented 60mL's of water given. c. On 11/13/20 at 12:30 AM, a Nursing Note documented Hospital did not send nutrition for patient. Contacted MD (Medical Doctor), per unit manager. MD said he had no idea what nutrition to put him on. MD said to give him water every couple of hours per water order and have the AM nurse contact the dietitian. d. On 11/13/20 at 1:20 AM, a Nursing Note documented 60mL's of water given. e. On 11/13/20 at 3:29 AM, a Nursing Note documented 60mL's of water given. f. On 11/16/20 at 3:33 PM, a Nutrition/Dietary Note documented . RD informed of resident's need for EN in the evening on 11/13. Nursing and RD discussed formula, as well as administration. Ordered [MEDICATION NAME] 1.5 @ 75 mL//hr to be titrated up by 5 mL every 2 hours to full rate. Current weight of 135.2# (pounds) (61.45 kg) (kilograms) with BMI (body mass index) of 20.5- within normal limits. Energy needs: Calories: 1,843.5-2,150.8 kcals/day (30-35 kcal/kg) Protein: 73.7-92.2 g PRO (protein) (1.2-1.5 g/kg) Fluids: 1,843.5-2,150.8 mL/day (1 mL/kcal) Reduce rate to 60 mL/hr. Titrate down gradually by 5 mL every 2 hours to new goal rate of 60mL. Formula to provide the following nutritional breakdown daily: Formula Volume: 1,440 mL Water Flush: 120 mL every 4 hours, 720 mL/day Total Fluid Provide: 2,160 mL Calories Provided: 2,160 kcals/day Protein Provide: 97.9 g PRO Implemented outlined order. RD will continue to monitor and follow-up on resident's tolerance. (Note: The feeding was documented as initiated on 11/14/20, at Night on the November 2020 MAR. Resident 2 was readmitted to the facility on [DATE] at 7:00 PM. Resident 2 went two days without a tube feeding.) g. On 11/19/20 at 6:19 AM, a Nursing Note documented . Feeding tube on continuous feeding as resident is NPO. h. On 11/20/20 at 1:15 PM, a Skilled Nursing Note documented . Tube Feeding: Resident is given [MEDICATION NAME] at 75 ml/hr and water at 30 ml/hr. Residents feeding tube is patent and flushes easily. Resident shows no adverse side effects from the food. i. On 11/21/20 at 11:40 AM, a Skilled Nursing Note documented . Tube Feeding: Resident continues on his tube feeding. Rate 75 ml/hr of [MEDICATION NAME] with 30 ml/hr of water. Residents skin around the tube is intact and shows no signs of breakdown. Residents tube is patent and flushes well. j. On 11/23/20 at 5:27 AM, an Orders - Administration Note documented NG tubing clogged this morning. Unable to administer medications. k. On 11/24/20 at 11:35 AM, a Nursing Note documented . Also new orders [MEDICATION NAME] @60ml/hr with 120ml q 4/hr flush. Pump settings adjusted and Foley catheter dc'd (discontinued), continue to assess. (Note: Resident 2 did not have an Enteral Feed Order for 5 days from 11/19/20 through 11/23/20.) l. On 11/26/20 at 9:26 AM, a Nursing Note documented Res (resident) pulled NG tube out about 08:30 am. NP (Nurse Practitioner) and DON reported. Called (Name of Radiology Services), will replace NG tube today. m. On 11/26/20 at 11:36 PM, a Nursing Note documented Team came approximately 2155 (9:55 PM) and replaced NG tube. At 2305 (11:05 PM) CNA (Certified Nursing Assistant) reported resident had pulled NG again. (Name of NP) NP contacted for further instruction. Talked about an IV (intravenous) for fluids tonight, concerned he would pull it out as he did the NG. She suggested this nurse speak to family and see if they felt like it was time to just keep him comfortable. (Name of resident 2's son), his son and POA (power of attorney) would not discuss it. He stated that this behavior was a result of resident getting better and not worse. He inquired how much progress is being made with ST and will he be able to eat soon. This nurse was unable to find any reports but assured (name of resident 2's son) the question would be left with day shift to inquire with ST. (Name of resident 2's son) suggested his dad be left alone for the night and then attempt to place NG again in the morning. This nurse discussed the conversation with (name of resident 2's son) with the NP and she agreed with waiting for the morning. Order an information will be passed on to day shift. n. On 11/27/20 at 4:03 PM, an Orders - Administration Note documented Awaiting tube placement after resident pulled tube out. (Note: Resident 2 was NPO had been without a tube feeding since 11/26/20 at 9:26 AM. The feeding was documented as started on 11/27/20, at Night on the November 2020 MAR. Resident 2 went without a tube feeding for approximately 31 hours.) o. On 11/28/20 at 1:56 AM, a Nursing Note documented Resident pulled his NG tube out again. p. On 11/28/20 at 2:36 AM, a Nursing Note documented (Name of resident 2's son) son/POA would prefer resident not be sent to the ED (Emergency Department) for placement. He is concerned that will make the resident more confused and cause a set back in his progress. (Name of resident 2's son) expressed frustration as the POA. He states he is not being kept in the loop, no one is calling to update him when things such as the NG tube being pulled or any communication of progress or concerns. He stated he is frustrated to not know how ST is going. He would like to know where his dad is with the progress as he is concerned about the lack of nutrition and hydration. (Name of resident 2's son) would like the results of the swallow eval (evaluation) he believes was recently done with the resident. (Name of resident 2's son) would like to be present when the NG is placed next so he can talk with his dad about keeping it in. This nurse will pass on concerns to day shift nurse. q. On 11/28/20 at 1:32 PM, a Nursing Note documented Resident was sent to ER (emergency room ) at (name of local hospital), per MD orders, via stretcher with (name of local transport company). Called and gave nurse to nurse to a nurse at the ER. Gave the nurse the instructions that the family requested. Notified family of the residents transfer and where he was going. Wife went with the resident. r. On 11/28/20 at 5:55 PM, a Nursing Note documented Resident returned from the ER and has a new feeding tube in place. The nurse got the resident hooked up to his feeding and comfortable in bed. The ER sent no new orders with the feeding tube. Resident was compliant with being moved back into bed and with the cares provided by staff. (Note: Resident 2 was NPO and had been without a tube feeding for approximately 16 hours.) s. On 11/28/20 at 11:41 PM, an Orders - Administration Note documented Enteral Feed Order every shift Enteral Nutrition via Pump - Titrate [MEDICATION NAME] 1.5 up to 60ml per hour DHT. Increase 5ml every 60ml per hour Pump is set at 60ml/hour and is well tolerated. t. On 12/2/20 at 2:00 AM, a Nursing Note documented Resident pulled out his NG tube at this time. Resident restless. Notified (name of MD). Verbal order to get NG tube replaced in the morning. u. On 12/2/20 at 11:13 AM, a Nursing Note documented Last night resident pulled out his NG tube, Physician (name of MD) notified and order to sent to (name of local hospital) for reinsertion today processed. Pt (patient) is arranged to go to radiology at 1:30 for it to be placed which is the earliest they can get him in with him being NPO. I have left info to update for his son, notified UM and DON, and notified the NP (name of NP). v. On 12/2/20 at 3:46 PM, a Nursing Note documented (Name of local Hospital) Radiology unable to place NG tube d/t (due to) pt refusal. New orders placed at this time per (Name of MD) for Dysphagia Puree and pudding thick liquids. (Note: Resident 2 was NPO and had been without a tube feeding for approximately 14 hours.) A review of resident 2's weight measurements revealed the following trend: a. On 11/18/20, resident 2 weighed 140.6 pounds. b. On 12/6/20, resident 2 weighed 127.1 pounds. (Note: This weight documented a 9.60% weight loss since 11/18/20.) c. On 12/9/20, resident 2 weight 117.9 pounds. (Note: This weight documented a 7.89% weight loss since 12/6/20.) A review of the Minimum Data Set Discharge Assessment completed on 12/12/20, documented resident 2's weight at 118 pounds. Resident 2 was documented as having a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months without a prescribed weight loss regimen. On 12/15/20 at approximately 9:30 AM, an interview was conducted with LPN 2. LPN 2 stated that she was able to change a resident feeding tube at the facility. LPN 2 stated that it would depend on the circumstances of the feeding tube and the type of feeding tube that had been placed. LPN 2 stated that resident 2 was sent out frequently to the hospital to be xrayed prior to tube placement and the tube would be stitched in place. On 12/16/20 at 1:33 PM, an interview was conducted with the UM. The UM stated resident 2 experienced a massive decline, went to the hospital where it was decided that he was not a good candidate to surgically place a gastric tube, and came back from the hospital with a replaced NG tube. The UM stated resident 2 returned from the hospital with an order for [REDACTED]. The UM further stated resident 2 pulled out his NG tube four times, the hospital opted not to replace it after the most recent time, and resident 2 was eating a little bit by mouth since then. On 12/16/20 at 2:19 PM, an interview was conducted with the RD. The RD stated resident 2 readmitted to the facility on [DATE] with an order for [REDACTED]. The RD further stated resident 2 was complicated and pulled out his NG tube four times in less than a week. The RD stated resident 2's weight was stable until mid-November when he experienced a significant weight loss of over 10% over the course of a couple months, which was attributed to him pulling out his NG tube four times, trying to reinsert the NG tube, hospitalization s, and [MEDICAL CONDITION] treatment. The RD stated resident 2's tube feeding administration was initially titrated up to provide additional kcal and protein, but was switched to [MEDICATION NAME] at the same rate and had to be titrated down to avoid overfeeding because [MEDICATION NAME] had a higher kcal concentration. On 12/17/20 at 11:28 AM, an interview was conducted with RN 1. RN 1 stated that she could not recall the events regarding resident 2's tube feeding on 11/12/20. RN 1 stated that she worked night shift 6:00 PM to 6:00 AM and did not to deal with resident admissions. RN 1 stated that the shift prior to the night shift was good to verify admission orders [REDACTED]. RN 1 stated that two nurses would usually verify the admission orders [REDACTED]. RN 1 stated that the nutrition that would be ordered for a resident would not be available at the facility. On 12/17/20 at 11:52 AM, a follow up interview was conducted with the UM. The UM stated that the nutrition orders for resident 2 were received from the hospital when he was admitted to the facility. The UM stated that the facility did not have the formula that was ordered by the hospital. The UM stated that she had called the hospital and requested that they send resident 2's formula. The UM stated that the hospital had agreed to send a 24 hour supply of formula for resident 2. The UM stated that the night shift nurse called her at midnight to ask what she should feed resident 2 because the hospital had not sent the formula. The UM stated that she had instructed the night nurse to call the MD. The UM stated that the MD instructed the night nurse to hang water through the night and call the dietician in the morning. The UM stated that the dietician was not called until later in the day on 11/13/20. The UM stated that she was the staff member in charge of contacting the dietician. The UM stated that she was not informed in the morning that she needed to call the dietician and the UM stated that she had forgotten about the conversation at midnight. The UM stated that she called the dietician on the evening of 11/13/20, and received the order for resident 2's tube feed. The UM stated that resident 2's tube feeding should have been hung the evening of 11/13/20. The UM stated that she was not aware that resident 2's tube feeding was not started until the evening of 12/14/20. The UM stated that she was not sure what the tube feeding orders were or if resident 2 received a tube feeding from 11/19/20 to 11/24/20.

Based on interview it was determined that the facility did not ensure that the designated Infection Preventionist (IP) who was responsible for the facility's infection prevention and control program (IPCP) had completed specialized training in infection prevention and control. Specifically, the Director of Nursing (DON) who was the designated IP had not completed the specialized training in infection prevention and control. Findings include: On 12/15/20 at approximately 10:30 AM, an interview was conducted with the Administrator. The Administrator stated that the DON was the facility's designated IP. The Administrator stated that the DON had not received a certification and the DON had not completed the specialized training in infection prevention and control. The Administrator stated that the Unit Manager (UM) was the back up IP. The Administrator stated that she was unsure if the UM had the IP certification. The Administrator further stated that there were no staff members in the facility that had completed the specialized training in infection prevention and control. On 12/15/20 at approximately 11:00 AM, an interview was conducted with the UM. The UM stated that she had not received a certification and had not completed the specialized training in infection prevention and control. The UM stated that she was the staff developer and assisted the DON with the IPCP. On 12/15/20 at approximately 11:15 AM, an interview was conducted with the DON. The DON stated that she had not received a certification and had not completed the specialized training in infection prevention and control. The DON stated that she had started the training in March 2020 when she worked at another Long Term Care facility but she had not completed the training. The DON stated that in November 2020 she started working at the facility.

Based on observation and interview it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed without eye protection and gowns in patient care areas. In addition, personal protective equipment (PPE) was not available for staff. Findings include: On 7/30/2020 at 1:35 PM, the Administrator (ADM) stated that the facility supply room was in the basement. The ADM stated that the facility was currently a COVID-19 positive facility. The ADM stated that all residents at the facility except for one had was COVID-19 positive. On 7/30/2020 at approximately 1:35 PM, an observation was made of the Central Supply area on the first floor of the facility. Supplies of PPE were observed in a locked storage room. The Central Supply Director (CSD) stated that most staff members did not have access to the supply room, but Administration personnel could retrieve the PPE supplies requested by staff members. The CSD stated that he supplied the floors with the supplies that they needed before he left the building for the day or weekend. The CSD stated that he was not in the building after 4:00 PM or on weekends. On 7/30/2020 at 1:40 PM, an observation was made of the staff entrance into the facility. There was a secured gate with a fence in front of the door. The Director of Nursing (DON) opened the gate and there was a resident inside the fenced area. There was a small plastic container with 3 drawers observed outside the door to the facility and inside the fenced area. The DON stated that staff donned their PPE outside the door. The DON stated that PPE was in the plastic container. The top drawer had 5 3m brand N95 masks and another box labeled N95 that was empty. The second drawer was observed to be empty. The bottom drawer had a package of 10 disposable gowns. The DON stated that Laundry restocked the PPE at 2:30 PM every day because shift change for nurses and Certified Nurses Aides (CNAs) was at 2:00 PM. The DON was not observed to don a gown or gloves prior to entering the facility. The DON was observed to wear an N95 mask and face shield. The DON stated that she had not tested positive for COVID-19. On 7/30/2020 at 1:50 PM, the CNA scheduler was interviewed. The CNA scheduler stated that staff donned their PPE outside the facility prior to entering. The CNA scheduler stated that staff entered the memory care unit and self screened inside a room directly inside the unit. The CNA scheduler stated that staff were unable to leave the screening equipment in the hallway because residents with dementia were touching the equipment. The room for screening was observed to be full of resident care equipment. There was no observed area for staff to place their masks or face shields. On 7/30/2020 at approximately 2:00 PM, an observation was made of a plastic container about halfway down the 3rd floor hall. The container was observed to have drawers. The DON stated there were gowns in the drawers for staff to don when entering the facility. There were other resident care supplies observed in the drawers. On 7/30/2020 at 2:10 PM, the DON lead surveyors to the break room and into an antechamber to the west hallway of the 3rd floor. Nurse 1 was observed to be sitting in a chair next to a resident. Nurse 1 was observed to be without eye protection and the resident was not observed to be wearing a mask. Nurse 1 stated, It's hot in here and I needed a break from my goggles. On 7/30/2020 at 2:20 PM, an observation was made a large garbage bag in the stair well on the 3rd floor. The DON stated the bag was full of clean reusable gowns for staff to wear. An observation was made of the east hallway of the second floor. Housekeeper (HK) 1 was observed to have a green colored N95 mask on and no eye protection. HK 1 was observed to ask the DON for a new N95 mask. The DON stated that she would get her one in a minute. On 7/30/2010 at approximately 1:00 PM, an interview was conducted with a Floor Staff (FS1). FS1 stated that she worked in the COVID-19 unit on the third floor of the facility. FS1 stated that staff working in the COVID-19 unit had to retrieve supplies and equipment from the clean area in the basement that included the supply room. FS1 stated that staff needed items quickly and therefore did not have time to doff their PPE before going into the storage room. FS1 also stated that PPE was not always available when staff arrived at work. FS1 stated that staff were required to wait multiple times for working staff to locate the correct PPE in the facility. Wait times were between 30 and 40 minutes, and at one time staff were required to wait approximately an hour while PPE was retrieved from another facility, because the facility did not have the PPE on site. FS1 stated that PPE was frequently not stored on the 3rd floor where staff members were required to enter the building. On 8/3/2020 at 3:11 PM, a phone interview was conducted with Nurse 3. Nurse 3 stated that she was an LPN and had tested positive for COVID-19. Nurse 3 stated that all staff entered through the 3rd floor east side entrance. Nurse 3 stated that staff donned PPE outside the facility. Nurse 3 stated that all staff wore an N95 mask, gloves, gown, and goggles or face shield. Nurse 3 stated that she removed her face shield while on break or away from the facility. Nurse 3 stated that she had to work with a surgical mask instead of an N95 mask because there were no N95 masks available outside the 3rd floor entrance. Nurse 3 stated that she called a nurse in the facility to get an N95 mask and the nurse told her that management was aware but there were no N95s in the hall. Nurse 3 stated that she had also worked half of a shift without a gown because there were no clean gowns. On 8/3/2020 at 3:14 PM, a phone interview was conducted with Nurse 4. Nurse 4 stated she was an LPN. Nurse 4 stated that all staff entered through an east side door onto the 3rd floor memory care unit. Nurse 4 stated that she entered the 3rd floor, did hand sanitation, filled out a form, checked her temperature, and had another staff member sign the form. Nurse 4 stated that she donned a gown, mask, gloves and placed a face shield on. Nurse 4 stated that she would remove PPE when taking a break or leaving the facility. Nurse 4 stated that she reused her masks for 3 shifts. Nurse 4 stated there were not enough N95s stored at the staff entrance. Nurse 4 stated that she had to wait outside till staff obtained an N95 mask for her and brought it outside. Nurse 4 stated that masks were not available and she had to wait for a staff member to find one and bring it out to her at least once a week. Nurse 4 stated that she usually had to wait an hour before staff brought a mask. On 8/4/2020 at 12:40 PM, an interview was conducted with Floor Staff 2 (FS2). FS2 stated that it had been difficult getting PPE since the plastic walls were established to designate COVID-19 areas in the facility. FS2 stated that staff were not fit tested for N95 masks for several weeks after starting to work in the facility's COVID-19 units. FS2 stated that floor staff were told that there was equipment or PPE in the COVID-19 units, but nobody knew where it was. FS2 stated that staff were still having difficulty receiving the PPE that they needed within the past two weeks. FS2 stated that the N95 masks were taken home by staff or stored in staff members' cars because FS2 and other staff were not aware that there was a space to keep them in the facility. FS2 stated that wait times to get PPE before starting a shift were often 40 minutes, and screening for shifts occurred on the COVID-19 unit. FS2 stated that there were storage drawers for PPE outside the third floor, but they were not always stocked. On 8/3/2020 at 3:28 PM, a phone interview was conducted with Nurse 2. Nurse 2 stated that if there were inadequate supplies on the COVID-19 units, the nursing staff would go down to Central Supply to retrieve items. Nurse 2 stated that staff working on the COVID-19 units had been in Central Supply multiple times. Nurse 2 stated that the screening process occurred on the COVID-19 unit, instead of before staff entered the facility. Nurse 2 stated that staff had to wait for PPE to be brought to the entrance before they could enter the facility. Nurse 2 stated that the facility had shortages in available of PPE, but someone had always brought it over to the facility or it had been misplaced. On 8/3/2020 at 4:00 PM, a phone interview was conducted with the ADM. The ADM stated that the facility staff were using KN95s until the week of 6/15/2020, when all staff changed to N95s. The ADM stated that all staff were fit tested with N95s and all staff were to be wearing N95s. On 8/4/2020 at 9:40 PM, a follow up phone interview was conducted with the CSD. The CSD stated that there were 4 types of N95 masks used by the staff. The CSD stated that he did not know how many staff required which type of masks. The CSD stated that he had a total count of how many N95 masks he had but did not divide them out into each type. The CSD stated that staff for the COVID-19 unit entered through the 3rd floor east side. The CSD stated that a laundry staff member delivered reusable gowns to the 3rd floor about 2:00 PM everyday. The CSD stated that staff requested N95 masks and he delivered them to the antechamber on the 3rd floor. The CSD stated that he sent 30-60 N95 masks to the 3rd floor at a time. The CSD stated that he thought staff took their N95 masks home with them. The CSD stated staff were to use a mask for 3 shifts before disposing of them and getting a new mask. On 8/4/2020 at 11:02 AM, a phone interview was conducted with the ADM, DON, Administrator in Training (AIT), and a Regional Nurse Consultant (RNC). The ADM stated that all staff should wear full PPE (N95 mask, eye protection, a gown, and gloves) while in the areas with COVID-19 positive residents. Staff should store their N95 face masks in the break rooms, located in the center of each hallway on the second and third floors. The ADM stated that the masks can be used for 2 1/2 days because taking them off during an employee break counted as 1 use. The ADM stated that staff should not retrieve items from Central Supply if they are working with COVID-19 residents. The ADM stated that there were not always masks at the entry site for the staff, because if we leave masks out, they get stolen. We have to keep them secure. The AIT stated that she and one of the unit managers would go to the facility at approximately 1:00 AM to retrieve items for the staff on the night shift if staff needed items that were unavailable on the floors, but they had not been called in the past few weeks. On 8/5/2020 at 2:25 PM, a follow up interview was conducted with the ADM and AIT. The AIT stated that staff members were provided a plastic shoe box container in which to store their face shields and N95 mask. The AIT stated that the containers were stored in the antechamber on the third floor. The AIT stated that staff who were working brought the container to the on-coming staff at the 3rd floor east side entrance.

