Every finding on record at Monument Healthcare Pioneer Trail

Based on interview and record review, the facility failed to ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, for 1 out of 27 sampled residents, a resident was not given an oral antibiotic that was susceptible to treat her urinary tract infection (UTI) and then required intravenous (IV) antibiotics. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included obstructive and reflex uropathy, type 2 diabetes mellitus, and dementia. On 4/1/25 at 8:23 AM, an interview was attempted with resident 15. Resident 15 was unable to answer any questions. Resident 15's medical record was reviewed. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 15 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated intact cognitive function. On 3/6/25 at 3:37 PM, a nurse practitioner note documented, . Pt [patient] was in the activities room participating in the activities, the dark urine flowing the [sic] the urinary bag, pt C/o [complaining of] feeling extremely tired and says, 'I always feel very tired'. C/o urinary mild dysuria and suprapubic tenderness.New order today Iron sulfate 325mg [milligrams] PO [by mouth] daily with Vitamin C 500mg after meals UA [urinalysis], C&S [culture and sensitivity] staff to notify provider when the lab result is available Staff to monitor pt closely, including vitals and notify provider if any concerns. On 3/7/25 at 3:58 PM, an electronic Medication Administration Record (eMAR) note documented, Changed foley catheter and drain bag using SILICONE 18 french catheter r/t [related to] latex allergy. as needed Foley catheter changed to obtain UA with C/S, sent to [name redacted] lab. On 3/10/25 at 2:41 PM, a laboratory result note documented, Pt had UA with C&S collected and sent to lab on 3/7/25. Abnormal findings (preliminary): Appearance SL [slightly] cloudy, Blood 1+, Protein 2+, Nitrite positive, LK [leukocyte] Esterase 1+, WCB [sic] [White blood cells] 30-5-0, Bacteria 2+, Renal cells 2-5. Organism 1: Gram negative Bacillus. Per NP [Nurse Practitioner], N.O. [new order] to start Ciprofloxacin 500mg BID [twice daily] x [for] 5 days and await for final culture. Pt updated. On 3/13/25 at 11:35 AM, a nurse practitioner note documented, Late Entry: [AGE] years old female resides at [name redacted] who was seen today for F/u [follow up] visit of UTI. Pt had c/o dysuria, flank pain and suprapubic tender. UA with C&S showed on 3/10 [25]; (preliminary): Appearance SL cloudy, Blood 1+, Protein 2+, Nitrite positive, LK Esterase 1+, WCB [sic] 30-5-0, Bacteria 2+, Renal cells 2-5. Organism 1: Gram negative Bacillus Ne [sic] order given to [sic] Ciprofloxacin 500mg BID x 5 days and await for final culture. In today visit, pt says she continues to be tired, AXO [alert and oriented] as her norm [normal], denies flank pain, suprapubic tenderness, dysuria. NAD [no abnormality detected], Vitals WNL [within normal limits]. Continue to Cipro to complete 5 days course. Waiting for final c&S result. It should be noted that the urine culture from 3/7/25, was resistant to Ciprofloxacin which was administered to the resident on 3/10/25 through 3/15/25. The facility received the urine culture results on 3/17/25. On 3/28/25 at 1:04 PM, an eMAR note documented, Meropenem Intravenous Solution Reconstituted 1 GM [gram] Use 1 gram intravenously STAT [immediately] for Rule out UTI. On 3/28/25 at 7:39 PM, a nurse practitioner note documented, Late Entry: pt has history of feeling tired and sleeping whole morning and waking up late as her baseline, however, the floor nurse was a little concerns [sic] that pt might be more tired and sleeping more than usual 3/27/25, Vitals WNL, NAD. However, pt seems more lethargic to NP. ordered some stat lab 3/27/25.Chest WBC [white blood cell] and Neutrophil looks normal though. IV fluid and other orders were ordered by Oncall provider 3/27 [25], night. Per staff, she continues to be really lethargic, extremely tired, mild tachycardia (102), other vitals look WNL. She has not eaten breakfast/ lunch, urine was not collected until this morning, pthas [sic] history of urosepsis, has foley catheter. IV fluid was running. Called family member and left message, has not called me back yet. Working dx [diagnosis]: UTI/ dehydration, AKI [acute kidney injury]. New orders today: Meropenem 1 gram IV Q [every] 12 hr [hours] X [for] 3 days (the lab takes about a week for urine culture, Meropenem according to the last urine C&S, She has resistant to many ABX [antibiotics] last time) . please monitor fluid input and urine output, notify provider if any concerns Vitals every 6 hr Stat CMP [comprehensive metabolic panel] tomorrow morning UA, C&S Contingency Plan: send pt to ER [emergency room ] if she requires higher care continue with IV fluid NS [normal saline] 75ml [milliliters]/hr (according to CMP result) Adjust ABX according to UA, C&S result. On 3/29/25 at 2:09 PM, a laboratory note documented, . Preliminary UA faxed back and will call NP with these results. UA abnormals as follows: Appearance: Cloudy, UA Blood- 1+, UA Protein- 2+, UA nitrite- Positive, UA Esterase- 3+, UA WBC- 30-50, UA Bacteria- 4+, UA Renal Cells- 5-10. On 4/2/25 at 9:07 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 15 had completed IV antibiotics for a UTI on 3/31/25. RN 1 stated that resident 15 had a change in condition and the NP ordered a urinalysis because resident 15 was not waking up. RN 1 stated that over the past week resident 15 had a flat affect and seemed off. On 4/2/25 at 9:46 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that resident 15 got UTI's quite often. The IP stated that it took a while for the urine culture to come back from the UA that was done on 3/7/25. The IP stated that resident 15 was given Ciprofloxacin for the UTI at the beginning of March and the urine culture showed that it was resistant to Ciprofloxacin. The IP stated that she did not chart when she called the lab requesting results from the urine culture. The IP stated that resident 15 had completed the Ciprofloxacin when the urine culture results came back and did not think she needed to follow up on that because resident 15 stopped complaining of painful urination. The IP stated she believed that resident 15's UTI never went away as she just completed IV antibiotics for another UTI. The IP stated they gave resident 15 IV antibiotics that were susceptible from the urine culture from the beginning of March as they were still waiting on culture results from the other day. On 4/3/25 at 8:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected nursing staff to call the lab the next day to see if there was any growth and if not then they would call intermittently. The DON stated that it should be charted in the chart every time the lab was called. The DON stated that resident 15 had a history of chronic UTI's. The DON stated that if a resident was prescribed a resistant antibiotic then staff should contact the physician with the results and get new orders for a different antibiotic. The DON stated that resident 15 was acting differently with the night nurse and the provider was notified and the provider ordered a UA and labs. The DON stated that the provider should have been contacted by nursing staff when results of the urine culture for resident 15 showed that Ciprofloxacin was resistant. On 4/3/25 at 9:01 AM, a follow up interview was conducted with the IP. The IP stated the Physician saw the urine culture results. The IP stated that resident 15 was put on an antibiotic that the urine culture from 3/7/25, was susceptible to.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was expired food in the dairy refrigerator, expired food in the main refrigerator, expired food in the resident refrigerator, unlabeled and undated food in the resident refrigerator, and the facility dish machine was not testing at the required levels. Findings included: On [DATE] at 8:05 AM, an initial tour of the kitchen was completed. The following observations were made: a. There was an opened bag of whipped topping with no visible opened date. b There was an open container of parmesan cheese with a use by date of [DATE]. c. There was an opened container of mozzarella cheese with a use by date of [DATE]. d. There was a box of lemons with a received date of [DATE]. e. There was a box of butterscotch cookie drops open to air and discolored with an opened date of [DATE]. On [DATE] at 10:01 AM, an initial inspection of the resident refrigerator was completed. The following observations were made: a. There was a bag of Diet Pepsi unlabeled and undated. b. A disposable container with resident's name and a date of [DATE]. c. A disposable container with resident's name and a date of [DATE]. There was a sign on the outer door of the refrigerator stating that all items in the fridge must have a date and the resident's name on it. After 3 days the item would be discarded. On [DATE] at 8:32 AM, during the initial tour the chemical dish machine was observed. The Dietary Aide (DA) stated that she had tested the machine this morning. The DA was observed to run a dish cycle and used a chemical strip to check the amount of sanitizer. The strip was observed to not change color. The DA stated that the process was to get a new lot of sanitizer strips if the sanitizer strip was not changing colors. The DA stated that she would look for a new batch of sanitizer strips. On [DATE] at 8:36 AM, the chemical dish machine was retested by the Dietary Manager (DM). The dish machine sanitizer strip was observed to not change color. On [DATE] at 8:40 AM, the chemical dish machine was retested with different sanitizer strips by the DM. The dish machine sanitizer strip was observed to not change color. On [DATE] at 8:45 AM, the chemical dish machine was retested with different sanitizer strips by the DM. The dish machine sanitizer strip was observed to not change color. The DM stated that she would contact a sister facility to see if they had different sanitizer strips that the facility could use. The DM stated that the facility would do the dishes by hand in the 3 compartment sink until the dish machine was sanitizing correctly. On [DATE] at 8:46 AM, an interview was conducted with the DM. The DM stated that the opened date on the whipped topping was smeared, but believed it had an open date of [DATE]. The DM stated that the whipped topping once opened was good for one week. The DM stated that she thought the dates on the cheese in there refrigerator were wrong. The DM stated that when the container of cheese was empty or past the use by date, kitchen staff should take the label off, wash the container, and put more cheese in the container and then date the label. The DM stated that the resident refrigerator was monitored by the night kitchen staff. The DM stated that all items in the resident refrigerator should have a name and date on it and items were thrown away after 3 days. On [DATE] at 11:08 AM, a follow up tour of the resident refrigerator was conducted. The following were observed: a. There was an undated pizza. b. There was pumpkin chocolate bread unlabeled and undated. c. There was a disposable container with a date of [DATE]. d. There was a brownie dated [DATE]. e. There was a disposable container of celery with a date of [DATE]. On [DATE] at 11:34 AM, a follow-up tour of the kitchen was conducted. The following were observed: a. There was a box of lemons with a received date of [DATE]. b. There was a box of butterscotch cookie drops, open to air, and discolored with an opened date of [DATE]. On [DATE] at 11:50 AM, a follow-up interview was conducted with the DM. The DM stated that the lemons that were in the refrigerator were good for 30 days after the received date. The DM stated that she did not think the butterscotch cookie drops were dated correctly. The DM stated that she would discard the lemons and the butterscotch cookie drops because they were beginning to change color. On [DATE] at 12:25 PM, the facility dish machine was observed. The DM was observed to run the dish machine and test the sanitizer level with sanitizer strips. The sanitizer strip was observed to change to a deep purple color and read 100 part per million. On [DATE] at 9:10 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the DM ran the kitchen and was in charge of kitchen staff and ensuring food items were discarded in a timely manner.

Based on observation, interview, and record review, the facility did not keep the resident environment as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 27 sampled residents, a resident was observed to have medication left at bedside and a resident that was a high risk for falls did not have interventions in place prior to the resident having a fall. Resident identifiers: 20 and 36. Findings included: 1. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, nonpyogenic thrombosis of intracranial venous system, edema, and chronic pain syndrome. On 4/1/25 at 3:32 PM, an observation and interview were conducted with resident 20. There was an orange tablet inside a medication cup on resident 20's bedside table. Resident 20 stated that the tablet was his buprenorphine medication which he took for pain. Resident 20 stated that explained why he was still experiencing pain. On 4/1/25 at 3:37 PM, an observation was made of resident 20 swallowing the orange tablet from the medication cup. Resident 20's medical record was reviewed. A Minimum Data Set (MDS) assessment dated [DATE], documented that resident 20 had a Brief Interview for Mental Status (BIMS) score of 14. A score of 13 to 15 indicated intact cognitive function. A review of resident 20's medication orders revealed an order for buprenorphine hydrochloride Sublingual Tablet 2 milligrams, give one tablet sublingually every six hours related to chronic pain syndrome. On 4/1/25 at 3:50 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 20 received scheduled buprenorphine at 2:00 AM, 8:00 AM, 2:00 PM, and 8:00 PM. RN 1 stated that resident 20 had chronic pain and consistently reported a pain level of 7 or 8. RN 1 stated that resident 20 should not have any medications at his bedside and that a nurse was required to watch him take the medication. RN 1 stated she got interrupted while bringing in resident 20's afternoon medication and had to call Certified Nursing Assistants to help her in the room. RN 1 stated that she did not watch resident 20 take his medication. RN 1 stated that she thought it was okay that resident 20 took his medication late. On 4/3/25 at 8:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 20 had not been assessed for the ability to self-administer medications and that medications should not have been left at the bedside. 33215 2. Resident 36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, chronic post-traumatic stress disorder, and major depressive disorder. Resident 36's medical was reviewed on 4/1/25 through 4/3/25. On 1/13/25 at 5:20 PM, a Morse Fall Scale Evaluation documented that resident 36 was a High Risk for Falling with a score of 50. An admission MDS assessment dated [DATE], documented that resident 36 had a Brief Interview for BIMS score of 99. A BIMS score of 99 indicated that the interview was not completed. On 1/17/25 at 1:13 PM, the Baseline Care Plan was documented as incomplete. The Description areas on the baseline care plan included: a. Communication/Comprehension, Psychosocial, Discharge Planning b. Activities of daily living, Functional Mobility, Fall, bowel and bladder, Skin c. Pain, High Risk, Elopement and Smoking, Medical Conditions, Terminal Care d. Nutrition e. Baseline Care Plan Summary (Review)/Conference Documentation It should be noted there was no information entered into the baseline care plan areas. On 2/5/25 at 4:15 AM, a Nursing Note documented Note Text: Aid [Certified Nursing Assistant] went in to check on the resident and saw [sic] lying on the floor by his bed. Aid called the nurse the nurse assessed the resident and didn't find any injuries. when asked if he hurt the resident stated that it did. No signs of bruising or lumps on the headwere [sic] noted. Resident was reassured, assessed for injuries, helped into his chair, Dr. [doctor] was called, and wife was notified. A care plan Focus initiated on 2/6/25, documented [name redacted] is at risk for falls r/t [related to] Confusion, Deconditioning, Gait/balance problems, Incontinence, Poor communication/comprehension, Psychoactive drug use, Unaware of safety needs, Vision/hearing problems. Interventions for safety were initiated on 2/6/25. It should be noted that a fall care plan was not initiated until after resident 36 had a fall. On 4/2/25 at 12:09 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC confirmed that resident 36's baseline care plan was incomplete. The RNC stated the base line care plan was to be completed by an interdisciplinary team within 48 hours of admission and would include disciplines like nursing and dietary. The RNC stated that some items on the care plan were not started until 1/17/25. The RNC stated that a fall care plan was not started until 2/6/25, after resident 36 had their first fall. The RNC confirmed if a resident was a high risk for falls there should be interventions in place for safety. The RNC stated the new process was to have the baseline care plan integrated into the admission assessment.

Based on interview and record review, the facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 27 sampled residents, a resident was given an oral antibiotic that was resistant to treat her urinary tract infection (UTI) and then required intravenous (IV) antibiotics. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included obstructive and reflex uropathy, type 2 diabetes mellitus, and dementia. On 4/1/25 at 8:23 AM, an interview was attempted with resident 15. Resident 15 was unable to answer any questions. Resident 15's medical record was reviewed. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 15 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated intact cognitive function. On 3/6/25 at 3:37 PM, a nurse practitioner note documented, . Pt [patient] was in the activities room participating in the activities, the dark urine flowing the [sic] the urinary bag, pt C/o [complaining of] feeling extremely tired and says, 'I always feel very tired'. C/o urinary mild dysuria and suprapubic tenderness.New order today Iron sulfate 325mg [milligrams] PO [by mouth] daily with Vitamin C 500mg after meals UA [urinalysis], C&S [culture and sensitivity] staff to notify provider when the lab result is available Staff to monitor pt closely, including vitals and notify provider if any concerns. On 3/7/25 at 3:58 PM, an electronic Medication Administration Record (eMAR) note documented, Changed foley catheter and drain bag using SILICONE 18 french catheter r/t [related to] latex allergy. as needed Foley catheter changed to obtain UA with C/S, sent to [name redacted] lab. On 3/10/25 at 2:41 PM, a laboratory result note documented, Pt had UA with C&S collected and sent to lab on 3/7/25. Abnormal findings (preliminary): Appearance SL [slightly] cloudy, Blood 1+, Protein 2+, Nitrite positive, LK [leukocyte] Esterase 1+, WCB [sic] [White blood cells] 30-5-0, Bacteria 2+, Renal cells 2-5. Organism 1: Gram negative Bacillus. Per NP [Nurse Practitioner], N.O. [new order] to start Ciprofloxacin 500mg BID [twice daily] x [for] 5 days and await for final culture. Pt updated. On 3/13/25 at 11:35 AM, a nurse practitioner note documented, Late Entry: [AGE] years old female resides at [name redacted] who was seen today for F/u [follow up] visit of UTI. Pt had c/o dysuria, flank pain and suprapubic tender. UA with C&S showed on 3/10 [25]; (preliminary): Appearance SL cloudy, Blood 1+, Protein 2+, Nitrite positive, LK Esterase 1+, WCB [sic] 30-5-0, Bacteria 2+, Renal cells 2-5. Organism 1: Gram negative Bacillus Ne [sic] order given to [sic] Ciprofloxacin 500mg BID x 5 days and await for final culture. In today visit, pt says she continues to be tired, AXO [alert and oriented] as her norm [normal], denies flank pain, suprapubic tenderness, dysuria. NAD [no abnormality detected], Vitals WNL [within normal limits]. Continue to Cipro to complete 5 days course. Waiting for final c&S result. It should be noted that the urine culture from 3/7/25, was resistant to Ciprofloxacin which was administered to the resident on 3/10/25 through 3/15/25. The facility received the urine culture results on 3/17/25. On 3/28/25 at 1:04 PM, an eMAR note documented, Meropenem Intravenous Solution Reconstituted 1 GM [gram] Use 1 gram intravenously STAT [immediately] for Rule out UTI. On 3/28/25 at 7:39 PM, a nurse practitioner note documented, Late Entry: pt has history of feeling tired and sleeping whole morning and waking up late as her baseline, however, the floor nurse was a little concerns [sic] that pt might be more tired and sleeping more than usual 3/27/25, Vitals WNL, NAD. However, pt seems more lethargic to NP. ordered some stat lab 3/27/25.Chest WBC [white blood cell] and Neutrophil looks normal though. IV fluid and other orders were ordered by Oncall provider 3/27 [25], night. Per staff, she continues to be really lethargic, extremely tired, mild tachycardia (102), other vitals look WNL. She has not eaten breakfast/ lunch, urine was not collected until this morning, pthas [sic] history of urosepsis, has foley catheter. IV fluid was running. Called family member and left message, has not called me back yet. Working dx [diagnosis]: UTI/ dehydration, AKI [acute kidney injury]. New orders today: Meropenem 1 gram IV Q [every] 12 hr [hours] X [for] 3 days (the lab takes about a week for urine culture, Meropenem according to the last urine C&S, She has resistant to many ABX [antibiotics] last time) . please monitor fluid input and urine output, notify provider if any concerns Vitals every 6 hr Stat CMP [comprehensive metabolic panel] tomorrow morning UA, C&S Contingency Plan: send pt to ER [emergency room ] if she requires higher care continue with IV fluid NS [normal saline] 75ml [milliliters]/hr (according to CMP result) Adjust ABX according to UA, C&S result. On 3/29/25 at 2:09 PM, a laboratory note documented, . Preliminary UA faxed back and will call NP with these results. UA abnormals as follows: Appearance: Cloudy, UA Blood- 1+, UA Protein- 2+, UA nitrite- Positive, UA Esterase- 3+, UA WBC- 30-50, UA Bacteria- 4+, UA Renal Cells- 5-10. On 4/2/25 at 9:46 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that resident 15 got UTI's quite often. The IP stated that it took a while for the urine culture to come back from the UA that was done on 3/7/25. The IP stated that resident 15 was given Ciprofloxacin for the UTI at the beginning of March and the urine culture showed that it was resistant to Ciprofloxacin. The IP stated that she did not chart when she called the lab requesting results from the urine culture. The IP stated that resident 15 had completed the Ciprofloxacin when the urine culture results came back and did not think she needed to follow up on that because resident 15 stopped complaining of painful urination. The IP stated she believed that resident 15's UTI never went away as she just completed IV antibiotics for another UTI. The IP stated they gave resident 15 IV antibiotics that were susceptible from the urine culture from the beginning of March as they were still waiting on culture results from the other day. On 4/3/25 at 8:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected nursing staff to call the lab the next day to see if there was any growth and if not then they would call intermittently. The DON stated that it should be charted in the chart every time the lab was called. The DON stated that resident 15 had a history of chronic UTI's. The DON stated that if a resident was prescribed a resistant antibiotic then staff should contact the physician with the results and get new orders for a different antibiotic. The DON stated that resident 15 was acting differently with the night nurse and the provider was notified and the provider ordered a UA and labs. The DON stated that the provider should have been contacted by nursing staff when results of the urine culture for resident 15 showed that Ciprofloxacin was resistant. On 4/3/25 at 9:01 AM, a follow up interview was conducted with the IP. The IP stated the Physician saw the urine culture results. The IP stated that resident 15 was put on an antibiotic that the urine culture from 3/7/25, was susceptible to. The facility policy Managing Infections: Antibiotic Stewardship was reviewed. Policy Statement Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Policy Interpretation and Implementation 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. 10. When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident during the next scheduled facility visit. 11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. The policy and procedure was in effect on February 1, 2024.

Based on interview and record review, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Specifically, for 1 out of 27 sampled residents, a resident that was a fall risk on admission did not have a baseline care plan developed within 48 hours of the resident's admission. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, chronic post-traumatic stress disorder, and major depressive disorder. Resident 36's medical was reviewed on 4/1/25 through 4/3/25. On 1/13/25 at 5:20 PM, a Morse Fall Scale Evaluation documented that resident 36 was a High Risk for Falling with a score of 50. An admission Minimum Data Set assessment dated [DATE], documented that resident 36 had a Brief Interview for Mental Status (BIMS) score of 99. A BIMS score of 99 indicated that the interview was not completed. On 1/17/25 at 1:13 PM, the Baseline Care Plan was documented as incomplete. The Description areas on the baseline care plan included: a. Communication/Comprehension, Psychosocial, Discharge Planning b. Activities of daily living, Functional Mobility, Fall, bowel and bladder, Skin c. Pain, High Risk, Elopement and Smoking, Medical Conditions, Terminal Care d. Nutrition e. Baseline Care Plan Summary (Review)/Conference Documentation It should be noted there was no information entered into the baseline care plan areas. On 4/2/25 at 12:09 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC confirmed that resident 36's baseline care plan was incomplete. The RNC stated the base line care plan was to be completed by an interdisciplinary team within 48 hours of admission and would include disciplines like nursing and dietary. The RNC stated that some items on the care plan were not started until 1/17/25. The RNC stated that a fall care plan was not started until 2/6/25, after resident 36 had their first fall. The RNC confirmed if a resident was a high risk for falls there should be interventions in place for safety. The RNC stated the new process was to have the baseline care plan integrated into the admission assessment.

Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 27 sampled residents, the provider failed to implement a GDR for a resident who had been receiving an antidepressant medication for depression since April 2024. There was no documentation stating that a GDR would be clinically contraindicated. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, progressive supranuclear ophthalmoplegia, myoneural disorder, type 2 diabetes, hypertensive heart disease with heart failure, and depression. Resident 9's medical record was reviewed on 3/31/25 through 4/3/25. On 4/2/24, a physician's order documented Escitalopram Oxalate Tablet 10 MG [milligrams] Give 1 tablet by mouth one time a day related to DEPRESSION. There had been no documented attempts to provide a GDR to resident 9 since the escitalopram was ordered. There was no physician documentation located stating that a GDR would be clinically contraindicated. On 4/2/25 at 12:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they were unable to locate any GDR or further documentation for resident 9 concerning the ordered escitalopram. The DON stated that they were performing a Performance Improvement Plan regarding their GDR process. The DON stated at the psychotropic meetings the pharmacist would either recommend maintaining the current medication regimen or recommend changes, including recommendations to perform any GDR. The recommendations would then be sent to the physician who would determine if new orders would be written.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 27 sampled residents, notification to the SSA and APS was not done when a resident with cognitive impairments punched another resident in the back. Resident identifiers: 20 and 36. Findings included: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, chronic post-traumatic stress disorder (PTSD), and major depressive disorder. Resident 36's medical was reviewed on 4/1/25 through 4/3/25. An admission Minimum Data Set assessment dated [DATE], documented that resident 36 had a Brief Interview for Mental Status (BIMS) score of 99. A BIMS score of 99 indicated that the interview was not completed. On 2/5/25 at 1:20 AM, a Nursing Note documented Note Text: Nurse heard banging coming from his room and headed to the room to check it out. room [ROOM NUMBER]A came out of his room and called the nurse. Nurse went into room [ROOM NUMBER] and saw room [ROOM NUMBER] go back to his room through the bathroom door. Listened to the resident explain the situation. Nurse then went to catch the resident who had just left his room and slammed his door. Nurse went [to] calm the resident down. Resident was clenching fists, and unclenching fists. The nurse guided the resident back into his room. Resident then hitthe [sic] closet. Nurse tried to leave the resident in his room for a few minutes to calm down, when that didn't work the nurse tried to bring him out to sit with her for a few minutes. That worked until the nurse needed to leave to pass meds [medications]. At that time theresident [sic] went back to his room and banged on the doors and walls. Nurse called the DON [Director of Nursing] [name redacted] and the director [name redacted], the nurse called his wife who talked to him for a while and helped us the staff be able to get his meds down and get the resident back into bed. The bathroom door between the two rooms was closed and locked so the resident couldn't return to room [ROOM NUMBER]. The nurse stationed herself next to the residents room for the next several hours. No injuries to resident's hands noted. A care plan Focus initiated on 2/6/25, documented BEHAVIORS: [name redacted] has a behavior concerns r/t [related to] Dementia with behavioral disturbances. PTSD. Resistive to cares. Physical aggression. H/O [history of] res [resident] to res altercation. History of becoming easily flustered with ADL [activities of daily living] care. The interventions initiated on 2/6/25, included: Administer medications as ordered. Monitor and document for side effects and effectiveness. Refer to current physician orders and medication administration records. Anticipate and meet the resident's needs. Resolved: Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. Educate the family and caregivers on successful coping and interaction strategies. Resident 36 needs encouragement and active support by family and caregivers when strategies were used. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resolved: Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention. Provide a program of activities that was of interest and accommodates residents status. 50200 2. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included nonpyogenic thrombosis of intracranial venous system, emphysema, chronic obstructive pulmonary disease, edema, and chronic pain syndrome. Resident 20's medical record was reviewed. On 2/5/25 at 2:01 AM, a nursing note documented, Note Text: Nurse heard banging coming from his room and headed to the room to check it out. [Resident 20] came out of his room and called the nurse. Nurse went into [resident 20's room] and saw [resident 36] go back to his room through the bathroom door. Listened to the resident explain the situation. Nurse then went to catch the resident who had just left his room and slammed his door. Nurse went [to] calm the resident down. Resident was clenching fists, and unclenching fists. The nurse guided the resident back into his room. Resident then hitthe [sic] closet. Nurse tried to leave the resident in his room for a few minutes to calm down, when that didn't work the nurse tried to bring him out to sit with her for a few minutes. That worked until the nurse needed to leave to pass meds. At that time theresident [sic] went back to his room and banged on the doors and walls. The resident stated that he was watching a movie and [resident 36] came in. resident told [resident 36] that he couldn't be in there. [Resident 36] grabbed his [NAME] [sic] resident stated that he was able to break his arm free and move towards the door. [Resident 36] than tried to hit the resident, the resident blocked it. The resident stated that as he was leaving his room, [resident 36] punched him in the back [sic] Nurse called the DON [name redacted] and the director [name redacted], the nurse called his wife who talked to him for a while and helped us the staff be able to get his meds down and get the resident back into bed. The bathroom door between the two rooms was closed and locked so the resident couldn't return to room. On 4/1/25 at 2:34 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that he has had no reportable incidents for 2025. On 4/1/25 at 3:33 PM, an interview was conducted with resident 20. Resident 20 stated that he was sitting in his wheelchair watching television on 2/4/25, when his bathroom door opened and resident 36 entered his room, accused him of being in resident 36's room. Resident 20 stated that resident 36 grabbed his forearm and held onto it. Resident 20 stated resident 36 had a crazy look in his eyes. Resident 20 stated that he was able to break free from the hold on his arm and went to his door to get some help. Resident 20 stated that he told Licensed Practical Nurse (LPN) 1 that resident 36 was in his room and something was wrong with him. Resident 20 stated that as he stood in the doorway trying to get the LPN's attention, resident 36 punched him in the back. Resident 20 stated that he spoke with the nurse on duty that night about the incident but did not recall speaking with any administrative staff regarding it. On 4/2/25 at 7:44 AM, an interview was conducted with LPN 1. LPN 1 stated that she was in the hallway when she heard resident 20 holler, followed by banging and a door slamming coming from resident 20's room. LPN 1 stated when she entered resident 20's room, she found resident 20 in his wheelchair. LPN 1 stated resident 20 informed her that resident 36 had entered his room grabbed his arm and punched him without any provocation or cause. LPN 1 stated that resident 20 was shaking and trembling after the incident. LPN 1 stated to prevent further access to resident 20's room she locked the shared bathroom door to stop resident 36 from entering resident 20's room. LPN 1 stated that she contacted resident 36's wife, who was able to calm him down. LPN 1 stated she reported the incident to the DON, who instructed her to notify the ADMIN. LPN 1 stated that she spoke with the ADMIN that night, who asked whether she could keep both the residents safe for the night or if she needed additional staff. LPN 1 stated that resident 20 feared for her safety and did not want her entering resident 36's room due to his anger. LPN 1 stated she recalled the incident clearly because it was highly emotional and took time to resolve. LPN 1 stated she did not recall being contacted by administrative staff following the incident. On 4/3/25 at 11:20 AM, an interview was conducted with the DON. The DON stated that LPN 1 contacted her on the night of the incident. The DON stated that they relied on resident 20's account of the event because he was cognitively intact. The DON stated that resident 36 entered resident 20's room and grabbed his arm. The DON stated resident 20 broke free from the grasp, and as he got up to leave the room, resident 36 hit him in the back. The DON stated that she would have consulted with corporate and the ADMIN to decide whether the incident was reportable to the SSA. On 4/3/25 at 11:36 AM, an interview was conducted with the ADMIN. The ADMIN stated that he served as the abuse coordinator for the facility. The ADMIN stated he did not recall when he was notified of the incident. The ADMIN stated that a nurse contacted him and that he might have come into the facility, though he could not remember for certain. The ADMIN stated that he followed the resident to resident abuse guidelines flowsheet and, because resident 36 did not act willfully, he chose not to report the incident to the SSA. On 4/3/25 at 11:46 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she had recently spoke with the ADMIN, who informed her that he followed the flow sheet and did not report the incident to the SSA. The RNC stated she would have preferred that the ADMIN had contacted her to discuss the incident after it occurred. On 4/3/25 at approximately 2:00 PM, an interview was conducted with the ADMIN. The ADMIN stated that he did not understand why he was being cited for not reporting and investigating. The ADMIN stated there were no abuse allegations, the resident to resident incident was not abuse, and there was no harm. The ADMIN stated that he was told not to report incidents like that. The ADMIN stated that he was following the abuse flow sheet that was provided with the SSA logo. The ADMIN stated that he was now going to get a red hand for abuse that did not happen.

Based on interview and record review, the facility in response to allegations of abuse did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 2 out of 27 sampled residents, a resident to resident allegation of abuse was not investigated. Resident identifiers: 20 and 36. Findings included: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, chronic post-traumatic stress disorder (PTSD), and major depressive disorder. Resident 36's medical was reviewed on 4/1/25 through 4/3/25. An admission Minimum Data Set assessment dated [DATE], documented that resident 36 had a Brief Interview for Mental Status (BIMS) score of 99. A BIMS score of 99 indicated that the interview was not completed. On 2/5/25 at 1:20 AM, a Nursing Note documented 'Note Text: Nurse heard banging coming from his room and headed to the room to check it out. room [ROOM NUMBER]A came out of his room and called the nurse. Nurse went into room [ROOM NUMBER] and saw room [ROOM NUMBER] go back to his room through the bathroom door. Listened to the resident explain the situation. Nurse then went to catch the resident who had just left his room and slammed his door. Nurse went [to] calm the resident down. Resident was clenching fists, and unclenching fists. The nurse guided the resident back into his room. Resident then hitthe [sic] closet. Nurse tried to leave the resident in his room for a few minutes to calm down, when that didn't work the nurse tried to bring him out to sit with her for a few minutes. That worked until the nurse needed to leave to pass meds [medications]. At that time theresident [sic] went back to his room and banged on the doors and walls. Nurse called the DON [Director of Nursing] [name redacted] and the director [name redacted], the nurse called his wife who talked to him for a while and helped us the staff be able to get his meds down and get the resident back into bed. The bathroom door between the two rooms was closed and locked so the resident couldn't return to room [ROOM NUMBER]. The nurse stationed herself next to the residents room for the next several hours. No injuries to resident's hands noted. A care plan Focus initiated on 2/6/25, documented BEHAVIORS: [name redacted] has a behavior concerns r/t [related to] Dementia with behavioral disturbances. PTSD. Resistive to cares. Physical aggression. H/O [history of] res [resident] to res altercation. History of becoming easily flustered with ADL [activities of daily living] care. The interventions initiated on 2/6/25, included: Administer medications as ordered. Monitor and document for side effects and effectiveness. Refer to current physician orders and medication administration records. Anticipate and meet the resident's needs. Resolved: Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him as passing by. Educate the family/caregivers on successful coping and interaction strategies. Resident 36 needs encouragement and active support by family and caregivers when strategies were used. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resolved: Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention. Provide a program of activities that was of interest and accommodates residents status. 50200 2. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included nonpyogenic thrombosis of intracranial venous system, emphysema, chronic obstructive pulmonary disease, edema, and chronic pain syndrome. On 2/5/25 at 2:01 AM, a nursing note documented, Note Text: Nurse heard banging coming from his room and headed to the room to check it out. [Resident 20] came out of his room and called the nurse. Nurse went into [resident 20's room] and saw [resident 36] go back to his room through the bathroom door. Listened to the resident explain the situation. Nurse then went to catch the resident who had just left his room and slammed his door. Nurse went [to] calm the resident down. Resident was clenching fists, and unclenching fists. The nurse guided the resident back into his room. Resident then hitthe [sic] closet. Nurse tried to leave the resident in his room for a few minutes to calm down, when that didn't work the nurse tried to bring him out to sit with her for a few minutes. That worked until the nurse needed to leave to pass meds. At that time theresident [sic] went back to his room and banged on the doors and walls. The resident stated that he was watching a movie and [resident 36] came in. resident told [resident 36] that he couldn't be in there. [Resident 36] grabbed his [NAME] [sic] resident stated that he was able to break his arm free and move towards the door. [Resident 36] than tried to hit the resident, the resident blocked it. The resident stated that as he was leaving his room, [resident 36] punched him in the back [sic] Nurse called the DON [name redacted] and the director [name redacted], the nurse called his wife who talked to him for a while and helped us the staff be able to get his meds down and get the resident back into bed. The bathroom door between the two rooms was closed and locked so the resident couldn't return to room. On 4/1/25 at 3:33 PM, an interview was conducted with resident 20. Resident 20 stated that he was sitting in his wheelchair watching television on 2/4/25, when his bathroom door opened and resident 36 entered his room, accused him of being in resident 36's room. Resident 20 stated that resident 36 grabbed his forearm and held onto it. Resident 20 stated resident 36 had a crazy look in his eyes. Resident 20 stated that he was able to break free from the hold on his arm and went to his door to get some help. Resident 20 stated that he told Licensed Practical Nurse (LPN) 1 that resident 36 was in his room and something was wrong with him. Resident 20 stated that as he stood in the doorway trying to get the LPN's attention, resident 36 punched him in the back. Resident 20 stated that he spoke with the nurse on duty that night about the incident but did not recall speaking with any administrative staff regarding it. On 4/2/25 at 7:44 AM, an interview was conducted with LPN 1. LPN 1 stated that she was in the hallway when she heard resident 20 holler, followed by banging and a door slamming coming from resident 20's room. LPN 1 stated when she entered resident 20's room, she found resident 20 in his wheelchair. LPN 1 stated resident 20 informed her that resident 36 had entered his room grabbed his arm and punched him without any provocation or cause. LPN 1 stated that resident 20 was shaking and trembling after the incident. LPN 1 stated to prevent further access to resident 20's room she locked the shared bathroom door to stop resident 36 from entering resident 20's room. LPN 1 stated that she contacted resident 36's wife, who was able to calm him down. LPN 1 stated she reported the incident to the DON, who instructed her to notify the Administrator (ADMIN). LPN 1 stated that she spoke with the ADMIN that night, who asked whether she could keep both the residents safe for the night or if she needed additional staff. LPN 1 stated that resident 20 feared for her safety and did not want her entering resident 36's room due to his anger. LPN 1 stated she recalled the incident clearly because it was highly emotional and took time to resolve. LPN 1 stated she did not recall being contacted by administrative staff following the incident. On 4/3/25 at 11:36 AM, an interview was conducted with the ADMIN. The ADMIN stated that he served as the abuse coordinator for the facility. The ADMIN stated he did not recall when he was notified of the incident. The ADMIN stated that a nurse contacted him and that he might have come into the facility, though he could not remember for certain. The ADMIN stated that he followed the resident to resident abuse guidelines flowsheet and, because resident 36 did not act willfully, he chose not to report the incident to the State Survey Agency (SSA). On 4/3/25 at 11:46 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she had recently spoke with the ADMIN, who informed her that he followed the flow sheet and did not report the incident to the SSA. The RNC stated she would have preferred that the ADMIN had contacted her to discuss the incident after it occurred. On 4/3/25 at approximately 2:00 PM, an interview was conducted with the ADMIN. The ADMIN stated that he did not understand why he was being cited for not reporting and investigating. The ADMIN stated there were no abuse allegations, the resident to resident incident was not abuse, and there was no harm. The ADMIN stated that he was told not to report incidents like that. The ADMIN stated that he was following the abuse flow sheet that was provided with the SSA logo. The ADMIN stated that he was now going to get a red hand for abuse that did not happen.