Based on interview and record review it was determined, for 8 of 35 sampled residents, that the facility failed to ensure the residents were free from abuse and neglect. Specifically, the facility did not provide protection to ensure that residents were free from verbal and physical abuse from other residents. Resident identifiers: 10, 14, 17, 32, 35, 43, 47, and 59. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/2020 at 8:43 AM, resident 10 was observed sitting in a wheelchair. Another resident forcefully kicked resident 10's wheelchair twice while he was sitting in it, swore at resident 10, and accused resident 10 of blocking the hall. Staff escorted the other resident away. There was no incident report completed. On 2/23/2020 at 5:07 PM, resident 10 and another resident were observed during a verbal altercation. Resident 10 was guided to the other side of the room and then staff walked away. Resident 10 then returned back to the other resident and resumed the verbal altercation. Staff again guided Resident 10 away to the other side of the room and then walked away. Resident 10 again returned to the other resident and resumed yelling at him. Staff then took Resident 10 by the hand and walked down the hall with him. There was no incident report completed. On 2/19/2020 resident 10's medical record was reviewed. Nursing progress notes revealed the following 13 abusive incidents: a. On 9/17/19, CNA (Certified Nursing Assistant) saw resident go into room [ROOM NUMBER] at approximately 1635 (4:35 PM) .When staff arrived to room this resident was laying on 306-1's bed, 306 was standing over him and the two of them were hitting each other .Nurse assessed for injuries and found a large bruise and skin tear to left arm near wrist, he has bruising to back of both hands, and swelling to left hand. b. On 9/17/19, At approximately 1500 (3:00 PM) staff witnessed resident and 306-1 coming out of room [ROOM NUMBER] fighting. They were both attempting to hit each other. c. On 9/17/19, At approximately 1613 (4:13 PM) nurse heard 314-3 yelling Get out of here from nurses station, nurse went to investigate and found 314-3 sitting on his bed with his hands up trying to stop this resident (resident 10) from punching him. d. On 10/8/19, Nurse heard loud angry growling coming from 319-1 when nurse went to investigate nurse saw this resident (resident 10) and 319-1 facing each other and they both had their arms out in front of them. When 319-1 went to hit this resident and this resident pushed 319- . e. On 10/25/19, .RN (Registered Nurse) reports resident (resident 10) was found on the floor in a supine position. Head was pointed towards the door and feet out stretched towards the window. Peer was on top of resident. f. On 10/29/19, At 1905 (7:05 PM), (resident 10) was observed laying (sic) on the ground in the hallway by room [ROOM NUMBER], and next to resident 318-2. Resident 318-2, stated that (resident 10) was trying to get into his sister's room, and so he grabbed him .lowered (resident 10) to the floor so that he would stop. g. On 10/30/19, He had a res (resident) to res where contact was made between anther (sic) resident and him .Some redness at the time that has since resolved. Res requires constant supervision and stand by from staff to maintain safety h. On 10/31/19, (Resident 10) continues to be agitated. He walked up to this nurse during shift report, grabbed nurse by the arm, and began punching nurse .staff was unable to stop him from going into others rooms, unless they were right next to him, either blocking the doorway, or calling out to him and directing him away while being right next to him. i. On 10/31/19, CNA (Certified Nursing Assistant) reports resident met peer at the end of the hall. Both were attempting to open the door that leads to the stairs. Resident pushed peers hands out of the way and they both started to slap at each others hands. j. On 11/1/19, . Resident went into room [ROOM NUMBER]. Resident in bed one got upset, got him from the arm and tried to throw him on the bed. k. On 11/1/19, Heard yelling and looked down the hall. Observed 306 bed 1 push resident (10) from the front. The resident fell to the ground striking his head against the floor. l. On 11/7/19, .RN reports resident (10) was found on the floor in peer's room. Central Supply Manager (CSM) interviewed. States observed peer dragging resident out of peers room. Resident was supine while being dragged. m. On 1/16/2020, Res had a physical encounter with another resident at dinner time this shift. Res went to take a cup from someone and the other person got upset and physical contact was made. (Incident report states resident 10 was struck in the eye and abdomen.) Resident 10's Care Plan contained the following focus areas and interventions pertaining to aggression and abuse prevention: a. Focus - (Resident 10) has behavioral issues such as wandering, responding to others with aggressive behaviors, risk of escalating behaviors. Date Initiated: 10/09/2019 Revision on: 11/08/2019 b. Focus - Not easily re-directible (sic) and can be aggressive (with staff and other residents) when attempting to re-direct. Date Initiated: 10/09/2019 Revision on: 11/29/2019 c. Interventions - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 10/09/2019 d. Interventions - If verbal cues do not work, take his hand and guide him away. If he begins hitting or kicking to residents, guide him away from behind. If he begins hitting or kicking staff, try to get to his side and maintain the safety of (resident 10) and staff. Date Initiated: 11/01/2019 On 2/20/2020 at 11:01 AM, RN 3 was interviewed. RN 3 stated that when residents had an altercation, We intervene. We pull them apart. We check for injuries and notify the providers and do an incident report. We can't do any restraints. We don't do any sort of physical restraints training. When asked specifically about resident 10, RN 3 stated, He'll kind of smack you a bit when he walks by if he's mad but that's it. Everyone just keeps an eye on him. On 2/20/2020 at 11:12 AM, CNA 4 was interviewed. CNA 4 stated that when residents were physically aggressive with each other, We intervene and separate them. We separate them by bringing one resident away and telling them to stop. We never have to hold residents, usually we just verbalize. When asked specifically about resident 10, CNA 4 stated, Almost daily when we change him he'll hit us, kick us, grab us, that sort of thing. And he squeezes hard! He did have a couple resident to resident incidents and some of the other residents complained about him going into their rooms. We all keep an eye on him to make sure he doesn't go into other resident's rooms. On 2/20/2020 at 11:22 AM, CNA 5 was interviewed. CNA 5 stated that (Resident 10) can be a bit aggressive. I haven't had any violence training, I don't think. I might have some coming up, I'm not sure. On 2/20/2020 at 11:32 AM, CNA 2 was interviewed. CNA 2 stated, There's times we've had to pull residents apart or hold them. The longest we've had to hold was for 30 seconds I think. In general I know we're not supposed to grab residents but I don't know what our policy is. When asked specifically about resident 10 she stated, This morning during cares he was swinging at us. We all just try to keep an eye on him to keep him safe when he's out in the hall. On 2/24/2020 at 1:14 PM Licensed Practical Nurse (LPN) 1 was interviewed and asked how staff keeps resident 10 safe. LPN 1 stated, (Resident 10) is more monitoring for agitation. He gets agitated when redirected. If there's a resident to resident we report it to the doctor and administrator. On 2/25/2020 at 3:30 PM the Director of Nursing (DON) was interviewed. The DON stated that when resident 10 had behaviors, the nurses are supposed to put in notes about immediate interventions. If they weren't enough interventions, we'll update the care plan in the next IDT (Interdisciplinary Team) meeting. We've asked the nurses to put their interventions on the nurses note or the incident note itself. If the resident being abused has a reaction, we teach the staff to report that as an incident. We found that the [MEDICATION NAME] was the best thing for (resident 10). His incidents have decreased since then. He's not a hoarder but if you tell him to leave he doesn't understand it; he can't follow directions. On 2/25/2020 at 5:00 PM, the Administrator was interviewed. The Administrator stated that the facility protects residents from other and responded to aggressive residents by staff being very aware of residents and by having staff act appropriately. The Administrator stated that there were a lot of opportunities for potential incidents. We try to do the best we can and we're not perfect with that. The Administrator stated that the facility proactively avoids resident to resident abuse by doing a lot of in-services and trainings included the journeys training for instructions on how to interact with the memory care population. That is the proactive piece of that, and I think that's probably not resident specific proactive, it's probably reactive on that. The program training especially for the Alzheimer's unit, the reactionary stuff is really proactive. There are times when there are near misses or near incidents when we say, 'hey, that happened, we say we should be smarter about that going forward'. The Administrator stated that the facility had regular abuse training, including types of abuse, who to report it to, the time frame, etc., and was completed upon hire and at least yearly. The Administrator stated that the facility had a monthly QA (Quality Assurance) meeting and we've QAPI'd (Quality Assurance and Performance Improvement) abuse and potential abuse, and staff addressed specific residents who are ramping up or who have had recent incidents. 2. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/2020 resident 32's medical record was reviewed. Nursing progress notes revealed the following abuse incidents: a. On 7/11/19, Pt wandering into other residents (sic) rooms today. She attempted to wander into 316-3 when the resident 316-3 kicked her in the lower leg. b. On 7/13/19, (Resident 32) was walking down the hall when 316-3 grabbed her by the right wrist and pulled her in a half circle. Nurse intervened . c. On 10/10/19, 318-2 pushed (Resident 32) into the wall, hitting her head, and her shoulder on the wall. d. On 10/25/19, RN states she observed resident fall to her hands and knees after 315 bed 1 grabbed her by the arms and pushed her out of room [ROOM NUMBER] .Has purple/red marks along forearm. e. On 11/8/19, CNA called RN to resident .CNA reports peer stood and pushed her to the floor after she reached for his coffee. f. On 11/16/19, (Resident 32) found on the floor in her room, laying (sic) between her part of the room and 308-2 part of the room .(Resident 32) was laying (sic) on her left side, and unresponsive. (Note: Neurological (Neuro) checks were not done and a head to toe assessment failed to detect a femoral neck fracture). g. On 11/17/19, (Resident 32) was found to be kneeling at the side of her bed closest to 308-2. When asked about if she saw what happened, (Resident 32) roommate 308-2 stated she was just trying to push (Resident 32) back onto her own side .From her reaction, it sounded like she pushed (Resident 32) and caused her to fall to the floor. h. On 11/18/19, Staff found (Resident 32) kneeling next to her bed .When staff asked (Resident 32) roommate who was nearby if she knew what happened, she became upset, and stated that she was just trying to push (Resident 32) away from her own bed. i. On 12/17/19, Staff entered (Resident 32) room when they heard her roommate screaming. (Resident 32) was found on the floor at the foot of her bed laying (sic) on her left side, and Her roommate was yelling at her. (Resident 32) had some bruising, and skin tears on bilateral forearms. Roommate became very defensive when asked about the incident stating that (Resident 32) was in roommate's area trying to take roommate's things. Wandering into others personal space, and taking their belongings d/t (due to) her confusion is a normal behavior for (Resident 32). j. On 2/4/2020, nurse called to lounge area and informed that this resident and 310-1 were fighting over the baby doll that (Resident 32) was holding .(Resident 32) wouldn't let 310-1 take the doll so 310-1 hit her in the left cheek and then she hit 310-1 back. k. On 2/5/2020, 310-1 hit (Resident 32) twice in the left arm/shoulder area. She hit 310-1 back who then hit her with a baby doll in the left shoulder. She then stood up from the chair and proceeded to hit 310-1 in the face/left cheek. Staff intervened and separated them from each other, but as she turned to walk away 310-1 kicked her in the legs. A Social Services Quarterly and Annual note dated 1/25/2020 stated D/t (due to) (Resident 32) severe dementia, she is at risk for exploitation/abuse d/t lack of social/safety awareness. (Resident 32) is a high wander risk d/t dementia & resulting lack of safety & personal awareness. She continues to collect things/moves things that aren't hers which is often upsetting to others. She requires almost constant staff supervision to redirect her from intruding on others personal space & rooms. During the last quarter, (Resident 32) has been victim of several altercations w/now-prior roommate. (Resident 32) roommate had shoved (Resident 32) several times, causing fall w/LOC (loss of consciousness) & a fx (fracture). Resident 32's Care Plan contained the following focus areas and interventions regarding physical harm: 1 . Focus - (Resident 32) will not experience any harm from gathering or hoarding behaviors through the next review date. Date Initiated: 10/30/2017 Revision on: 07/12/2019 Target Date: 10/12/2019 Interventions - Intervene as necessary to protect the rights and safety of others. Approach/Speak In a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 04/25/2018 Revision on: 08/16/2018 2 . Focus - (Resident 32) responds only verbally to verbal redirection and has difficulty physically responding to verbal redirection. Date Initiated: 05/24/2017 Revision on: 09/06/2018 Interventions - (Resident 32) needs increased physical redirection along with verbal redirection. Date Initiated: 08/16/2018 Revision on: 09/06/2018 Between 2/18/2020 and 2/20/2020, multiple observations were made of resident 32 entering other resident's rooms and leaving with items. The resident was redirected by staff on two occasions. Observations include: a. On 2/19/2020 at 11:12 AM, resident 32 observed entering room [ROOM NUMBER] and leaving with a pillow. b. On 2/19/2020 at 11:45 AM, resident 32 observed attempting to take a candy bar from another resident. Resident 32 was redirected by staff. c. On 2/20/2020 at 11:19 AM, resident 32 observed carrying two pillows, one [MEDICATION NAME], two pencils, and a few crumpled tissue papers. Resident 32 entered room [ROOM NUMBER] and left shortly thereafter. d. On 2/20/2020 at 11:29 AM, resident 32 observed walking down the hall with two towels. Resident entered and exited two rooms at the far west end of the hall. e. On 2/20/2020 at 11:37 AM, resident 32 was observed walking down the hall with two stuffed animals. It was not observed where she obtained them. f. On 2/22/2020 at 11:20 AM, resident 32 was observed carrying a pillow that she had retrieved from another resident's room. Resident 32 was also observed taking tissues from a housekeeping cart and leaving them in room [ROOM NUMBER]. g. On 2/23/20 at 5:25 PM, resident 32 was observed dropping off items that were in her hands on the nurse's cart. Resident 32 then took several medication cups from the nurse's cart. Resident 32 then grabbed a bed sheet and deodorant that she found on a cart in the hall. Resident 32 went into room [ROOM NUMBER] and came out empty handed shortly thereafter. Resident 32 was then guided by staff into the lounge. Further investigation regarding resident 32's fall with loss of consciousness and a [MEDICAL CONDITION] on 11/16/19 revealed the following nursing progress notes: a. 11/16/19 7:15 PM (Resident 32) found on the floor in her room, laying between her part of the room and 308-2 part of the room .(Resident 32) was laying on her left side, and unresponsive. VS (vital signs), 84/48 (blood pressure), respirations (resp) 18, HR (heart rate) 72, SPO2 (blood oxygenation) 97%. She slowly became responsive, assessed her hips and shoulders, then proceeded to roll her onto her back where a complete physical assessment could be done. Mo (sic) injuries noted at this time 308-2 stated that she pushed (resident 32) down .Neuro checks initiated. Pt (patient) lifted to a chair and removed form the room. b. 11/17/19 5:03 AM While staff was getting her ready for bed, she looked like she was in pain. Resident had a dose of schedule [MEDICATION NAME]. It seemed that help her with pain. c. 11/18/19 1:33 AM .(Resident 32) has been limping on her left leg while walking, and has decreased use of left arm, and was seen cradling it some. After speaking to family and hospice X-ray of left shoulder only was obtained. Results of x-ray state No evidence of acute bone abnormality. (Resident 32) has been asleep since about 2100 (9:00 PM) .While awake (resident 32) was walking around the unit, but after sometime it was obvious that she was in pain and she was given pain medication and encouraged to sit either in a normal chair or a wheelchair. d. 11/19/19 4:51 PM Resident having pain in left hip, arm, and rib areas. Resident putting light pressure on LLE (lower left extremities). MD (medical director) and hospice nurse notified, x-ray of left hip .ordered. X-ray result impression: suspected non-displaced left femoral neck fracture. Recommended MRI (Magnetic Resonance Imaging) of left hip for confirmation of fracture. On 2/21/2020 at 7:18 PM, CNA 11 was interviewed. CNA 11 stated that abuse occured when someone got hurt. CNA 11 stated that she had not witnessed abuse, but had witnessed resident to resident altercations where residents were punching each other. On 2/21/2020 at 6:48 PM, CNA 9 was interviewed. CNA 9 stated that she had witnessed several resident to resident altercations. CNA 9 stated that the residents were separated and calmed down by distraction. CNA 9 stated that the residents had to be taken to their rooms because the activity room was closed in the evening after dinner. CNA 9 stated that she had witnessed residents hitting each other. CNA 9 stated that she reported abuse to the nurse, who reported it to the Administrator. On 2/21/2020 at 7:10 PM, CNA 4 was interviewed. CNA 4 stated that she had assisted when residents were hitting each other, and pulled them off each other. CNA 4 stated that the residents calmed down quickly after being separated. CNA 4 stated that there were tussles, but no abusive residents. On 2/21/2020 at 6:36 PM an interview was conducted with CNA 10. CNA 10 stated that she had witnessed some residents hitting each other, but it was normal for their diagnosis. CNA 10 stated that it's not really abuse if they don't get hurt, and they don't know they're being abusive. CNA 10 stated that residents were separated when hitting, and staff helped them feel safe and comfortable. On 2/21/2020 at 7:02 PM, LPN 2 was interviewed. LPN 2 stated that when residents yelled at each other but did not have emotional reponses afterward, it was not abusive. LPN 2 stated that when there were physical confrontations, the residents were separated and checked for injuries. LPN 2 stated that the residents were questioned about who touched who and where, and if there were injuries, it would be reported to the Administrator. LPN 2 stated that when there was an altercation, staff removed the person easiest to redirect. LPN 2 stated that hitting, yelling and kicking were abusive, but no abuse was occurring in the facility. LPN 2 stated that the victim must feel bad for it to be abuse. LPN 2 stated that she had witnessed resident 26 yell at other residents, resident 32 wander into other residents areas, and resident 10 getting really close to other residents and bothering a lot of people. On 2/22/2020 at 11:34 AM, CNA 8 was interviewed. CNA 8 stated that she had pulled residents off each other when there were altercations. CNA 8 stated that staff then got them away from each other, redirected them to another activity, and checked to see if they had been hurt. CNA 8 stated that if staff suspected abuse, it would be stoped and reported to the supervisor, the nurse, or the Administrator. On 2/22/2020 at 11:40 AM, CNA 7 was interviewed. CNA 7 stated that she had only witnessed one resident-resident altercation, and the residents had been separated by staff. CNA 7 stated that she let the nurse know about the incident. On 2/24/2020 at 1:12 PM, LPN 1 stated that resident 32 frequently wandered, going into other rooms. We have to monitor for her safety. We just have to keep an eye on her and make sure we can catch her before she goes into other resident rooms. On 2/25/2020 at 8:12 AM, RN 3 was interviewed. RN 3 stated that she remembered when resident 32 was pushed to the floor and stated, I walked into the room and asked her roommate what happened. (Roommate) said ,'I pushed her down'. A head to toe assessment was done (of resident 32), I checked her hips and shoulder then got her back up in her chair. We did neuro checks because obviously being pushed that hard she would have hit her head. On 2/25/2020 at 9:40 AM, MD 1 was interviewed. MD 1 stated that it was not automatic that a resident would be sent to the emergency department, but if the resident was unresponsive and unable to give an accurate account, then sending them out to the hospital would be appropriate. On 02/20/2020 at 11:01 AM, RN 5 was interviewed. RN 5 stated that for aggressive residents, If there's any physical aggression we intervene. We pull them apart. We check for injuries. We notify the providers and do an incident report. We don't do any sort of physical intervention training here. When asked specifically about resident 32, RN 5 stated, We all just try and keep an eye on her. She wanders into other resident's rooms and will sometimes take things. It bothers the other residents. We just have to try and catch her before she does it. On 2/20/2020 at 11:22 AM, CNA 5 was interviewed. CNA 5 stated that to keep residents safe, I've never had to pull any residents apart. I haven't had any violence training. I might have some coming up, I'm not sure. On 2/20/2020 at 11:32 AM, CNA 2 was interviewed. CNA 2 stated, There's times we've had to pull residents apart or hold them. The longest we've had to hold was for 30 seconds. In general I know we're not supposed to grab residents but I don't know what our policy is. On 2/24/2020 at 1:12 PM, LPN 1 was interviewed. LPN 1 stated that resident 32 wanders and goes into other rooms. We have to monitor for her safety. It upsets the other residents. We just have to keep an eye on her and make sure we can catch her before she goes into other resident's rooms. On 2/25/2020 at 3:18 PM, the DON was interviewed. The DON stated, We try to keep things in (resident 32's) arms. We are trying to keep books, pillows, stuffed animals, and things stocked on the unit to keep her hands full. As long as we have things there she doesn't feel the need to steal. We've purchased pillows, stuffed animals, books, and residents will take them and wander and leave them somewhere. We can't even figure out where they're hiding some of this stuff. We also try to feed her and then have her sit down; she'll sit and fall asleep. We have staff give her a bag of cheerios to walk with and eat. I need to find out how this is being communicated this to staff. On 2/25/2020 at 5:00 PM, the Facility Administrator was interviewed. The Administrator stated that residents were kept safe by staff being very aware of other residents. Having staff act appropriately. The Administrator stated that there were a lot of opportunities for potential incidents. We try to do the best we can and we're not perfect with that. The Administrator stated that training included a lot of in-services. The journeys training is the - which would deal with that population, is the proactive piece of that, and I think that's probably not resident specific proactive, it's probably reactive on that. The reaction is creating proactive for the next possible event. How do we prevent this next time on a reactive basis? The program training especially for the Alzheimer's unit, the reactionary stuff is really proactive. There are times when there are near misses or near incidents when we say, 'hey, that happened, we say we should be smarter about that going forward'. The Administrator stated, We have regular abuse training, types of abuse, who to report it to, the time frame, etc. That's probably our most - our first training that is done. Orientation, upon hire and at least regularly. When asked if there is a quality assurance (QA) process and if so, how has resident to resident abuse been addressed, the Administrator stated, We have a monthly QA meeting and we've QAPI'd (Quality Assurance and Performance Improvement) abuse and potential abuse, we talk in the QA specifics, particularly specific residents who are ramping up or who have had recent incidents. Those are the kinds of things. 3. Resident 14 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 14's medical record was reviewed on 2/19/20. A progress note for resident 14 dated 9/17/19 documented Nurse heard resident yelling 'Get out of here' coming from his room around 1613 (4:13 PM). Nurse went into his room to investigate and found him holding his arms up in the air while 317-3 was standing over him attempting to punch him. Resident stated that 317-3 came into his room and punched him twice in the face. Nurse separated the residents and escorted 317-3 out of resident's room. Nurse then assessed resident for injuries and found his left eye was bruising up and his left cheek was starting to swell. Ice pack was applied to resident's left cheek and eye, PRN pain medication was offered but resident refused it. MD (medical doctor), DON (Director of Nursing), administrator, and daughter notified. A follow-up progress note dated 9/19/19 documented .Recalls incident where peer punched him. Recognizes peer. Avoids peer's path and eye contact with peer. Bruising to left eye is purple/yellow/green. An incident report investigation conducted by the facility administrator on 9/25/19, documented On 09/17/2019, From (resident 14's) description (resident 10) went into (resident 14's) room and sat on the bed with (resident 14) prior to having a physical altercation with (resident 14). (Resident 10) initially started to push (resident 14), which escalated to throwing punches. During the incident (resident 14) attempted to defend himself as (resident 10) punched him several times. The residents separated as (resident 14) backed off, followed by (resident 10) backing off. The residents were assessed for injuries and vital signs were taken. (Resident 14) presented with a bruise under is left eye. (Resident 10) was unable to provide information regarding the incident due to his diagnosis. [MEDICAL CONDITION] with behavioral disturbance. When asked post immediate incident, (resident 10) is unable to offer further details. (Resident 14) was able to describe the incident as detailed above. Caregivers were unable to offer further details. The residents were separated and kept apart from each other that evening. The incident was reported to the administrator. Police official was called and met with the residents and the administrator. APS (adult protective services) was informed of the incident. The physician was notified of the incident. Facility leadership instructed caregivers to keep the residents apart from each other in dining room and other areas. Caregivers were also instructed to watch for early signs of escalating behavior and intervene as appropriate. (Resident 14) indicated that he felt 'jittery' in the facility, didn't fear the resident involved, and apart from the bruising is not currently exhibiting signs of pain, distress, or harm. As such, abuse is substantiated. 4. Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 35's medical record was reviewed on 2/19/20. A review of resident 35's progress notes revealed the following documentation: a. On 7/15/19 About 0006 (12:06 AM), (resident 35) was heard yelling for nurse from her bedroom. When approached by nurse (resident 35) stated that her roommate (resident 49) tried to rape her. When questioned further about the incident she stated that (resident 49) came to her and put her hand down (resident 35's) pants while she was sleeping. When I spoke to (resident 49) about the incident, resident stated that she thought (resident 35) wanted sex. A staff member has been in front of their door since the incident to monitor, and ensure a repeat incident doesn (sic) not occur. b. On 7/23/19 At approximately 1815 (6:15 PM) CNA (certified nursing assistant) and 315-3 notified nurse that (resident 49) had managed to get into room [ROOM NUMBER] while staff was cleaning up dinner. 315-3 stated that (resident 49) 'tried to get at' (resident 35). Nurse and CNA went to talk to resident and she stated (resident 49) walked toward her and (resident 35) put her hands up and told her to stop and then 315-3 said something to (resident 49) also and then (resident 49) left the room. Resident (35) upset that (resident 49) will not leave her alone. Staff notified to keep eyes on (resident 49) and try to keep her from resident. c. On 7/24/19 At approximately 1500 (3:00 PM) nurse was informed by CNAs that (resident 49) had walked into the dinning room during an activity and that she tried to grab (resident 35's) crotch. (Resident 35) stated that she slapped (resident 49's) hand away. The activities person saw her slapping (resident 49's) hands and interveened (sic) and then took (resident 35) to the other nurse on duty. Resident stated that (resident 49) came up to her and was reaching to grab her between the legs when she slapped her hand away. (Resident 49) was taken back to her room and nurse took (resident 35) down to speak with DON who will notify the administrator. Staff keeping the two residents separated. Will continue to monitor the situation. A review of the facility incident reports pertaining to the incidents with resident 35 and resident 49 revealed the following: a. The incident report investigation for the incident on 7/15/19, conducted on 7/23/19 by the facility administrator, documented . On 07/15/2019 at approximately 12:16am, a nurse heard loud noises coming from (res (TRUNCATED)

Based on observation, interview and record review, it was determined for 1 of 35 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, one resident's care plan was not updated, the resident was not monitored more frequently, moved closer to the nurses' station, nor moved to the third floor for better supervision. Also, the facility failed to keep the facility in good repair and caused the resident to have a fall. Resident identifier: 18. Findings include: Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 2/20/2020, resident 18's medical record revealed that resident 18 had eight falls with over a seven month period. Nurse's notes had falls occurring on: a. On 6/6/2019 resident 18's roommate was calling for help. We found resident 18 on the floor, laying on resident 18's right side with head towards nightstand. Resident 18 had legs semi-extended. Resident was alert. Nurse and CNAs checked for injuries no injuries were noted. b. On 6/7/2019 resident 18 had another fall this am. Resident 18 was found on the floor parallel next to his bed on his back. When asked what happened, he stated that he fell out of bed, that he did not hit his head. c. On 7/8/2019 resident 18 had un-witnessed fall and has a laceration to left side of head, glued shut by hospice on 7/8. d. On 8/17/2019 resident 18 was found by a CNA in the resident's room found him in the bathroom on the floor. He was setting right in front of the toilet with his back leaning against bathroom wall. Resident 18 was patiently waiting for someone to come and help him up. e. On 10/1/2019 resident 18 had an un-witnessed fall. Resident 18 was found on his knees beside table and chair. No injuries noted. f. On 11/21/2019 it was reported to nurse that resident 18 was near the window and fell during the night. Resident was helped into bed by roommate. Resident was assessed by nurse and found no injuries. g. On 1/6/2020 resident 18 had an un-witnessed fall from toilet about 1300 (1:00 PM) due to toilet broken. Res denied head hit. Skin intact, no bruises noted this time. h. On 1/29/2020 resident 18 was founding sitting on floor in his room about 17:20 PM. Resident 18 is alert to self and complaining of pain on left buttock. Resident 18 could not move of left leg while staff was assessing him. Reported to Centric Physicians. X-ray was ordered and resident's X-ray on the Left hip was taken and the results was faxed back that stated Resident 18 had a fractured femoral neck. Resident 18 was transported to St. Mark's hospital Emergency department. Director of Nursing (DON) was notified and resident 18's sister was called, who said she would contact resident 18's daughter. On 2/25/2020 an interview with the DON was conducted. The DON stated that the following interventions were implemented: 1. Floor mats and pads. 2. Found that he could walk with a walker, so we took those away because they could have been a bigger problem due to resident 18 being unsteady. 3. Good footwear, reminders, wears shoes. 4. Resident 18 doesn't acknowledge his needs. 5. Resident 18 would be found in the bathroom. The DON continued by saying he was admitted from home on the dementia unit. Now I'm more inclined to think he has dementia than when we first got here. He could remember a lot long term but his long term wasn't the greatest. He's fastidious.

Based on interview and record review it was determined, for 2 of 35 sampled residents, that the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice. Specifically, full and complete neuro checks were not performed on three separate occasions for two residents who suffered falls with head injuries, and a resident was not taken to the hospital upon being found unresponsive. Additionally, it was discovered this resident had a [MEDICAL CONDITION] three days later. Resident identifiers: 10 and 32. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/20 resident 10's medical record was reviewed. Nursing progress notes revealed the following incidents: a. On 10/27/19 at 12:10 PM, Resident (10) was ambulating down hall headed east by shower room when he came up to laundry barrel in hall and he reached for hand rail on wall when he lost balance falling to floor on left side staff that seen (sic) him fall reported that he didn't see him hit his head but was noted to have approx 1 x 1 cm (centimeter) bruise with approx 1/4 cm skin tear on left temple area . b. On 11/8/19 at 4:24 PM, .Neuro checks have been within normal range.(Note: There is no progress note indicating why neuro checks were being done) c. On 11/9/19 at 3:27 AM, Re-injured left eyebrow on fall 11/08/19. (Note: There is no progress note documenting a fall, however, there is an incident report dated 11/7/19 documenting resident 10 being found on the floor) d. On 12/31/19 at 4:12 AM, Approximately 2215 (10:15 PM), (resident 10) fell in his bedroom, and hit his head on the heater in his room. When a facility resident had an unwitnessed fall or an observed fall with head injury, irregularly spaced neurological assessments (neuro checks) were performed over a period of 48 hours. Neurological assessments include, at a minimum, pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; equality of hand grip strength; and level of consciousness. Resident 10's neuro checks sheet for the fall on 10/27/19 was missing the following; a. All assessments of level of consciousness, pupil size and reactivity, and hand grip strength. b. All assessments for the 11th, 15th, 19th, 24th, and 48th hours. The neuro check sheets for the falls on 11/9/19 and 12/31/19 were requested. However, the Director of Nursing stated they were missing from the resident's medical record and was unable to provide them. 2. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/20 resident 32's medical record was reviewed. Nursing progress notes revealed the following incidents: a. On 10/10/19, 318-2 pushed (Resident 32) into the wall, hitting her head, and her shoulder on the wall. b. On 11/8/19, CNA (Certified Nursing Assistant) called RN to resident .CNA reports peer stood and pushed her to the floor after she reached for his coffee. c. On 11/16/19, (Resident 32) found on the floor in her room, laying (sic) between her part of the room and 308-2 part of the room .(Resident 32) was laying (sic) on her left side, and unresponsive. The neuro checks sheet for the fall on 10/10/19 was missing the following: a. On the 11th hour check, level of consciousness, pupil size and reactivity, and hand grip strength assessments. b. On the15th hour check, level of consciousness, pupil size and reactivity, and hand grip strength assessments. c. All assessments for the 19th, 24th, 32nd, 40th, and 48th hours. The neuro checks sheet for the fall on 11/8/19 was missing the following: a. For the 45 minute check, blood pressure, pulse, oxygen, level of consciousness, pupil size and reactivity, and hand grip strength assessments. b. For the 90 minute, 2nd and 3rd hour checks, the level of consciousness, pupil size and reactivity, and hand grip strength assessments. c. All assessments for the 1st, 4th, 5th, 6th, 10th, 14th, 30th, 38th, and 46th hours. For the fall on 11/16/19, the assessments of resident 32's level of consciousness, pupil size and reactivity, and hand grip strength were not performed until 14 hours after the fall. There were 11 required times that were missed. Further investigation regarding resident 32's fall on 11/16/19 revealed the following nursing progress notes: a. On 11/16/19 at 7:15 PM, (Resident 32) found on the floor in her room, laying between her part of the room and 308-2 part of the room .(Resident 32) was laying on her left side, and unresponsive .She slowly became responsive, assessed her hips and shoulders, then proceeded to roll her onto her back where a complete physical assessment could be done. Mo (sic) injuries noted at this time 308-2 stated that she pushed (resident 32) down .Neuro checks initiated. Pt (patient) lifted to a chair and removed form the room. b. On 11/17/19 at 5:03 AM, While staff was getting her ready for bed, (Resident 32) looked like she was in pain. Resident had a dose of schedule [MEDICATION NAME]. It seemed that help her with pain. c. On 11/18/19 at 1:33 AM, .(Resident 32) has been limping on her left leg while walking, and has decreased use of left arm, and was seen cradling it some .While awake (resident 32) was walking around the unit, but after sometime it was obvious that she was in pain and she was given pain medication and encouraged to sit either in a normal chair or a wheelchair. d. On 11/19/19 at 4:51 PM, Resident having pain in left hip, arm, and rib areas. Resident putting light pressure on LLE (lower left extremities). MD (medical director) and hospice nurse notified, x-ray of left hip .ordered. X-ray result impression: suspected nondisplaced left femoral neck fracture. Recommended MRI (Magnetic Resonance Imaging) of left hip for confirmation of fracture. On 2/25/2020 at 8:12 AM, RN 3 was interviewed. RN 3 stated that, I walked into the room and asked her roommate what happened. (Roommate name) said ,'I pushed her down'. A head to toe assessment was done, I checked her hips and shoulder then got her back up in her chair. We did neuro checks because obviously being pushed that hard she would have hit her head. On 2/25/2020 at 9:40 AM, a Medical Doctor (MD) 1 was interviewed. MD 1 stated that resident 32 should have been sent to the emergency room that night. MD 1 stated, It's not an automatic given, but if the resident was unresponsive and unable to give an accurate account then sending them out to the hospital would be appropriate.

Based on interview, observation, and record review, the facility did not ensure that all employees were trained in emergency procedures, and that employees appropriately implemented the emergency procedures. Specifically, a resident who had displayed confusion was unaccompanied to a medical appointment. The resident subsequently wandered away from the appointment and was found deceased approximately 12 days later. Facility staff did not respond timely when they determined that the resident was missing. The deficient practice identified for resident 93 was found to have occurred at an Immediate Jeopardy level. Additionally, another resident eloped from the facility, and was out of the facility overnight before facility staff identified that he had eloped. The deficient practice for resident 16 was found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. Resident identifiers: 16 and 93. NOTICE: Notice of Immediate Jeopardy was given in writing and verbally to the facility Administrator (ADM) on [DATE] at 3:00 PM. The ADM was asked to develop an immediate plan to ensure resident safety. PLAN: On [DATE] the ADM provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated [DATE] stated the following: Mr. (Long Term Care Manager) Long Term Care Survey Section Utah Department of Health Bureau of Health Facility Licensing and Certification 3760 South Highland Drive, Suite 200 P.O. Box 3 Salt Lake City, UT ,[DATE] Re: Allegation of Abatement of Immediate Jeopardy Citations. Dear Mr. (Long Term Care Manager): This letter is in response to the initial findings of the recertification survey conducted at Canyon Rim Care Center on [DATE]. On [DATE] the surveyors met with the Facility Administrator and the Director of Nursing and issued to Canyon Rim Care Center two Immediate Jeopardy Citations. The noted areas of concern that we address in this letter and plan of correction are: F323 (42 CFR 483.23(d) (2)) - Each resident receives adequate supervision and assistance devices to prevent accidents; and, F518 (42 CFR 483.75(m) (2)) - Train all employees in emergency procedures. The findings of the State allege that the surveyors' primary concern was related to resident 93's safety, ensuring residents receive adequate supervision and assistance and ensure employees have training in emergency procedures relating to resident safety and procedures related to elopement. Status of residents cited in the survey. The status of resident #93 cited by the surveyors is, to date, as follows: (1) Resident #93 has not been located with a 100% certainty. Notification was received on [DATE] @ (at) 2:30 pm from (name of the police officer redacted) with Unified Police and reported that according to the Utah State Medical Examiner it has been 90% confirmed that the victim identified is resident # 93. This letter and plan of correction is a formal presentation to demonstrate the actions of Canyon Rim staff and its efforts to ensure ongoing substantial compliance with Medicare/Medicaid regulatory guidelines. Below are the steps we have taken to abate the Immediate Jeopardy Citations. F 323: Adequate supervision to prevent accidents. The plan of correction to address this citation includes the following: a) The facility has implemented the Resident Elopement Guideline. The purpose of this guideline is 'To assess residents for elopement risk factors and use of elopement precautions as a means to prevent elopement and improve safety, providing for appropriate steps to identify, prevent and respond promptly to resident elopement.' For a full description of the 'Elopement Policy', 'Resident Elopement Guideline', 'Resident Profile' and the 'Action Checklist to a Suspected Resident Elopement' (Please see the attachments). b) Effective [DATE], an Elopement Binder has been placed at each nurses' station. This binder contains the 'Elopement Policy,' 'Resident Elopement Guideline', 'Resident Profile' (indicating information that remains constant for residents on that unit) (ex. (example) age, gender, etc.) and an 'Action Checklist to a Suspected Resident Elopement' form. This will assist staff in the event of an elopement to respond in an expeditious manner. c) Effective [DATE], the facility has implemented a practice of conducting a 'head count' 3 times in 24 hours, at nurse shift report and at noon meal (+/- 1 hour time frame). This is in addition to the frequent current monitoring, which is completed at meal times, shift report, Medication Administration, and also predicted upon individual resident needs. d) Education/Training to staff. Since [DATE] staff has been educated on the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile', and 'Action Check List to a Suspected Resident Elopement'. Staff scheduled to work this day (Jan. (January) 11, 2017) received education on or prior to the start of their shift, this education will continue until all staff members have received education prior to receiving, resident care assignments. On [DATE] a Wandering/Elopement quiz was issued for staff members to demonstrate proper understanding. Staff scheduled to work this day (Jan. 12, 2017) received education and quiz on or prior to the start of their shift, this education will continue until all staff members have received education and quiz prior to receiving resident care assignments. All staff who have not received education and who have not completed the quiz have been called [DATE] and notified that prior to working a shift and prior to receiving resident care assignments that they will need to receive this education and quiz. Staff will not be allowed to work their scheduled shifts unless they have received the education and have passed the Wandering/Elopement quiz with 100% accuracy. Staffing agencies/temporary staff have been notified that staff will not be able to work scheduled shifts, until they have received the education and have passed the Wondering/Elopement quiz with 100% accuracy. e) A Wandering/Elopement drill was held on [DATE] @ 4:29PM (Day Shift) and 10:35PM (Night Shift). In each drill 'missing resident' was found by participants. Staff was able to correctly verbalize process if missing resident had not been located. A Wander/Elopement drill will be held once per shift, per quarter. The Wander/Elopement Drill will be conducted by Administrator/Designee. Staff response during the drill will be reviewed during Quality Assurance Performance Improvement meeting. These drills will help to verify staff response in the event of an elopement and that the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile', and 'Action Checklist to a Suspected Resident Elopement' forms are being used appropriately. f) Increased monitoring by QAPI (Quality Assurance Performance Improvement) Team. The Quality Assurance Performance Improvement team, shall track any incident of elopement on a weekly basis (or until a lesser frequency is deemed appropriate) to identify patterns, trends and causal factors. The Committee shall identify and implement interventions to prevent elopement as necessary. Any trends or findings will be reported to the larger QAPI committee on a monthly basis, until a lesser frequency is deemed appropriate. g) On [DATE], a 'head count' of the facility was conducted to ensure that all residents were accounted for. On [DATE], staff were notified that, effective immediately, no resident will be able to leave for an appointment without being accompanied, until further assessments are completed. On [DATE], all residents were assessed for risk using the 'Wander Risk Assessment' located in Point Click Care. Those identified as 'High Risk' residents were restricted from leaving the facility for appointments unless accompanied. 'At Risk' residents are restricted from leaving the facility for appointments unaccompanied until reviewed by the IDT (Interdisciplinary Team), for safety and that their care plans have been up-dated. On [DATE] an IDT meeting was conducted which included: Administrator, Director of Nursing, Social Worker, Recreation Therapist, Director of Rehabilitation, and C.N.A. (Certified Nurse Assistant) Coordinator. This Interdisciplinary Team reviewed both the Wander Risk Assessment and the BIMS (Brief Interview for Mental Status), and assessed whether current residents were safe to be unaccompanied while on transportation for appointment. All care plans have been updated on current residents, to reflect whether they will need to be accompanied to appointments as of [DATE]. h) A Brief Interview of Mental Status (BIMS) assessment will be conducted by LCSW (Licensed Clinical Social Worker)/SSW (Social Services Worker) on residents to further identify cognitive impairment and risk for wandering. On [DATE] an IDT meeting was conducted which included: Administrator, Director of Nursing, Social Worker, Recreation Therapist, Director of Rehabilitation, and C.N.A. Coordinator. This Interdisciplinary Team reviewed both the Wander Risk Assessment, and the BIMS and assessed whether current residents were safe to be unaccompanied while on transportation for appointment. All care plans have been updated on current residents to reflect whether they will need to be accompanied to appointments as of [DATE]. i) On [DATE], residents who are able to leave the facility unaccompanied were identified. On [DATE] residents were educated by the DON (Director of Nursing)/Administrator/Designee regarding the Sign Out/Sign In book and the procedure to follow when leaving the facility unaccompanied. [DATE] The Elopement Binders located at the nurses' stations have been updated to reflect a copy of the Sign Out Policy, along with a list of residents who have been identified by the IDT, to leave the building unaccompanied. F518- Train employees in emergency procedures. The plan of correction to address this citation includes the following: a) Education/Training to staff. Since [DATE], staff have been educated on the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile' and 'Action Check List to a Suspected Resident Elopement'. On [DATE] (sic), a Wandering/Elopement quiz was issued for staff members to demonstrate proper understanding. Staff scheduled ([DATE]) received education and quiz on or prior to the start of their shift. This education and quiz will continue until all staff members have received education and quiz prior to receiving care assignments. All staff who have not received education and who have not completed the quiz have been called as of [DATE] and notified that prior to working a shift and prior to receiving resident care assignments, that they will need to receive this education and quiz. Staff will not be allowed to work their scheduled shifts, unless they have received the education and passed the Wander/Elopement with 100% accuracy. Staffing agencies/temporary staff have been notified that staff will not be allowed to work scheduled shifts, until they received the education and have passed the Wander/Elopement quiz with 100% accuracy. b) A Wander/Elopement drill was held [DATE] @ 4:29PM (Day Shift) as well as 10:35PM (Night Shift). In each drill 'missing resident' was found by participants. Staff was able to correctly verbalize process if missing resident had not been located. A Wander/Elopement drill will be held once per shift, per quarter. The Wander/Elopement Drill will be conducted by Administrator/Designee. Staff response during the drill will be reviewed during Quality Assurance Performance Improvement meeting. These drills will help verify staff response in the event of an elopement and that the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile' and 'Action Checklist to a Suspected Resident Elopement' forms are being used appropriately. c) On [DATE] staff were re-educated regarding the 'Sign Out Policy'. d) On [DATE] a tracking spreadsheet was implemented to ensure that all staff received the identified training. e) Increased monitoring by the QAPI Team. The Quality Assurance Performance Improvement team, shall track any incident of elopement on a weekly basis (or until a lesser frequency is deemed appropriate) to identify patterns, trends and causal factors. The Committee shall identify and implement interventions to prevent elopement as necessary. Any trends or findings will be reported to the larger QAPI committee on a monthly basis, until a lesser frequency is deemed appropriate. We believe, that with the above, actions, we have abated the immediate jeopardy concerns. On [DATE] at approximately 10:00 AM, the surveyors confirmed the abatement of the Immediate Jeopardy. Deficient practice with actual harm that is not Immediate Jeopardy remained for the risk of injury. Findings include: IMMEDIATE JEOPARDY: 1. Resident 93 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on [DATE]. Resident 93's Preadmission Screening Resident Review (PASRR) Level II dated [DATE] was reviewed. The PASRR indicated that resident 93 had a medical history significant for chronic malnutrition, increasing confusion, and poor concentration, and inability to care for himself . (resident 93) told hospital staff that he has '300 homes'. The PASRR indicated that resident 93 had recently been diagnosed with [REDACTED]. The PASRR also indicated that resident 93 has demonstrated poor ability to prepare his own meals or effectively manage his nutritional needs. He is at risk for wandering. Due to his increasing confusion and chronic mental illness he has been going in and out of jail. he has been discharged to less restrictive settings, but has wandered and has been picked up by police multiple times (due to) his wandering and for concerns for his safety. He us unable to manage his medications and needs supervision and reminders to carry out ADLs (Activities of Daily Living). The PASRR also indicated that resident 93 had increasing confusion and disorientation. In addition, the PASRR indicated that resident 93 has a history of wandering . His insight and judgment are impaired. He had been living in a SNF (skilled nursing facility) since [DATE], but was discharged to the shelter and was told to go to (the local mental health facility) for mental health and case management services. However, due to pt's (patient's) impaired cognition and inability to care for himself, he ended up living out on the streets and was not able to care for himself. He did not know how to get to (the local mental health facility) and stopped taking his medications as he was unable to obtain more medications. He decompensated and was found in a Chinese restaurant being disruptive (and) delusional, talking about being in a war and in the military, and appeared to be responding to internal stimuli. He would not leave the restaurant and the police were called. Pt was pink sheeted and taken . (to local hospital). He was admitted to the inpatient psychiatric unto (sic) for further psychiatric stabilization and evaluation. The PASRR indicated that resident 93 had a history of [REDACTED]. The PASRR also revealed that resident had difficulty with recall, and was not oriented to place, situation or time. The PASRR revealed that resident 93 was a substantial danger to himself or others; and that the nursing facility's supervision and structure mitigated this danger. A psychiatric assessment dated [DATE] from a local hospital was reviewed. The assessment indicated that resident 93 exhibited disorganized behavior. The assessment also stated that resident 93's Insight into problems appears to be poor. Judgment appears fair. A short attention span is evident. The assessment also indicated that resident 93 was assessed using the MOCA (Montreal Cognitive Assessment). Pt (patient) scored ,[DATE] indicating moderate to severe deficits. pt with cognitive deficits severe enough, that he is unable to care for himself independently at home without regular assistance. Pt would benefit from placement in a skilled setting for safety, med (medication) management, STM (Short Term Memory) deficits and completion of ADLs. A facility nursing admission form dated [DATE] indicated that resident 93 was oriented to person, but not place, time or situation. The admission form also indicated that resident 93 was confused, had short term memory loss, hallucinations, delusions, and disorganized thinking. A Wandering Risk evaluation dated [DATE] for resident 93 was reviewed. Facility staff documented that resident 93 could not follow instructions, was ambulatory, had a history of [REDACTED]. On [DATE], at 2:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 state that when resident 93 was readmitted to the facility in [DATE], he was confused and unable to answer questions. LPN 1 also stated that resident 93 did not know where he was and had no short term memory. Nurses notes for resident 93 revealed the following entries: a) On [DATE], . Resident confused and disoriented and carrying his belongings up to the front door then to look out then he walks back to room repeatedly. unable to appropriately answer questions on the TB ([MEDICAL CONDITION]) test questionnaire . I will alert night shift to monitor residents whereabouts and watch front door for elopement for his safety. b) On [DATE], Resident is alert and oriented x 1 with confusion and delusional and hallucination's (sic) behavior, naked and dancing at his room after eating dinner, is abler (sic) to redirect easily, then has cloths (sic) on and walking out his room closing to the front door (sic). c) On [DATE] at 1:02 AM, Resident is alert and oriented x 1, needs to redirect for time, date, place, and situations . d) On [DATE] at 7:39 PM, Resident continues to have confusion and delusions but able to fine (sic) room. e) On [DATE] at 11:03 PM, Pt (patient) is A&Ox2 (alert and oriented x 2). f) On [DATE] at 10:04 AM, Per Dietary Manager, (resident 93) is confused and therefore has increased intake of food as he asks for meals (i.e. breakfast) for three hours in a row. Yesterday, resident ate breakfast when it was served. At 9:15 am, he came and asked when breakfast would be served and if he could have it. He was offered a second breakfast meal. Again, one hour later, he inquired as to when breakfast would be served. Weight gain is likely RT (related to) excessive intake and confusion over meals/satiety. g) On [DATE] at 7:01 PM, Pt displayed confusion and delusions. Pt had trouble finding his room and came out of room aprox (approximately) 3x wearing no clothing. When asked to go put clothes on pt complied. however cannot communicate needs. Meals provided however pt is confused on what each meal is. h) On [DATE] Pt displayed confusion and delusions. however cannot communicate needs. i) On [DATE] at 12:47 PM, MDS (Minimum Data Set) interview: Res (resident) is A&Ox1. Resident was getting ready for a Dr. (doctor) Appt (appointment). Res is returning to us given a failed discharge. Res is confused and delusional. Resident needs a (sic) assistance from aids for most of his ADLs r/t to dementia and confusion. j) On [DATE] at 3:20 PM, Resident admission paperwork from (name of local hospital) had follow up (appointment at local mental health facility) . today at 1:30 (PM). Resident aware of apps (appointments) and able to get ready on his own. Transport through (name of transport company) took him at 12:45 (PM). At approx (approximately). 3:30 (PM) I received a call from transport that they could not find him. I notified DON (Director of Nursing) and called (name of local mental health facility) and they stated that they did not have record of him having an app today and told him that since he had skipped his last 2 apps in Oct.(October) that he would have to wait and they could schedule something with him. He told them that since he did not have his ID (identification) on him that he would call them later and left about 1:45 (PM) or so. Van returned a bit later and could not find him. Transport called me and notified me. DON, (name of physician), and Social Services . notified. k) On [DATE] at 3:32 PM, Admissions got word from police that (resident 93) had been picked up and was safe. l) On [DATE] at 3:34 PM, (nurse practitioner) has requested resident have a Guardian or POA (Power of Attorney). m) On [DATE] at 3:48 PM, the social worker and DON were notified of the nurse practitioner's desire to be set up for resident 93. n) On [DATE] the DON documented Resident left facility yesterday with facility transport for an appointment (at) 130pm. Apparently per (name of local mental health facility) staff resident did not have an appointment. (Name of local mental health facility) stated that he left their facility at approx. 145pm. This nurse was notified at approx. 