Based on record review, interviews, and facility document and policy review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 (Resident #4) of 6 residents reviewed for abuse prohibition. Resident #189 touched Resident #4, a severely cognitively impaired resident, inappropriately on the breast on 10/23/2022 and the facility failed to implement adequate interventions to address Resident #189's behavior. This failure resulted in Resident #189 touching Resident #4 inappropriately on the legs, private area, and breast area on 12/26/2022. It was determined that the reasonable person in Resident #1's position would have experienced psychosocial harm as a result of sexual abuse. Findings included: The facility policy titled, Freedom from Abuse, Neglect and Exploitation, dated November 2017 and last revised 09/13/2022, revealed, The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. The policy indicated under the Guidelines section, 3. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This includes but is not limited to: a. Take steps to prevent further potential abuse. b. Report the allegation to appropriate authorities within required timeframes. c. Conduct a thorough investigation of the allegation. d. Document and report the result of the investigation of the allegation. e. Take appropriate corrective action. f. Revise the resident care plan if indicated, to reflect changes to needs or preferences related to an abuse incident. The policy further indicated under the Guidelines section, 5. Resident to resident abuse: a. Cognitive impairment or mental disorder does not preclude a resident from being abusive. b. In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm. c. Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abuse, aggressive interactions (e.g. physical, sexual, or verbal aggression; taking, touching, or rummaging through another's property; wandering into another's rooms/space). The policy indicated sexual abuse was, a. Non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent or a resident who does not want the contact to occur. A review of Resident #4's Admission Record revealed the facility admitted the resident on 11/01/2018 with diagnoses that included Alzheimer's disease with early onset, major depressive disorder, moderate intellectual disabilities, and generalized anxiety disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. The MDS indicated the resident required limited assistance from staff with most activities of daily living but required extensive assistance from staff for dressing and personal hygiene. A review of Resident #4's comprehensive care plans revealed a Focus, initiated on 11/06/2018, that indicated the resident had impaired thought processes related to Alzheimer's disease and unspecified dementia without behavioral disturbance. The care plan Focus indicated Resident #4 experienced frequent confusion and forgetfulness and had significant difficulty with recall. A review of Resident #189's Admission Record revealed the facility most recently admitted the resident on 07/08/2022 with diagnoses that included metabolic encephalopathy, schizoaffective disorder - depressive type, major depressive disorder - recurrent severe without psychotic features, dementia - unspecified severity with other behavioral disturbance, and schizoaffective disorder - bipolar type. A review of a significant change in status MDS, with an ARD of 10/06/2022, revealed a Staff Assessment for Mental Status (SAMS) that indicated Resident #189 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident had physical behavioral symptoms directed towards others (such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually), other behavioral symptoms not directed toward others (such as hitting or scratching self, pacing rummaging, public sexual acts, etc), and wandered one to three days of the seven-day assessment period. These behaviors significantly interfered with the resident's care and participation in activities or social interaction and significantly intruded on the privacy or activity of others and disrupted care or the living environment of others. The MDS indicated the behaviors had worsened since the previous MDS. A review of Progress Notes, dated 10/11/2022 and completed by Registered Nurse (RN) #9, indicated nurses and certified nursing assistants (CNAs) reported Resident #189 was having increased sexual behaviors. In an interview on 08/23/2023 at 9:17 AM, RN #9 stated Resident #189 became very sexual and was masturbating and asking females to get into bed with them. There had to be two staff present when providing care for Resident #189 to protect the staff. RN #9 said Resident #189 was difficult to redirect and very handsy. A review of Progress Notes for Resident #189, dated 10/12/2022 and completed by the Social Worker (SW), indicated a call was received from the nurse practitioner (NP) related to Resident #189's increased sexual behaviors. The note indicated the NP increased the resident's sertraline (an antidepressant medication). A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:20 PM, indicated the resident was sexually inappropriate with staff and other residents. The note indicated Resident #189 was redirected several times during the shift. A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:30 PM, indicated Resident #189 was found in the lobby with another resident and had the resident cornered in the phone booth and was staring at their private areas. The note indicated no physical contact was made, but the cornered resident appeared to be no [sic] a fan of the situation. A review of an incident report, dated 10/23/2022 and prepared by Licensed Practical Nurse (LPN) #11, revealed Resident #4 was in the dining room sitting at a table with Resident #189 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The incident report indicated the residents were separated and a nurse stayed in the dining room with Resident #189 until they finished breakfast. According to the incident report, Resident #4 stated I want to get away from [Resident #189]. There were no injuries noted to Resident #4. A review of Progress Notes for Resident #189, dated 10/23/2022 at 8:30 AM and completed by LPN #11, revealed Resident #189 was in the dining room sitting at a table with Resident #4 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The note indicated the residents were separated and a nurse stayed with Resident #189 until they finished breakfast. In an interview on 08/23/2023 at 12:20 PM, LPN #11 stated on 10/23/2022 someone reported to her that they saw Resident #189 grab Resident #4's breast. LPN #11 stated she did a report, a progress note, and contacted the Director of Nursing (DON) and Administrator right away. LPN #11 said she separated the two residents and monitored them closely. She said staff were to check both residents frequently and report any issues to the DON. LPN #11 stated staff were notified at the meetings during shift change by the DON and the Administrator to keep an eye on Resident #189 to prevent that kind of incident and how to report abuse. LPN #11 said Resident #189 was masturbating a lot prior to this incident and was somewhat redirectable. LPN #11 stated after the investigation, abuse was not substantiated because both residents had dementia. A review of Resident #189's comprehensive care plan revealed a Focus, initiated on 02/11/2019, that addressed behaviors and indicated the resident had a history of delusions and hallucinations and was often nervous they had done something wrong and would be arrested. On 10/27/2022, the care plan Focus was updated to indicate Resident #189 had recently had an increase in socially inappropriate sexual behaviors. Interventions directed staff to educate Resident #189 and staff on successful coping and interaction strategies such as one to one visit/interventions, activities, deep breathing, reading, redirect with suggestions of working with maintenance, watching favorite movies, exercise etc., redirect inappropriate gestures/behaviors, encourage to keep hands clasped on head or knees during care. On 10/23/2022 an intervention was added that instructed staff to redirect away from female residents. A review of Progress Notes for Resident #189, dated 10/25/2022, indicated the resident touched or grabbed multiple staff today. The note indicated Resident #189 grabbed one resident's side and was trying to force them closer to them. The note indicated Resident #189 removed their clothing and grabbed their genitalia and was trying to force the CNA's face towards their genitalia. The note indicated a nurse and the CNA spoke with the SW about Resident #189's behavior and indicated the interdisciplinary team (IDT) was discussing the situation with the physician and NP to find possible medication changes. A review of Progress Notes for Resident #189, dated 10/27/2022, indicated Resident #189 put their hands down their pants and grabbed a CNA's buttocks when the CNA was placing water on the resident's bedside table. The note indicated the resident was redirected and told the behavior was inappropriate. A review of Progress Notes for Resident #189, dated 11/08/2022, indicated the resident continued to have sexual behaviors and was very difficult or unsuccessful with redirection. A review of Progress Notes for Resident #189, dated 11/12/2022, indicated the resident continued to have sexual behaviors with improvement with redirection. The note indicated Resident #189 continued to stare at females and make sexual sounds. A review of Progress Notes for Resident #189, dated 11/14/2022, indicated the resident was in another resident's room with their pants down. The note indicated Resident #189 was taken to their room and tried three times to touch the nurse inappropriately. The note indicated Resident #189 was reminded of proper behavior towards others and was brought to the front lobby area to be monitored. A review of Progress Notes for Resident #189, dated 11/17/2022, indicated the resident continued to have sexual behaviors towards female staff. The note indicated the resident refused to keep their brief and pants in place while in bed. A review of Progress Notes for Resident #189, dated 11/22/2022, indicated the resident was awake all night and was continuously attempting to go into other resident's rooms. The note indicated the resident repeatedly attempted to go into the hallway without pants. The note indicated Resident #189 continued into the day yelling repetitive words and laughing loudly and needed to be checked every five minutes. A review of Progress Notes for Resident #189, dated 11/26/2022 indicated the resident was difficult to direct. The note indicated the resident was propositioning staff for sex. A review of Progress Notes for Resident #189, dated 12/08/2022, indicated the resident was found in another resident's room pouring water on their comforter. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident needed frequent intervention and redirection to stay in their room, stay out of other resident's rooms and to not touch staff. The note indicated Resident #189 did not adhere to staff request for long and would stay in their room and keep their clothes on for approximately two to five minutes and would then come back out undressed and walking around the hall and into other resident's rooms. The note indicated Resident #189 either forgot or disregarded staff direction. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident required multiple staff interventions and redirection to stay in their room, keep their clothes on, keep out of other resident's rooms and to not touch staff. The note indicated the resident either forgot or disregarded staff direction within minutes of being reminded. A review of Progress Notes, dated 12/16/2022, indicated Resident #189's sexual behavior continued, and they required redirection and cueing. A review of Progress Notes, dated 12/17/2022, indicated Resident #189's sexual behavior towards staff and residents continued. A review of Progress Notes, dated 12/21/2022, indicated Resident #189 needed cueing for sexually inappropriate behaviors and required frequent reorientation to be appropriate and refrain from wandering to other resident rooms. A review of Progress Notes, dated 12/26/2022 at 3:28 PM, indicated Resident #189 continued to stare at female residents, but the nurse had not heard any sexual comments on this day. The note indicated Resident #189 told the CNA during a shower that they wanted sex so bad but did not ask the CNA for sex. A review of an incident report, dated 12/26/2022, revealed staff and residents witnessed Resident #189 in front of Resident #4 in the activity room. Resident #189 was seen massaging Resident #4's foot, and then stroked their hand up Resident #4's leg. Resident #4 was yelling for Resident #189 to go away and was swatting at Resident #189's hands with their hands. Resident #189's hands continued up Resident #4's leg to their private area, over the clothing, and then attempted to pull up Resident #4's shirt. The incident report indicated the kitchen staff (Cook #10) yelled at Resident #189 to stop and Resident #189 stepped back. In an interview on 08/23/2023 at 8:47 AM, Cook #10, who witnessed the 12/26/2022 incident, stated the incident occurred after dinner around 7:00 PM. Resident #4 was sitting in a chair. Cook #10 said she witnessed Resident #189 rubbing Resident #4's legs. She told Resident #189 to stop but Resident #189 kept touching Resident #4 and began touching Resident #4's breast over Resident #4's shirt. Cook #10 stated she knew it was not right. Resident #4 kept telling Resident #189 to stop and was slapping Resident #189's hands away. Cook #10 stated she left the two residents alone while she left to get a nurse to help. Cook #10 stated she was not aware of any previous incidents between Resident #4 and Resident #189 and had not been told about any interventions related to Resident #189. Cook #10 stated she did not receive any training or in-services after the incident on 12/26/2022. A review of Progress Notes for Resident #189, dated 12/26/2022 at 7:01 PM, revealed Resident #189 was seen trying to pull up Resident #4's shirt. The note revealed Resident #189 had been more mobile and was walking better so Resident #189 was able to leave their room sometimes and go to the activity and day room independently without staff seeing them. A nursing staff member was called into the room immediately by another resident. A review of Progress Notes for Resident #189, dated 12/26/2022, revealed staff and resident questioning determined that Resident #189 was witnessed stroking their hand up Resident #4's leg and private area over Resident #4's clothes. A review of Progress Notes, dated 12/27/2022 at 8:34 AM, indicated the Administrator interviewed Resident #189 about the incident and the resident did not recall the incident or know details about it. The note indicated the Administrator made Resident #189 aware the details of the allegation were inappropriate and unacceptable. The note indicted the Administrator used simple language that the resident could understand to explain how to avoid those types of situations in the future. A review of Progress Notes, dated 12/27/2022 at 1:22 PM, indicated Resident #189 required frequent reorientation and redirection to their room on this day. A review of a Progress Note, dated 12/28/2022, indicated Resident #189 was discharged from the facility. In an interview on 08/23/2023 at 11:19 AM, CNA #21 stated staff were told to take another staff member in with them to Resident #189's room, to report any sexual inappropriate behavior, and keep a watchful eye. The intervention seemed to work because there were fewer reports of incidents related to staff. After the incident with Resident #4, staff were told to keep an eye on Resident #189 if they were going to be out of their room. The amount of redirecting depended on the day; sometimes they would have to redirect Resident #189 multiple times but other times Resident #189 would be agreeable after the first redirection. She did not recall a one to one supervision intervention but whoever was on the resident's hall or in the dining room would be responsible to watch over Resident #189. In an interview on 08/23/2023 at 11:41 AM, RN #2 stated Resident #189 had some serious mental illness issues. She recalled Resident #189 began having increased sexual activity such as masturbating, grabbing at staff, and making comments to staff that they were going to marry them. She said Resident #189 was basically always under supervision when out of their room and ate at an individual table with a supervising staff person in the dining room. The interventions seemed to be more of a preventative measure rather than a solution and Resident #189 was only redirectable for a short time and then they would have to redirect them continually. In an interview on 08/23/2023 at 9:17 AM, RN #9 stated Resident #189 was initially in a wheelchair but as time went on, Resident #189 was able to walk independently. She said Resident #189 could sometimes be redirected but most of the time Resident #189 would keep doing whatever inappropriate thing they were doing, and it would take several attempts to redirect. RN #9 stated staff tried to keep Resident #189 in their room. RN #9 stated Resident #189 was very active at night and went into other residents' rooms. She said at times staff would have to physically move Resident #189 in their wheelchair back to their room. RN #9 said redirection would only work some of the time and one to one supervision became necessary for a short time. She stated one to one supervision was not for days or weeks straight. RN #9 stated Resident #4 was sitting in a chair in the activity room and Resident #189 started groping Resident #4. The two residents were separated, and she asked Resident #4 if they were okay and Resident #4 said yes. She assessed Resident #4 for any injury or bruising and none were noted. She recalled Resident #189 had started touching Resident #4 at their legs and had gone up their legs (near their private area) and then maybe the chest area. In an interview on 08/24/2023 at 12:33 PM, the DON stated for resident-to-resident abuse, the expectation was that staff provided a safe environment to the resident and then notified their direct supervisor. The DON stated a resident touching another resident would be considered abuse and she would expect that to be reported immediately or as soon as possible. The DON stated she would expect staff to implement the care plan interventions related to supervision of residents and keeping the residents separated. The DON indicated it would be a breach in facility policy if two residents were left unsupervised in an altercation/incident. The DON stated redirection was an appropriate intervention after Resident #189 touched Resident #4's breast in the dining room on 10/23/2022. The DON stated she felt like Resident #189 could be redirected and would respond but it probably depended on the time of day and who the staff person was who was working with Resident #189. The DON stated she would consider inappropriate touching as abuse. In an interview on 08/24/2023 at 12:59 PM, the Administrator stated he would expect staff to report a resident-to-resident incident to the Administrator and separate the two residents. The Administrator stated care staff were expected to follow care plan interventions.

Based on record reviews, interviews, and facility document and policy review, the facility failed to report allegations of abuse within the required two-hour timeframe. This failure affected 4 of 5 total allegations of abuse reviewed by the survey team, involving 5 (Residents #4, #189, #15, #19, and #16) of 6 sampled residents reviewed for abuse concerns. On 10/22/2022 and 12/26/2022, facility staff observed Resident #189 touch Resident #4 inappropriately. The facility did not report either allegation of sexual abuse to the state survey agency. On 03/16/2023, Resident #15 alleged Resident #4 hit them, but the facility did not report the allegation of physical abuse to the state survey agency until 03/19/2023 after a second allegation was made. On 04/27/2023, Resident #19 alleged that Resident #16 inappropriately touched them, and the facility did not report the allegation of sexual abuse to the state survey agency until 04/28/2023. Findings included: A review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, dated 11/2017, revealed, 3. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately, and indicated staff should, b. Report the allegation to appropriate authorities within required timeframes. Review of a document provided by the facility titled, Resident-to-Resident Altercation Flowchart, dated 11/01/2018 from the Utah Department of Health, revealed when a resident-to-resident altercation occurred, the first step was to determine if the resident acted willfully. The flowchart indicated, Willful means that the individual's act was deliberate - not inadvertent or accidental - regardless of whether or not the individual intended to inflict injury or harm. The flowchart then indicated if the facility determined the act was willful or they were unable to determine, the facility should determine whether the victim suffered pain, physical injury, or psychological or emotional harm as a result of the altercation. The flowsheet indicated that, If the victim(s) cannot give a response, consider whether a reasonable person would have experienced psychological distress. If the answer was yes or the facility was unable to determine, the incident should be reported to the state survey agency. The flowchart further instructed the facility on the following: Use of this flowsheet must provide for immediate reporting (F609) or the facility must clearly document the rationale for not reporting. 1. A review of Resident #4's Admission Record revealed the facility admitted the resident on 11/01/2018 with diagnoses that included Alzheimer's disease with early onset, major depressive disorder, moderate intellectual disabilities, and generalized anxiety disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. A review of Resident #4's comprehensive care plans revealed a Focus, initiated on 11/06/2018, that indicated the resident had impaired thought processes related to Alzheimer's disease and unspecified dementia without behavioral disturbance. The care plan Focus indicated Resident #4 experienced frequent confusion and forgetfulness and had significant difficulty with recall. A review of Resident #189's Admission Record revealed the facility most recently admitted the resident on 07/08/2022 with diagnoses that included metabolic encephalopathy, schizoaffective disorder - depressive type, major depressive disorder - recurrent severe without psychotic features, dementia - unspecified severity with other behavioral disturbance, and schizoaffective disorder - bipolar type. A review of a significant change in status MDS, with an ARD of 10/06/2022, revealed a Staff Assessment for Mental Status (SAMS) that indicated Resident #189 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident had physical behavioral symptoms directed towards others (such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually), other behavioral symptoms not directed toward others (such as hitting or scratching self, pacing rummaging, public sexual acts, etc.), and wandered one to three days of the seven-day assessment period. A review of Resident #189's comprehensive care plan revealed a Focus, initiated on 02/11/2019, that addressed behaviors and indicated the resident had a history of delusions and hallucinations and was often nervous they had done something wrong and would be arrested. On 10/27/2022, the care plan Focus was updated to indicate Resident #189 had recently had an increase in socially inappropriate sexual behaviors. A review of an incident report, dated 10/23/2022 at 8:32 AM and prepared by Licensed Practical Nurse (LPN) #11, revealed that while Resident #4 was in the dining room, Resident #189 grabbed Resident #4's breast. According to the incident report, Resident #4 stated, I want to get away from [Resident #189]. In an interview on 08/23/2023 at 12:20 PM, LPN #11 stated someone reported to her that they saw Resident #189 grab Resident #4's breast. LPN #11 stated she completed a report, a progress note, and contacted the Director of Nursing (DON) and the Administrator right away. A review of an incident report, dated 12/26/2022 at 5:49 PM and prepared by Registered Nurse (RN) #9, revealed staff and residents witnessed Resident #189 in front of Resident #4 in the activity room. Resident #189 was seen massaging Resident #4's foot, and then stroked their hand up Resident #4's leg. Resident #4 was yelling for Resident #189 to go away and was swatting at Resident #189's hands with their hands. Resident #189's hands continued up Resident #4's leg to their private area, over the clothing, and then Resident #189 attempted to pull up Resident #4's shirt. Kitchen staff (Cook #10) yelled at Resident #189 to stop, and Resident #189 stepped back. In an interview on 08/23/2023 at 8:47 AM, Cook #10 stated the incident occurred after dinner around 7:00 PM. Cook #10 indicated she saw Resident #4 sitting in a chair, and she witnessed Resident #189 rubbing Resident #4's legs. She told Resident #189 to stop, but Resident #189 kept touching Resident #4 and began touching Resident #4's breasts over Resident #4's shirt. Cook #10 indicated she notified the nurse (RN #9). In an interview on 08/23/2023 at 9:17 AM, RN #9 stated she could not recall the details of the incident and did not recall if she was an eyewitness to it or if she was called to the incident. RN #9 stated Resident #4 was sitting in a chair in the activity room and Resident #189 started groping Resident #4. RN #9 said she separated the residents and notified the Administrator of the incident. In an interview on 08/24/2023 at 12:33 PM, the Director of Nursing (DON) stated a resident touching another resident would be considered abuse, and she would expect that to be reported immediately or as soon as possible. The DON indicated she would report to the Administrator, and depending on the severity, the Administrator would report to corporate, the police, the state health department, and Adult Protective Services (APS). The DON indicated allegations of sexual abuse should be reported within two hours. In an interview on 08/22/2023 at 2:00 PM, the Administrator stated he did the reportables and he did not have a report to the state survey agency for the incidents involving Resident #4 and Resident #189 on 10/23/2022 or 12/26/2022. He stated, For whatever the reason it wasn't [was not] reportable at the time. After reviewing the incident reports, the Administrator stated it was not reportable because Resident #4 was swatting the perpetrator away; there was not actually any touching, and kitchen staff intervened. In an interview on 08/22/2023 at 2:30 PM, the Administrator referred to the document titled, Resident-to Resident Altercation Flowchart, dated 11/01/2018 from the Utah Department of Health, and said the facility had not reported these incidents because both residents were cognitively impaired. 2. A review of Resident #4's Admission Record revealed the facility admitted the resident on 11/01/2018 with diagnoses that included Alzheimer's disease with early onset, major depressive disorder, moderate intellectual disabilities, and generalized anxiety disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. A review of Resident #4's comprehensive care plans revealed a Focus, initiated on 11/06/2018, that indicated the resident had impaired thought processes related to Alzheimer's disease and early onset and unspecified dementia without behavioral disturbance. The care plan Focus indicated Resident #4 experienced frequent confusion and forgetfulness and had significant difficulty with recall. A review of Resident #15's Admission Record revealed the facility most recently admitted the resident on 11/16/2020 with diagnoses that included cerebral infarction, dementia in other diseases classified elsewhere - unspecified severity with agitation, and vascular dementia. A review of a quarterly MDS, with an ARD of 01/16/2023, revealed Resident #15 had a BIMS score of 8, indicating the resident had moderate cognitive impairment Per the MDS, the resident exhibited verbal behavioral symptoms directed towards others (such as threatening others, screaming at others, or cursing at others) one to three days of the seven-day assessment period. A review of Resident #15's comprehensive care plans revealed a Focus, initiated on 01/13/2020, addressing behaviors. This care plan Focus was updated on 03/20/2023 to indicate Resident #15 claimed another resident hit them in the left eye. A review of Resident #15's Progress Notes revealed a Physician/Practitioner Note, dated 03/16/2023 at 8:36 PM and documented by Nurse Practitioner (NP) #4, that indicated Resident #15 was seen that day for a regulatory visit. The note indicated, [Resident #15] tells me [the resident's] room-mate [sic] hit [Resident #15] on the side of the face. NP #4 indicated they were not sure if this was true, because Resident #15 had dementia, and the resident accused of hitting them (Resident #4) was not the resident's roommate. A review of Resident #15's Progress Notes revealed an IDT [Interdisciplinary Team] Note, dated 03/17/2023 at 9:37 AM and documented by the Administrator. The IDT Note indicated the NP's assessment revealed no injury and the Administrator was notified immediately. The note further indicated, No harm or injury, no change to resident routine. Not reportable per crosswalk. A review of Resident #15's Progress Notes revealed an IDT Note, dated 03/19/2023 at 9:45 PM, that indicated Resident #15 made a second allegation of another resident hitting them in the eye that night at dinner time. The note further indicated, Due to second allegation a report was filed to APS [Adult Protective Services] and DHS [Department of Health and Human Services]. A review of an Initial Report, dated 03/19/2023, revealed the facility submitted an initial report of alleged resident to resident physical abuse to the state survey agency. The Initial Report indicated the facility became aware on 03/19/2023 at 8:30 PM and the Administrator was notified at 8:40 PM that Resident #15 reported to a certified nursing assistant (CNA) that Resident #4 hit them that evening (03/19/2023) after meal service, around 6:30 PM. Resident #15 said Resident #4 had hit them before but was unclear on the date or time. The report indicated that Due to claim from [Resident #15] that [Resident #4] hit [him/her] in the eye before, although there is no evidence of injury, harm and [Resident #15] is at baseline, this report is being submitted and investigation begun. A review of an email correspondence, Subject: Initial entity report, from the Administrator to the state survey agency revealed the initial report was submitted on 03/19/2023 at 9:32 PM. In an interview on 08/22/2023 at 12:19 PM, NP #4 stated she saw Resident #15 for a regulatory visit. After reviewing her visit note, NP #4 stated she was not sure if Resident #15's allegation was true, because the resident had dementia. NP #4 said she assumed she spoke with the Director of Nursing (DON) or one of the nurses regarding the allegation. In an interview on 08/24/2023 at 12:33 PM, the DON stated her expectation was that staff provide a safe environment to the resident and then notify their direct supervisor. The DON indicated Resident #15 told the NP that Resident #4 had hit them in the eye. The DON said after NP #4 notified her of the allegation, she notified the Administrator. The DON said if Resident #15 originally made the allegation on 03/16/2023, the initial report should have been submitted on 03/16/2023. In an interview on 08/24/2023 at 12:59 PM, the Administrator stated he would expect abuse allegations to be reported within two hours. After reviewing the facility's investigation, the Administrator stated they decided to report the incident between Resident #4 and Resident #15 after Resident #15 made the second allegation on 03/19/2023. When asked why they decided to report after the second allegation, the Administrator stated because it was the second time and just to be on the safe side. The Administrator said Resident #15 was telling multiple people about the allegation, so they felt it was best to report it to the state at that point. 3. A review of Resident #19's Admission Record revealed the facility admitted the resident on 04/06/2023 with diagnoses that included dependence on wheelchair, adjustment disorder with anxiety, major depressive disorder, anxiety disorder, contracture of muscle, and ankylosing spondylitis (a type of arthritis characterized by long-term inflammation of the joints of the spine) of unspecified sites in spine. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2023, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #19's comprehensive care plans revealed a Focus, initiated on 04/20/2023, that indicated the resident had a mood problem related to adjustment disorder with anxiety. The care plan Focus indicated Resident #19 had a history of inviting adult conversation and relationships then follows with accusatory statements when it does not go [the resident's] way. A review of Resident #16's Admission Record revealed the facility admitted the resident on 01/26/2023 with diagnoses that included Parkinson's disease, type 2 diabetes mellitus with diabetic neuropathy, hyperlipidemia, and hypertension. A review of an admission MDS, with an ARD of 01/31/2023, revealed Resident #16 had a BIMS score of 11, indicating the resident had moderate cognitive impairment. A review of Resident #16's comprehensive care plans revealed a Focus, initiated on 01/31/2023, that indicated the resident had impaired cognitive function/dementia or impaired thought processes r/t [related to] Disease Process of Parkinson's Disease. A review of an Initial Report, dated 04/28/2023, revealed the facility submitted an initial report of alleged sexual abuse to the state survey agency. The Initial Report indicated Resident #19 alleged Resident #16 made unwanted physical contact on or around [Resident #19's] chest area in the dining room before dinner on 04/27/2023. The report indicated this incident was unwitnessed. A review of an email correspondence, Subject: initial entity report, from the Administrator to the state survey agency revealed the initial report was not submitted until 04/28/2023 at 3:55 PM. A review of Resident #19's Progress Notes, revealed no note on 04/27/2023 regarding the resident's allegation. However, a late entry Physician/Practitioner Note, dated 04/28/2023 at 7:56 PM and documented by Nurse Practitioner (NP) #4, indicated NP #4 evaluated Resident #19 on 04/28/2023 as there were reports that another resident had inappropriately touched [Resident #19]. In an interview on 08/22/2023 at 8:30 PM, Certified Nursing Assistant (CNA) #19 stated she recalled the incident with Resident #19. She indicated she did not see anything happen, but she had come in at the tail end of dinner and went into the dining room to help. When she arrived, CNA #20 told her that Resident #19 was ready to go back to their room. CNA #19 helped Resident #19 back to their room, and while heading down the hall, Resident #19 told CNA #19 they wanted to talk to her in private. CNA #19 said when they got to Resident #19's room, Resident #19 told her that Resident #16 had been rubbing Resident #19's arm and shoulders and had then touched them on the chest. Resident #19 reported they told Resident #16 to stop. CNA #19 indicated she then called for Licensed Practical Nurse (LPN) #22, who was coming on shift. According to CNA #19, Resident #19 then reported the same allegation to LPN #22. CNA #19 stated she would report any allegation of abuse immediately and would expect the administrative staff to do the same. In an interview on 08/22/2023 at 10:22 PM, LPN #22 stated she had just arrived on shift probably right before 7:00 PM when Resident #19 reported the allegation. Resident #19 told her they were wearing a gown and Resident #16 came over and was tickling them. At first, they liked it, but then they changed their mind and asked Resident #16 to stop. Resident #19 mentioned that Resident #16 had touched their breast. LPN #22 indicated she notified the Director of Nursing (DON) and the Administrator of the allegation that evening by phone. In an interview on 08/24/2023 at 12:33 PM, the DON stated a resident touching another resident would be considered abuse, and she would expect that to be reported immediately or as soon as possible. The DON indicated she would report to the Administrator, and depending on the severity, the Administrator would report to corporate, the police, the state health department, and Adult Protective Services (APS). The DON indicated allegations of sexual abuse should be reported within two hours. The DON confirmed Resident #19's allegation should have been reported on 04/27/2023 when the allegation was first made.