330pm that transport was there to pick up resident but he was not there. Transport staff looked in the surrounding area but was unable to locate resident. This was reported to facility management and provider, when facility management was looking into this issue the (former) Admissions Coordinator came in and stated that the resident was at (name of local hospital), and that he had received an email from our facility marketer stating he was at that hospital. This nurse was told by floor nurse that he was going to be coming back to facility. This morning [DATE] Admissions Coordinator called (name of local hospital) to see about admission of this resident. Per report from (former) Admissions Coordinator resident was not at (name of local hospital). Apparently the email the Admission Coordinator received was referring to a previous admission related to this resident. At this point this nurse notified Administrator. Decision was made to call police and provider per facility policy. Police put out a BOLO (Be on look out) report for a missing persons. Local hospitals and homeless shelter called and asked for them to be on the look out for the resident as well. Resident does not have any contacts listed. Will update medical records as more information becomes available. On [DATE] at 9:25 AM, an interview was conducted with the facility Administrator (ADM) regarding resident 93. The ADM stated that a transportation company was contracted to pick up resident 93 from the facility, and transport him to his appointment at a local mental health facility for an appointment on [DATE] at 1:30 PM. The ADM stated that the transportation company staff member who dropped resident 93 off at the facility felt that it was safe and told the resident that she would be back to pick the resident up. The ADM stated that when the transportation company returned at approximately 3:30 PM, resident 93 was unable to be located. The ADM stated that he called the local mental health facility, and determined that the mental health facility had canceled the appointment without contacting the facility, and resident 93 took off. The ADM stated that there was then a communication breakdown in which the ADM thought resident 93 had been found and taken to a local hospital. The ADM confirmed that he did not call the local hospital to confirm the information he received. The ADM stated that the next day, [DATE], when he became aware that resident 93 was, in fact, not at the local hospital, multiple staff members began to drive around the area in an attempt to locate resident 93. The ADM stated that staff were unsuccessful in their attempts to locate resident 93. The ADM stated that on [DATE] he was notified by the local police department that resident 93 had been found deceased outside. On [DATE] at 1:15 PM, a follow up interview was conducted with the facility ADM. When asked about resident 93, the ADM stated that my estimation was that (resident 93) was able to make his own decisions. (resident 93) was able that day, and was alert and oriented enough to, make the decision to go to the appointment. When asked about the process of staff accompanying confused residents to appointments, the ADM stated he did not know why facility staff were not doing that. The ADM stated that when he became aware that resident 93 was not at the appointment, he called his corporate risk management representative. On [DATE] the driver who transported resident 93 to his appointment on [DATE] wrote the following statement: On Monday [DATE]th 2016 as part of my driving schedule I had a pickup from Canyon Rim Care Center. (resident 93) (was) going to (name of local mental health facility) . As part of my routine when picking up at Canyon Rim I ask if the resident needs a CNA (Certified Nursing Assistant) to go with them. When picking up (resident 93) I asked that question and was told he was good to go by himself . I arrived (at the local mental health facility) and unloaded (resident 93), who was ambulatory I watched him walk into the Clinc (sic). Talking with him he said he knew where he was going and seemed ok by himself. I had written our transportation (number) on his paperwork and told him I would be back for him and to wait on the first floor lobby. I came back to pickup (resident 93) and he was not in front the lobby (sic). After looking for him I talked to the receptionist who told me he did attempt to check in but did not have an appointment. They had told him to sit down and wait for his ride, which he did. At some point he left the lobby. I looked everywhere at (name of the local mental health facility) but did not find him. When I returned to Canyon Rim the Nurse told me he (resident 93) is responsible for himself. On [DATE] at 4:10 PM, an interview was conducted with the former Admissions Director (AD). The former AD stated that on [DATE], he became aware that resident 93 was missing. The former AD stated that he had been in contact with the corporate Community Relations Director (CRD) at that time, and that the corporate CRD informed him that resident 93 was at a local hospital. The former AD, stated that he then relayed the information from the corporate CRD to the DON and ADM, who then called off the search for resident 93. The former AD stated that he did not call the local hospital to confirm the information he had received until the morning of [DATE]. On [DATE] at 11:40 AM, an interview was conducted with the facility DON regarding resident 93. The DON confirmed what she documented in a nurses note on [DATE], and what the ADM stated in his interview. The DON stated that she had since determined that the local mental health facility had canceled resident 93's appointment without notifying facility staff. The DON stated that prior to this incident certain residents were accompanied by facility staff to appointments outside of the facility. The DON stated that she was not aware of how facility staff determined if residents required staff to accompany them to appointments or not. The DON stated that she was not aware of resident 93's increased confusion upon his readmission to the facility. On [DATE] at 2:15 PM, an additional interview was conducted with the DON. The DON confirmed that she did not contact the local hospital to confirm that resident 93 was there. The DON also confirmed that after being told by the former AD that resident 93 was at a local hospital, the search for resident 93 was called off. On [DATE] at 11:22 PM, an interview was conducted with the facility Social Services Worker (SSW). The SSW stated that she did not have any concerns with resident 93 being left alone, and was not aware of any behavior or memory issues resident 93 was experiencing. The SSW stated that she was unaware of facility procedures regarding transporting residents safely prior to the incident that occurred with resident 93. The SSW stated that she was not aware of resident 93's increased confusion upon his readmission to the facility. On [DATE] at 1:00 PM, an interview was conducted with the corporate Licensed Clinical Social Worker (LCSW). The LCSW stated that with regard to resident 93, she was aware that resident 93 went to an appointment , but when facility staff went to pick the resident up, the resident was not there. The LCSW stated that she did not assist the facility with regard to resident 93's situation, nor did she initiate any changes to corporate/facility policies and procedures afterward. An inservice agenda dated [DATE] was reviewed. The agenda revealed that the DON had provided education for facility staff, and had defined elopement as when a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. Review of the facility Policy and Procedure Resident Elopement Guideline documented: Purpose: To assess residents for elopement risk factors and use of elopement precautions as a means to prevent elopement and improve safety, providing for appropriate steps to identify, prevent, detect and respond promptly to resident elopement. Guideline: The facility shall take the following steps to identify, prevent, detect and respond to situations of resident elopement Assessment: 1. Residents admitted with known history of elopement shall have a plan of care for risk of elopement developed upon admission. 2. Residents with an episode of elopement who have not previously been identified as being at risk for elopement shall be assessed utilizing the Elopement Risk Evaluation, added to the list of elopement risk residents and a plan of care developed. 3. Resident demonstrating behavior indicating risk for elopement shall be assessed utilizing the Wandering Risk Assessment, added to the list of elopement risk residents and a plan of care developed. Training: 1. Upon hire new employees shall be informed of the Elopement Guidelines. 2. Each employee shall be informed of their responsibility in regard to: a. Door alarms and security measures to prevent resident elopement. b. Reporting behavior of residents which may include they are a risk for elopement. c. Implementation of Action Checklist to a Suspected Resident Elopement. d. Resident Profile completed for residents identified as having the potential to wander based on their Wandering Risk Assessment score. Precautions: 1. Photographs of residents shall be taken on admission and periodically as appearances change and shall be placed in the Medical record. 2. Residents clothing shall be labeled with identification. Review of the facility policy and procedure for Elopements documented: Policy Statement Staff sha

Based on interview, observation, and record review, the facility did not ensure that 7 of 68 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who had displayed confusion was unaccompanied to a medical appointment. The resident subsequently wandered away from the appointment and was found deceased approximately 12 days later. The deficient practice identified for resident 93 was found to have occurred at an Immediate Jeopardy level. Additionally, one resident experienced a fall that resulted in an injury after not receiving staff assistance, and another resident had multiple falls before he had a fall with an injury, during which time interventions were not in place to prevent the fall. The deficient practice for residents 19 and 106 were found to have occurred at a harm level and will not be included in the Immediate Jeopardy. Also, two residents experienced falls in a shower room that was supposed to be locked, one resident experienced multiple falls without appropriate staff intervention, one resident eloped from the facility, and one resident experienced burns on his fingers without timely staff assessment. The deficient practice for residents 16, 22, 55, and 76 was found to have occurred at a potential for harm and will also not be included in the Immediate Jeopardy. Resident identifiers: 16, 19, 22, 55, 76, 93, and 106. NOTICE: Notice of Immediate Jeopardy was given in writing and verbally to the facility Administrator (ADM) on [DATE] at 3:00 PM. The ADM was asked to develop an immediate plan to ensure resident safety. PLAN: On [DATE] the ADM provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated [DATE] stated the following: Mr. (Long Term Care Manager) Long Term Care Survey Section Utah Department of Health Bureau of Health Facility Licensing and Certification 3760 South Highland Drive, Suite 200 P.O. Box 3 Salt Lake City, UT ,[DATE] Re: Allegation of Abatement of Immediate Jeopardy Citations. Dear Mr. (Long Term Care Manager): This letter is in response to the initial findings of the recertification survey conducted at Canyon Rim Care Center on [DATE]. On [DATE] the surveyors met with the Facility Administrator and the Director of Nursing and issued to Canyon Rim Care Center two Immediate Jeopardy Citations. The noted areas of concern that we address in this letter and plan of correction are: F323 (42 CFR 483.23(d) (2)) - Each resident receives adequate supervision and assistance devices to prevent accidents; and, F518 (42 CFR 483.75(m) (2)) - Train all employees in emergency procedures. The findings of the State allege that the surveyors' primary concern was related to resident 93's safety, ensuring residents receive adequate supervision and assistance and ensure employees have training in emergency procedures relating to resident safety and procedures related to elopement. Status of residents cited in the survey. The status of resident #93 cited by the surveyors is, to date, as follows: (1) Resident #93 has not been located with a 100% certainty. Notification was received on [DATE] @ (at) 2:30 pm from (name of the police officer redacted) with Unified Police and reported that according to the Utah State Medical Examiner it has been 90% confirmed that the victim identified is resident # 93. This letter and plan of correction is a formal presentation to demonstrate the actions of Canyon Rim staff and its efforts to ensure ongoing substantial compliance with Medicare/Medicaid regulatory guidelines. Below are the steps we have taken to abate the Immediate Jeopardy Citations. F 323: Adequate supervision to prevent accidents. The plan of correction to address this citation includes the following: a) The facility has implemented the Resident Elopement Guideline. The purpose of this guideline is 'To assess residents for elopement risk factors and use of elopement precautions as a means to prevent elopement and improve safety, providing for appropriate steps to identify, prevent and respond promptly to resident elopement.' For a full description of the 'Elopement Policy', 'Resident Elopement Guideline', 'Resident Profile' and the 'Action Checklist to a Suspected Resident Elopement' (Please see the attachments). b) Effective [DATE], an Elopement Binder has been placed at each nurses' station. This binder contains the 'Elopement Policy,' 'Resident Elopement Guideline', 'Resident Profile' (indicating information that remains constant for residents on that unit) (ex. (example) age, gender, etc.) and an 'Action Checklist to a Suspected Resident Elopement' form. This will assist staff in the event of an elopement to respond in an expeditious manner. c) Effective [DATE], the facility has implemented a practice of conducting a 'head count' 3 times in 24 hours, at nurse shift report and at noon meal (+/- 1 hour time frame). This is in addition to the frequent current monitoring, which is completed at meal times, shift report, Medication Administration, and also predicted upon individual resident needs. d) Education/Training to staff. Since [DATE] staff has been educated on the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile', and 'Action Check List to a Suspected Resident Elopement'. Staff scheduled to work this day (Jan. (January) 11, 2017) received education on or prior to the start of their shift, this education will continue until all staff members have received education prior to receiving, resident care assignments. On [DATE] a Wandering/Elopement quiz was issued for staff members to demonstrate proper understanding. Staff scheduled to work this day (Jan. 12, 2017) received education and quiz on or prior to the start of their shift, this education will continue until all staff members have received education and quiz prior to receiving resident care assignments. All staff who have not received education and who have not completed the quiz have been called [DATE] and notified that prior to working a shift and prior to receiving resident care assignments that they will need to receive this education and quiz. Staff will not be allowed to work their scheduled shifts unless they have received the education and have passed the Wandering/Elopement quiz with 100% accuracy. Staffing agencies/temporary staff have been notified that staff will not be able to work scheduled shifts, until they have received the education and have passed the Wondering/Elopement quiz with 100% accuracy. e) A Wandering/Elopement drill was held on [DATE] @ 4:29PM (Day Shift) and 10:35PM (Night Shift). In each drill 'missing resident' was found by participants. Staff was able to correctly verbalize process if missing resident had not been located. A Wander/Elopement drill will be held once per shift, per quarter. The Wander/Elopement Drill will be conducted by Administrator/Designee. Staff response during the drill will be reviewed during Quality Assurance Performance Improvement meeting. These drills will help to verify staff response in the event of an elopement and that the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile', and 'Action Checklist to a Suspected Resident Elopement' forms are being used appropriately. f) Increased monitoring by QAPI (Quality Assurance Performance Improvement) Team. The Quality Assurance Performance Improvement team, shall track any incident of elopement on a weekly basis (or until a lesser frequency is deemed appropriate) to identify patterns, trends and causal factors. The Committee shall identify and implement interventions to prevent elopement as necessary. Any trends or findings will be reported to the larger QAPI committee on a monthly basis, until a lesser frequency is deemed appropriate. g) On [DATE], a 'head count' of the facility was conducted to ensure that all residents were accounted for. On [DATE], staff were notified that, effective immediately, no resident will be able to leave for an appointment without being accompanied, until further assessments are completed. On [DATE], all residents were assessed for risk using the 'Wander Risk Assessment' located in Point Click Care. Those identified as 'High Risk' residents were restricted from leaving the facility for appointments unless accompanied. 'At Risk' residents are restricted from leaving the facility for appointments unaccompanied until reviewed by the IDT (Interdisciplinary Team), for safety and that their care plans have been up-dated. On [DATE] an IDT meeting was conducted which included: Administrator, Director of Nursing, Social Worker, Recreation Therapist, Director of Rehabilitation, and C.N.A. (Certified Nurse Assistant) Coordinator. This Interdisciplinary Team reviewed both the Wander Risk Assessment and the BIMS (Brief Interview for Mental Status), and assessed whether current residents were safe to be unaccompanied while on transportation for appointment. All care plans have been updated on current residents, to reflect whether they will need to be accompanied to appointments as of [DATE]. h) A Brief Interview of Mental Status (BIMS) assessment will be conducted by LCSW (Licensed Clinical Social Worker)/SSW (Social Services Worker) on residents to further identify cognitive impairment and risk for wandering. On [DATE] an IDT meeting was conducted which included: Administrator, Director of Nursing, Social Worker, Recreation Therapist, Director of Rehabilitation, and C.N.A. Coordinator. This Interdisciplinary Team reviewed both the Wander Risk Assessment, and the BIMS and assessed whether current residents were safe to be unaccompanied while on transportation for appointment. All care plans have been updated on current residents to reflect whether they will need to be accompanied to appointments as of [DATE]. i) On [DATE], residents who are able to leave the facility unaccompanied were identified. On [DATE] residents were educated by the DON (Director of Nursing)/Administrator/Designee regarding the Sign Out/Sign In book and the procedure to follow when leaving the facility unaccompanied. [DATE] The Elopement Binders located at the nurses' stations have been updated to reflect a copy of the Sign Out Policy, along with a list of residents who have been identified by the IDT, to leave the building unaccompanied. F518- Train employees in emergency procedures. The plan of correction to address this citation includes the following: a) Education/Training to staff. Since [DATE], staff have been educated on the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile' and 'Action Check List to a Suspected Resident Elopement'. On [DATE] (sic), a Wandering/Elopement quiz was issued for staff members to demonstrate proper understanding. Staff scheduled ([DATE]) received education and quiz on or prior to the start of their shift. This education and quiz will continue until all staff members have received education and quiz prior to receiving care assignments. All staff who have not received education and who have not completed the quiz have been called as of [DATE] and notified that prior to working a shift and prior to receiving resident care assignments, that they will need to receive this education and quiz. Staff will not be allowed to work their scheduled shifts, unless they have received the education and passed the Wander/Elopement with 100% accuracy. Staffing agencies/temporary staff have been notified that staff will not be allowed to work scheduled shifts, until they received the education and have passed the Wander/Elopement quiz with 100% accuracy. b) A Wander/Elopement drill was held [DATE] @ 4:29PM (Day Shift) as well as 10:35PM (Night Shift). In each drill 'missing resident' was found by participants. Staff was able to correctly verbalize process if missing resident had not been located. A Wander/Elopement drill will be held once per shift, per quarter. The Wander/Elopement Drill will be conducted by Administrator/Designee. Staff response during the drill will be reviewed during Quality Assurance Performance Improvement meeting. These drills will help verify staff response in the event of an elopement and that the 'Resident Policy', 'Resident Elopement Guideline', 'Resident Profile' and 'Action Checklist to a Suspected Resident Elopement' forms are being used appropriately. c) On [DATE] staff were re-educated regarding the 'Sign Out Policy'. d) On [DATE] a tracking spreadsheet was implemented to ensure that all staff received the identified training. e) Increased monitoring by the QAPI Team. The Quality Assurance Performance Improvement team, shall track any incident of elopement on a weekly basis (or until a lesser frequency is deemed appropriate) to identify patterns, trends and causal factors. The Committee shall identify and implement interventions to prevent elopement as necessary. Any trends or findings will be reported to the larger QAPI committee on a monthly basis, until a lesser frequency is deemed appropriate. We believe, that with the above, actions, we have abated the immediate jeopardy concerns. On [DATE] at approximately 10:00 AM, the surveyors confirmed the abatement of the Immediate Jeopardy. Deficient practice with actual harm that is not Immediate Jeopardy remained for the risk of injury. Findings include: IMMEDIATE JEOPARDY: Resident 93 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on [DATE]. Resident 93's Preadmission Screening Resident Review (PASRR) Level II dated [DATE] was reviewed. The PASRR indicated that resident 93 had a medical history significant for chronic malnutrition, increasing confusion, and poor concentration, and inability to care for himself . (resident 93) told hospital staff that he has '300 homes'. The PASRR indicated that resident 93 had recently been diagnosed with [REDACTED]. The PASRR also indicated that resident 93 has demonstrated poor ability to prepare his own meals or effectively manage his nutritional needs. He is at risk for wandering. Due to his increasing confusion and chronic mental illness he has been going in and out of jail. he has been discharged to less restrictive settings, but has wandered and has been picked up by police multiple times (due to) his wandering and for concerns for his safety. He us unable to manage his medications and needs supervision and reminders to carry out ADLs (Activities of Daily Living). The PASRR also indicated that resident 93 had increasing confusion and disorientation. In addition, the PASRR indicated that resident 93 has a history of wandering . His insight and judgment are impaired. He had been living in a SNF (skilled nursing facility) since [DATE], but was discharged to the shelter and was told to go to (the local mental health facility) for mental health and case management services. However, due to pt's (patient's) impaired cognition and inability to care for himself, he ended up living out on the streets and was not able to care for himself. He did not know how to get to (the local mental health facility) and stopped taking his medications as he was unable to obtain more medications. He decompensated and was found in a Chinese restaurant being disruptive (and) delusional, talking about being in a war and in the military, and appeared to be responding to internal stimuli. He would not leave the restaurant and the police were called. Pt was pink sheeted and taken . (to local hospital). He was admitted to the inpatient psychiatric unto (sic) for further psychiatric stabilization and evaluation. The PASRR indicated that resident 93 had a history of [REDACTED]. The PASRR also revealed that resident had difficulty with recall, and was not oriented to place, situation or time. The PASRR revealed that resident 93 was a substantial danger to himself or others; and that the nursing facility's supervision and structure mitigated this danger. A psychiatric assessment dated [DATE] from a local hospital was reviewed. The assessment indicated that resident 93 exhibited disorganized behavior. The assessment also stated that resident 93's Insight into problems appears to be poor. Judgment appears fair. A short attention span is evident. The assessment also indicated that resident 93 was assessed using the MOCA (Montreal Cognitive Assessment). Pt (patient) scored ,[DATE] indicating moderate to severe deficits. pt with cognitive deficits severe enough, that he is unable to care for himself independently at home without regular assistance. Pt would benefit from placement in a skilled setting for safety, med (medication) management, STM (Short Term Memory) deficits and completion of ADLs. A facility nursing admission form dated [DATE] indicated that resident 93 was oriented to person, but not place, time or situation. The admission form also indicated that resident 93 was confused, had short term memory loss, hallucinations, delusions, and disorganized thinking. A Wandering Risk evaluation dated [DATE] for resident 93 was reviewed. Facility staff documented that resident 93 could not follow instructions, was ambulatory, had a history of [REDACTED]. On [DATE], at 2:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 state that when resident 93 was readmitted to the facility in [DATE], he was confused and unable to answer questions. LPN 1 also stated that resident 93 did not know where he was and had no short term memory. Nurses notes for resident 93 revealed the following entries: a) On [DATE], . Resident confused and disoriented and carrying his belongings up to the front door then to look out then he walks back to room repeatedly. unable to appropriately answer questions on the TB ([DIAGNOSES REDACTED]) test questionnaire . I will alert night shift to monitor residents whereabouts and watch front door for elopement for his safety. b) On [DATE], Resident is alert and oriented x 1 with confusion and delusional and hallucination's (sic) behavior, naked and dancing at his room after eating dinner, is abler (sic) to redirect easily, then has cloths (sic) on and walking out his room closing to the front door (sic). c) On [DATE] at 1:02 AM, Resident is alert and oriented x 1, needs to redirect for time, date, place, and situations . d) On [DATE] at 7:39 PM, Resident continues to have confusion and delusions but able to fine (sic) room. e) On [DATE] at 11:03 PM, Pt (patient) is A&Ox2 (alert and oriented x 2). f) On [DATE] at 10:04 AM, Per Dietary Manager, (resident 93) is confused and therefore has increased intake of food as he asks for meals (i.e. breakfast) for three hours in a row. Yesterday, resident ate breakfast when it was served. At 9:15 am, he came and asked when breakfast would be served and if he could have it. He was offered a second breakfast meal. Again, one hour later, he inquired as to when breakfast would be served. Weight gain is likely RT (related to) excessive intake and confusion over meals/satiety. g) On [DATE] at 7:01 PM, Pt displayed confusion and delusions. Pt had trouble finding his room and came out of room aprox (approximately) 3x wearing no clothing. When asked to go put clothes on pt complied. however cannot communicate needs. Meals provided however pt is confused on what each meal is. h) On [DATE] Pt displayed confusion and delusions. however cannot communicate needs. i) On [DATE] at 12:47 PM, MDS (Minimum Data Set) interview: Res (resident) is A&Ox1. Resident was getting ready for a Dr. (doctor) Appt (appointment). Res is returning to us given a failed discharge. Res is confused and delusional. Resident needs a (sic) assistance from aids for most of his ADLs r/t to dementia and confusion. j) On [DATE] at 3:20 PM, Resident admission paperwork from (name of local hospital) had follow up (appointment at local mental health facility) . today at 1:30 (PM). Resident aware of apps (appointments) and able to get ready on his own. Transport through (name of transport company) took him at 12:45 (PM). At approx. 3:30 (PM) I received a call from transport that they could not find him. I notified DON (Director of Nursing) and called (name of local mental health facility) and they stated that they did not have record of him having an app today and told him that since he had skipped his last 2 apps in Oct.(October) that he would have to wait and they could schedule something with him. He told them that since he did not have his ID (identification) on him that he would call them later and left about 1:45 (PM) or so. Van returned a bit later and could not find him. Transport called me and notified me. DON, (name of physician), and Social Services . notified. k) On [DATE] at 3:32 PM, Admissions got word from police that (resident 93) had been picked up and was safe. l) On [DATE] at 3:34 PM, (nurse practitioner) has requested resident have a Guardian or POA (Power of Attorney). m) On [DATE] at 3:48 PM, the social worker and DON were notified of the nurse practitioner's desire to be set up for resident 93. n) On [DATE] the DON documented Resident left facility yesterday with facility transport for an appointment (at) 130 pm. Apparently per (name of local mental health facility) staff resident did not have an appointment. (Name of local mental health facility) stated that he left their facility at approx. 145 pm. This nurse was notified at approx. 330 pm that transport was there to pick up resident but he was not there. Transport staff looked in the surrounding area but was unable to locate resident. This was reported to facility management and provider, when facility management was looking into this issue the (former) Admissions Coordinator came in and stated that the resident was at (name of local hospital), and that he had received an email from our facility marketer stating he was at that hospital. This nurse was told by floor nurse that he was going to be coming back to facility. This morning [DATE] Admissions Coordinator called (name of local hospital) to see about admission of this resident. Per report from (former) Admissions Coordinator resident was not at (name of local hospital). Apparently the email the Admission Coordinator received was referring to a previous admission related to this resident. At this point this nurse notified Administrator. Decision was made to call police and provider per facility policy. Police put out a BOLO (Be on look out) report for a missing persons. Local hospitals and homeless shelter called and asked for them to be on the look out for the resident as well. Resident does not have any contacts listed. Will update medical records as more information becomes available. On [DATE] at 9:25 AM, an interview was conducted with the facility Administrator (ADM) regarding resident 93. The ADM stated that a transportation company was contracted to pick up resident 93 from the facility, and transport him to his appointment at a local mental health facility for an appointment on [DATE] at 1:30 PM. The ADM stated that the transportation company staff member who dropped resident 93 off at the facility felt that it was safe and told the resident that she would be back to pick the resident up. The ADM stated that when the transportation company returned at approximately 3:30 PM, resident 93 was unable to be located. The ADM stated that he called the local mental health facility, and determined that the mental health facility had canceled the appointment without contacting the facility, and resident 93 took off. The ADM stated that there was then a communication breakdown in which the ADM thought resident 93 had been found and taken to a local hospital. The ADM confirmed that he did not call the local hospital to confirm the information he received. The ADM stated that the next day, [DATE], when he became aware that resident 93 was, in fact, not at the local hospital, multiple staff members began to drive around the area in an attempt to locate resident 93. The ADM stated that staff were unsuccessful in their attempts to locate resident 93. The ADM stated that on [DATE] he was notified by the local police department that resident 93 had been found deceased outside. On [DATE] at 1:15 PM, a follow up interview was conducted with the facility ADM. When asked about resident 93, the ADM stated that my estimation was that (resident 93) was able to make his own decisions. (resident 93) was able that day, and was alert and oriented enough to, make the decision to go to the appointment. When asked about the process of staff accompanying confused residents to appointments, the ADM stated he did not know why facility staff were not doing that. The ADM stated that when he became aware that resident 93 was not at the appointment, he called his corporate risk management representative. On [DATE] the driver who transported resident 93 to his appointment on [DATE] wrote the following statement: On Monday [DATE]th 2016 as part of my driving schedule I had a pickup from Canyon Rim Care Center. (resident 93) (was) going to (name of local mental health facility) . As part of my routine when picking up at Canyon Rim I ask if the resident needs a CNA (Certified Nursing Assistant) to go with them. When picking up (resident 93) I asked that question and was told he was good to go by himself . I arrived (at the local mental health facility) and unloaded (resident 93), who was ambulatory I watched him walk into the Clinc (sic). Talking with him he said he knew where he was going and seemed ok by himself. I had written our transportation (number) on his paperwork and told him I would be back for him and to wait on the first floor lobby. I came back to pickup (resident 93) and he was not in front the lobby (sic). After looking for him I talked to the receptionist who told me he did attempt to check in but did not have an appointment. They had told him to sit down and wait for his ride, which he did. At some point he left the lobby. I looked everywhere at (name of the local mental health facility) but did not find him. When I returned to Canyon Rim the Nurse told me he (resident 93) is responsible for himself. On [DATE] at 4:10 PM, an interview was conducted with the former Admissions Director (AD). The former AD stated that on [DATE], he became aware that resident 93 was missing. The former AD stated that he had been in contact with the corporate Community Relations Director (CRD) at that time, and that the corporate CRD informed him that resident 93 was at a local hospital. The former AD, stated that he then relayed the information from the corporate CRD to the DON and ADM, who then called off the search for resident 93. The former AD stated that he did not call the local hospital to confirm the information he had received until the morning of [DATE]. On [DATE] at 11:40 AM, an interview was conducted with the facility DON regarding resident 93. The DON confirmed what she documented in a nurses note on [DATE], and what the ADM stated in his interview. The DON stated that she had since determined that the local mental health facility had canceled resident 93's appointment without notifying facility staff. The DON stated that prior to this incident certain residents were accompanied by facility staff to appointments outside of the facility. The DON stated that she was not aware of how facility staff determined if residents required staff to accompany them to appointments or not. The DON stated that she was not aware of resident 93's increased confusion upon his readmission to the facility. On [DATE] at 2:15 PM, an additional interview was conducted with the DON. The DON confirmed that she did not contact the local hospital to confirm that resident 93 was there. The DON also confirmed that after being told by the former AD that resident 93 was at a local hospital, the search for resident 93 was called off. On [DATE] at 11:22 PM, an interview was conducted with the facility Social Services Worker (SSW). The SSW stated that she did not have any concerns with resident 93 being left alone, and was not aware of any behavior or memory issues resident 93 was experiencing. The SSW stated that she was unaware of facility procedures regarding transporting residents safely prior to the incident that occurred with resident 93. The SSW stated that she was not aware of resident 93's increased confusion upon his readmission to the facility. On [DATE] at 1:00 PM, an interview was conducted with the corporate Licensed Clinical Social Worker (LCSW). The LCSW stated that with regard to resident 93, she was aware that resident 93 went to an appointment , but when facility staff went to pick the resident up, the resident was not there. The LCSW stated that she did not assist the facility with regard to resident 93's situation, nor did she initiate any changes to corporate/facility policies and procedures afterward. An inservice agenda dated [DATE] was reviewed. The agenda revealed that the DON had provided education for facility staff, and had defined elopement as when a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. HARM 1. Resident 106 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at approximately 7:20 AM, an interview was conducted with LPN 7. LPN 7 was asked if anyone had been either discharged from the unit or sent off the unit over the last few days for any reason. LPN 7 stated that on the previous day resident 106 was sent to the local emergency room due to a broken hip from a fall he had on [DATE]. On [DATE] Resident 106's medical record was reviewed. Review of resident 106's Admission MDS dated [DATE] revealed that the section on falls indicated that resident 106 had experienced at least one recent fall, and triggered a car plan for falls to be developed. Review of resident 106's significant change MDS dated [DATE] revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 5, indicating cognitive impairment. The section on falls indicated that resident 106 had experienced at least one recent fall, and triggered a car plan for falls to be developed. Review of resident 106's care plan [DATE] revealed key areas of focus were: a) Resident Safety: Resident 106 was admitted to the 3rd floor for confusion and exit seeking behaviors; b) Limited Physical Mobility: Resident 106 has limited physical mobility

Based on observation, interview, and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 68 sample residents. Specifically, residents' pain was not addressed in a timely manner. The deficient practice for all residents 29, 75, and 106 was found to have occurred at a harm level. Resident identifiers: 29, 49, 75, and 106. Findings include: 1. Resident 106 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 12/28/16 Resident 106's medical record was reviewed. On 12/28/16 at approximately 7:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) 7. LPN 7 was asked if anyone had been either discharged from the unit or sent off the unit over the last few days for any reason. LPN 7 stated that on the previous day resident 106 was sent to the local emergency room due to a broken hip from a fall he had on 12/26/16. On 12/28/16 Resident 106's medical record was reviewed. Nurses notes revealed the following: a) On 12/23/16 at 2:31 PM: (Resident 106) is usually alert and oriented to himself, he is frequently confused, delusional, and experiences hallucinations; for example, he believes he is on a cruise ship and he sees animals in the facility, even giving some of them names. He has a BIMS score of 4/15 . b) On 12/26/16 at 10:01 PM: Late Entry: pt (patient) found on floor lying on side. pt was using walker to ambulate. staff assisted pt up into wheelchair and assisted with adls (activities of daily living) and brief change and assisted into bed. pt complained of pain in hip area. Assessed area, no grimace or complaints of pain to touch, no injury, redness, bruising noted. neuro checks started. vitals within normal limits at this time. c) On 12/27/16 at 10:49 AM: Resident alert and oriented x (times) 1. No future (sic) injury noted to previous fell (sic). Amb (ambulate) with w/c (wheelchair) by staff. Adls extensive assist with one person for transfer, bed mobility, and toileting. NPO (nothing by mouth). cont (continue) [DEVICE] (gastrostomy) feeding. Abd (abdomen) was soft. No N/V (nausea/vomiting) noted. Resident wandering with w/c on (sic) hallway. No change from baseline. Bowel sounds present. Alarm in place. Keep low bed while he stay in bed. Elevated HOB (head of bed) 30-40 degrees. Call light within reach. Cont (continue) to monitor. d) On 12/27/16 at 4:14 PM: Resident has increased pain in R (right) -hip. Pain to touch on R-hip. Weakness on r-side. Reported to (name of nurse practitioner) New order: Stat (immediate) check X-Ray to R-hip. All conditions has reported to his POA (power of attorney) . The nurse has called Lab and scheduled X-Ray. (Note: The resident fell at 10:01 PM the night before, more than 18 hours before staff assessed the resident for pain.) e) On 12/27/16 at 8:25 PM: xray received. [MEDICAL CONDITION], md and um (unit manager) was notified, orders to be sent to (local hospital). notified pt poa. pt left in wheelchair with transportation set up through avalon. sent facesheet and xray results. Review of resident 106's Medication Administration Record [REDACTED]. On 12/28/16 at 1:25 PM, an interview was conducted with Physical Therapist (PT) 1. When asked about resident 106, PT 1 stated that on 12/27/16 between 11:30 and 12:00 PM, she had brought resident 106 downstairs from the third floor in his wheelchair. PT 1 stated that the resident was unable to participate in physical therapy due to his inability to get out of his wheelchair because of pain. PT 1 stated that she went back up to the third floor and asked a Certified Nursing Assistant(CNA) if resident 106 had experienced a change in condition which may have resulted in resident 106 being unable to get out of his wheelchair. PT 1 stated that the CNA told her that she was unaware of any problems with resident 106. PT 1 stated she then asked Registered Nurse (RN) 2 if resident 106 had a change in condition. PT 1 stated that RN 2 told her resident 106 had experienced a fall the previous night but was ok. (Note: The PT reported resident 106's pain on 12/27/16 at approximately 12:00 PM, however licensed nursing staff did not address resident 106's pain until approximately 4:00 PM.) On 12/28/16 at 1:50 PM, an interview was conducted with resident 106's family member. The family member stated that she had arrived at the facility on 12/27/16 at approximately 2:00 PM and resident 106 was in severe major pain. The family member stated that resident 106 was also diagnosed with [REDACTED]. The family member also stated she was not notified on 12/26/16 about resident 106's fall. (Note: The family member reported resident 106's pain on 12/27/16 at approximately 2:00 PM, however licensed nursing staff did not address resident 106's pain until approximately 4:00 PM. In addition, no documentation could be found to indicate that resident 106's ribs had been evaluated for pain.) On 12/28/16 at 11:15 AM, an interview was conducted with RN 2. RN 2 stated that resident 106 had voiced no complaints of pain during the morning of 12/27/16. (Note: Nurses notes from 11/10/16 indicated that the resident was unable to verbalize his needs due to confusion.) 2. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 29's medical record was reviewed on 1/16/17. On 9/16/16, the facility staff completed a quarterly Minimum Data Set (MDS) assessment for resident 29. The facility staff assessed resident 29 as having frequent moderate pain with a pain intensity score of 8. On 12/20/16, the facility staff completed a quarterly MDS assessment for resident 29. The facility staff assessed resident 29 as having moderate cognitive impairment. The facility staff assessed resident 29 as having frequent moderate pain. The facility staff did not document a pain intensity score. On 3/12/14, the facility staff developed a Pain care plan which was updated on 8/9/16. The facility staff developed a goal of (Resident 29's) pain will be effectively managed without adverse medication side effects this quarter. (goal of 4/10) and (Resident 29's) physical function will not be limited by pain this quarter. The approaches developed to achieve the goals included: Listen to input (resident 29) has about his pain. Report significant findings to MD (Medical Doctor); Monitor (resident 29) for non verbal indicators of pain; Please ask (resident 29) about non-pharmacological approaches to manage his pain if appropriate; Please provide (resident 29) with his pain medications as per current orders in an appropriate manner and monitor effectiveness. On 9/25/16, a physician's orders [REDACTED]. On 10/4/16, a physician's orders [REDACTED]. Review of the electronic progress notes revealed the following entries: a. 10/28/16 at 8:00 PM: [MEDICATION NAME] Capsule give 400 mg by mouth three times a day for LEG PAIN related to [DIAGNOSES REDACTED] . 400 mg capsule unavailable. 300 mg capsule administered. b. 11/7/16 at 2:53 AM: [MEDICATION NAME] Tablet Give 200 mg by mouth one time only related to [DIAGNOSES REDACTED] .for 1 day. Resident c/o (complains of) increased restlessness and unable to get comfortable at night. Through nonverbal communication, frustrated resident was wanting increase [MEDICATION NAME] dose. Obtain 1 x (one time) order that did not arrive during shift. NP (Nurse Practitioner) to follow up with resident to eval (evaluate) for permanent changes in med (medications). The Medication Administration Records (MARs) from November 2016 through January 2017 were reviewed. The licensed nursing staff documented the following: a. November 2016: i. [MEDICATION NAME] 5/325 mg was administered to resident 29, 30 times for pain scores that ranged from 2-10 (on a pain score level of 0-10). Eighteen times the pain score was documented as a 10. (Note: There was no documentation of where resident 29's pain was or a description of the pain.) The licensed nursing staff documented that the [MEDICATION NAME] was E (effective), but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 50 mg was administered to resident 29, 32 times for pain scores that ranged from 3-10. Five times the pain score was documented as a 10. (Note: There was no documentation of where resident 29's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. b. December 2016: i. [MEDICATION NAME] 5/325 mg was administered to resident 29, 34 times for pain scores that ranged from 5-10. Twenty-four times the pain score was documented as a 10. (Note: There was no documentation of where resident 29's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 50 mg was administered to resident 29, 32 times for pain scores that ranged from 3-10. Five times the pain score was documented as a 10. (Note: There was no documentation of where resident 29's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. c. January 2017: i. [MEDICATION NAME] 5/325 mg was administered to resident 29, one time for pain score of 5. (Note: There was no documentation of where resident 29's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 50 mg was administered to resident 29, 15 times for pain scores that ranged from 2-10. Eight times the pain score was documented as a 10. (Note: There was no documentation of where resident 29's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. On 1/17/17 at 1:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 29 had been having increased pain since the beginning of December 2016 and was unsure as to why. The DON stated that resident 29's primary care physician was to reassess resident 29 to determine what was causing his pain. On 1/17/17 at 2:23 PM, the DON was re-interviewed. The DON stated that she did not know why resident 29 had pain scores of 10 when his goal pain score was a 4. The DON stated that since the resident 29's ongoing pain was brought to her attention, that she was now looking into his increased pain. 3. Resident 75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/4/17 at 10:24 AM, an interview was conducted with resident 75. Resident 75 stated that she had problems with her teeth. Resident 75 stated that she had pain because of her rotten teeth for the past couple of months. Resident 75 stated that she was told that she had to wait until my insurance kicked in before she would be able to see a dentist for her pain. On 1/4/17 at 10:30 AM, an observation was made of resident 75's teeth. Resident 75 had the front two teeth missing with the right molar teeth that appeared to have been ground down. Resident 75's medical record was reviewed on 1/10/17. The care plans developed for resident 75 were reviewed. The facility had not developed or revised a care plan that addressed resident 75's dental status. On 10/4/16, an order was received to administer [MEDICATION NAME] 650 mg every 6 hours as needed for pain, [MEDICATION NAME] 500 mg every 12 hours as needed for pain and [MEDICATION NAME] 750 mg every 8 hours as needed for pain. The electronic progress notes for resident 75 were reviewed. The licensed nursing staff documented the following: a. 11/1/16 at 5:35 PM: Resident at nurses cart crying in pain from teeth and lower jaw. Resident stated not much is helping at this time. Sent message to NP (Nurse Practitioner) (name redacted) to update her on resident pain control issues. b. 11/1/16 at 9:53 PM: .Resident requested Tylenol for pain on teeth. c. 11/3/16 at 4:18 PM: N/O (new order) - [MEDICATION NAME] 10% PRN (as needed) for tooth/mouth pain. d. 1/10/2017 at 1:22 PM: Rt. (Resident) assessed. Rt. states that she has pain on the Lower R (right) side of her mouth, but the order for [MEDICATION NAME] helps alleviate the pain. She also states that sometimes she mixes together salt and warm water in order to swish around in her mouth which helps alleviate the pain. Rt. reports that she has spoken with social services and they are working on making her dentist and eye appointments. Vision assessed. L (left) eye is WNL (within normal limits), R eye rt. reports she can not see out of. Both eyes PERRLA (Pupils Equal Round and Reactive to Light and Accommodation). Rt. is missing some teeth in lower front of mouth but all teeth intact on lower R side. No redness or injury noted in mouth at this time. Nurse will continue to monitor. The MARs from November 2016 through January 2017 were reviewed. The licensed nursing staff documented the following: a. November 2016: i. [MEDICATION NAME] 650 mg was administered 14 times for pain scores that ranged from 3-10. 5 times the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 500 mg was administered 27 times for pain scores that ranged from 3-10. Six times the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. iii. [MEDICATION NAME] 750 mg was administered 16 times. The licensed nursing staff did not document a pain score or why the [MEDICATION NAME] was administered. (Note: There was no documentation of where resident 75's pain was or a description of the pain.). The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. b. December 2016: i. [MEDICATION NAME] 650 mg was administered 18 times for pain scores that ranged from 4-10. Two times the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 500 mg was administered 26 times for pain scores that ranged from 3-9. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. iii. [MEDICATION NAME] 750 mg was administered 10 times. The licensed nursing staff did not document a pain score or why the [MEDICATION NAME] was administered. (Note: There was no documentation of where resident 75's pain was or a description of the pain.). The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. c. January 2017: i. [MEDICATION NAME] 650 mg was administered 5 times for pain scores that ranged from 5-9. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 750 mg was administered 5 times for pain scores that ranged from 5-10. Once the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.). The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. On 1/10/17 at 8:07 AM, resident 75 was re-interviewed. Resident 75 stated that her tooth pain was rated at a 10 on a pain scale of 1-10 with 10 being excruciating and intolerable. Resident 75 stated that her pain decreased down to a 5 after she took her pain medications. On 1/11/17 at 8:16 AM, resident 75 was re-interviewed. Resident 75 stated that her right lower jaw area hurt from her teeth that had been ground down and her right upper gums. Resident 75 stated that she had not used the prescribed [MEDICATION NAME] because the [MEDICATION NAME] was not effective. Resident 75 stated that she gargled with salt water which helped some, but that she was in a lot of pain. Resident 75 stated that she had not been told when she would be able to see the dentist. On 1/11/17 at 9:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 75 frequently complained of dental pain. LPN 1 that she had reported her her concerns about resident 75 seeing a dental multiple times in the last couple of months. On 1/11/17 at 2:20 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that resident 75 complained of mouth pain all the time. UM 1 stated that the dentist confused her with another resident but that resident 75 was seen by a dentist the first part of October 2016 and had a lot of nubs. On 1/12/17, resident 75 was seen by a mobile dental company. The Dentist documented that resident 75 had a deep [MEDICATION NAME] decay to tooth 2 with root tip exposure to teeth 13 and 19. The Dentist documented that resident 75 was referred for oral surgery for [REDACTED]. 4. Resident 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 49's medical record was reviewed on 1/11/17. On 1/11/17 at 9:26 AM, resident 49 was observed to be complaining to a nurse of right sided mouth pain. Resident 49 complained that he had a tooth that was causing him pain. Resident 49 stated that he had previously spoken to the facility Social Services Worker (SSW) about his tooth pain and was told he could not see a dentist because of his insurance and that he would have to wait for three months. On 1/11/17 at 11:50 AM, resident 49 was observed at the nurses station complaining that his tooth pain had not improved. Licensed Practical Nurse (LPN) 1 stated to resident 49 that she had already administered Tylenol and [MEDICATION NAME] without any help. LPN 1 stated that she would have to notify the Nurse Practitioner. On 1/11/17 at 2:20 PM, UM 1 was interviewed. UM 1 stated that she was not aware that resident 49 was having tooth pain. On 1/11/17 at 4:12 PM, UM 1 was re-interviewed. The UM stated that emergency dental services were to be provided despite payor status. On 1/12/17 at 10:20 AM, an interview was conducted with the SSW. The SSW stated that she did not know why resident 49 or resident 75 were told that they had to wait for a dentist appointment. (Cross refer to F323 and F412)