Based on interviews, record review, and facility policy and document review, the facility failed to follow and implement their abuse policies by failing to protect a resident from further potential abuse for 1 (Resident #4) of 7 residents reviewed for abuse prohibition. Specifically, Resident #4 was sexually abused by Resident #189 on 10/23/2022. Resident #189 continued having sexually inappropriate behaviors and then Resident #4 was sexually abused by Resident #189 again on 12/26/2022. During the incident on 12/26/2022, a staff member left the residents alone to get help while Resident #189 was still abusing Resident #4. Findings included: A review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, dated November 2017 and last revised 09/13/2022, revealed, The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. The policy indicated under the Guidelines section, 3. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This includes but is not limited to: a. Take steps to prevent further potential abuse. A review of Resident #4's Admission Record revealed the facility admitted the resident on 11/01/2018 with diagnoses that included Alzheimer's disease with early onset, major depressive disorder, moderate intellectual disabilities, and generalized anxiety disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. The MDS indicated the resident required limited assistance from staff with most activities of daily living but required extensive assistance from staff for dressing and personal hygiene. A review of Resident #4's comprehensive care plans revealed a Focus, initiated on 11/06/2018, that indicated the resident had impaired thought processes related to Alzheimer's disease and unspecified dementia without behavioral disturbance. The care plan Focus indicated Resident #4 experienced frequent confusion and forgetfulness and had significant difficulty with recall. A review of Resident #189's Admission Record revealed the facility most recently admitted the resident on 07/08/2022 with diagnoses that included metabolic encephalopathy, schizoaffective disorder - depressive type, major depressive disorder - recurrent severe without psychotic features, dementia - unspecified severity with other behavioral disturbance, and schizoaffective disorder - bipolar type. A review of a significant change in status MDS, with an ARD of 10/06/2022, revealed a Staff Assessment for Mental Status (SAMS) that indicated Resident #189 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident had physical behavioral symptoms directed towards others (such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually), other behavioral symptoms not directed toward others (such as hitting or scratching self, pacing rummaging, public sexual acts, etc), and wandered one to three days of the seven-day assessment period. These behaviors significantly interfered with the resident's care and participation in activities or social interaction and significantly intruded on the privacy or activity of others and disrupted care or the living environment of others. The MDS indicated the behaviors had worsened since the previous MDS. A review of Resident #189's comprehensive care plan revealed a Focus, initiated on 02/11/2019, that addressed behaviors and indicated the resident had a history of delusions and hallucinations and was often nervous they had done something wrong and would be arrested. On 10/27/2022, the care plan Focus was updated to indicate Resident #189 had recently had an increase in socially inappropriate sexual behaviors. Interventions directed staff to educate Resident #189 and staff on successful coping and interaction strategies such as one to one visit/interventions, activities, deep breathing, reading, redirect with suggestions of working with maintenance, watching favorite movies, exercise etc., redirect inappropriate gestures/behaviors, encourage to keep hands clasped on head or knees during care. On 10/23/2022 an intervention was added that instructed staff to redirect away from female residents. A review of a facility incident report dated 10/23/2022 revealed Resident #4 was in the dining room sitting with an unnamed resident when the other resident grabbed Resident #4's breast. Resident #4 slapped the hand of the other resident. The report indicated Resident #4 stated, I want to get away from [the other resident]. A review of Progress Notes, dated 10/11/2022, indicated nurses and certified nursing assistants (CNAs) reported Resident #189 was having increased sexual behaviors. A review of Progress Notes for Resident #189, dated 10/12/2022, indicated a call was received from the nurse practitioner (NP) related to Resident #189's increased sexual behaviors. The note indicated the NP increased the resident's sertraline (an antidepressant medication). A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:20 PM, indicated the resident was sexually inappropriate with staff and other residents. The note indicated Resident #189 was redirected several times during the shift. A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:30 PM, indicated Resident #189 was found in the lobby with another resident and had the resident cornered in the phone booth and was staring at their private areas. The note indicated no physical contact was made, but the cornered resident appeared to be no [sic] a fan of the situation. A review of an incident report, dated 10/23/2022 and prepared by Licensed Practical Nurse (LPN) #11, revealed Resident #4 was in the dining room sitting at a table with Resident #189 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The incident report indicated the residents were separated and a nurse stayed in the dining room with Resident #189 until they finished breakfast. According to the incident report, Resident #4 stated I want to get away from [Resident #189]. There were no injuries noted to Resident #4. A review of Progress Notes for Resident #189, dated 10/23/2022 at 8:30 AM, revealed Resident #189 was in the dining room sitting at a table with Resident #4 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The note indicated the residents were separated and a nurse stayed with Resident #189 until they finished breakfast. A review of Progress Notes for Resident #189, dated 10/25/2022, indicated the resident touched or grabbed multiple staff today. The note indicated Resident #189 grabbed one resident's side and was trying to force them closer to them. The note indicated Resident #189 removed their clothing and grabbed their genitalia and was trying to force the CNA's face towards their genitalia. The note indicated a nurse and the CNA spoke with the SW about Resident #189's behavior and indicated the interdisciplinary team (IDT) was discussing the situation with the physician and NP to find possible medication changes. A review of Progress Notes for Resident #189, dated 10/27/2022, indicated Resident #189 put their hands down their pants and grabbed a CNA's buttocks when the CNA was placing water on the resident's bedside table. The note indicated the resident was redirected and told the behavior was inappropriate. A review of Progress Notes for Resident #189, dated 11/08/2022, indicated the resident continued to have sexual behaviors and was very difficult or unsuccessful with redirection. A review of Progress Notes for Resident #189, dated 11/12/2022, indicated the resident continued to have sexual behaviors with improvement with redirection. The note indicated Resident #189 continued to stare at females and make sexual sounds. A review of Progress Notes for Resident #189, dated 11/14/2022, indicated the resident was in another resident's room with their pants down. The note indicated Resident #189 was taken to their room and tried three times to touch the nurse inappropriately. The note indicated Resident #189 was reminded of proper behavior towards others and was brought to the front lobby area to be monitored. A review of Progress Notes for Resident #189, dated 11/17/2022, indicated the resident continued to have sexual behaviors towards female staff. The note indicated the resident refused to keep their brief and pants in place while in bed. A review of Progress Notes for Resident #189, dated 11/26/2022 indicated the resident was difficult to direct. The note indicated the resident was propositioning staff for sex. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident needed frequent intervention and redirection to stay in their room, stay out of other resident's rooms and to not touch staff. The note indicated Resident #189 did not adhere to staff request for long and would stay in their room and keep their clothes on for approximately two to five minutes and would then come back out undressed and walking around the hall and into other resident's rooms. The note indicated Resident #189 either forgot or disregarded staff direction. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident required multiple staff interventions and redirection to stay in their room, keep their clothes on, keep out of other resident's rooms and to not touch staff. The note indicated the resident either forgot or disregarded staff direction within minutes of being reminded. A review of Progress Notes, dated 12/16/2022, indicated Resident #189's sexual behavior continued, and they required redirection and cueing. A review of Progress Notes, dated 12/17/2022, indicated Resident #189's sexual behavior towards staff and residents continued. A review of Progress Notes, dated 12/21/2022, indicated Resident #189 needed cueing for sexually inappropriate behaviors and required frequent reorientation to be appropriate and refrain from wandering to other resident rooms. A review of Progress Notes, dated 12/26/2022 at 3:28 PM, indicated Resident #189 continued to stare at female residents, but the nurse had not heard any sexual comments on this day. The note indicated Resident #189 told the CNA during a shower that they wanted sex so bad but did not ask the CNA for sex. A review of an incident report, dated 12/26/2022, revealed staff and residents witnessed Resident #189 in front of Resident #4 in the activity room. Resident #189 was seen massaging Resident #4's foot, and then stroked their hand up Resident #4's leg. Resident #4 was yelling for Resident #189 to go away and was swatting at Resident #189's hands with their hands. Resident #189's hands continued up Resident #4's leg to their private area, over the clothing, and then attempted to pull up Resident #4's shirt. The incident report indicated the kitchen staff (Cook #10) yelled at Resident #189 to stop and Resident #189 stepped back. A review of Progress Notes for Resident #189, dated 12/26/2022 at 7:01 PM, revealed Resident #189 was seen trying to pull up Resident #4's shirt. The note revealed Resident #189 had been more mobile and was walking better so Resident #189 was able to leave their room sometimes and go to the activity and day room independently without staff seeing them. A nursing staff member was called into the room immediately by another resident. A review of Progress Notes for Resident #189, dated 12/26/2022, revealed staff and resident questioning determined that Resident #189 was witnessed stroking their hand up Resident #4's leg and private area over Resident #4's clothes. A review of Progress Notes, dated 12/27/2022 at 8:34 AM, indicated the Administrator interviewed Resident #189 about the incident and the resident did not recall the incident or know details about it. The note indicated the Administrator made Resident #189 aware the details of the allegation were inappropriate and unacceptable. The note indicted the Administrator used simple language that the resident could understand to explain how to avoid those types of situations in the future. A review of behavior tracking forms for Resident #189 for the timeframe from 10/01/2022 through 12/29/2022 revealed that sexually inappropriate was indicated on 57 dates during that time period. In an interview on 08/23/2023 at 8:47 AM, Cook #10, who witnessed the 12/26/2022 incident, stated the incident occurred after dinner around 7:00 PM. Resident #4 was sitting in a chair. Cook #10 said she witnessed Resident #189 rubbing Resident #4's legs. She told Resident #189 to stop but Resident #189 kept touching Resident #4 and began touching Resident #4's breast over Resident #4's shirt. Cook #10 stated she knew it was not right. Resident #4 kept telling Resident #189 to stop and was slapping Resident #189's hands away. Cook #10 stated she left the two residents alone while she left to get a nurse to help. Cook #10 stated she worked in the kitchen, so she did not often deal with those types of situations, and her first priority was getting a nurse. Cook #10 stated she was not aware of any previous incidents between Resident #4 and Resident #189 and had not been told about any interventions related to Resident #189. Cook #10 stated she did not receive any training or in-services after the incident on 12/26/2022. In a follow up interview on 08/23/2023 at 1:20 PM, Cook #10 stated she ran to the nurses' station to call for a nurse. Cook #10 indicated no more than a minute passed between witnessing the incident and getting the nurse. In an interview on 08/23/2023 at 9:17 AM, Registered Nurse (RN) #9 stated Resident #189 had become very sexual, possibly due to a medication change, and would ask females to get into bed with the resident. RN #9 said two staff would always work together with Resident #189 for their own protection. RN #9 stated Resident #189 was difficult to redirect and very handy. RN #9 stated Resident #4 was sitting in a chair in the activity room and Resident #189 started groping Resident #4. Once RN #9 arrived at the scene, the two residents were separated. She recalled Resident #189 had started touching Resident #4 at their legs and had gone up their legs (near the private area) and then maybe the chest area. RN #9 stated the first thing to do in this situation would be to separate the residents and notify the Administrator and the residents' families. In an interview on 08/24/2023 at 12:33 PM, the Director of Nursing (DON) stated that in the case of resident-to-resident abuse, the expectation was that staff provide a safe environment to the resident and then notify their direct supervisor. The DON stated it would be a breach in policy if two residents were left unsupervised in an altercation. The DON stated she would consider inappropriate touching as abuse. In an interview on 08/24/2023 at 12:59 PM, the Administrator stated he would expect staff to report a resident-to-resident incident to the Administrator and separate the two residents.