Based on observation, interview and record review, it was determined that for 2 of 68 sampled residents, the facility did not arrange for emergency dental services. Specifically, two residents requested to see a dentist due to tooth pain. The deficient practice identified for resident 75 was cited at harm. Resident identifiers: 49, and 75. Findings include: 1. Resident 75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/4/17 at 10:24 AM, an interview was conducted with resident 75. Resident 75 stated that she had problems with her teeth. Resident 75 stated that she had pain because of her rotten teeth for the past couple of months. Resident 75 stated that she was told that she had to wait until my insurance kicked in before she would be able to see a dentist for her pain. On 1/4/17 at 10:30 AM, an observation was made of resident 75's teeth. Resident 75 had the front two teeth missing with the right molar teeth that appeared to have been ground down. Resident 75's medical record was reviewed on 1/10/17. The care plans developed for resident 75 were reviewed. The facility had not developed or revised a care plan that addressed resident 75's dental status. On 10/4/16, an order was received to administer [MEDICATION NAME] 650 mg every 6 hours as needed for pain, [MEDICATION NAME] 500 mg every 12 hours as needed for pain and [MEDICATION NAME] 750 mg every 8 hours as needed for pain. The electronic progress notes for resident 75 were reviewed. The licensed nursing staff documented the following: a. 11/1/16 at 5:35 PM: Resident at nurses cart crying in pain from teeth and lower jaw. Resident stated not much is helping at this time. Sent message to NP (Nurse Practitioner) (name redacted) to update her on resident pain control issues. b. 11/1/16 at 9:53 PM: .Resident requested Tylenol for pain on teeth. c. 11/3/16 at 4:18 PM: N/O (new order) - [MEDICATION NAME] 10% PRN (as needed) for tooth/mouth pain. d. 1/10/2017 at 1:22 PM: Rt. (Resident) assessed. Rt. states that she has pain on the Lower R (right) side of her mouth, but the order for [MEDICATION NAME] helps alleviate the pain. She also states that sometimes she mixes together salt and warm water in order to swish around in her mouth which helps alleviate the pain. Rt. reports that she has spoken with social services and they are working on making her dentist and eye appointments. Vision assessed. L (left) eye is WNL (within normal limits), R eye rt. reports she can not see out of. Both eyes PERRLA (Pupils Equal Round and Reactive to Light and Accommodation). Rt. is missing some teeth in lower front of mouth but all teeth intact on lower R side. No redness or injury noted in mouth at this time. Nurse will continue to monitor. The MARs from November 2016 through January 2017 were reviewed. The licensed nursing staff documented the following: a. November 2016: i. [MEDICATION NAME] 650 mg was administered 14 times for pain scores that ranged from 3-10. 5 times the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 500 mg was administered 27 times for pain scores that ranged from 3-10. Six times the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. iii. [MEDICATION NAME] 750 mg was administered 16 times. The licensed nursing staff did not document a pain score or why the [MEDICATION NAME] was administered. (Note: There was no documentation of where resident 75's pain was or a description of the pain.). The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. b. December 2016: i. [MEDICATION NAME] 650 mg was administered 18 times for pain scores that ranged from 4-10. Two times the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 500 mg was administered 26 times for pain scores that ranged from 3-9. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. iii. [MEDICATION NAME] 750 mg was administered 10 times. The licensed nursing staff did not document a pain score or why the [MEDICATION NAME] was administered. (Note: There was no documentation of where resident 75's pain was or a description of the pain.). The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. c. January 2017: i. [MEDICATION NAME] 650 mg was administered 5 times for pain scores that ranged from 5-9. (Note: There was no documentation of where resident 75's pain was or a description of the pain.) The Licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. ii. [MEDICATION NAME] 750 mg was administered 5 times for pain scores that ranged from 5-10. Once the pain score was documented as a 10. (Note: There was no documentation of where resident 75's pain was or a description of the pain.). The licensed nursing staff documented that the [MEDICATION NAME] was E, but did not document a method to determine how the [MEDICATION NAME] was effective. On 1/10/17 at 8:07 AM, resident 75 was re-interviewed. Resident 75 stated that her tooth pain was rated at a 10 on a pain scale of 1-10 with 10 being excruciating and intolerable. Resident 75 stated that her pain decreased down to a 5 after she took her pain medications. On 1/11/17 at 8:16 AM, resident 75 was re-interviewed. Resident 75 stated that her right lower jaw area hurt from her teeth that had been ground down and her right upper gums. Resident 75 stated that she had not used the prescribed [MEDICATION NAME] because the [MEDICATION NAME] was not effective. Resident 75 stated that she gargled with salt water which helped some, but that she was in a lot of pain. Resident 75 stated that she had not been told when she would be able to see the dentist. On 1/11/17 at 9:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 75 frequently complained of dental pain. LPN 1 that she had reported her her concerns about resident 75 seeing a dental multiple times in the last couple of months. On 1/11/17 at 2:20 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that resident 75 complained of mouth pain all the time. UM 1 stated that the dentist confused her with another resident but that resident 75 was seen by a dentist the first part of October 2016 and had a lot of nubs. On 1/12/17, resident 75 was seen by a mobile dental company. The Dentist documented that resident 75 had a deep [MEDICATION NAME] decay to tooth 2 with root tip exposure to teeth 13 and 19. The Dentist documented that resident 75 was referred for oral surgery for [REDACTED]. 2. Resident 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 49's medical record was reviewed on 1/11/17. On 1/11/17 at 9:26 AM, resident 49 was observed to be complaining to a nurse of right sided mouth pain. Resident 49 complained that he had a tooth that was causing him pain. Resident 49 stated that he had previously spoken to the facility Social Services Worker (SSW) about his tooth pain and was told he could not see a dentist because of his insurance and that he would have to wait for three months. On 1/11/17 at 11:50 AM, resident 49 was observed at the nurses station complaining that his tooth pain had not improved. Licensed Practical Nurse (LPN) 1 stated to resident 49 that she had already administered Tylenol and [MEDICATION NAME] without any help. LPN 1 stated that she would have to notify the Nurse Practitioner. On 1/11/17 at 2:20 PM, UM 1 was interviewed. UM 1 stated that she was not aware that resident 49 was having tooth pain. On 1/11/17 at 4:12 PM, UM 1 was re-interviewed. The UM stated that emergency dental services were to be provided despite payor status. On 1/12/17 at 10:20 AM, an interview was conducted with the SSW. The SSW stated that she did not know why resident 49 or resident 75 were told that they had to wait for a dentist appointment. (Cross refer to F250 and F309)

Based on interview, observation, and record review the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 9 of 68 sample residents. Specifically, a resident experienced a fall with an injury after waiting for staff to assist him. The deficient practice resulted in a finding of harm for resident 19. In addition, observations were made of residents not receiving timely assistance with their needs, and staff and residents reported that there were not enough staff available to meet residents' needs. Resident identifiers: 14, 19, 20, 25, 45, 82, 94, 107, and 108. Findings include: HARM: 1. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/4/17 at 12:15 PM, an observation of resident 19 was made. Resident 19 appeared to have a blue/purple mark over his right eye. An interview was immediately conducted with resident 19. Resident 19 stated that a few days ago, he was in his room and needed staff assistance. Resident 19 stated that he required assistance to get to the bathroom, and had pressed his call light to alert staff he needed help. Resident 19 stated that he waited approximately 30 minutes, but no staff responded. Resident 19 stated that he knew he was supposed to wait for staff before he went to the bathroom, but he couldn't wait anymore. Resident 19 stated that he tried to get out of bed, but fell and hit his head on the garbage can, causing a laceration over his eye that had required several stitches. Resident 19 stated that the facility did not have enough staff to meet his needs, and staffing was particularly low at nights, which was when the fall occurred. Resident 19's medical record was reviewed on 1/4/17. Resident 19's quarterly MDS assessment dated [DATE], and his significant change MDS assessment dated [DATE], both revealed that resident 19 had a Brief Interview for Mental Status (BIMS) score of 15. Nurses notes for resident 19 revealed the following: a) On 12/26/16 at 3:47 AM, CNA transferred resident with w/c (wheelchair) to the 3 east nurse station due to resident had a fall from his bed and face hit to his garbage can, and caused a laceration on his right eyebrow. The laceration still bleed (sic) slowly. Nurse called (name of physician). New order to send resident to ER (emergency room ) . b) On 12/26/16 at 6:07 AM, Resident returned to the facility from ER of (name of hospital). Resident had a CT (computed tomography) (of the) head without contrast noted from the ER note, was treated with stitched (sic) to the laceration on right eyebrow . Resident 19's care plan for falls dated 10/25/16 was reviewed. The falls care plan indicated that the resident needs prompt response to all requests for assistance. A Fall Risk Evaluation was completed by facility staff on 12/26/16. The evaluation indicated that resident 19 was a high risk for falls. On 1/12/17 at 9:30 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that resident 19 was pretty with it and was a good historian. UM 1 stated that she was aware of resident 19's injury on 12/26/16, and was told resident 19 rolled out of bed. UM 1 stated she was not aware that resident 19 had reported the fall was due to waiting an extensive period of time for a call light to be answered. On 1/12/17 at 9:35 AM, the facility SSW was interviewed. The SSW stated that resident 19 was cognitively intact. On 1/12/17 at 12:15 PM, an interview was conducted with the facility DON. The DON stated she was unaware of the circumstances regarding resident 19's fall on 12/26/16. POTENTIAL FOR HARM 1. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 25's medical record was reviewed on 1/3/17. A quarterly Minimum Data Set (MDS) assessment dated [DATE] for resident 25 was reviewed. The MDS indicated that resident 25 was always incontinent of both bowel and bladder, was not not on a toileting program. A care plan dated 9/23/16 revealed that resident 25 had bladder incontinence related to her dementia. On 1/2/17 facility staff completed a Monthly Assessment for resident 25. Facility staff indicated on the assessment that resident 25 was alert but not oriented, and was confused with short term memory impairment and impaired decision making ability. The assessment also indicated that resident 25 was incontinent of both bowel and bladder, and required the use of pads/briefs. On 11/20/16 facility staff documented in a nurses note that resident 25 was alert and oriented to her self only, and was not able to make her needs known to staff. On 1/4/17 a continuous observation was made of resident 25 by two surveyors. a) At 9:00 AM, resident 25 was observed to be seated in her wheelchair in the dining room while an activity was being held. b) At 10:00 AM, the activity concluded, however, resident 25 was not assisted out of the dining room. c) At 11:16 AM, a hospice worker entered the dining room and performed nail care for resident 25. d) At 11:55 AM, the hospice worker pushed resident 25's wheelchair up to a table in preparation for lunch. e) At approximately 12:35 PM, resident 25 was served lunch in the dining room. (Note: Resident 25 was not toileted or repositioned for at least a period of 3 hours and 25 minutes during the continual observation.) On 1/4/17 at 12:25 PM, an interview was conducted with Certified Nursing Assistant (CNA) 14. CNA 14 stated that resident 25 required total assistance with toileting and other Activities of Daily Living (ADLs). CNA 14 stated that she was assigned to resident 25 that day, but confirmed she had not assisted resident 25 with toileting that day. On 1/4/17 at 12:30 PM, an interview was conducted with CNA 11. CNA 11 stated that resident 25 required total assistance with toileting and other ADLs. CNA 11 stated that she was not assigned to resident 25 that day, and had not assisted resident 25 with toileting that day. On 1/4/17 at 12:35 PM, an interview was conducted with CNA 15. CNA 15 stated that resident 25 required total assistance with toileting and other ADLs. CNA 15 stated that she was assigned to work with resident 25 that day. CNA 15 stated that despite the continuous observation of resident 25 by two surveyors, she had assisted resident 25 to the bathroom at 10:30 AM. On 1/12/17 at 9:30 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that residents were supposed to be repositioned and/or toileted at least every two hours. On 1/10/17 at 12:20 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 25 should have been toileted and/or had her brief changed at least every two hours. 2. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's medical record was reviewed on 1/11/7. On 10/17/16, the facility staff completed a quarterly MDS Assessment for resident 14. The facility staff assessed resident 14 as being severely cognitively impaired and required extensive assistance of one person for bed mobility. On 1/11/17 from 8:08 AM through 11:50 AM, resident 14 was continuously observed while laying in her bed. The following was identified: a. At 8:08 AM, resident 14 was laying in bed on her left side, facing towards the wall. On 1/11/17 at 8:08 AM, the call light sounded in room [ROOM NUMBER]. Licensed Practical Nurse (LPN) 1 entered room [ROOM NUMBER] and stated to the resident, Someone will be right with you. LPN 1 turned the call light off and left the room. At 8:18 AM, Certified Nurse Assistant (CNA) 4 entered room [ROOM NUMBER] to change the soiled bedding as requested. b. As of 9:50 AM, facility staff had not entered resident 14's room. c. At 10:00 AM, CNA 4 entered resident 14's room and left within approximately five seconds. CNA 4 did not provide cares to resident 14. d. At 11:49 AM, CNA 1 and CNA 4 entered resident 14's room. CNA 1 and CNA 4 woke resident 14 and began providing personal cares in preparation for the noon meal. On 1/11/17 at approximately 12:15 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 14 was to be turned and repositioned every 2 hours to prevent skin breakdown. CNA 1 was not aware that resident 14 had not been repositioned for almost 3 1/2 hours. 3. On 1/11/17 at 8:08 AM, the call light sounded in room [ROOM NUMBER]. Licensed Practical Nurse (LPN) 1 entered room [ROOM NUMBER] and stated to the resident, Someone will be right with you. LPN 1 turned the call light off and left the room. At 8:18 AM, Certified Nurse Assistant (CNA) 4 entered room [ROOM NUMBER] to change the soiled bedding as requested. 4. On 1/4/17 at approximately 10:45 AM resident 45 was interviewed. When asked about staffing levels, resident 45 stated that they could use more staff because on occasion it took a while for staff to give him the proper assistance he required. 5. On 1/4/17 at approximately 9:30 AM resident 107 was interviewed. When asked about staffing levels, resident 107 stated that he felt the facility was short staffed, but could not provide additional information. 6. On 1/3/17 at approximately 3:30 PM resident 20 was interviewed. When asked about staffing levels, resident 20 stated that sometimes staff took a long time to answer call lights. Resident 20 stated that she will sometimes need help getting her wheelchair moved closer to the bed in the morning if it gets moved during the night and she has to wait a long time for staff to push it close to her bed so she can use the bathroom and move around the unit. 7. On 1/9/17 at approximately 2:40 PM Staff Member (SM) 4 was interviewed. SM 4 stated that she felt like there was not enough help. SM 4 stated that some of the staff were good but some were bad. SM 4 stated that certain tasks didn't get finished just because there was not enough time to get everything done. 8. On 1/9/17 at approximately 3:00 PM SM 5 was interviewed. SM 5 stated that on Saturdays and Sundays they were often short staffed. SM 5 stated that she would frequently get phone calls on the weekends asking if she could work. 9. On 1/10/16 at approximately 11:45 AM SM 6 was interviewed. SM 6 stated that they were short staffed on CNAs. She believed that for about the last month and a half they had been using a lot of agency CNAs. SM 6 stated that there was less office staff and administrative staff on weekends, which made it difficult. 10. On 1/10/16 at approximately 12:05 PM SM 7 was interviewed. SM 7 stated that the weekends were a little bit tougher than the weekdays. SM 7 stated that there were less office staff on the weekends to help out with unexpected situations when they happened. 11. On 1/3/17 at 3:56 PM, resident 82's sister was interviewed. She stated that the facility had not enough staff members available, especially not enough aides. Resident 82's sister stated that she would come to visit her brother daily because available staff members did not provide good care for her brother. Residents 82's sister stated that a few times she had observed that her brother did not eat his meals and that he did not receive showers on time. 12. On 1/9/16 at 1:10 PM, resident 94 was observed sitting in the wheelchair in the dining room in the basement. He stated that he wanted to go back to his room. Resident 94 stated that an aide told him that she would be back to pick him up half an hour ago but no one came to pick him up yet. Resident 94 stated that the facility did not have enough aides available most of the time. Resident 94 stated that in the past he had waited for 20 minutes or longer for staff assistance. 13. On 1/16/17 at 10:50 AM, resident 108 stated that facility had not enough staff available. He stated that he was pretty independent, and did not require a lot of assistance now. Resident 108 stated that right after his admission to the facility, he needed to wait longer for his medication administration and aides to come and help him to the bathroom. (Cross refer to F312 and F323)

Based on interview and record review the facility did not provide and document sufficient preparation and orientation to 5 of 68 sample residents to ensure safe and orderly transfer or discharge from the facility. The deficient practice for resident 93 resulted in a finding of harm. Resident identifiers: 88, 93, 110, 112, and 113. Findings include: 1. Resident 93 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/28/16, resident 93's medical record was reviewed. Resident 93's History and Physical dated 10/2/16 was reviewed. The History and Physical revealed that resident 93's confusion has been worsening and is continuous. The History and Physical indicated that resident 93 was asked about why he is here, he just mumbles and no other significant subjective information can be obtained from him. In addition the History and Physical revealed that resident 93 was transferred to the general psychiatric unit. Nurses notes for resident 93 revealed the following: a) On 10/14/16, resident 93 was admitted to the facility from a local hospital after being found face down in a parking lot. Resident 93 was assessed as being alert and oriented x 3 or 4. b) On 10/21/16 at 3:12 PM, resident 93 . has made statements of concern about leaving and how that will effect him because he's mentally in a good place right now . c) On 10/21/16 at 3:21 PM, resident 93 . has clear speech. Res (resident) is slow to respond. Res does have episodes of confusion and easily forgets. res was homeless prior to recent hospital stay. d) On 10/27/16, . shows some confusion presented as slow to respond to certain questions. e) On 10/28/16 at 4:48 PM, SSW (Social Services Worker) discussed with the resident plans for a forthcoming discharge from the facility on October 29th. Resident indicates that he may seek to stay with friends living in the local area, but had not made any definite arrangements. Resident indicates that he would like to take public transportation to get to his destination. Resident information (sic) on the local public homeless shelter. SSW also confirmed that resident had an appointment to meet with (name of local practitioner) . for medical follow-up examination. The resident was provided with contact information on a number of local home health agencies for which he was told that he could make arrangements after he had obtained a more permanent address. SSW has attempted to contact (name of local mental health facility) to see if the resident might possibly have additional resources to help him obtain housing through that organization . f) On 10/28/16 at 5:28 PM, . Case manager with (name of local mental health facility) stopped by the facility on the evening of 10/28/16 to meet with the resident. Resident was advised that he should come to the (name of local mental health facility) location in downtown Salt Lake City following the time of his discharge in order to make further arrangements for ongoing services. g) On 10/29/16, . His plan is to go to (name of local homeless shelter). He received education on his medications and how to take them. h) 10/31/16, Resident was discharged on [DATE] . Resident came back to facility today and sat in day room with his possessions. When asked to leave resident refused and stated that he was going into protective custody. When SW (social worker) asked if he had any contact info (information) he stated that he did not, but they were coming sometime today to pick him up. SW explained that he had been discharged and was no longer to remain at facility. Facility offered to pay for a taxi cab to transport him to the (homeless shelter) but resident refused, and indicated that he was going to stay where he was. Local police were contacted and resident was escorted off of the property per administrative decision. Resident 93's care plans were reviewed. A discharge care plan developed on 10/26/16 for resident 93 indicated that resident 93 was admitted as a long-term care resident. (Resident 93) requires assistance with daily cares due to frequent confusion related to medical issues. A falls care plan developed on 10/26/16 for resident 93 indicated that the resident was at risk for falls related to his confusion. Resident 93's Social Services Discharge Planning Review dated 10/28/16 was reviewed. The discharge planning document revealed that resident 93's cognitive status was listed as a concern about returning home. Resident 93's Preadmission Screening Resident Review (PASRR) Level II dated 11/22/16 was reviewed. The PASRR indicated that resident 93 had a medical history significant for chronic malnutrition, increasing confusion, and poor concentration, and inability to care for himself . (resident 93) told hospital staff that he has '300 homes'. The PASRR indicated that resident 93 had recently been diagnosed with [REDACTED]. The PASRR also indicated that resident 93 has demonstrated poor ability to prepare his own meals or effectively manage his nutritional needs. He is at risk for wandering. Due to his increasing confusion and chronic mental illness he has been going in and out of jail. he has been discharged to less restrictive settings, but has wandered and has been picked up by police multiple times (due to) his wandering and for concerns for his safety. He us unable to manage his medications and needs supervision and reminders to carry out ADLs (Activities of Daily Living). The PASRR also indicated that resident 93 had increasing confusion and disorientation. In addition, the PASRR indicated that resident 93 has a history of wandering . His insight and judgment are impaired. He had been living in a SNF (skilled nursing facility) since 10/14/16, but was discharged to the shelter and was told to go to (the local mental health facility) for mental health and case management services. However, due to pt's (patient's) impaired cognition and inability to care for himself, he ended up living out on the streets and was not able to care for himself. He did not know how to get to (the local mental health facility) and stopped taking his medications as he was unable to obtain more medications. He decompensated and was found in a Chinese restaurant being disruptive (and) delusional, talking about being in a war and in the military, and appeared to be responding to internal stimuli. He would not leave the restaurant and the police were called. Pt was pink sheeted and taken . (to local hospital). He was admitted to the inpatient psychiatric unto (sic) for further psychiatric stabilization and evaluation. The PASRR indicated that resident 93 had a history of [REDACTED]. The PASRR also revealed that resident had difficulty with recall, and was not oriented to place, situation or time. The PASRR revealed that resident 93 was a substantial danger to himself or others; and that the nursing facility's supervision and structure mitigated this danger. Per nurses notes, the resident was then readmitted to the facility on [DATE]. On 1/12/17 at 9:35 AM, the facility Social Services Worker (SSW) was interviewed. When asked about resident 93, the SSW stated that when resident 93 was discharged from the facility the first time, she didn't have any concerns he would fail in the community. The SSW stated that resident 93 seemed with it and she was aware that resident 93 did not have a support system outside of the facility. On 12/28/16, the facility Administrator (ADM) was interviewed. The ADM stated that resident 93 was discharged in October because he no longer met criteria. On 1/12/17 at 9:35 AM, the facility SSW was interviewed. When asked about preparing residents for a safe discharge, the SSW stated that her assistant had mostly been handling the discharges. The SSW stated that she would provide 3 brochures, make sure a follow up appointment was made with a physician, and arrange home health services if a resident had a place to live. The SSW stated that the facility also provided a sack lunch and bus fare for residents if they were being discharged to the homeless shelter. The SSW stated that prior to 12/1/16, her understanding was that even if the PASRR office approved a resident to stay at the facility several months, the facility would not be reimbursed for some residents, and the facility was forced to discharge residents due to financial/payment issues. The SSW stated that she had since clarified with the PASRR office that residents were allowed to stay for the entire time approved by the PASRR office. The SSW stated that this misunderstanding was ongoing during the time that resident 93 was discharged from the facility, and that resident 93 had been discharged due to fears that the facility would not be reimbursed for his stay. The SSW stated that the previous admissions director was telling people up front that they would be discharged back to the homeless shelter if they came from the homeless shelter. 