Based on interviews, record review, and facility document and policy review, the facility failed to develop and implement a care plan with appropriate interventions to prevent resident-to-resident sexual abuse. Specifically, Resident #189 began having increased sexual behaviors toward staff and residents on approximately 10/11/2022. On 10/23/2022, Resident #189 touched Resident #4 inappropriately on the breast and on 12/26/2022 a second incident occurred where Resident #189 and Resident #4 were left unsupervised and Resident #189 touched Resident #4 on the legs, private area, and breast area. The facility did not implement Resident #189's care plan that directed staff to redirect the resident away from female residents. Findings included: The facility policy titled, Freedom from Abuse, Neglect and Exploitation dated November 2017 and last revised 09/13/2022, revealed, The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. The policy further indicated, e. Take appropriate corrective action. f. Revise the resident care plan if indicated, to reflect changes to needs or preferences related to an abuse incident. A review of Resident #4's Admission Record revealed the facility admitted the resident on 11/01/2018 with diagnoses that included Alzheimer's disease with early onset, major depressive disorder, moderate intellectual disabilities, and generalized anxiety disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. The MDS indicated the resident required limited assistance from staff with most activities of daily living but required extensive assistance from staff for dressing and personal hygiene. A review of Resident #4's comprehensive care plans revealed a Focus, initiated on 11/06/2018, that indicated the resident had impaired thought processes related to Alzheimer's disease and unspecified dementia without behavioral disturbance. The care plan Focus indicated Resident #4 experienced frequent confusion and forgetfulness and had significant difficulty with recall. A review of Resident #189's Admission Record revealed the facility most recently admitted the resident on 07/08/2022 with diagnoses that included metabolic encephalopathy, schizoaffective disorder - depressive type, major depressive disorder - recurrent severe without psychotic features, dementia - unspecified severity with other behavioral disturbance, and schizoaffective disorder - bipolar type. A review of a significant change in status MDS, with an ARD of 10/06/2022, revealed a Staff Assessment for Mental Status (SAMS) that indicated Resident #189 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident had physical behavioral symptoms directed towards others (such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually), other behavioral symptoms not directed toward others (such as hitting or scratching self, pacing rummaging, public sexual acts, etc), and wandered one to three days of the seven-day assessment period. These behaviors significantly interfered with the resident's care and participation in activities or social interaction and significantly intruded on the privacy or activity of others and disrupted care or the living environment of others. The MDS indicated the behaviors had worsened since the previous MDS. A review of Progress Notes, dated 10/11/2022 and completed by Registered Nurse (RN) #9, indicated nurses and Certified Nursing Assistants (CNA) reported Resident #189 was having increased sexual behaviors. In an interview on 08/23/2023 at 9:17 AM, RN #9 stated Resident #189 became very sexual and was masturbating and asking females to get into bed with them. There had to be two staff present when providing care for Resident #189 to protect the staff. RN #9 said Resident #189 was difficult to redirect and very handsy. A review of Progress Notes for Resident #189, dated 10/12/2022 and completed by the Social Worker (SW), indicated a call was received from the nurse practitioner (NP) related to Resident #189's increased sexual behaviors. The note indicated the NP increased the resident's sertraline (an antidepressant medication). A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:20 PM, indicated the resident was sexually inappropriate with staff and other residents. The note indicated Resident #189 was redirected several times during the shift. A review of Progress Notes for Resident #189, dated 10/22/2022 at 6:30 PM, indicated Resident #189 was found in the lobby with another resident and had the resident cornered in the phone booth and was staring at their private areas. The note indicated no physical contact was made, but the cornered resident appeared to be no [sic] a fan of the situation. A review of an incident report, dated 10/23/2022 and prepared by Licensed Practical Nurse (LPN) #11, revealed Resident #4 was in the dining room sitting at a table with Resident #189 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The incident report indicated the residents were separated and a nurse stayed in the dining room with Resident #189 until they finished breakfast. According to the incident report, Resident #4 stated I want to get away from [Resident #189]. There were no injuries noted to Resident #4. A review of Progress Notes for Resident #189, dated 10/23/2022 at 8:30 AM and completed by LPN #11, revealed Resident #189 was in the dining room sitting at a table with Resident #4 when Resident #189 grabbed Resident #4's breast. Resident #4 slapped Resident #189's hand. The note indicated the residents were separated and a nurse stayed with Resident #189 until they finished breakfast. In an interview on 08/23/2023 at 12:20 PM, LPN #11 stated on 10/23/2022 someone reported to her that they saw Resident #189 grab Resident #4's breast. LPN #11 stated she did a report, a progress note, and contacted the Director of Nursing (DON) and Administrator right away. LPN #11 said she separated the two residents and monitored them closely. She said staff were to check both residents frequently and report any issues to the DON. LPN #11 stated staff were notified at the meetings during shift change by the DON and the Administrator to keep an eye on Resident #189 to prevent that kind of incident. LPN #11 said Resident #189 was masturbating a lot prior to this incident and was somewhat redirectable. A review of Resident #189's comprehensive care plan revealed a Focus, initiated on 02/11/2019, that addressed behaviors and indicated the resident had a history of delusions and hallucinations and was often nervous they had done something wrong and would be arrested. On 10/27/2022, the care plan Focus was updated to indicate Resident #189 had recently had an increase in socially inappropriate sexual behaviors. Interventions directed staff to educate Resident #189 and staff on successful coping and interaction strategies such as one to one visit/interventions, activities, deep breathing, reading, redirect with suggestions of working with maintenance, watching favorite movies, exercise etc. (initiated on 02/11/2019), redirect inappropriate gestures/behaviors and encourage to keep hands clasped on head or knees during care (initiated on 11/14/2022). On 10/23/2022 an intervention was added that instructed staff to redirect away from female residents and on 11/14/2022 an intervention was added to redirect the resident as needed. A review of Progress Notes for Resident #189, dated 10/25/2022, indicated the resident touched or grabbed multiple staff today. The note indicated Resident #189 grabbed one resident's side and was trying to force them closer to them. The note indicated Resident #189 removed their clothing and grabbed their genitalia and was trying to force the CNA's face towards their genitalia. The note indicated a nurse and the CNA spoke with the SW about Resident #189's behavior and indicated the interdisciplinary team (IDT) was discussing the situation with the physician and NP to find possible medication changes. A review of Progress Notes for Resident #189, dated 10/27/2022, indicated Resident #189 put their hands down their pants and grabbed a CNA's buttocks when the CNA was placing water on the resident's bedside table. The note indicated the resident was redirected and told the behavior was inappropriate. A review of Progress Notes for Resident #189, dated 11/08/2022, indicated the resident continued to have sexual behaviors and was very difficult or unsuccessful with redirection. A review of Progress Notes for Resident #189, dated 11/12/2022, indicated the resident continued to have sexual behaviors with improvement with redirection. The note indicated Resident #189 continued to stare at females and make sexual sounds. A review of Progress Notes for Resident #189, dated 11/14/2022, indicated the resident was in another resident's room with their pants down. The note indicated Resident #189 was taken to their room and tried three times to touch the nurse inappropriately. The note indicated Resident #189 was reminded of proper behavior towards others and was brought to the front lobby area to be monitored. A review of Progress Notes for Resident #189, dated 11/17/2022, indicated the resident continued to have sexual behaviors towards female staff. The note indicated the resident refused to keep their brief and pants in place while in bed. A review of Progress Notes for Resident #189, dated 11/22/2022, indicated the resident was awake all night and was continuously attempting to go into other resident's rooms. The note indicated the resident repeatedly attempted to go into the hallway without pants. The note indicated Resident #189 continued into the day yelling repetitive words and laughing loudly and needed to be checked every five minutes. A review of Progress Notes for Resident #189, dated 11/26/2022 indicated the resident was difficult to direct. The note indicated the resident was propositioning staff for sex. A review of Progress Notes for Resident #189, dated 12/08/2022, indicated the resident was found in another resident's room pouring water on their comforter. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident needed frequent intervention and redirection to stay in their room, stay out of other resident's rooms and to not touch staff. The note indicated Resident #189 did not adhere to staff request for long and would stay in their room and keep their clothes on for approximately two to five minutes and would then come back out undressed and walking around the hall and into other resident's rooms. The note indicated Resident #189 either forgot or disregarded staff direction. A review of Progress Notes for Resident #189, dated 12/11/2022, indicated the resident required multiple staff interventions and redirection to stay in their room, keep their clothes on, keep out of other resident's rooms and to not touch staff. The note indicated the resident either forgot or disregarded staff direction within minutes of being reminded. A review of Progress Notes, dated 12/16/2022, indicated Resident #189's sexual behavior continued, and they required redirection and cueing. A review of Progress Notes, dated 12/17/2022, indicated Resident #189's sexual behavior towards staff and residents continued. A review of Progress Notes, dated 12/21/2022, indicated Resident #189 needed cueing for sexually inappropriate behaviors and required frequent reorientation to be appropriate and refrain from wandering to other resident rooms. A review of Progress Notes, dated 12/26/2022 at 3:28 PM, indicated Resident #189 continued to stare at female residents, but the nurse had not heard any sexual comments on this day. The note indicated Resident #189 told the CNA during a shower that they wanted sex so bad but did not ask the CNA for sex. Further review of Resident #189's comprehensive care plan revealed the care plan was not updated to reflect new interventions to address Resident #189's inappropriate sexual behaviors as the resident continued having inappropriate sexual behaviors following the incident with Resident #4 on 10/23/2022. The care plan instructed staff to redirect the resident, but per the Progress Notes, the resident could not always be redirected, indicating this was not an appropriate intervention. A review of an incident report, dated 12/26/2022, revealed staff and residents witnessed Resident #189 in front of Resident #4 in the activity room. Resident #189 was seen massaging Resident #4's foot, and then stroked their hand up Resident #4's leg. Resident #4 was yelling for Resident #189 to go away and was swatting at Resident #189's hands with their hands. Resident #189's hands continued up Resident #4's leg to their private area, over the clothing, and then attempted to pull up Resident #4's shirt. The incident report indicated the kitchen staff (Cook #10) yelled at Resident #189 to stop and Resident #189 stepped back. In an interview on 08/23/2023 at 8:47 AM, Cook #10, who witnessed the 12/26/2022 incident, stated the incident occurred after dinner around 7:00 PM. Resident #4 was sitting in a chair. Cook #10 said she witnessed Resident #189 rubbing Resident #4's legs. She told Resident #189 to stop but Resident #189 kept touching Resident #4 and began touching Resident #4's breast over Resident #4's shirt. Cook #10 stated she knew it was not right. Resident #4 kept telling Resident #189 to stop and was slapping Resident #189's hands away. Cook #10 stated she left the two residents alone while she left to get a nurse to help. Cook #10 stated she was not aware of any previous incidents between Resident #4 and Resident #189 and had not been told about any interventions related to Resident #189. A review of Progress Notes for Resident #189, dated 12/26/2022 at 7:01 PM, revealed Resident #189 was seen trying to pull up Resident #4's shirt. The note revealed Resident #189 had been more mobile and was walking better so Resident #189 was able to leave their room sometimes and go to the activity and day room independently without staff seeing them. A nursing staff member was called into the room immediately by another resident. A review of Progress Notes for Resident #189, dated 12/26/2022, revealed staff and resident questioning determined that Resident #189 was witnessed stroking their hand up Resident #4's leg and private area over Resident #4's clothes. A review of Progress Notes, dated 12/27/2022 at 8:34 AM, indicated the Administrator interviewed Resident #189 about the incident and the resident did not recall the incident or know details about it. The note indicated the Administrator made Resident #189 aware the details of the allegation were inappropriate and unacceptable. The note indicted the Administrator used simple language that the resident could understand to explain how to avoid those types of situations in the future. A review of Progress Notes, dated 12/27/2022 at 1:22 PM, indicated Resident #189 required frequent reorientation and redirection to their room on this day. A review of a Progress Note, dated 12/28/2022, indicated Resident #189 was discharged from the facility. In an interview on 08/23/2023 at 11:19 AM, CNA #21 stated staff were told to take another staff member in with them to Resident #189's room, to report any sexual inappropriate behavior, and keep a watchful eye. The intervention seemed to work because there were fewer reports of incidents related to staff. After the incident with Resident #4, staff were told to keep an eye on Resident #189 if they were going to be out of their room. The amount of redirecting depended on the day; sometimes they would have to redirect Resident #189 multiple times but other times Resident #189 would be agreeable after the first redirection. She did not recall a one to one supervision intervention but whoever was on the resident's hall or in the dining room would be responsible to watch over Resident #189. In an interview on 08/23/2023 at 11:41 AM, RN #2 stated Resident #189 had some serious mental illness issues. She recalled Resident #189 began having increased sexual activity such as masturbating, grabbing at staff, and making comments to staff that they were going to marry them. She said Resident #189 was basically always under supervision when out of their room and ate at an individual table with a supervising staff person in the dining room. The interventions seemed to be more of a preventative measure rather than a solution and Resident #189 was only redirectable for a short time and then they would have to redirect them continually. In an interview on 08/23/2023 at 9:17 AM, RN #9 stated Resident #189 could sometimes be redirected but most of the time Resident #189 would keep doing whatever inappropriate thing they were doing, and it would take several attempts to redirect. RN #9 stated staff tried to keep Resident #189 in their room. RN #9 stated Resident #189 was very active at night and went into other residents' rooms. She said at times staff would have to physically move Resident #189 in their wheelchair back to their room. RN #9 said redirection would only work some of the time and one to one supervision became necessary for a short time. She stated one to one supervision was not for days or weeks straight. In an interview on 08/24/2023 at 12:33 PM, the DON stated she would expect staff to implement the care plan interventions related to supervision of residents and keeping the residents separated. The DON stated redirection was an appropriate intervention after Resident #189 touched Resident #4's breast in the dining room on 10/23/2022. The DON stated she felt like Resident #189 could be redirected and would respond but it probably depended on the time of day and who the staff person was who was working with Resident #189. In an interview on 08/24/2023 at 12:59 PM, the Administrator stated he would expect staff to report a resident-to-resident incident to the Administrator and separate the two residents. The Administrator stated care staff were expected to follow care plan interventions.

Based on interviews, record review, and facility document and policy review, the facility failed to protect the resident's right to obtain copies of the resident's medical record upon request for 1 (Resident #37) of 1 sampled discharged resident. Findings included: A review of a facility policy titled, Resident Records- Identifiable Information, revised 05/04/2023, indicated, 5. Medical records will be kept confidential, except when release is: a. To the individual or their representative where permitted by applicable law. A review of Resident #37's Admission Record indicated the facility admitted the resident on 05/20/2023 with diagnoses including the presence of a left artificial knee joint, major depression, and anxiety disorder. The record indicated the resident was discharged from the facility on 06/06/2023 to a private home with home health services. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2023, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Further review revealed there was an active discharge plan in place for the resident to return to the community. A review of Resident #37's Care Plan, initiated on 05/31/2023, revealed that the resident wished to be discharged home. Interventions directed staff to make arrangements with required community resources to support independence post-discharge. A review of Resident #37's physician's Order Summary Report for active orders as of 05/23/2023 indicated Resident #37 could administer their own medications, manage their own finances, and participate in their own plan of care. A review of Resident #37's Discharge Planning and Summary, with a discharge date of [DATE], indicated the resident requested to be discharged and was discharged home. According to the summary, medical records that were reviewed with the resident that would be sent with the resident or to the receiving provider included order summaries for pharmacy, diet, wound, and oxygen as applicable, advance directives, transfer/discharge report, and pertinent laboratory and/or diagnostic results. During an interview on 08/23/2023 at 8:42 AM, Resident #37 stated they received a few records but not all of them. The resident stated they wanted the medication records from the facility. Resident #37 stated a charge for the records was not discussed. The resident reported having a friend go to the facility to obtain the records. However, when the friend arrived, the facility staff was surprised to learn that they were locked out of some of the resident's records. The resident reported that the facility never contacted them about additional medical records being available. A review of an email from the Administrator to Certified Nursing Assistant (CNA) #12 on 06/08/2023 revealed the Administrator documented that Resident #37 would like a copy of their medical records. Per the email, the Administrator asked that CNA #12 call the resident, send records request forms, and help the resident identify what they wanted and how to get the records. A review of an Authorization For Release Of Medical Records form revealed that on 06/12/2023, Resident #37 signed the release for the resident's provider to obtain All medical records to date. An email to CNA #12, copied to Legal, dated 06/12/2023 at 1:37 PM, revealed a request for the CNA to send the requested records and verify receipt. A review of an email from the provider's office to CNA #12, dated 06/12/2023 at 3:07 PM, revealed the provider's office verified receipt. A review of the email revealed the facility provided Progress Notes, physician Order Summary Report, and laboratory results (two pages) from laboratory tests collected on 05/22/20233. On 08/23/2023 at 8:57 AM, the Director of Nursing (DON) indicated that CNA #12 was the staff that was responsible for medical records and medical record requests. On 08/23/2023 at 9:03 AM, CNA #12 was interviewed regarding the facility's process for releasing medical records to discharged residents. The CNA reported that the process was to have the resident or representative complete a records request form and forward the request to the legal team. The legal team then notified the CNA whether they would release the records or if they wanted the CNA to release the records. The CNA stated she emailed Resident #37 a release form and notified the resident of the cost for the records. According to CNA #12, she never heard back from the resident but received a request for records from the resident's physician. An interview with CNA #12 on 08/23/2023 at 10:45 AM revealed she had a discussion later with Resident #37 and told the resident copies of the resident's records were being sent to the physician. Resident #37 asked for the same records. CNA #12 stated the medical records sent to the physician included nursing notes, physician orders, and laboratory results. An interview with CNA #12 on 08/24/2023 at 8:53 AM revealed she did not have documentation of Resident #37's medical record request. However, the CNA stated the resident wanted the entire medical record. She stated when Resident #37's friend came in to pick up records, the CNA told the friend that all the resident's documents were not available. Subsequently, the resident's friend took what the CNA had for the provider's office, printed out the remainder of the resident's record, and kept it in a drawer; however, no one ever came to pick up Resident #37's medical record. An interview with the DON on 08/24/3023 at 10:38 AM revealed her expectation was that the facility would follow through in a timely manner and get requested records for residents. On 08/24/2023 at 11:41 AM, the DON stated during an interview that the facility received an email request for medical records from Resident #37 on 06/08/2023. On 06/09/2023, the DON reported that a medical records request form was mailed to the resident, and on 06/12/2023, the medical records were sent to the physician's office, who confirmed receipt. The DON stated the resident's friend came to the facility on [DATE] or 06/14/2023 to get the resident's records. The DON also reported that on 06/15/2023, medical records staff notified the resident that the remainder of the records were ready to be picked up. The DON stated there was no documentation related to a request for medical records, the release of the records, nor contact made with the resident. According to the DON, the resident did not pick up the records, and after 30 days passed, the records were destroyed. On 08/24/2023 at 10:57 AM, an interview with the Administrator revealed the process for obtaining a copy of medical records included obtaining a signed request for records authorization form that was forwarded to the company legal department, and it was managed from there. If it was a simple request, the legal department gave the facility authorization to release the records. The Administrator indicated the facility usually did not charge residents for a copy of the records, or they may charge a small amount. The Administrator indicated the facility utilized a form that residents could mark the records they wanted. The Administrator indicated if a resident requested all of the record, anything that was part of the medical record would be provided, excluding incident reports and emails. The Administrator stated medication administration records would be included when requested.

Based on interview and observation, the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, one resident was missing a personal item that was not located and not replaced. Resident identifier: 33. Findings include: Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysthymic disorder, dysphagia, post-traumatic stress disorder, [CONDITION(S)], a history of transient ischemic attacks, heart failure, anxiety, and diabetes. On 10/13/21 at 9:47 AM, resident 33 was interviewed. Resident 33 stated that he was missing a beautiful southwest blanket for over a month. Resident 33 stated that staff had looked for it, but could not find it. Resident 33 stated that he did not know the status of looking for his blanket and no resolution occurred. On 10/14/21, resident 33's medical record review was completed. Resident 33 had an inventory list made in 2017 when he was admitted to the facility. Resident 33 did not have an additional inventory list created. Resident 33's nursing notes did not include documentation about lost possessions. A review of grievances did not reveal that resident 33 had completed a grievance form. On 10/14/21 at 11:46 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that if a resident reported missing clothing or other items, staff checked the laundry, notified the Assistant Laundry Manager ([NAME]), and the laundry staff would assist with helping find the missing items. RN 1 stated that there were no grievance forms for nursing staff to complete. RN 1 stated that after staff looked for the missing item and could not locate it, they would notify the family and find out what they wanted to do, to have the item replaced or a financial refund. RN 1 stated that the Administrator worked with the family. On 10/14/21 at 12:22 PM, housekeeper (HK) 1 was interviewed. HK 1 stated that she had looked for resident 33's missing blanket along with the other housekeeping staff and they were unable to locate the blanket. On 10/14/21 at 12:24 PM, the [NAME] was interviewed. The [NAME] stated that resident 33 had reported to her that his blanket was missing approximately one month ago. The [NAME] stated that resident 33 was missing a southwest style blanket and stated that she had reported the loss to her manager, the Housekeeping Manager (HM). The [NAME] revealed the areas where the laundry was stored in the laundry room. The [NAME] stated that if her supervisor was not available, she would have let the Administrator know about the missing blanket, but she attempted to follow the chain of command. The [NAME] stated that she had looked in other residents' rooms when she returned laundry, because she knew what the blanket looked like, but had not seen it anywhere. On 10/14/21 at 12:51 PM, the Housekeeping Manager was interviewed. The HM stated that he was told that resident 33 was missing a blanket approximately a month ago. The HM stated that he had looked through the laundry with the [NAME] and had not found the blanket. The HM stated that he would start looking in the other residents' closets to see if he could find the blanket. The HM stated that if an item was not included on a resident's inventory list, he would assume the resident did not bring the item into the facility or that the family had taken the item, and therefore it would not be replaced or reimbursed. The HM stated that it usually took about 2 weeks to look through the closets and determine if a resident's belongings were misplaced. The HM stated that when he finished his process, he would work with the Administrator to replace the missing item. The HM stated that he had not talked to the Administrator. On 10/14/21 at 1:21 PM, Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated that she had looked for resident 33's missing blanket, and when it was not located in his room or in the laundry room, she had searched everyone's closets. CNA 3 stated that she had searched everyone's closets, then asked the laundry personnel, who also could not locate resident 33's blanket. CNA 3 stated that the blanket was blue with a tribal print. CNA 3 stated that the blanket must have been taken out of the building by someone discharging from the facility. CNA 3 stated that she reported the missing blanket to the Director of Nursing (DON). On 10/14/21 at 2:06 PM, the DON was interviewed. The DON stated that resident 33 had lost an older blanket as well. The DON stated that resident 33 had not been asked to create a new inventory list since his 2017 admission inventory list, and many of resident 33's belongings were not on the old list. The DON stated that resident 33 had mentioned to her that he had a missing blanket in passing between one and two months prior. The DON stated that she did not play a role in the missing items process, and that the social worker was involved. On 10/14/21 at 2:46 PM, the Social Worker (SW) was interviewed. The SW stated that when a resident was missing items, the CNAs reported to her. The SW stated that she had not received information that resident 33 was missing a blanket. The SW stated that she initiated the grievance process by interviewing the resident, writing up the grievance form, and reviewing the resident's inventory list. The SW stated that she would look for missing items and talk to the staff, then approach the Administrator to determine how the issue would be solved. The SW stated that she not been informed, and therefore the grievance process was not completed for resident 33's missing blanket. The SW stated that she educated the new employees at the facility about how to complete the grievance process during orientation, so all staff should know that she was the manager responsible to complete grievances.

Based on interview and record review it was determined, for 1 of 5 sample staff, that the facility did not conducted testing based on parameters. Specifically, a staff member was not tested twice weekly according to the community transmission rate. Staff identifiers: Staff 1. Findings include: According to the Center for Disease Control and Prevention (CDC) the community transmission was red on 9/20/21, 9/27/21, 10/4/21 and 10/12/21. https://covid.cdc.gov/covid-data-tracker/#county-view|Utah| |Risk|community_transmission_level According to the Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements revised on 9/10/21, routine staff testing for High (red) community transmission unvaccinated staff was required twice weekly. Staff testing was completed on 9/13/21, 9/16/21, 9/20/21, 9/23/21, 9/27/21, 9/30, 10/4/21, 10/7/21 and 10/11/21. Staff 1's testing was reviewed on 10/14/21. According to the form provided by the facility Staff 1 missed missed testing on 9/13/21, 9/16/21 and 10/7/21. On 10/14/21 at approximately 10:00 AM, an interview was conducted with the facility Infection Preventionist (IP). The IP stated that staff 1 was absent during testing conducted on 9/13/21 and 9/16/21. The IP stated that staff 1 refused to be tested on [DATE]. The IP stated that if staff were not tested or refused testing, the staff member was reminded of importance of testing. The IP stated she did not have documentation regarding a discussion about testing with staff 1.