2. Resident 110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 110's medical record was reviewed on 12/28/16. Resident 110's History and Physical dated 11/7/16 was reviewed. The History and Physical stated that resident 110 had recently attempted suicide, and was at the hospital for evaluation. Resident 110's PASRR dated 11/10/16 was reviewed. The PASRR letter of determination indicated that resident 110 was approved for nursing facility services on a short term stay from 11/10/16 to 2/8/17. The PASRR also indicated that resident 110 had been hosptalized on [DATE] for chest pain, intoxication, and threats for self harm. The PASSR also indicated that records indicate pt (patient) has a long history of alcoholism and had been drinking significant amounts of alcohol and was not taking his medications as indicated. this puts him at risk for harm. He was in the ER (emergency room ) overnight and left (name of hospital) AMA (against medical advice). He returned to theER on [DATE] after a suicide attempt by overdosing . due to worsening depression, (resident 110) was admitted to the inpatient geropsych unit at (name of hospital) for psychiatric evaluation and treatment, medication supervision, assistance with ADL's (Activities of Daily Living), ongoing medical care, and therapies as needed. The PASRR also indicated that resident 110 had moderate to severe impairment in judgment, and fair insight. The PASRR recommended that the facility continue to monitor medical and psychiatric needs to ensure safety and that pt is properly managing his medical needs. Monitor and treat psychiatric symptoms as needed. Please refer to housing and other community resources. Offer support and redirection from facility staff. On 12/28/16, facility staff provided surveyors with a list of residents who had been recently discharged . The discharged list indicated that resident 110 had been discharged on [DATE] to a local homeless shelter. A social services note dated 11/18/16 for resident 110 revealed the following: SSW approached the resident to discuss a forthcoming discharge from the facility on 11/21/16 at 12:00 PM. The resident indicated that he does not currently have housing resources nor did he have a fixed address in which to live. The resident reported that he does not have a primary care provider at the present time, nor does he have have (sic) a doctor or clinic he would prefers (sic) to use. The resident indicates that he does not have any means of transportation available to him to pick him up on the date of his discharge and he would therefore likely utilize public transportation at that time. The resident was provided with a list of community resources to assist him in locating housing and ongoing community-based medical assistance. A nurses note dated 11/22/16 for resident 110 revealed the following: . Resident given copy of community resources and their (numbers). Resident educated on medications and inhalers when to take them and what they are for. Resident discharged with all belongings at this time. On 1/5/17 at 1:15 PM, an interview was conducted with the facility ADM. When asked about resident 110, the ADM stated that resident 110 wanted to discharge to the homeless shelter, and we try hard to maintain the residents' wishes. The ADM stated that resident 110 chose to leave and that it was not a payment issue . When asked how the facility staff ensured that residents were discharged safely, the ADM stated that the discharge planning process was overseen by the SSW. On 12/28/16 at 3:30 PM, the facility SSW was interviewed. The SSW stated that when resident 110 was admitted he had been homeless, and it was agreed that he would discharge homeless. The SSW stated that even though PASRR had approved resident 110 for a stay at the facility through February 2017, the facility couldn't hang on to him because he didn't have a skilled need anymore. On 1/12/17 at 9:35 AM, the facility SSW was re-interviewed. The SSW stated that prior to 12/1/16, her understanding was that even if the PASRR office approved a resident to stay at the facility several months, the facility would not be reimbursed for some residents, and the facility was forced to discharge residents due to financial/payment issues. The SSW stated that she had since clarified with the PASRR office that residents were allowed to stay for the entire time approved by the PASRR office. The SSW stated that this misunderstanding was ongoing during the time that resident 110 was discharged from the facility, and that resident 110 had been discharged due to fears that the facility would not be reimbursed for his stay. 3. Resident 112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 112's medical record was reviewed on 12/28/16. Resident 112's History and Physical dated 11/8/16 was reviewed. The History and Physical revealed that resident 112 had a history of [REDACTED]. Review of the electronic nurses notes revealed the following entries: a) 11/7/16 at 7:58 PM: Resident, new admitted (sic). Transfer from another facility. Resident alert and oriented X 1 (person). Able to make needs known to staff. b) 11/8/16 at 6:00 AM: pt. (patient) woke up demanding to go outside to smoke, edu (educated) pt on scheduled smoke times. pt got upset started yelling and ramming electric w/c (wheelchair) into outside doors. staff attempted to de-escalate pt and continue edu pt on smoke break policy. pt also demanded coffee edu pt that kitchen will bring up coffee when it opens this morning. pt stood up out of w/c into fight position with fists aimed at aide threatening to punch her. no contact was made. pt also took the oxygen tank from the crash cart in attempt to break open the door. pt was compliant in giving tank back. staff lock (sic) tank and crash cart in another room. pt did calm down more as am (morning) staff started to arrive. c) 11/8/16 at 12:47 PM: Resident alert and oriented X 2 (person and place). Repeated questions.Verbally abuse (sic) to staff and 'I don't want to stay here. I need to leave' said he (sic). C/o (complained of) pain in lle (left lower extremity), given prn (as needed) Tylenol with helping. Agitate (sic) at times. Reported to NP (Nurse Practitioner) and MD (Medical Doctor). d) 11/9/16 at 6:27 AM: Pt woke up demanding to smoke and leave facility. pt ramming electric wheel chair into doors trying to leave. pt running into carts and throwing chairs around. pt used personal cell phone to call 911. fire department showed and said this was the 3rd facility they had been to looking for this pt. e) 11/9/16 at 9:48 AM: RN (Registered Nurse) Note: Res has been anxious this morning and wanting to leave the facility. Res continues to ask 'when can I leave .I want out of here .damn this place sucks nothing to do and I hate it here'. Social services has been notified. Res also has been mumbling, under his breath, things that he wants to do to other residents such as, 'why dont (sic) I just pull her hair and throw her on the ground . I think she needs a good punch in the face if you want to calm her down I would like to hit her so hard'. This was not just one resident but multiple residents he was referring to. His statements are directed towards (sic). f) 11/9/16 at 10:23 AM: Due to his violent statements directed towards women, leaving the lock down unit via elevator, and wanting to leave building. IDT (Interdisciplinary Team) staff decided to notify police of his statements and have a police officer come and visit with him prior to leaving AMA (Against Medical Advice). Belongings have been gathered, RN and social worker, and given to resident. Resident is waiting at front door to leave. Res is his own POA (Power of Attorney) and can make the decision to leave AMA. g) 11/9/16 at 12:42 PM: Resident left AMA approximately 11:00 AM this morning. Res was given a sack lunch, bus fare, and all belongings. h) 11/9/16 at 12:44 PM: Res also signed release from responsibility for discharge against medical advice form prior to leaving AMA. On 12/28/16 at 3:29 PM, an interview was conducted with the SSW. The SSW stated that she thought that resident 112 was alert and oriented despite the nurses documentation that resident 112 was only alert and oriented X 1. The SSW stated that resident 112 was placed on the secured unit related to his behaviors at a previous long-term care facility. The SSW stated that the facility Director of Nursing (DON) told her that resident 112 was his own power of attorney and had the right to leave the facility if he chose too. The SSW stated that she was not directly involved in resident 112's discharge but had attempted to calm him down on 11/8/16. The SSW stated that she had not received, nor provided behavior management training for residents with behaviors. The SSW stated that she did not consult the Corporate Licensed Clinical Social Worker (LCSW) for advice or direction related to resident 112's behaviors or desire to leave the facility. The SSW stated that she did not contact the consultant LCSW regarding resident 112 leaving the facility because she oversees more of the policy and procedural types of things. The SSW stated that she did not consider placement for resident 112 in a geriatric psychiatric facility because my understanding is that if someone is not committed to be here . then we don't have the right to hold them against their will. The SSW stated that she was unaware of resident 112's current whereabouts. On 12/28/16 at 4:18 PM, an interview was conducted with the DON. The DON stated that resident 112 had the right to leave on his own and that the facility cannot keep him against his will. He knew where he was going and his name. The DON stated that she spoke with resident 112 prior to him leaving the facility and assessed him as being alert and oriented to person, place, and time despite being assessed by another facility RN as being alert and oriented to person only. The DON stated that resident 112 had a plan as to where he was going, so he was provided with a bus fare and a packed lunch. The DON stated that the Corporate LCSW was not contacted and that she did not think of alternative placement as he seemed just fine. The DON stated that there had not been any training related to how to de-escalate residents during verbal or physical outbursts. The DON stated that she was unaware of what the behavioral interventions were for resident 112 because social work does all that. 4. Resident 88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 88's medical record was reviewed on 1/6/17. The facility staff developed a Discharge Plan care plan related to the need for a long term care stay. The facility staff documented that resident 88 had a [DIAGNOSES REDACTED]. The facility staff further documented that resident 88 was homeless and not likely to return to the community due to his cognitive impairments. (Note: The date of when the care plan was developed was not documented.) Review of the electronic nursing notes revealed the following entries: a) 8/26/16 at 11:05 PM: Resident is AOX2 (alert and oriented to person and place) with confusion and needs to be reoriented and redirected. b) 8/28/16 at 7:25 AM: .Resident is AOX2 and can verbalize needs. Resident has bout (sic) of confusion and has to be reoriented and redirected.Resident had said that he had 9/10 since the preceding (sic) month and has just made it known.reported 9/10 pain. Resident has requested nurse to call ambulance or give him a pain pill. Preferably a [MEDICATION NAME], Oxy ([MEDICATION NAME]) or a shot of some sort. Resident has been given Tylenol 650 and [MEDICATION NAME] throughout the day and had very little complaints of pain. Resident has been found napping in bed. When nurse walks into room resident begins cringing and twitching. When nurse leaves resident is quiet and napping. NP (Nurse Practitioner) (name redacted) was called and had ordered a 1X (one time) dose of [MEDICATION NAME] 5/325. Resident was administered pill and after swallowing pill jumped up out of bed and picked coffee cup up and went down the elevator to seek out coffee. Resident went to smoke break and was asked about shift in pain level is sudden and cannot explain (sic). He said smoking and coffee drinking is a diversion for pain. Resident was given warm packs throughout the noc (night). Resident said warm pads are stupid and do not work. c) 8/31/16 at 9:39 AM: It was reported by NOC (night) nurse that resident has been heating towles (sic) in the resident microwave after repeatedly being told not to This AM (morning) resident was seen with some towels and was wanting to heat them in microwave, when floor nurse stopped him and explained that that is not safe and can not be happening, resident walked away mumbling under his breath.Will address with DON. d) 9/1/116 at 12:20 PM: .Resident was beligerent (sic) and abusive towards staff and yelling out that he needed to go to th (sic) ER (emergency room ).admitted for dementia . and med (medication) management. e) 9/1/16 at 12:27 PM: Resident had episode of violence and agression this AM. Resident denied pain at morning med pass and after breakfast proclaimed his pain was 9/10, Tylenol given. Later resident came out of room w/ (with) towels and nurse reminded him they are not to be microwaved, resident ignored nurse and walked into day room and microwaved the towels. Nurse reached to open the microwave door, as previously (8/30/16) resident set off fire alarm in building by burning toast in microwave, and resident elbowed nurse in chest. Nurse then moved around resident touching his arm so she could open the door to microwave when resident balled up his fist held it to nurses face and threatened to punch nurse. (Unit Manager) witnessed and was able to intervene quickly. Resident stated he wanted to go to ER for neck pain. Resident would not sit down or talk with nurse or UM and stormed off into his room. Resident was assessed by PT (Physical Therapy) and after administration of [MEDICATION NAME] resident has calmed down. f) 9/1/16 at 2:13 PM: This morning resident attempted to microwave towels in order to make a heat pack. Staff nurse intervened since resident set off fire alarm two days ago using a microwave. Resident immediately became aggressive and balling his fists and both physically and verbally threatened to punch the nurse. At that point UM2 (Unit Manager 2) intervened and resident continued to be beligerent (sic) to the nurse and UM2. Resident stated he was in pain and needed to go to the ER. UM2 suggested resident sits down on the couch and his pain can be addressed. Resident refused and continued to use profanity. UM2 said to (resident 88) that when he's ready to talk she would be available. 5 minutes later resident was observed attempting to lay down on the floor in the hall. He was assissted (sic) to w/c by UM2, CNA (Certified Nursing Assistant) and PT. PT then took resident to the gym to apply heat to shoulder/neck area. g) 9/1/16 at 2:37 PM: Resident was moved to room [ROOM NUMBER]-1 for safety puposes (sic). Resident was compliant with move. h) 9/1/16 at 2:59 PM: Resident is to be moved to 3rd floor for aggressive behaviors towards staff and lack of safety awareness (see nurses notes). Resident will be moving to room [ROOM NUMBER]-1. Appropriate parties have been notified. i) 9/2/16 at 8:37 AM: .admitted to (facility) on 8/26/16 from (local hospital) for observation r/t (related to) recent amnesia where he was found at (city) airport wandering around not knowing who he was and where he was at. (Resident 88) has a strong history of mental health issues and has spent some time in a psych (psychiatric) ward in (name of city redacted). (Resident 88) has recently became (sic) homeless after loosing (sic) his trailer at a KOA (Kampground Of America) on (name of street redacted). (Resident 88) made statement while at (local) hospital that, 'he smoked POT daily and has a strong hx (history) of [MEDICAL CONDITION]'. (Resident 88) has recently became aggressive towards staff members at (the facility) where he elbowed an RN in the chest and threatened to punch the same RN after RN stopped him from microwaving towels. (Resident 88) is at (the facility) for LTC (long-term care) or until a safe discharged can be providing (sic). j) 9/8/16 at 1:01 AM: Nurse noted that the resident has been very anxious and agitated regarding his medication this evening. He started asking the nurse for his medication at 1900 (7:00 PM). He was told by the nurse that it would be a little while before he would get his meds. He asked if it would be a half hour. The nurse stated it would likely be longer than that and he needed to be patient because the nurse has to prioritize the care of all residents in her care. He walked away and was back within a few minutes asking for meds again. This went on for a period of time beofre (sic) nurse just went to the other cart and gave him medication. There was no reason he would not be able to wait for his meds while the nurse cared for other resident with more urgent needs. k) 9/9/16 at 4:58 AM: Resident is very anxious and agitiated (sic) about getting medications this evening. he states he has pain 9.8 out of 10. He suffers from [MEDICAL CONDITION] for depsite (sic) taking trazadone (sic). He is up and down through the night turning his tv on very loudly disturbing his room mate. He is not compliant with leaving it turned down when staff assists him in turning it down so he doesn't wake up the entire hall. Not easily redirected. l) 9/16/16 at 3:20 AM: Resident room was moved this evening after smoke break. The resident is wheeling around in a wheelchair that does not belong to him. This nurse asked him why he was in a w/c. The nurse has observed him to have a steady gait when walking and standing in the past and he does not have an order for [REDACTED]. The nurse told him that she would get his meds as soon as possible but that it was necessary for her to prioritize the care of all residents. She told the resident to go where he is most comfortable and she would find him as soon as she could get to his meds. Resident then started moaning and groaning as if he was in great pain and asked the nurse why she was mad at him. Nurse believe sthe (sic) moaning and groaning to be a behavior. Nurse told him that she is not mad at him but that it is necessary for the nurse to prioritize care for all residents. At the time the resident was doing this the nurse was obciously (sic) dealing with four other resident with escalated behaviors two of whom were actively exit seeking and requiring a lot of one on one attention. The resident sat right by the nurse and followed her around in the w/c. The nurse had administered meds to the three people before him and then handed him his meds he was immediately fine and no longer in any pain. m) 9/22/16 at 2:54 PM: Resident is demonstrating some forgetfulness asking repeatedly if he got the PRN (as needed) medication. NP (name redacted) notified. n) 9/28/16 at 11:45 AM: SSW discussed plans for a forthcoming discharge with the resident. The resident was advised that discharge was being initiated as soon as possible whereas they no long required skilled nursing services. Resident reports that they do not currently have a fixed address and would therefore seek residence at (the local) homeless shelter. SW advised the resident that a follow-up appointment had ben scheduled for medical evaluation with (name of physician redacted) of the (name of the family health center). (Name of physician) should be available to provide ongoing services to the resident for primary medical care needs. As the resident will not have a fixed address, they were supplied with pamphlet information and contact phone numbers for several home health agencies serving the local area. The resident was advised that they could call any of these organizations when they had decided which services would work best for them at their new location. Client will be utilize (sic) the local public transportation system later today to transition to his new destination. On 1/17/16 at 11:52 AM, an interview was conducted with the SSW. The SSW stated that resident 88 was discharged as the facility was notified that they would no longer be reimbursed for resident 88's care by another stage agency. The SSW stated that the only discharge plan or orientation to discharge provided to resident 88 was the pamphlet that he was given which had a list of home health agencies and their phone numbers. 5. Resident 113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 113's medical record was reviewed on 1/17/17. Review of the electronic progress notes revealed the following entries: a) 11/16/16 at 11:32 PM: Pt is A&Ox4 (alert and oriented to person, place, time and situation). He is able to make needs known but is not med (medication) complaint. Pt was very upset that we didn't have more pain medicine available and refused all meds until he is given pain meds. He was rude to all staff, with complaints about his television, smoke breaks, meds etc.He had c/o (complaints of) left leg pain and was given [MEDICATION NAME] with little relief. Staff provided redirection, med management, teaching, reassurance, and a safe environment. b) 11/21/16 at 3:16 AM: pt went loa (leave of absence) with another resident to gas station. pt did not come

Based on interview and medical record review it was determined, for 2 of 34 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, facility staff did not assess and monitor a resident's change in condition to determine if the resident required additional interventions. Subsequently, the resident died less than 24 hours after the change in condition was identified by facility staff. Additionally, facility staff were not coordinating care with a contracted hospice company for one of the facility residents. Resident identifiers: 40 and 60. Findings include: 1. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 40's medical record was reviewed. Review of the medical record revealed a "History and Physical Report" from a local acute care hospital dated [DATE]. The following was documented in the "History and Physical Report": "History of Present Illness: 58 yo (year old) man with h/o (history of) ESLD (End Stage Liver Disease) and [MEDICAL CONDITION] presented to the ED (Emergency Department) with complaints of generalized weakness, cough, and fever. ... Says he is still drinking but does not quantify. ..." "Past Medical History: ESLD due to Etoh (alcohol) and Hep C ([MEDICAL CONDITION]) . . . hx (history) etoh withdrawal [MEDICAL CONDITION] . . ." "Assessment and Plan: . . . 1. ... 8. Etoh abuse. He is still drinking. Has h/o withdrawal [MEDICAL CONDITION]. No w/d (withdrawal) symptoms yet. -CIWA (Clinical Institute Withdrawal Assessment) protocol -SW (Social Work) consult -restart [MEDICATION NAME] ..." Review of the "Departmental Notes" revealed the following entries: 1. " [DATE] 1:16 AM Role: Nurse -- Resident pleasant and compliant with medication administration. he is alert and oreintated (sic) and able to toilet himself independently. he has call light within reach and is able to effectively communicate needs to staff." 2. "[DATE] 11:06 AM Role: Nurse -- Resident continues on IV (intravenous) ABX (antibiotic) treatment without showing any noted ASE (adverse side effects) or poor reactions to the med. Difficult with [MEDICATION NAME] and meds hesitant to take and only would sip the [MEDICATION NAME]. Pt (patient) teaching given but resident still stating that he does not need it. I will inform (name of Medical Director) of the difficulty. 1:1 (one on one) today with admissions coordinator and with the medical records about his paperwork. Ambulatory and about the facility without any falls or incidences. Refuses to eat in the dining room. Intake good for breakfast in his room. Continent of B&B (bowel and bladder)." 3. "[DATE] 7:20 PM Role: Nurse -- ABX ran this am (morning) without any issues." 4. "[DATE] 6:17 PM Role: Nurse -- Resident A/O X2 (alert and oriented times two). Amb (ambulates) with walker. C/O (complains of) back pain. Anxiety status. Given PRN (as needed) [MEDICATION NAME] 50 MG (milligrams) po (by mouth) and [MEDICATION NAME] 0.5 mg po at 1200 PM. Check VS (Vital Signs); BP (Blood Pressure) ,[DATE], P (pulse) 57, R (respirations) 20, and Sat (oxygen saturation) 90% RA (room air). He has nausea and vomiting. Dizziness, UA (urinalysis) (sic) retention. Called (name of Medical Director). Report to D.O.N (Director of Nursing) and NP (Nurse Practitioner) (name). Start [MEDICATION NAME] 5 mg po one dose. (Name of Medical Director) called back about 5 PM. N.O (New Order): Give [MEDICATION NAME] 0.5 mg po now. Recheck BP after 30 mins. (minutes). The nurse rechecked BP ,[DATE] after 30 mins. Patient denies nausea and vomiting this time. UA one time no UA retention right now. Reported (name of Medical Director). Will cont (continue) to monitor." 5. "[DATE] 7:26 PM Role: Nurse -- N.O: Clonidin (sic) 0.1 mg po one dose now. The nurse given the medication to patient from EK (Emergency Kit). No ASE notes (sic). Cont to monitor." 6. "[DATE] 5:55 PM Role: Nurse -- Resident was found in his door way SOB (short of breath). Checked his O2 (oxygen) was 84 %. Obtained O2 and put on 4 liters, O2 went up to 90 %. went back down in the low 80's (sic). At this point resident became unresponsive. Attempted to call name, sternal rubs with no response. Check all vitals, they were steadily declining. BP was ,[DATE] and 38 pulse. Could not feel pulse. Transferred to the floor, obtained crash cart. At this time another nurse notified, MD (Medical Director), checked chart (was full code, called 911) and attempted to reach family was hung up on by family, tried again then no answer. From crash cart attempted to deliver oxygen with ambu bag, obtained aed (automatic external defibrillator) machine and followed direction and started chest compressions and breaths as directed from aed. Paramedics arrived and intubated him, hooked up to their monitor, continued chest compressions and obtained intra-osseal access. Attempted to resistate (sic) for 30 minutes. Time of death 1648 (4:48 PM). Continued to attempt to notify family with no response. Notified (name) Mortuary for pick up." No documentation could be found to show that facility staff monitored resident 40 after the administration of the [MEDICATION NAME] or continued to monitor resident 40 for resolution of the change in condition. No documentation could be found to show that facility staff assessed resident 40 for resolution of his change in condition. No documentation could be found to show that facility staff notified the facility Medical Director regarding the results of the last ordered treatment. On [DATE] at 9:00 AM, the facility Medical Director (MD) was interviewed via telephone. The MD stated resident 40's blood pressure was significantly elevated when facility staff notified her. The MD stated that she would have expected facility staff to re-check resident 40's blood pressure to ensure that resident 40's blood pressure had decreased. The MD stated that resident 40's elevated blood pressure would have caused his nausea and vomiting. The MD further stated that because resident 40 had experienced a change in condition that she would have expected staff to monitor resident 40 closely and re-check resident 40 after the [MEDICATION NAME] was administered to ensure that resident 40's symptoms had resolved. The MD stated that she was not notified of any thing additional regarding resident 40 until after he had been pronounced dead. On [DATE] at 9:10 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that when a resident experienced a change in condition, such as resident 40, he would have expected facility staff to monitor the resident and do more vital signs to see if the change in condition had resolved. 2. Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 60's medical record was reviewed. A physician order [REDACTED]. A "Care Plan Considerations/ MDS Analysis of Findings" sheet in resident 60's chart revealed the following information, "...He (resident 60) is being followed by Hospice as of [DATE]..." The only documentation that could be found in resident 60's chart from the Hospice agency were physician orders [REDACTED]. On [DATE] at 9:10 AM, an interview was conducted with Unit Manager (UM). The UM stated, "All of their (Hospice agency) documentation should be in the chart, they (the Hospice agency) don't have computer access." On [DATE] at 10:22 AM, an interview was conducted with the facility DON. The DON stated there should have been nurses notes and a care plan in resident 60's chart from the Hospice agency. The DON stated that resident 60 was admitted to Hospice on [DATE]. The DON stated the Hospice agency sent over their care plan and nurses notes for resident 60 today, [DATE].