Based on interview and record review it was determined, for 1 of 28 sample residents, that the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident did not receive catheter care treatment after developing signs of a urinary tract infection ([CONDITION(S)]) and after a positive urine culture. Resident identifier: 7. Findings include: Resident 7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 7 was admitted to hospice services on 4/23/21. On 10/12/21 at 1:18 PM, resident 7 stated that he had problems with his catheter. Resident 7 stated that when staff worked with it, he experienced pain in his penis. On 10/14/21, resident 7's electronic medical record review was completed. Resident 7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cath (catheter) size 18 Fr. (french). Cath cares per orders. Change foley catheter and drainage bag monthly . Resident's history revealed: a. A physician's note dated 6/15/21 revealed that resident 7 had scant cloudy discharge in the urine and no discharge from the urethra. b. A nursing note dated 7/22/21 revealed that resident 7 had redness and swelling around the urethra and was given a course of [MEDICATION(S)] ([MEDICATION(S)], antibiotic), 500 mg (milligrams) PO (by mouth) for 7 days. Nursing progress notes were reviewed and revealed the following: a. On 8/2/21 at 7:56 PM, the urethral area was slightly red, drainage in catheter bag was slightly cloudy and had a slight tinge of blood. b. On 8/5/21 at 5:39 PM, Pt (patient) has foul smelling urine that is has (sic) thick mucousy drainage. NP (nurse practitioner) notified, with N.O. (new order) to collect a urine sample and send for UA (urinalysis). c. On 8/5/21 at 6:58 PM, Sample collected and sent to [local hospital] for abnormal results with dip (urine dipstick test). Foley catheter changed with 18 Fr in order to get clean sample d. On 8/8/21 at 6:42 PM, Got the UA results back. UA with C&S (culture and sensitivity) showed positive for proteus penneri. C&S results sent to hospice/[doctor], awaiting response for ABX (antibiotics) orders . UA results from urine obtained on 8/5/21 at 6:15 PM, .Blood in urine 2+ (indicating some, normal is negative. Trace of protein (normal is negative). Leukocyte Esterase 2+, normal is negative. Red blood cells were 15-20 in the HPF (high powered field); normal is 0-10. White blood cells (WBC) were 15-20 wbc/hpf, with normal 0-10. Bacteria was 2+ with normal being none/few. The organism detected was proteus penneri greater than 100,000 colony forming units per milliliter. Resident 7's Proteus Penneri culture was susceptible to 12 antibiotics. e. On 8/8/21 at 7:01 PM, Returned call from [doctor] r/t (related to) UA results, He was notified of the colony, colony count and susceptibility. He wanted to know if the resident was showing s/sx (signs/symptoms). He was notified that the resident had no s/sx of [CONDITION(S)] . [Note: resident 7 did not have symptoms of a [CONDITION(S)], but did have signs of a [CONDITION(S)].] f. On 8/10/21 at 6:33 PM, Pt's urine continues to have chunks and other abnormal discharge. CNA (certified nursing assistant) noted that resident had some pus at the insertion site on penis. Pt also had some complaints of pain. It was noted a little later that resident was not having any output. Nurse attempted to flush catheter, with no success, likely d/t being clogged. Sterile technique used to replace foley and catheter. Pt was able to get approximately 800 mls (milliliters) of urine output. Abnormal chunks/mucous still noted even in new catheter. There is also still foul odor to the urine. The hospice nurse was notified. g. On 8/11/21 at 10:39 PM, the hospice nurse notified the staff nurse that the doctor ordered [MEDICATION(S)] (an antibiotic) 1 gram intramuscular daily for three days. h. On 8/11/21 at 12:21 PM, an IDT (interdisciplinary team) meeting was held and the doctor expressed multiple concerns about the effectiveness of an ABX (antibiotics) . other than the sediment and the odor to the urine, patient is doing well and afebrile (without fever) now that the catheter is draining, he is no longer having pain. Multiple options discussed, as the sediment clogging the catheter is the main issue at present .Order for [MEDICATION(S)] DC'd (discontinued). Resident 7's medication and treatment administration records revealed that resident 7 did not receive an antibiotic. On 8/12/21 at 8:00 AM, resident 7 was prescribed [CONDITION(S)]-STAT liquid (cranberry, vitamin C, [MEDICATION(S)]), 30 ml by mouth one time a day for a history of UTIs. i. On 8/17/21 at 11:25 PM, Resident [has] c/o of bladder pain and stated that he felt like he needed to urinate badly. Catheter was flushed three times and it did not relieve the pain or need to urge to urinate. Catheter was changed per order size 18 FR. Drained 550 cc of urine. Urine was cloudy and had sediment in it. Resident stated that bladder pain was gone and the urge to urinate after draining bladder On 10/14/21 at 1:31 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 7 usually had a small amount of sediment in his urine, but no purulent discharge. RN 1 stated that resident 7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated that resident 7's urethral opening was purple and sore. RN 1 stated that resident 7 continued to have catheter difficulty through the end of August. On 10/14/21 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the facility was informed of the positive urinalysis results on 8/8/21, but did not treat the [CONDITION(S)]. The DON stated that resident 7's symptoms increased until an intervention was ordered for 8/12/21. The facility provided the following additional information: McGeer Surveillance Definitions for Urinary Tract Infections (UTIs), 2012. For residents with an indwelling catheter, must have at least one sign or symptom: . Recent catheter trauma, catheter obstruction or new-onset hematuria are useful localizing signs that are consistent with [CONDITION(S)] but are not necessary for diagnosis . d. Purulent discharge from around the catheter . 2. Urinary catheter specimen culture with at least [100,000] cfu/mL of any organism(s) Loeb Minimum Criteria for Initiating Antibiotics for a Urinary Tract Infection identified subjective symptoms, but did not address a positive urine culture. Proteus Penneri is a gram negative rod-shaped bacteria. Proteus species are the leading cause of more complicated UTIs compared to other uropathogens [Borne, 2015].Borne Mehrad, [NAME] M, [NAME] G. Zhanel, Joseph P Lynch. Antimicrobial Resistance in Hospital-Acquired Gram-Negative Bacterial Infections: American College of Chest Physicians. May 2015; 147(5): 1413-1421. https://www.researchgate.net/profile/[NAME]-Abhadionmhen/publication/ 9015_Antimicrobial_properties_of_Vernonia_amygdalina_on_Escherichia_coli_and_Proteus_species_isolated_from_urine_samples_Potential_antimicrobial_alternative_for_urinary_tract_infection/links/612c8ace 02a0068b32d/Antimicrobial-properties-of-Vernonia-amygdalina-on-Escherichia-coli-and-Proteus-species-isolated-from-urine-samples-Potential-antimicrobial-alternative-for-urinary-tract-infection.pdf

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19. A focused COVID-19 Infection Control survey was completed on 6/29/2020. The facility was found to not be in compliance with 42 CFR §483.80 infection control regulations. The facility did not ensure staff implemented policy and procedures to prevent the transmission of the COVID-19 virus. Specifically, staff did not don appropriate personal protective equipment (PPE) prior to entering a resident room that was on droplet precautions pending the results of COVID-19 testing, placed a water mug from a room where the resident was on droplet precautions pending the results of a COVID-19 test on top of a hydration cart, filled the mug with water, replaced the lid then delivered the water mug back to the resident on droplet precautions. Additionally, multiple staff members were observed in a resident room who was on droplet precautions pending the results of a COVID-19 test, without wearing the appropriate PPE. No hand hygiene was observed when the staff members exited the resident room who was on droplet precautions pending the results of a COVID-19 test. These findings placed all the residents at risk for exposure to COVID-19. Resident identifier 1, 2 and 3. Findings include: An on-site focused COVID-19 infection control survey was conducted on 6/29/2020 between 9:30 AM and 11:30 AM. On 6/29/2020 at approximately 9:45 AM, an entrance interview was conducted with the facility Administrator (ADM). The ADM was asked if there were any current resident's who had been tested for COVID-19. The ADM stated that there were three current residents who had COVID-19 testing that was pending. The ADM identified that residents 1, 2, and 3 who had been tested on Friday, June 26, 2020 and June 27, 2020. On 6/29/2020 at approximately 9:50 AM, a tour of the south hall was conducted. There was personal protective equipment (PPE's) in plastic bins that were observed outside of rooms for resident 2 and 3. The plastic bin outside of resident 2's room was within close proximity to resident 1's room. There were red signs posted on resident 1, 2 and 3's room doors which directed staff and visitors to check with the charge nurse prior to entering the room. On 6/29/2020 at approximately 9:55 AM, certified nurse assistant (CNA) 1 was observed while exiting resident 1's room. Resident 1's door was in the open position. CNA 1 was wearing a face shield and mask and was not observed to remove a gown or gloves. CNA 1 was holding a water mug with a lid and a washable plastic straw. CNA 1 took the water mug to the hydration cart. CNA 1 removed the lid and straw from the mug and placed them on top of the stainless steel hydration cart upside down with the straw touching the top of the cart. CNA 1 grabbed the ice scoop out of the ice chest, filled the scoop with ice then placed the ice scoop against the rim of the mug to fill the mug with ice. CNA 1 then dispensed water from the water dispenser on top of the hydration cart. CNA 1 replaced the lid and straw on the ice mug and entered resident 1's room without performing hand hygiene, donning gloves or a gown. CNA 1 exited resident 1's room, entered another resident room to retrieve another water mug. CNA 1 did not perform hand hygiene prior to entering another resident room. During the same observation, CNA 2 was observed in resident 1's room. CNA 2 was not wearing gloves or a gown. CNA 2 retrieved a clear trash bag where linen had been placed. CNA 2 exited resident 1's room and proceeded to ambulate down the hallway. Multiple other staff members were observed refilling other residents' water mugs with the now contaminated ice scoop, water dispenser and hydration cart. An interview was conducted with the registered nurse (RN) 1 on 6/29/2020 at 10:05 AM. RN 1 was assigned to care for the residents that resided on the south hallway. RN 1 was asked what infection control precautions had been implemented for resident 1. RN 1 stated resident 1 had episodes of diarrhea on 6/28/2020. RN 1 stated that resident 1 was placed on droplet precautions pending the results of a COVID-19 test. RN 1 stated that droplet precautions included donning a mask, face shield, gown and gloves. Additionally, RN 1 was asked how infection control requirements were communicated with staff. RN 1 stated that the nurse's conducted a shift report to let the CNA's know which resident's were on isolation precautions. A conference was held with the ADM, the director of nursing (DON) and the infection preventionist (IP) on 6/29/2020 at 10:09 AM to notify them of the observations and potential spread of COVID-19. The DON and IP stated that employees were to don PPE which included a mask, face shield, gloves, and a gown prior to entering a room when droplet precautions had been implemented. Immediate intervention which included inserving all staff related isolation precautions including the use of PPEs and hand hygiene. Additionally, CNA 1 and CNA 2 were sent home to change their clothing. CNA 2 did not return to the facility. The ADM further stated that all the water mugs that were in resident rooms had been removed to be washed in the dishwasher and that the hydration cart, ice chest, and water dispenser were being disinfected to prevent any potential contamination. A telephone interview was conducted with CNA 1 on 6/29/2020 at 1:48 PM. CNA 1 stated that he had been trained on the importance of social distancing and the use of PPE's. CNA 1 stated that he was not aware that resident 1 had been placed on droplet because because the door was wide open. CNA 1 stated that resident 1's door should have been closed. CNA 1 stated that water mugs from resident's on droplet precautions should not have been removed from the room to prevent cross contamination. A telephone interview was conducted with CNA 2 on 6/29/2020 at 2:00 PM. CNA 2 stated that she had been trained related to COVID-19 precautions. CNA 2 stated that a face mask, face shield, gown, gloves and shoe protectors were to be worn. CNA 2 stated that she was not aware that resident 1 had been placed on droplet precautions. CNA 2 stated that soiled linens should have been labeled as on precautions prior to being removed from resident 1's room. Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/28/2020, resident 1 complained of diarrhea. Resident 1's primary care physician was notified and an order to obtain a COVID-19 test was given. There were no orders for isolation precautions during the testing of COVID-19 nor documentation that resident 1 had been put on droplet precautions (meaning that staff and visitors were required to wear gloves, masks, face shields and gowns). The COVID-19 test was obtained on 6/28/2020. The results of the testing was not available at the time of the survey. Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] after a being hosptalized on [DATE] for a fractured humerus. A psychiatric evaluation was completed and resident 2 was diagnosed with [REDACTED]. On 6/28/2020 resident 2 complained of diarrhea. Resident 2's primary care physician was notified and an order to obtain a COVID-19 test was given. There were no orders for isolation precautions during the testing of COVID-19 nor documentation that resident 2 had been put on droplet precautions (meaning that staff and visitors were required to wear gloves, masks, face shields and gowns). The COVID-19 test was obtained on 6/28/2020. The results of the testing was not available at the time of the survey. Resident 3's medical record was reviewed. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documentation that resident 3 had diarrhea or a high temperature. Additionally, there was no documentation that resident 3's physician ordered a COVID-19 test or that the testing had been completed. The facility staff did not document that resident 3 had been placed on droplet precautions. The results of the testing was not available at the time of the survey. A review of the facility COVID-19 policy related to prevention, surveillance, education, suspected cases and new admissions was conducted. The policy had the following under SUSPECTED CASE OF COVID 19 . 4. Personal Protective Equipment should be implemented when symptoms are identified. a. For suspected cases of COVID-19, CDC (Centers for Disease Control and Prevention) is recommending wearing a gown, gloves, facemask and goggles or a face shield and N95 masks. The IP was re-interviewed on 6/20/2020 at 10:40 AM. The IP stated, I had not considered water mugs coming out of resident rooms. The IP stated that water mugs would not be refilled from the hydration cart and that the facility would implement a new procedure for refilling them. The IP stated employees would continue to be educated daily on COVID-19 precautions, the implementation of PPE and refilling water mugs.

Based on interview and record review, the facility did not ensure that 1 of 7 sample residents was free of significant medication errors. Specifically, a resident was given his roommate's medications, and was subsequently hospitalized . As of 10/27/19, the facility had identified the concern, and had implemented a Quality Assurance (QA) plan which included audits, monitoring, and preventative measures to prevent further incidences. Therefore, past non-compliance at a harm level was cited. Resident identifier: 1. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 10/28/19. A nurses' progress note on 10/20/19 at 10:56 PM documented .Resident was given [MEDICATION NAME] and [MEDICATION NAME] in error. Resident responsive to stimuli. Neuro (neurological) checks within normal limits. Another nurses' noted dated 10/21/19 at 3:32 AM documented (Resident 1) in 21-B, reports c/o (complaints of) SOB (shortness of breath) with rales and crackles. that began on 10/20/2019 2:30 AM and have gotten worse since the onset. NA (?) make the symptoms worse, while Oxygen 4L (liter) improve the symptoms. Other relevant information - Medication error at about 2000 (10:00 PM) .The relevant areas to the change in condition is: Respiratory Status Changes, Shortness of breath, Abnormal lung sounds, Labored breathing. Assessment : The current problem seems to be related to Cardiac, Respiratory, .Medication error. Recommendation: (name redacted) NP (nurse practitioner) was notified and made aware of the resident's current status. The following orders were received: hospitalization with emergency transport. A follow up nurses' note dated 10/21/19 at 7:35 AM documented REsident (sic) taken to the hospital at about 3:30 am by EMTs (emergency medical transport). Pt (patient) was stabilized on a [MEDICAL CONDITION] (bilevel positive airway pressure) breathing machine and began improving according to ER (emergency room ) nurse sho (sic) also expected his non-responsiveness will pass in the next 12 hours as the medication wears off. (Note: resident 1 was admitted to the local hospital and did not return to this facility.) A hospital progress note dated 10/21/19 at 3:25 AM, documented [AGE] year-old male brought in by EMS (emergency medical services) in severe respiratory distress. According to paramedics the patient allegedly was given his roommates medications by mistake. This happened between 7:00 p.m. and 11:00 p.m. last night. Apparently the year (sic) was recognized right away and they opted to just monitor the patient. Over the last several hours he has apparently had worsening trouble breathing and decreased mental status. Patient is apparently normally alert and talkative. He is a full code. When his breathing became worse and his oxygen saturations began to drop they contacted 911. By EMS arrival the patient was obtunded but breathing on his own. He was placed on [MEDICAL CONDITION] (continuous positive airway pressure) which he fought briefly and then tolerated. EMS states that he was not opening his eyes and was responding only to pain. Medications given in error were [MEDICATION NAME] 10 mg, [MEDICATION NAME] 200 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 100 mg. It also appears that he was given his usual evening medication including 10 mg of [MEDICATION NAME] 40 mg, and [MEDICATION NAME] 125 mg. A follow up hospital note from a re-evaluation on 10/21/19 at 4:45 AM, documented I discussed this case with poison Control. Based on the medication and amounts that patient received they estimated at least another 10-12 hours of sedation. They were not aware of any potentially useful reversal agents. Patient did have a gag reflex. He did respond to pain but not voice. Over the course of the 1st hour he stayed on [MEDICAL CONDITION] he was moaning more and becoming somewhat more responsive to pain. His ABG (arterial blood gases) done 1 hr after arrival showed PH of 7.33 with pCO2 of 46 and a PO2 of 133. His oxygen saturation remained at or above 97% on [MEDICAL CONDITION]. patient was switched to [MEDICAL CONDITION]. He tolerated this well. Patient was becoming more verbal and moving more. Vital signs remained within the normal range. The on-call respiratory tech is agreeable to staying in the hospital to monitor the patient. I will be available should his respiratory status decline. He will be admitted to our step-down ICU (intensive care unit), where he will be kept on [MEDICAL CONDITION] and monitored. A Quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] documented under section G, that resident 1 required limited assistance from 1 person for bed mobility, ambulation, and toilet use. Resident 1 was documented as needing extensive assistance of 1 person to transfer from bed, and needed set up and supervision assistance only for eating. A progress note from resident 1's new admitting facility, dated 10/23/19, documented (Resident 1's) current reason for skilled stay is lethargic and weak, confused, requires ext (extensive) assist with cares and staff to anticipate needs, requires assist with eating, nutrition and medication management. Alertness/Cognition/Orientation: responds to loud voice, able to answer simple questions appropriately, speech slurred, drowsy. The resident's functional status ability is: The resident is dependent with bed mobility; transfers did not occur; extensive assist with eating; dependent with toileting; walking did not occur; and locomotion did not occur. An addition progress note, dated 10/27/19, documented Resident in bed this morning during breakfast. He is a total feed. He doesn't attempt to do any help. Staff will attempt to get him out of bed for lunch and take him to the assist dine (sic). On 10/28/19 at 10:31 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that on 10/21/19 an agency nurse who was not familiar with the residents, was administering medications. The DON stated that the nurse went to administer resident 1's medications and got resident 1 mixed up with his roommate. The DON stated that the error was realized about 10 minutes later, the doctor was called and regular vital sign checks and monitoring was started. The DON stated that resident 1 started having a change in condition around 3:00 AM on 10/21/19, the nurse called the doctor, who ordered that the resident be sent to the ER. The DON stated that the facility had since started a 4 point process to correct medication errors. On 10/28/19 at 12:09 PM, a phone interview was conducted with resident 1's family member. The family member stated that resident 1 had not been out of bed, could not move his arms, and could not see as well since the medication error. The family member stated that prior to the medication error resident 1 was able to get up and feed himself which he could no longer do. On 10/28/19 at 1:30 PM, a phone interview was conducted with the Medical Doctor (MD) 1. MD 1 stated on 10/20/19 a nurse gave resident 1 his roommate's medications, which were mostly psychiatric medications. MD 1 stated that the combination of medications resident 1 received would definitely cause sedation and respiratory depression, especially since resident 1 did not usually take any similar medications.