Based on observation, interview and record review, it was determined the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, two rooms (rooms 314 and 319) on the secured unit opened further than the allowed six inches, placing the residents residing in the secured unit at risk for injury. This failure created a situation of immediate jeopardy which had a potential for causing serious injury, impairment or death to residents in the facility. Resident identifiers: 4, 12, 16, 25, 26, 29, 30, 31, 32, 35, 36, 37, 39, 42, 44, 45, 56, 58, 59, 60, 62, 65, 66, and 71. In addition, the windows in resident rooms 201-203 and rooms 205-220 had windows which opened greater than the allowable six inches. The windows were not equipped with a safety device to prevent the windows from opening greater than the six inches allowed. The deficient practice identified for rooms 201-203 and rooms 205-220 was found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. NOTICE: Notice of immediate jeopardy was given verbally to the Administrator on 6/19/12 at 3:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to two rooms (rooms 314 and 319) in the secured unit which were not equipped with a safety device to prevent the windows from opening greater than six inches. PLAN: On 6/20/12 at 8:00 AM, the Administrator provided the surveyors with a written plan of action to remove the immediate jeopardy to residents in the facility. The written plan dated 6/20/12 revealed the following: "Canyon Rim Correction Related to Windows. Submitted: June 20, 2012 Immediate Jeopardy was removed. Protective Measures are in place to prevent reoccurrence. Allegation of Abatement of Immediate Jeopardy and Compliance: June 19, 2012 Immediate Correction: Windows in room 314 and 319 were secured at 2:20 pm on June 19, 2012. Audits: 100% audit of facility windows was conducted and facility rounds completed to ensure all windows had proper securing devices and verified units in proper working order on June 19, 2012. In servicing/Education Staff Education An in-service with facility staff was conducted on 3/19/12 regarding the importance of assuring the locks are in place in each window to provide for patient safety. Education provided to staff and residents regarding heating and cooling units function optimally when windows remain closed. Staff and residents educated that at no time are windows allowed to be opened more than 6 inches, and that the windows maintain a lock to prevent opening greater than 6 inches. If residents report they are not comfortable with ambient temperature, nursing is to report to maintenance and place it on the maintenance log. If residents wish to go outdoors for fresh air, staff should assist them to the courtyard. In the event a lock needs replaced, a supply is maintained at the nurses station and will be installed immediately by nursing or maintenance and logged on the maintenance log. All new staff hired will receive above training on proper window locks and how to report and obtain replacement locks during facility general orientation. Any staff that were not on shift on June 18th/19th will receive above education prior to working next scheduled shift. Resident Education Resident Counsel (sic) was held 6/19/12 to educate residents on the importance of not removing securing devices on the windows. Residents were educated that the air conditioning system function (sic) more effectively if the windows are left closed but that they can open if they choose 6 inches. This is for their safety. If the temperature in the resident room is not comfortable they should report to the staff and if they want to go outside to the courtyard staff will assist with that as well. A letter of explanation as to the safety purpose of window security locks will be provided to each new admission as part of the admission process. Oversight and Monitoring The facility maintains replacement locks, located at each nurses cart. Nursing staff has been trained on proper installation in the event one is missing. Maintenance director will inspect weekly to ensure an adequate supply of extra locks. Rounds will be conducted daily coordinated by the maintenance department to assure windows are secured. Grand rounds will be completed weekly by the Administrator which will include checking the window locks to ensure they are in place and windows secure. Audit report findings reviewed by QA (Quality Assurance) monthly and as needed until a lesser frequency is deemed appropriate." Prior to leaving the facility on 6/20/12, the surveyors confirmed the components outlined in the written plan of action had been implemented. During the survey on 6/20/12, the surveyors confirmed removal of the immediate jeopardy situation as of 6/20/12. Deficient practice with potential for more than minimal harm remained for the risk of injury. Findings included: Immediate Jeopardy 1. On 6/18/12 at 9:24 AM, the window in room 313 was observed to be open approximately four inches and did not have a window screen. On 6/19/12 at 7:15 AM, the windows/screens on the secure unit were checked to ensure the windows did not open greater than six inches. Two windows in rooms 314 and 319 were observed to open the full length of the window track. The windows did not contain a safety device which prevented the window from opening greater than six inches. The third floor windows were approximately three feet higher than the floor, with an air conditioning unit placed directly below the window. The air conditioning unit had a lip that extended approximately 3-4 inches from the wall which would allow a resident to use the air conditioner unit as a step. The windows were approximately four feet long and the window opened approximately two feet. The third floor windows which faced south were approximately 35 to 36 feet higher than the ground level and directly overlooked a cement driveway. The third floor windows which faced north were approximately 10 - 12 feet higher than the ground level and directly overlooked a grassy area next to a road with two lanes of traffic extending east and west of the facility. 2. The medical records for the residents residing in rooms 314 and 319 were reviewed on 6/19/12. The following residents were identified as being at risk of a serious injury, impairment or death: a) Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 29 resided in room 313-2. Resident 29's medical record was reviewed on 6/19/12. Review of resident 29's medical history revealed that on 5/9/10, facility licensed nursing staff assessed resident 29 has being at high risk for wandering, verbally abusive, and socially inappropriate/disruptive behaviors. On 6/6/12, the facility Unit Manager (UM) ,1 who also served as the secured unit manager, completed a "Wandering/Exit Seeking Evaluation" for resident 29. UM 1 assessed resident 29 has having: (1) a history of wandering, exit seeking and/or elopement; (2) was independently mobile and cognitively impaired; and (3) had a potential for exit seeking or elopement. UM 1 additionlly documented that resident 29 had delusions, hallucinations and delirium. b) Resident 58 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 58 resided in room 313-3. Resident 58's medical record was reviewed on 6/19/12. Review of the "Wandering/Exit Seeking Evaluation" completed by facility staff on 1/5/12 revealed that resident 58 had the following: (1) History of wandering, exit seeking and/or elopement. The facility staff documented that resident 58 stated that she "Works hear (sic) and needs to go home. She will wander into other res (resident's) room."; (2) Verbalized the intent to leave/go home; (3) Has a cognitive impairment and is independently mobile; (4) wandering aimlessly without intent or purpose; (5) has a wandering behavior pattern or routine that was tied to the resident's past; (6) exhibits signs of sun downing; (7) had a lack of impaired judgment (sic)/lack of safety awareness; (8) was readmitted to the facility in the last 30 days; and (9) resident had a potential for exit seeking/elopement "all hours of the day." c) Resident 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 62 resided in room 314-1. Resident 62's medical record was reviewed on 6/19/2. On 5/3/12, UM 1 completed a "Wandering/Exit seeking Evaluation" assessment. UM 1 assessed resident 62 as follows: (1) had a history of [REDACTED]. Review of the "Monthly Summary" completed revealed the following: (1) 4/16/12: "Resident continues to have episodes of hallucinations and delusions requiring frequent redirection. ..." (2) 5/16/12: "...Continues to have delusions about being Hitler. Will have crying outbursts "I loved the Jews". Disrupts other residents when delusional. Difficult to redirect. ..." d) Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 65 was residing in room 314-2. Resident 65's medical record was reviewed on 6/19/12. On 1/6/12, a facility staff member completed a "Wander/Exit Seeking Evaluation". The staff member assessed resident 65 as having: (1) A history of wandering, exit seeking and/or elopement; (2) Verbalized the intent to leave/go home; and (3) Had cognitive impairment and was independently mobile. Review of the "Monthly Summary" completed for resident 65 on 5/19/12 revealed that "Pt (patient) wanders but is stable." e) Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 66 was residing in room 314-3. Resident 66's medical record was reviewed on 6/19/12. Review of an "Initial Psychiatric Assessment" completed by an outside psychiatric facility on 4/21/09 revealed that resident 66 was assessed as having (1) a history of suicidal ideation, but denied any active ideations; (2) had ongoing psychotic symptoms and mood instability with a "...Closed head injury with cognitive and mood changes."; and (3) was "...Violent/assaultive towards other." On 5/19/12, a "Monthly Summary" was completed by a facility licensed nurse. The licensed nurse documented that resident 66 as having "Frequent delusions, hallucinations. Often talks to self, mumbles, makes hand gestures. ..." 3. In addition to the residents that resided in rooms 314 and 319, the following residents resided on the secured unit. The residents were identified as being at risk for wandering or elopement out of the facility. (Note: The following residents resided on the west side of the secured unit.) a) Resident 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 44 resided in room 315-2 Resident 44's medical record was reviewed on 6/18/12. On 6/23/10, the Resident Services Director (RSD) assessed resident 44 as wandering and as having socially inappropriate/disruptive behaviors. The RSD documented "(Resident 44) cont (continues) to reside on care unit for safty (sic)and is oblivious to needs and safety ..." On 5/21/12, a licensed nurse completed a "Monthly Summary" for resident 44. The licensed nurse documented that resident 44 wandered and had delusions. A "Wandering/Exit Seeking Evaluation" assessment was not available for review at the time of the survey. b) Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 31 resided in room 315-1. Resident 31's medical record was reviewed on 6/19/12. On 6/6/12, UM (Unit Manager) 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 31. UM 1 assessed resident 31 as having: (1) a history of wandering, exit seeking and/or elopement; and (2) was cognitively impaired and was independently mobile. c) Resident 37 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 37 resided in room 317. Resident 37's medical record was reviewed on 6/19/12. On 5/25/12, a facility licensed nurse completed a "Monthly Summary" for resident 37. The licensed nurse documented that resident 37 had verbal behaviors that were directed towards others and wandered. The licensed nurse also documented that resident 37 had hallucinations and delusions. On 5/23/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 37. UM 1 assessed resident 37 as having a history of wandering, exit seeking and/or elopement and had " ...tried to leave facility, when LOA (leave of absence) with sister she left the Hotel and wandered to the homless (sic) shelter." d) Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 12 resided in room 318. Resident 12's medical record was reviewed on 6/19/12. Review of the history and physical completed at a local hospital on [DATE] revealed that resident 12 was admitted to the hospital for " ...increasingly aggressive behaviors and suicidal ideation. " On 2/11/11, a facility licensed nurse completed a " Wandering/Exit Seeking Evaluation " assessment for resident 12. The licensed nurse assessed resident 12 as having (1) a history of wandering, exit seeking and/or elopement and had eloped from previous facilities in the past; (2) had schizoaffective disorder; and (3) had a history of [REDACTED]. 4. On 6/19/12, medical records were reviewed for the residents who resided on the east side of the facility. The residents were identified as being at risk for wandering or elopement out of the facility or had a history of [REDACTED]. However, the residents/employees were not required to enter a code to exit the west side of the building. The residents that resided on the west side were allowed to wander throughout the 3rd floor secured unit, including the east side of the building. The residents that resided on the west side could not exit the 3rd floor without staff assistance.) a) Resident 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 71 resided in room 301-1. Resident 71's medical record was reviewed on 6/19/12. Review of the "Mental Status Examination/Summary" completed by a health care professional, revealed that resident 71 had a history of [REDACTED]. Resident stated that the voices where (sic) often telling him that he should hurt himself." The "Mental Status Examination/Summary" additionally revealed that resident 71 had "a long history of suicidal thoughts, but no suicide attempts." On 5/22/12, a facility licensed nurse completed a "Wandering/Exit Seeking Evaluation" assessment for resident 71. The licensed nurse assessed resident 71 as having: (1) a history of wandering, exit seeking and/or elopement; (2) was cognitively impaired and was independently mobile; and that resident 71 had a history of [REDACTED]. b) Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 56 was residing in room 301-2. Resident 56's medical record was reviewed on 6/19/12. On 5/22/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment. for resident 56. UM 1 assessed resident 56 as having: (1) a history of psychiatric hospitalization s; and (2) had a traumatic brain injury and a history of substance abuse. c) Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 25 was assessed on 1/25/10 as having behavioral symptoms which included wandering, verbally abusive, and socially inappropriate/disruptive behavior. Resident 25 was additionally assessed as having delirium, and dementia. On 5/1/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 25. UM 1 assessed resident 25 as having a cognitive impairment and was independently ambulatory. d) Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 45 resided in room 302-2. On 7/21/10, the RSD assessed resident 45 as having behaviors which included wandering and socially inappropriate/disruptive behavior. The RSD assessed resident 45 as having delirium, a psychiatric [DIAGNOSES REDACTED]..cont to reside on care unit for safety and is oblivious to needs and safety, he is verbally aggressive with staff and is socially inappropriate with comments, very demanding ..." On 5/17/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 45. UM 1 assessed resident 45 as having: (1) a history of wandering, exit seeking and/or elopement; (2) had "left the facility with out (sic) staff supervision"; (3) verbalized the intent to leave/go home; and had cognitive impairment and was independently mobile. e) Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 42 resided in room 303. Resident 42's medical record was reviewed on 6/19/12. On 6/5/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 42. UM 1 assessed resident 42 as having a cognitive impairment and was independently mobile. On 6/15/12, a facility licensed nurse completed a monthly summary for resident 42. The licensed nurse assessed resident 42 as having delusions. f) Resident 59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 59 resided in room 304. Resident 59's medical record was reviewed on 6/19/12. Review of the history and physical completed on 4/27/11 revealed that resident 59 had a history of [REDACTED]. On 5/7/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 59. UM 1 assessed resident 59 as having: (1) a history of wandering, exit seeking and/or elopement; and (2) had stated "wanting to go home." On 6/6/12, the licensed nursing staff completed a "Monthly Summary" for resident 59. The licensed nursing staff documented that resident 59 had hallucinations and delusions. g) Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30 resided in room 305. Resident 30's medical record was reviewed on 6/19/12. Review of the care plan developed for resident 30 revealed a care plan for "Mood Disorder ..." The facility staff documented that resident 30 had "been verbaly (sic) aggressive towards other residents making threats....has delusions and is at risk for wandering/exit seeking." On 4/23/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment. for resident 30. UM 1 assessed resident 30 as having a cognitive impairment and was independently mobile. h) Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 32 resided in room 306-1. Resident 32's medical record was reviewed on 6/19/12. On 6/5/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 32. UM 1 assessed resident 32 as having: (1) a cognitive impairment and was independently mobile; (2) had a history of [REDACTED]. g) Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 60 resided in room 306-2 Resident 60's medical record was reviewed on 6/19/12. Review of a "...Psychiatric Assessment" completed at a psychiatric facility on 12/22/09 revealed that resident 60 was "...disorganized when asked about suicide, pointed to a place on his arm and stated that he would do it here." The "Psychiatric Assessment" documented that resident 60 was "violent/assaultive towards others." On 5/14/12, a facility licensed nurse completed a "Monthly Summary" for resident 60. The licensed nurse assessed resident 60 as wandering with hallucinations and delusions. On 5/14/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment. for resident 60. UM 1 assessed resident 60 as having: (1) a cognitive impairment and was independently mobile; and (2) verbalized the intent to leave/go home. h) Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 36 resided in room 308. Resident 36's medical record was reviewed on 6/19/12. On 3/19/10, the RSD assessed resident 36 as having a history of wandering and being socially inappropriate/disruptive behavior. The RSD additionally documented that resident 36 had delirium and dementia. A "Wandering/Exit Seeking Evaluation" was not available for review at the time of the survey. i) Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 39 resided in room 309-2. Resident 39's medical record was reviewed on 6/19/12. On 2/11/09, the facility RSD assessed resident 39 as having had a history of [REDACTED]. On 5/2212, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 39. UM 1 assessed resident 39 as having: (1) a [DIAGNOSES REDACTED]. j) Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4 resided in room 309-1. Resident 4's medical record was reviewed on 6/19/12. Review of the history and physical completed on 1/26/09 at an acute hospital revealed that resident 4 had a "...long history of schizophrenia paranoid type. ...He is very paranoid with a lot of religious delusions, persecutory delusions about the people of Utah, religious delusions that God is dead, that the devil is coming after everybody..." On 6/14/12, a facility licensed nurse completed a "Monthly Summary" for resident 4. The licensed nurse documented that resident 4 had physical behaviors that were directed towards others, verbalized behavioral symptoms directed towards others, wandered, and had hallucinations and delusions. On 4/2412, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 4. UM 1 assessed resident 4 as having: (1) a history of wandering, exit seeking and/or elopement; and (2) had a cognitive impairment and was independently mobile. k) Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 16 resided in room 310-2. Resident 16's medical record was reviewed on 6/19/12. On 5/4/10, the facility RSD assessed resident 16 as wandering with delirium. On 5/22/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 16. UM 1 assessed resident 16 as having: (1) schizophrenia; and (2) had a history of [REDACTED]. l) Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 26 was residing in room 310-1. Resident 26's medical record was reviewed on 6/19/12. On 4/19/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 26. UM 1 assessed resident 26 as having: (1) a history of wandering, exit seeking and/or elopement; and (2) was cognitively impaired and was independently mobile. m) Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 35 resided in room 312. Resident 35's medical record was reviewed on 6/19/12. On 7/19/10, the RSD documented that resident 35 had wandering and socially inappropriate/disruptive behaviors. The RSD documented that resident 35 had delirium and "...cont to reside on care unit for safety, he is oblivious to needs and safety and does wander in and out of rooms and areas, he is socially inappropriate with yelling out ..." On 6/4/12, UM 1 completed a "Wandering/Exit Seeking Evaluation" assessment for resident 35. UM 1 assessed resident 35 as being cognitively impaired and was independently mobile. 5. On 6/19/12, the following facility staff were interviewed related to whether the windows on the 3rd floor of the facility were able to open greater than six inches and the process of who and when to contact if the windows did open greater than six inches: a) At 9:03 AM: The Maintenance Director was interviewed. The Maintenance Director stated that he was not aware of any items that needed to be repaired on the 3rd floor. b) At 9:07 AM: Restorative Nurse Assistant (RNA) 2 stated that if he identified an item that needed to be fixed or repaired, he would complete a maintenance request in the maintenance log book. RNA 2 stated that he was not aware of any items that needed to be fixed or repaired on the 3rd floor. c) At 9:15 AM: Certified Nurse Assistant (CNA) 3 was interviewed. CNA 3 stated that he notified the Maintenance Director verbally, right away, when an item needed to be fixed or repaired. CNA 3 stated that he was not aware of any items on the 3rd floor that needed to be fixed or repaired. (Note: CNA 3 was in room 314 just prior to the interview. The window had been opened all the way and did not have a screen on the window.) d) At 9:15 AM and 12:51 PM: Registered Nurse (RN) 4 was interviewed. RN 4 stated that there were eight residents on the unit that were physically capable of transferring themselves. RN 4 stated that resident 12 had a history of [REDACTED]. . . .she was just giving me grief." RN 4 further stated that he did not know why the window in room 314 had been opened earlier. RN 4 entered room 314 and asked resident 66 if he had opened the window. Resident 66 did not respond to RN 4. RN 4 demonstrated opening the window the length of the track and then closed it. RN 4 did not report that the window had opened greater than six inches and did not have a safety mechanism to prevent the window from opening greater than six inches. e) At 9:25 AM, the CNA supervisor was interviewed. The CNA supervisor stated that she notified the Maintenance Director verbally, right away, when an item needed to be fixed or repaired. The CNA supervisor stated that she was not aware of any items on the 3rd floor that needed to be fixed or repaired. f) At 12:55 PM, UM 1 was interviewed. UM 1 stated that there were seven residents on the unit that were physically capable of transferring themselves. UM 1 further stated that the windows in the secured unit were secured with screws to prevent the windows from opening all the way. UM 1 stated that the Administrator and Maintenance Director completed safety rounds and checked the windows. UM 1 was not aware of how often the safety rounds were completed. g) At 1:00 PM, RN 6 was interviewed. RN 6 stated that the windows on the 3rd floor were secured so that they could not open all the way. h) At 1:05 PM, the Maintenance Director stated that he checked the doors and windows in the facility on a monthly basis. The Maintenance Director stated that he last checked the doors and windows on 5/23/11. The Maintenance Director further stated that the facility had a HUD (Housing and Urban Development) inspection recently. i) At 1:15 PM, Housekeeping Staff Member (HSM) 1 was interviewed. HSM 1 stated that HSMs deep cleaned all of the resident rooms monthly. HSM 1 stated that part of the process of cleaning was to ensure that the windows on the 3rd floor were secure. HSM 1 stated that she notified the Maintenance Director verbally, right away, when an item needed to be fixed or repaired. HSM 1 stated that she was not aware of any items on the 3rd floor that needed to be fixed or repaired. 6. On 6/19/12, the preventative maintenance logs completed by the maintenance director were reviewed. The preventative maintenance logs revealed that (1) the heating, ventilation, and air conditioning units were inspected in May 2012. (Note: The heating and air conditioning units were located approximately one foot below the windows in the resident rooms.); and (2) the maintenance director checked the windows, screens, blinds, and valances on 6/7/12. The "Window Rounds" completed by the maintenance director on 6/7/12 did not indicate that the windows were checked to ensure the windows did not open further than six inches. 7. Review of the HUD inspection completed on 2/14/12 revealed that the following windows in the facility had the "secondary means egress window is blocked" in resident rooms 301, 304, 306, 308, 310, 312, and 314. 8. On 6/19/12, at approximately 1:30 PM, the Administrator was interviewed. The Administrator stated that he was aware of the HUD inspection that was completed on 2/14/12. The Administrator stated that the he believed that "safety trumps all" but that HUD had an "issue" with all windows that were blocked. The Administrator stated that the facility had residents with behaviors which were difficult to manage and that if a window was "free flowing", that a resident had removed the device to prevent the window from opening greater than six inches. The Administrator provided documentation of the following: a) 4/17/12: A letter from the Corporate Director of Real Estate to a HUD account executive. " Please find attached Project Owner's Certification for the Exigent and Fire Safety Hazard cited during the HUD REAC (?) inspection today's date following items were cited during the inspection. ...Rooms 301, 304, 306, 308, 310, 312, and 314 - living room - only egress window blocked. These items will be appealed. Facility residents are not capable of self- preservation, therefore windows on 3rd floor need to be locked in order to prevent behavioral resident from jumping through window during possible emergency event. This is a safety only practice. ... " b) 4/17/12: An "Office of Public Housing Real Estate Assessment Center Request for Technical Review (TR) or Database Adjustment (DBA) of a Physical Inspection Score" was completed. TR documented that the windows in rooms 308, 310, 312 and 314 were blocked. c) 4/18/12: A "PROJECT OWNER'S CERTIFICATION THAT THE PHYSICAL CONDITION OF THE PROJECT IS IN COMPLIANCE WITH THE PHYSICAL CONDITION STANDARDS OF 24 C.F.R. 5.703 AND STATE AND LOCAL CODES....the owner of Canyon Rim Care Center, Salt Lake City, UT [PHONE NUMBER]4, (the 'Projected'), by and through its duly authorized representative identified below, hereby certifies that: (1) All ph