Based on observation, interview and record review, it was determined, for 1 of 7 sampled residents, the facility did not ensure that pain management was provided for residents who required such services, consistent with professional standards of practice and the residents' goals and preferences. Specifically, one resident did not receive consistent and ongoing pain monitoring and prescribed pain medication while on respite care. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/28/19, resident 1 was observed in his room. Resident 1 stated that he did not receive all the medications he needed. Resident 1 stated that his pain was usually around 4 or 5 when he wasn't moving, but when he got himself out of bed, the pain was 8 or 9 out of 10. Resident 1 stated that his right shoulder was bone on bone so when he moved, he was close to screaming because of pain. Resident 1 stated that he had chronic back pain, and severe pain in his left thigh muscle. Resident 1 stated that the nurses haven't asked me about my pain. Resident 1 stated that he was taking narcotic pain medication twice a day at home, when he needed it. Resident 1 stated that the more he moved, the more pain he experienced. Resident 1 stated that he had been in severe pain dozens of times a day. Resident 1 stated that he could not call for help every time he went to the restroom because it was at least 4 to 5 times a day and he could not wait for staff. Resident 1 stated that he was in real bad pain when they talked to me a few days ago. On 10/28/19 a record review was conducted for resident 1's electronic medical record. Review of resident 1's physician orders [REDACTED]. This order was started on 10/26/19 at 11:00 AM. Review of resident 1's pain scores revealed the following: a. On 10/26/19, no pain scores were recorded for resident 1. b. On 10/27/19 at 12:49 AM, a pain score was recorded at 0/10. c. On 10/28/2019 at 1:05 PM, a pain score was recorded at 5/10. d. On 10/28/19 at 10/28/2019 1:32 PM, a pain score was recorded at 3/10. The Treatment and Monitoring for resident 1 was that nurses were to Question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident is not able to answer, use PAINAD scale. every shift. One entry for the morning of 10/27/19 recorded no pain, but non-pharmacological pain interventions were utilized, which included repositioning, reassurance/emotional support, rest period/quiet environment, and laughter/socialization. Review of the Medication Administration Record [REDACTED]. Resident 1's baseline care plan revealed that pain was not addressed. The two focuses included in resident 1's care plan were: a. activities of daily living (ADL) deficit, and b. limited physical mobility. The electronic record revealed that the required tasks for the Certified Nursing Assistants (CNAs) to complete for resident 1 included documentation that assistance required was for resident 1's Activities of Daily Living (ADLs), ranging from supervision to extensive assistance. A nursing note on 10/26/19 at 5:27 PM, revealed Resident did not bring prescription of [MEDICATION NAME] with him. Hospice notified, but they were unwilling to provide more because he is 'on hold with them'. On call provider (name withheld) not answering phone. (Note: The on-call physician was not contacted after the Hospice company stated that resident 1 was not currently receiving hospice services.) Resident 1 was followed by a hospice company, who provided documentation for resident 1's admission. The hospice company included the order for [MEDICATION NAME] 325-[MEDICATION NAME] 10 mg tablet, 1 tablet by mouth every four hours, if needed, on resident 1's orders, and included information that it was not being provided by the hospice comapny. The respite stay was expected to be for 9 days while family was out of town. The hospice company progress notes revealed that resident 1 had a prescription for [MEDICATION NAME] 325-[MEDICATION NAME] 5 mg. The prescription stated: a. On 7/8/19, the order was for 1-2 tablets every 6 hours as needed for pain. b. On 9/24/19, the order one tablet every 6 hours. (Note: This prescription was increased to twice as much [MEDICATION NAME] (10 mg versus 5 mg previously) and the frequency of medication administration decreased from 6 hours to four hours.) c. On 10/11/19, the order was for 325-10, one tablet every 4 hours. The order was completed on 10/20/19, with additional doses that were not provided by the hospice company. On 8/6/18, a hospice company progress note revealed that resident 1 had pain with active ROM (range of motion) of left thigh. Pain is also chronic for resident 1's lower back. On 10/28/19 at 12:20 PM, an interview was conducted with CNA 1. CNA 1 stated that she did not assist resident 1 since he was admitted . CNA 1 stated that she was assigned to the hall, but resident 1 did not require assistance. On 10/28/19 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that she brought resident 1 his breakfast, brought resident 1 a drink at breakfast, and refilled his water, but did not assist resident 1 to the restroom or assist him with any other cares On 10/28/19 at 12:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should have attempted more than once to obtain pain medication for resident 1. On 10/28/19 at 12:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that all residents' pain was assessed upon admission. RN 1 stated that she was aware that resident 1 had requested pain medications on 10/26/19, but resident 1's narcotic pain medication was not available. RN 1 stated that resident 1 had reported pain at 7, which was not recorded in the medical record. RN 1 stated that resident 1 had reported pain. RN 1 stated that she did not know if resident 1's pain was related to [MEDICAL CONDITION]. RN 1 stated that resident 1 had a list of current orders with pain medication but because staff didn't have a signed prescription, they could not get resident 1's pain medication. On 10/28/19 at 12:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 1 had complained of chronic back pain on the weekend. LPN 1 stated that resident 1 did not ask for help most of the time, so he was not assessed when he transferred or ambulated. On 10/28/19 at 12:27 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that she was informed that resident 1 required pain medications approximately one hour earlier. The NP stated that the office had been contacted over the weekend, on 10/26/19, due to resident 1's pain. The NP reported that facility staff did not report significant pain for resident 1. The NP stated that pain medication was not provided, but a prescription could have been faxed for narcotic medication if a report of serious pain had been conveyed by staff. The NP stated that weekend on-call providers did not visit residents at facilities.

Based on observation, interview and record review it was determined, for 5 of 5 sample residents, that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail and enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, nursing staff had telephone orders signed by the physician that were available to fill in for scheduled 2 medications. In addition, residents narcotic record log did not match the Medication Administration Records (MAR) for narcotic administration. Resident identifiers: 1, 2, 3, 4 and 5. Findings include: 1. On 4/30/19 at 1:00 PM, an observation was made with Registered Nurse (RN) 1 of her medication cart narcotic drawer. There were 5 telephone orders that were signed by the MD with his Drug Enforcement Administration (DEA) number written on them. The telephone orders did not have a date, resident name, medication or dosing instructions. The telephone orders were stamped with V.O.R.B. (verbal order read back). 2. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 5/1/19. Resident 2's physicians orders revealed the following: a. On 3/7/19, [MEDICATION NAME] immediate 5mg (milligrams) tablet (1) tab (tablet) po (oral) Q (every) 4h (hours) prn (as needed) pain (times) 30. The telephone order had Licensed Practical Nurse (LPN) 1's signature. There was a stamp V.O.R.B. with the Medical Director's (MD) signature and the MD's DEA number. b. On 3/18/19, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab. Give 1 tab po Q4 hours prn pain. The telephone order had to dispense 60 tablets with no refills. The telephone order had a nurses signature with V.O.R.B stamped above it and the physicians signature with the DEA number. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] immediate 5 mg every 4 hours as needed revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/6/19 at 12:30 AM, 3/7/19 at 8:00 PM, 3/8/19 at 5:00 AM and 3/12/19 at 6:30 AM. It should be noted that 4 doses were signed out on the narcotic record log and were not signed out as administered on the MAR. The (MONTH) 2019 MAR revealed on 3/9/19 at 1:25 AM that [MEDICATION NAME] was administered but the narcotic record log did not have the medication signed out. In addition, the MAR revealed that [MEDICATION NAME] 5 mg was administered on 3/27 at 4:27 PM and 3/31/19 at 5:59 PM. There was no corresponding narcotic record log available for the 2 doses. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] table 5-325 mg every 4 hours as need revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/14/19 at 10:30 PM, 3/15/19 at 2:30 AM, 3/20/19 at 6:00 AM, 3/20/19 at 9:00 AM, 3/22/19 at 6:00 AM, 3/23/19 at 11:00 PM, 3/25/19 at 6:00 AM, 3/26/19 at 3:00 PM, 3/26/19 at 7:00 PM, 3/27/19 at 4:50 PM, 3/28/19 at 3:00 AM, 3/31/19 at 6:00 PM, 3/31/19 at 10:00 PM, 4/3/19 at 5:00 AM, 4/4/19 at 2:40 AM, 4/4/19 at 9:30 PM, 4/5/19 at 5:00 PM, and 4/5/19 at 7:30 AM. It should be noted that 17 doses were signed out on the narcotic record log and were not signed out as administered on the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] tablet 5-325 mg every 4 hours as needed revealed the following: a. On 3/30/19, the MAR revealed that the [MEDICATION NAME] was administered three times that day at 1:59 AM, at 1:38 PM and at 6:37 PM. The narcotic record revealed [MEDICATION NAME] was pulled medication supply and administered at 12:30 AM, no time was documented, at 1:30 PM and at 6:30 PM. b. On 4/5/19, the MAR revealed that the [MEDICATION NAME] was signed as administered three times that day at 8:40 AM, at 1:55 PM, and at 7:44 PM. The narcotic record revealed [MEDICATION NAME] was pulled at 5:00 AM, at 7:30 AM, at 1:40 PM and at 7:45 PM. On 5/1/19 at 3:15 PM, an interview was conducted with LPN 1. LPN 1 stated that the Medical Director (MD) provided signed telephone order with his DEA number that were not filled in with the resident name, medication or dosing instructions. LPN 1 stated that the telephone order dated 3/7/19 for [MEDICATION NAME] had been signed by the MD prior to 3/7/19. LPN 1 stated that she filled in the order section on 3/7/19 and sent the telephone order to the pharmacy. LPN 1 stated that she called the MD to obtain a verbal order for the medication. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 5/1/19. Resident 4's telephone orders revealed the following: a. On 1/25/19 at 4:35 PM, a verbal order for [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG give 1 tablet by mouth every 4 hours as needed for pain related to Generalized abdominal pain. The physician signed the order on 1/30/19 at 5:06 PM. There was no script in the medical record. The order was discontinued on 3/4/19. b. On 2/15/19, [MEDICATION NAME] 10/325 1 tab po Q4H PRN. The order was to dispense 120 with no refills. The MD signed with the DEA number on the telephone order. There was no nurses signature. V.O.R.B was stamped on the telephone order. c. On 3/22/19, [MEDICATION NAME] tablet 10-325 MG. Give 1 tablet Q 4 hours prn, NTE (not to exceed) 300 mg in 24 hr. Give 1 tablet po q 4 hours. NTE 3000mg in 24 hours. The order was to dispense 120 tablets with 3 refills. The telephone order had the MD signature and his DEA number. RN 1's signature with V.O.R.B was on the telephone order. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed that the medication was documented as signed out on the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 2/23/19 at 7:25 AM, 3/9/19 at 10:30 AM, 4/7/19 at 12:00 PM, 4/11/19 at 9:00 PM, 4/12/19 at 9:00 PM, 4/14/19 at 1:20 PM, 4/15/19 at 9:55 PM, 4/18/19 at 9:00 PM, 4/26/19 at 6:45 PM and 4/28/19 at 9:00 PM. It should be noted that 10 doses were documented as administered in the narcotic log but not documented as administered in the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed the following: a. On 2/4/19 at 12:10 PM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 was administered and there was no record of the medication being administered according to the narcotic record log. b. On 2/22/19 at 11:33 AM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered and there was no record of the medication being administered according to the narcotic record log. c. On 3/21/19 at 6:00 AM, the MAR revealed that the nurse did not sign in the MAR that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered. The narcotic record log revealed that on 3/20/19 at 5:30 AM and 3/20/19 at 6:00 AM the medication was administered. d. 3/29/19 at 6:00 AM, the MAR revealed that the nurse did not sign that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg as being administered. The narcotic record log revealed that on 3/29/19 at 6:00 AM the [MEDICATION NAME] was administered. On 5/1/19 at 3:00 PM, an interview was conducted with LPN 2. LPN 2 stated that the MD provided the nurses signed telephone orders that did not have the residents name, medication or dispensing instruction. LPN 2 stated that she called the MD prior to filling in name, medication and dispensing instruction on the telephone orders. LPN 2 stated that she did not sign the telephone orders. LPN 2 confirmed that she wrote the telephone order on 2/15/19 for the [MEDICATION NAME] 10/325. LPN 2 stated that on 2/15/19 she used a telephone order that the MD had signed and not filled in. 4. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/1/19 resident 5's medical records were reviewed. Review of resident 5's physician orders [REDACTED]. a. On 10/3/18, a telephone order for [MEDICATION NAME] Extended Release (ER) 10 milligrams by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. b. On 10/14/18, a telephone order for [MEDICATION NAME] (HCL) with Tylenol (APAP) 10/325 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. c. On 10/25/18, an order for [REDACTED]. The amount of medication ordered dispensed was 60 tablets. d. On 11/11/18, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. e. On 12/3/18, a telephone order for [MEDICATION NAME] HCL ER 10 mg 1 tablet by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. f. On 1/29/19, a telephone order for [MEDICATION NAME] 10/325 mg 1 tablet by mouth every 6 hours as needed was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. g. On 3/7/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. h. On 4/17/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by Registered Nurse (RN) 1. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL APAP 10/325 mg every 6 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 8/29/18 at 9:00 PM, 9/7/18 at 1:00 AM, 9/12/18 at 4:00 AM, 9/13/18 at 2:00 AM, 10/3/18 at 2:00 AM, 10/12/18 at 1:00 AM, 11/13/18 (day not documented clearly but located between 11/9/18 and 11/22/18) at 1:00 AM, 11/26/18 at 9:50 AM, 11/28/18 at 10:00 AM, 11/29/18 at 4:00 PM, 12/1/18 at 10:10 AM, 12/2/18 at 10:30 AM, 12/18/18 at 5:00 AM, 12/29/18 at 11:59 PM, 1/22/19 at 7:00 AM, 2/1/19 at 5:00 AM, 2/15/19 at 3:00 AM, 2/15/19 at 11:30 PM, 2/17/19 at 1:20 AM, 3/16/19 at 6:00 AM, 3/21/19 at 11:00 PM, 3/31/19 at 3:00 PM, 4/12/19 at 6:20 AM, 4/20/19 at 12:45 AM, 4/25/19 at 1:00 AM, 4/25/19 at 11:30 PM, and 4/30/19 at 11:00 PM. It should be noted that 27 doses were documented as administered in the narcotic record log but not documented as administered in the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Reformulated 10 mg tablet ER by mouth twice daily revealed the following: a. On 11/8/18 at 10:00 AM, the medication was documented as refused and wasted. The narcotic log contained only one nurse signature for the wasted medication. b. The medication was documented as signed out on the narcotic record log on 2/2/19 at 9:30 PM and then again at 9:45 PM. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. c. The medication was documented as signed out in the narcotic log on 2/9/19 at 11:30 PM twice. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. d. On 4/13/19 at 19-23 (7:00 PM to 11:00 PM), there was a code documented which was to HOLD the medication and see progress notes. Review of the progress notes revealed no documentation for this medication. The medication was documented as signed out in the narcotic log and was deducted from the medication count. On 5/1/19 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 5 often refused her pain medications. The DON stated that if the resident refused the medication that the nursing staff should be documenting that in a progress note. The DON further stated that if the medication was pulled prior to the resident refusing then the nursing staff should be wasting the medication. The DON stated that the narcotic log should have two licensed nursing staff signatures when a narcotic was wasted. The DON stated that the documentation in the Narcotic Record log and the MAR should match. On 5/1/19 at 3:40 PM, an interview was conducted with LPN 3. LPN 3 stated that the pharmacy delivered two times a day except for Sunday afternoon. LPN 3 stated that narcotics were delivered in a different colored bag. LPN 3 stated that if a resident ran out of a narcotic pain medication that the nursing staff could write the prescription with the signed script provided by the MD. LPN 3 stated that nursing staff then call the MD to inform him of the new order. LPN 3 stated that she did not document that she called and notified the MD of the narcotic order that was written. LPN 3 stated that the nursing staff filled out paperwork because they were agents' of the MD. LPN 3 stated that an agent meant that they could write prescriptions on behalf of the MD. LPN 3 stated that as an agent the staff could only write for a refill of an existing order or a verbal order to write a new prescription. LPN 3 stated that the MD had provided the facility nursing staff with pre-signed blank telephone orders, and that she had used these to write prescriptions for narcotic pain medications in the past. LPN 3 stated that she was not aware any exclusions for being an agent and writing medication orders. LPN 3 again stated that she could write a prescription for narcotic pain medications. LPN 3 stated she could write for Scheduled II narcotics. LPN 3 stated that [MEDICATION NAME] was a Scheduled II and that Oxy was a Scheduled III and she could write a prescription for both of them. LPN 3 stated that she had written prescriptions for [MEDICATION NAME] and [MEDICATION NAME] as an agent for the MD. LPN 3 stated she had never written a prescription for [MEDICATION NAME] or [MEDICATION NAME]. LPN 3 stated that she had reconciled the narcotic log in the past. LPN 3 stated she looked at the narcotic sheets for anything strange. LPN 3 stated she looked at the dosage and checked if there were any missing doses. LPN 3 stated she would look at nursing notes or the MAR to see why a medication was not administered. LPN 3 stated I look for anything that is out of the norm. LPN 3 stated that whoever reconciled the narcotic log would sign in the DON spot located at the bottom of the sheet. LPN 3 stated that the narcotic logs were reviewed monthly at the end of the month for any discrepancies. LPN 3 stated that she had never reconciled the narcotic record log together with the MAR. On 5/1/19 at 4:01 PM, a follow-up interview was conducted with the DON. The DON stated that when she reconciled the narcotic logs she looked for the correct count and that the dose documented as given matched up. That the count is accurate. The DON stated that she did not compare the narcotic record log to the MAR. The DON stated they were not capturing or identifying discrepancies between the MAR and narcotic record log. The DON was asked how she identified or monitored to ensure that nursing staff were not diverting narcotics. The DON stated she made sure all the medication cards match, but not from MAR to narcotic sheet. 5. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was admitted to hospice on 1/3/19 for end of life cares, and passed away on 1/12/19. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that when a resident was on hospice, all of the resident's medications were provided by the hospice company. LPN 1 stated that the facility created a narcotic record log to track all hospice provided narcotics. On 4/30/19 resident 1's medical records were reviewed. Review of resident 1's physician orders [REDACTED]. a. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml (milliliters) 1ml by mouth every hour as needed for pain/shortness of breath. b. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.25ml by mouth every hour as needed for pain/shortness of breath. c. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.5ml by mouth every hour as needed for pain/shortness of breath. d. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.75ml by mouth every hour as needed for pain/shortness of breath. e. On 1/8/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 20mg/ml 0.5ml by mouth every six hours for pain/terminal restlessness. f. On 1/3/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.5ml by mouth every two hours as needed for anxiety/restlessness. g. On 1/3/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.75ml by mouth every two hours as needed for anxiety/restlessness. h. On 1/8/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml 0.5ml by mouth every six hours for terminal restlessness. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed that the medication was documented as signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 1/6/19 at 2:00 PM, 1/8/19 at 10:00 AM, 1/10/19 at 8:00 PM, 1/10/19 at 10:00 PM, 1/11/19 at 2:00 AM, and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed on 1/8/19 at 6:00 PM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed that the medication was documented as signed out of the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates: 1/3/19 at 7:30 PM and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed on 1/12/19 at 6:00 AM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. It should be noted that during resident 1's nine day stay at the facility: a. Six doses of [MEDICATION NAME] were signed out in the narcotic log but were not documented as administered on the MAR. b. One dose of [MEDICATION NAME] was documented as administered in the MAR but not signed out of the narcotic log. c. Two doses of [MEDICATION NAME] Concentrate were signed out in the narcotic log but were not documented as administered on the MAR. d. One dose of [MEDICATION NAME] Concentrate was documented as administered in the MAR but not signed out on the narcotic record log. 6. Resident 3 was admitted to the facility 9/29/17, discharged on [DATE] for pacemaker replacement and returned on 1/12/19, with [DIAGNOSES REDACTED]. On 4/30/19 resident 3's medical record was reviewed. Resident 3's active physician's orders [REDACTED].> a. On 7/27/18, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours for pain. This order was discontinued 2/1/19. b. On 2/1/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 10-325 mg, give 1 tablet by mouth every 6 hours for pain. c. On 1/3/18, an order was entered into the electronic medication order system for [MEDICATION NAME] HCL Tablet 50 mg, give 1 tablet by mouth every 4 hours as needed for pain. Resident 5's signed physician orders [REDACTED]. a. On 9/8/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 1 and contained a V.O.R.B. (verbal order read back) stamp. b. On 9/23/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. c. On 10/7/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 180 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. d. On 11/8/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 4 and contained a V.O.R.B. stamp. e. On 11/24/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. f. On 1/7/19, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 2 and contained a V.O.R.B. stamp. g. On 12/22/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. h. On 12/31/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. i. On 1/25/19, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 5 and contained a V.O.R.B. stamp. j. On 2/1/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. k. On 2/28/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. l. On 4/1/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. m. On 9/29/18, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 90 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. n. On 11/23/18, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 180 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. o. On 1/25/19, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. p. On 4/27/19, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by LPN 5 and contained a V.O.R.B. stamp. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 7.5-325 mg every 6 hours revealed that on 1/6/19 at 6:00 AM, the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log for the following dates: 2/26/19 at 6:00 PM, 3/6/19 at 12:00 PM, and 3/10/19 at 6:00 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as signed out of the narcotic log, but was then documented on the MAR as not being administered on the following dates: 3/21/19 at 6:00 AM and 3/29/18 at 6:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 9/6/18 at 8:30 PM, 10/4/18 at 9:00 AM, 10/10/18 at 8:00 PM, 10/11/18 at 8:00 PM, 10/16/18 at 8:00 PM, 10/23/18 at 8:00 PM, 10/25/18 at 3:00 AM, 10/25/18 at 9:00 PM, 10/28/18 at 9:30 AM, 11/5/18 at 10:50 AM, 11/7/18 at 8:00 PM, 11/8/18 at 9:00 PM, 11/9/18 at 9:00 PM, 11/14/18 at 8:00 PM, 11/15/18 at 3:00 PM, 11/15/18 at 9:00 PM, 11/19/18 at 3:00 PM, 11/20/18 at 9:00 PM, 11/21/18 at 9:00 PM, 11/28/18 at 9:00 PM, 11/30/18 at 4:00 PM, 12/4/18 at 9:00 PM, 12/5/18 at 9:00 PM, 12/7/18 at 9:00 PM, 12/12/18 at 9:00 PM, 12/13/18 at 9:00 PM, 12/18/18 at 9:20 PM, 12/19/18 at 3:00 AM, 12/19/18 at 8:00 PM, 12/29/18 at 9:50 AM, 1/13/19 at 4:35 PM, 1/15/19 at 9:00 PM, 1/16/19 at 9:00 PM, 1/17/19 at 10:00 PM, 1/23/19 at 9:00 PM, 1/24/19 at 2:30 PM, 1/29/19 at 9:00 PM, 1/30/19 at 8:30 PM, 2/4/19 at 8:55 PM, 2/5/19 at 9:00 PM, 2/7/19 at 10:15 AM, 2/9/19 at 1:45 PM, 2/10/19 at 10:00 AM, 2/12/19 at 8:30 PM, 2/19/19 at 9:00 PM, 2/20/19 at 8:00 PM, 2/21/19 at 10:00 AM, 2/21/19 at 2:00 PM, 2/21/19 at 9:00 PM, 3/1/19 at 1:45 PM, 3/5/19 at 3:15 PM, 3/20/19 at 2:30 PM, 3/21/19 at 9:00 PM, 3/26/19 at 4:00 PM, 3/28/19 at 7:45 PM, 4/2/19 at 10:30 AM, 4/2/19 at 8:30 PM, 4/10/19 at 9:00 PM, 4/11/19 at 9:00 PM, 4/15/19 at 9:15 PM, 4/17/18 at 9:00 PM, 4/18/19 at 9:00 PM, 4/23/19 at 8:00 PM, and 4/29/19 at 8:15 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log for the following dates: 12/20/18 at 8:30 PM, 12/25/18 at 2:04 AM, 12/30/18 at 9:50 AM, and 2/8/19 at 1:46 PM. It should be noted that from (MONTH) (YEAR) through (MONTH) 2019, resident 3 had: a. One dose of [MEDICATION NAME] 7.5-325 mg was documented as administered on the MAR but was not documented as signed out on the narcotic log. b. Three doses of [MEDICATION NAME] 10-325 mg were documented as administered on the MAR but were not documented as signed out on the narcotic log. c. Two doses of [MEDICATION NAME] 10-325 mg were documented as signed out of the narcotic log, but were then documented on the MAR as not being administered. d. Fifty-two doses of [MEDICATION NAME] were documented as administered in the narcotic log but not documented as administered on the MAR. e. Four doses of [MEDICATION NAME] were documented as administered on the MAR but were not documented as administered in the narcotic log. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that if a resident asked for narcotic pain medication, the nurse signed the narcotic record log and document on the MAR that the medication was administered. LPN 1 stated that if the resident did not have an order for [REDACTED]. LPN 1 stated that the facility MD had all of the nurses listed as agents which meant that the nurses were able to write scripts for the facility MD. LPN 1 stated that the MD kept a stack of blank signed scripts at the facility, and that those were kept in the medication cart's narcotic drawers to be filled out as needed. LPN 1 stated that after she filled out the script she would then fax it to the pharmacy. LPN 1 stated that the pharmacy only delivered medications once or twice a day, so after faxing the script LPN 1 would then call the pharmacy for the combination code to the lock, to access the emergency kit in order to administer the narcotic to the resident as quickly as possible. LPN 1 stated that that the pharmacy would only give the combination code to the nurse after receiving the fax with the signed script. LPN 1 reported that narcotic medications in the nurses carts were counted at the beginning and end of each shift with the on-coming and off-going nurses to ensure all narcotics were correctly signed out of the Narcotic Log. On 4/30/19 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facilities process to obtain narcotics was to have the MD write a script and send it to the pharmacy for narcotics. The DON stated that if there were no refills for the narcotic medications then the MD would have to fill out another script and fax it to the pharmacy. On 4/30/19 at 3:29 PM, a follow up interview was conducted with the DON. The DON stated that the process for administering narcotics to a resident was that a resident needed to request a prn medication and then the nurse was to check the MAR for the order and the time it was last administered. The DON stated that the nurse was to sign on the MAR and the narcotic record log when a narcotic was administered. The DON stated that the narcotic record and the MAR were to match. The DON stated that the facility did not have a reconciliation process for narcotics. The DON stated that the nurses completed a count at every shift change. The DON stated that the Count was when both nurses compared the narcotic record sheet and the actual number of pills in the narcotic drawer. The DON stated that there was no process for reconciling the narcotics, the narcotic record log and the MAR. The DON stated that the MD had given approval for all the nurses to be Agents. The DON stated that an agent was able to fill in a signed script for narcotics with the MD's verbal permission. The DON stated that nurses were able to fill in the presigned scripts for scheduled 2 medications. The DON provided a copy of the agent contract. A form titled Designating Agent of Practitioner For Communicating Controlled Substance Pres

Based on interview and record review, it was determined that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose, excessive duration, without adequate monitoring, or without adequate indication for its use. Specifically, 2 residents did not have adequate monitoring of PT/INR ([MEDICATION NAME] ratio/international normalized ratio) laboratory values. One resident was administered 2 additional doses of [MEDICATION NAME] after the INR was high. The findings for resident 15 were cited at a HARM level. Resident 143 was cited at a potential for harm. Resident identifiers: 15 and 143. Findings include: HARM 1. Resident 15 was admitted on [DATE], discharged on [DATE], readmitted on [DATE] and discharged on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On 6/21/18, resident 15's medical record was reviewed. A care plan dated 3/13/18 and revised on 4/17/18 revealed a Focus of (Resident 15) has an alteration in hematological status. She is at risk for [MEDICAL CONDITION] related to epistaxis (nose bleed). (Resident 15) is also at risk for prolonged bleeding related to anticoagulant medication. Recent transfusion and alterations in labs. The goal developed was, (Resident 15) will remain free of complications related to altered hematological status through the review date. Some of the interventions developed revealed, Monitor/document/report PRN (as needed) following s/sx (signs and symptoms) of [MEDICAL CONDITION]:.low hgb/hct (hemoglobin/hematocrit). and Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Resident 15's History and Physical dated 5/16/18 revealed, CC (chief complaint)/Reason for admission: [MEDICAL CONDITION], hypovolemia. The laboratory values documented were hgb was 8.2 g/dL (grams per deciliter) which was low. The Hct was 27.4% which was low. (Note: There were no reference ranges documented on the History and Physical.) The Assessment and Plan revealed [MEDICAL CONDITION]: Hgb 8.2 on admission, stable from discharge and records from SNF (Skilled Nursing Facility). Resident 15's physician's orders [REDACTED]. a. 6/3/18, [MEDICATION NAME] Sodium Tablet Give 2.5 mg (milligrams) by mouth one time a day every Sun (Sunday), Tue (Tuesday) related to unspecified [MEDICAL CONDITION]. b. 6/2/18, [MEDICATION NAME] Sodium Tablet Give 5 mg by mouth one time a day every Mon (Monday), Wed (Wednesday), Thu (Thursday), Fri (Friday), Sat (Saturday) related to unspecified [MEDICAL CONDITION]. Nursing progress notes revealed the following: a. 6/1/18 at 8:05 PM, Pt (patient) readmitted to (name of nursing facility) from (name of hospital) following weight gain r/t (related to) [MEDICAL CONDITIONS] and [MEDICAL CONDITION].Pt has a bruise to her mid back, and some small bruises to bilateral arms. b. 6/4/18 at 4:08 PM, New order to draw PT/INR ([MEDICATION NAME] time/international normalized ratio) tomorrow r/t [MEDICATION NAME] use. c. 6/6/18 at 6:12 PM, Lab (Laboratory) results from 6/5: PT patient (sic) 42.8 (H) (high), INR 4.4 (H). Results faxed to MD (Medical Doctor) and left message with MD. Response pending. d. 6/7/18 at 1:24 PM, .Pt has had a bloody nose today likely r/t elevated INR. MD called again today about her INR level, with new orders to hold the [MEDICATION NAME] for 2 days and recheck PT/INR on 6/9/18. e. 6/7/18 at 3:06 PM, Pt's nose has continued bleeding despite clamp. MD called. Pt sent to hospital for cauterization or balloon placement. f. 6/7/18 at 5:28 PM, (Local Hospital) just called and stated pt's Hematocrit was low enough that she needed a blood transfusion, so they were sending her to (another hospital) for a blood transfusion, and also so she can get [MEDICAL TREATMENT] in the morning. MD notified. Resident 15's laboratory values completed on 6/5/18 at 6:23 PM were reviewed. Resident 15's PT was 42.8 seconds with a reference range of 8.8-11.5 seconds. Resident 15's INR was 4.4 with a reference range of 1.5-3.5. There was a written note signed by a nurse on the form that revealed, Faxed, noted (and) left message with MD 6/6/18 at 1810 (6:10 PM). An additional written note signed by a nurse with no date revealed, Hold [MEDICATION NAME] re(check) PT/INR (on) 6/9/18. Resident 15's (MONTH) (YEAR) Medication Administration Record [REDACTED]. (Note: Resident 15 had a PT/INR obtained on 6/5/18. The results were high and resident 15 was administered [MEDICATION NAME] on 6/5/18 and 6/6/18.) Resident 15's History and Physical from the hospital dated 6/7/18 revealed a chief complaint of low blood counts and need for [MEDICAL TREATMENT]. The History and Physical further revealed that .She presented to (local hospital) with a chief complaint of epistaxis. Which apparently has been happening now for the past 3-4 days. This apparently was successfully cauterized. Her INR is noted (sic) be approximately 7.8. For [DIAGNOSES REDACTED]. The History and Physical from the local hospital further revealed that resident 15's hgb was 6.0 g/dL which was a panic low with a reference range of 12.1 - 15.2 g/dL. Resident 15's Hct was 19.6 % which was a panic low with a reference range of 36.0 to 15.2%. Resident 15's PT was 72 seconds with a reference range of 9-12 seconds. Resident 15's INR was 7.7 which was a panic high with a reference range of .9-1.2. The Diagnosis, Assessment & Plan revealed 1. Acute blood loss [MEDICAL CONDITION] -will be tranfuse (sic) 1 unit PRBCs (packed red blood cells) now - will hold off on the 2nd unit PRBCs unless necessary. She will definitely need a 2nd unit of blood. But this can be given during [MEDICAL TREATMENT]. In addition, 5. Coagulopathy - INR currently is 7.7 - Will give vitamin K mg p.o (orally) (times) 1. (Note: Resident 15 was readmitted from the hospital on [DATE] with a hgb of 8.2 g/dL which was low and Hct was 27.4% which was low. Upon readmission to the hospital on [DATE] resident 15's Hgb was 6.0 g/dL panic low and Hct was 19.6% panic low. Resident was readmitted to the hospital and received PRBCs for the blood loss and Vitamin K for the high INR.) On 6/20/18 at 8:00 AM, the Director of Nursing (DON) was interviewed. The DON stated that the nursing staff obtained a physician's orders [REDACTED]. The DON stated that nursing staff obtained the blood sample in the early afternoon. The DON stated that [MEDICATION NAME] was administered during Flex hours in the evening with was between 3:00 PM and 7:00 PM. The DON stated that the [MEDICATION NAME] was administered as ordered until the laboratory results were returned and the physician provided new orders. On 6/20/18 at 10:55 AM, a follow up interview was conducted with the DON. The DON stated that she wanted to provide a Homelike environment for residents, so [MEDICATION NAME] was to be administered as ordered until the laboratory results were returned. The DON stated that PT/INR results may not be provided to the facility until the day after the blood sample was obtained. The DON stated that [MEDICATION NAME] was to be administered until the physician provided new orders. On 6/20/18 at 2:35 PM, a follow up interview was conducted with the DON. The DON stated that resident 15 did not have a reference range for the PT/INRs. The DON stated that she did not know why resident 15 received an additional 2 doses of [MEDICATION NAME] after the laboratory results revealed her PT/INR were high. The DON stated there was not a policy and procedure for [MEDICATION NAME] and PT/INR monitoring. On 6/20/18 at 9:18 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that nursing staff obtained blood samples prior to 2:00 PM and the local hospital laboratory picked up the samples around 2:00 PM. [MEDICATION NAME] doses were administered after dinner so the PT/INR results were returned prior to administering the evening dose of [MEDICATION NAME]. POTENTIAL FOR HARM 2. Resident 143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 143's medical record was reviewed on 6/21/18. Resident 143's Home Discharge - Physician Med (medication) Order dated 9/15/17 revealed to hold [MEDICATION NAME] 5 mg at night. The orders further revealed, INR in AM - on [MEDICATION NAME]. INR on 9/15 was 5.4. [MEDICATION NAME] on hold. In addition, the physician [MEDICATION NAME]([MEDICATION NAME]) 250 mg (1 tablet) po BID (twice daily) for 5 days. There were no INRs in resident 143's medical record for 9/16/17. The facility nursing staff filled out a physician referral form dated 9/19/17. The form revealed that a facility nurse documented, Resident Nurse Observations/Patient Complaints: very, very confused, confusion over hospital orders, need PT/INR drawn today! [MEDICATION NAME]? The Physician documented, [MEDICATION NAME] 2.5 mg M (Monday) W (Wednesday) F (Friday) (and) 5 mg other days. Recheck [MEDICATION NAME] on (sic) wk (week). The form further revealed, INR (equals) 1.4. Resident 143 had a physician's orders [REDACTED]. (Note: Resident 143 completed [MEDICATION NAME] ordered on [DATE]. Resident 143 was ordered a different antibiotic on 10/2/17.) The Nursing (YEAR) Drug Handbook stated that [MEDICATION NAME] and [MEDICATION NAME] medications both have a drug interaction warning with [MEDICATION NAME]. The warning revealed, (MONTH) increase anticoagulant effect. Monitor patient carefully for bleeding. Reduce anti coagulant dosage as directed. (YEAR) Wolters Kluwer. Nursing (YEAR) Drug Handbook. Philadelphia. page 1494. Resident 143's nurses notes revealed the following entries: a. 10/5/17 at 5:27 PM, Pt is alert and oriented x 2 today with confusion. Remains on ABX (antibiotic) for UTI without adverse reactions. HRR (heart rate reserve) lung sounds CTA (clear to auscultation) and bowel sounds active (times) 4.New orders.check PT/INR, CBC and CMP (comprehensive metabolic panel) today instead of tomorrow and abdominal ultrasound on 10/6/17 noted. Blood specimen collected from right hand and sent to lab for analysis. Resting quietly in bed at this time without s/sx (sign or symptoms) of pain or distress. Will continue to monitor. b. 10/5/17 at 11:59 PM, .Received a phone call from (local hospital) lab to (sic) critical results. INR 8.8, NA + (sodium) 120, K+ (potassium) 6.9. (Physician) on call for (Resident 143's physician) gave order to transport to hospital for evaluation and treatment. Daughter notified et (and) agreed with transport.(Local hospital) notified. Resident 143's laboratory results revealed the following: a. 9/27/17, PT was 20 which was high and INR was 2.0. b. 10/5/17 at 4:00 PM, the blood sample was collected. The laboratory received the blood sample at 10:30 PM. PT was 100.4 high and INR was 8.8 PH. The results were called to the facility nurse at 10:57 PM. (Note: According to the laboratory results form the reference range for PT was 8.8-11.5 seconds and the reference range for INR was 1.5-3.5.) A review of resident 143's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the resident 143's Emergency Provider Report dated 10/5/17 at 11:57 PM revealed, .Sodium 119 PL (panic low), Plasma Potassium 6.9 PH (panic high).INR (1.5 - 3.5) 10.5 PH. I discussed the case with the hospitalist (name of physician removed) and he accepted the patient for admission. Primary Impression: Altered mental status. Secondary Impressions: Coagulopathy, Dehydration, [MEDICAL CONDITIONS]. On 6/20/18 at 9:30 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that PT/INR laboratory draws were completed Monday through Friday and sent to the local hospital laboratory. LPN 1 stated that after a blood sample was obtained she tried to call the laboratory prior to administering [MEDICATION NAME] to obtain the PT/INR results. LPN 1 stated that after receiving the results she notified the physician and the physician provided new orders. LPN 1 stated that she called physicians multiple times with laboratory results. LPN 1 stated that if the physician did not respond timely then she called the facility Medical Director. LPN 1 stated that she was the nurse for resident 143 on 10/5/17. LPN 1 stated that she did not remember why she contacted the physician to obtained an order for [REDACTED]. LPN 1 stated that she did not administer the [MEDICATION NAME] the evening on 10/5/17. LPN 1 stated that the night nurse administered the [MEDICATION NAME]. On 6/20/18 at 2:35 PM, the Clinical Resource Nurse (CRN) was interviewed. The CRN stated that [MEDICATION NAME] was to be administered as normal until the results were returned and the physician provided new orders. The CRN stated that if a resident was on antibiotic, then she would have increased monitoring of sign and symptoms of bleeding.

Based on observation, interview, and record review it was determined for 2 of 31 sampled residents that the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a hospice resident reported that her pain medication was ineffective and her hourly pain medication was not being administered; and a vulnerable resident was observed to be in pain without any observed relief provided. The deficient practices identified was found to have occurred at a harm level. Resident identifiers 23 and 38. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 8:16 AM, resident 23 was interviewed. Resident 23 stated her pain was located in the head, neck, and back and was currently a 8/10 (On a numeric pain scale of 0 to 10. With 0 meaning no pain and 10 the worst pain.). Resident 23 stated that [MEDICATION NAME] was recently started for her pain and that the pain was not controlled with medication. On 6/18/18 at 9:00 AM, an observation was made of resident 23 ambulating to the smoking patio for the scheduled smoke time. On 6/18/18, resident 23's electronic medical records were reviewed. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] (Concentrate) Solution 20 MG (milligrams)/ML (milliliter), Give 1 ml (milliliter)by mouth three times a day for pain. The order was initiated on 6/15/2018. b. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 0.5 ml by mouth every 1 hours as needed for pain, SOB (shortness of breath). The order was initiated on 5/4/2018. c. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 1 ml by mouth every 1 hours as needed for pain, SOB. The order was initiated on 5/4/2018. d. [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 15 MG, Give 1 tablet by mouth every 4 hours as needed for pain. The order was initiated on 5/13/2018. e. [MEDICATION NAME] Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for General Discomfort related to PAIN The order initiated was on 12/21/2017. f. [MEDICATION NAME] Tablet, Give 800 mg by mouth every 8 hours as needed for Pain related to PAIN The order was initiated on 12/27/2017. g. [MEDICATION NAME] Patch 72 Hour 75 MCG (microgram) /HR (hour), Apply 1 patch [MEDICATION NAME] every 72 hours for Pain - Moderate related to PAIN The order was initiated on 5/2/2018. h. [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for pain. The order was initiated on 5/4/18 and discontinued on 5/13/18. i. Admit onto Hospice Care with (name of hospice company) for [DIAGNOSES REDACTED]. The order was initiated on 5/1/18. Review of the Medication Administration Record [REDACTED] a. No doses of [MEDICATION NAME] or [MEDICATION NAME] 0.5 ml were administered. b. The [MEDICATION NAME] 1 ml every hour was administered ten times until 6/20/18, and 6 of those administrations had a pre-administration pain score of greater than 4 out of 10. c. On 6/19/18, two doses of [MEDICATION NAME] 1 ml were administered at 1:26 PM and 6:29 PM. The pre-administration pain score at 1:26 PM was documented as a 2 by Licensed Practical Nurse (LPN) 3. The pre-administration pain score at 6:29 PM was documented as a 3 by LPN 3. d. On 6/20/18 at 1:50 PM, the patient reported a pre-[MEDICATION NAME] administration pain score of 10/10, and the documentation indicated that it was ineffective. e. The [MEDICATION NAME] was administered 84 times and 68 of those administrations had a pre-administration pain score of greater than 4 out of 10. Review of the MAR for (MONTH) (YEAR) revealed the following: a. [MEDICATION NAME] was administered 3 times on 5/11/18 with a pre-administration pain score of 6/10, on 5/12/18 with a pre-administration pain score of 6/10, and on 5/15/18 with a pre-administration pain score of 4/10. The medication administration on 5/12/18 was documented as ineffective. b. No doses of [MEDICATION NAME] were administered. c. The [MEDICATION NAME] 1 ml every hour was administered 14 times and 11 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/15/18 and 5/24/18, the post pain administration was documented as ineffective. d. [MEDICATION NAME] was administered 71 times and 62 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/2/18 at 8:24 AM, 5/26/18 at 2:15 PM, and 5/29/18 at 6:44 PM the post pain administration was documented as ineffective. e. [MEDICATION NAME] was administered 28 times and 22 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/12/18 at 5:32 PM the post pain administration was documented as ineffective. Review of the Pain Level Summary for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that resident 23 had 231 episodes of pain with a pain score of greater than 4 out of 10. All values were scored with a numeric pain scale. The summary documented the episodes with a warning of High of 4 exceeded. Review of the Care Plan revealed resident 23 has potential for pain. She has recent back pain related to [MEDICAL CONDITION]. Heat/cold effective at times, pain medication effective at times. Scans and pain medications adjusted to meet needs Interventions listed on the care plan include the following: a. Assist with heat/cold packs to lower back pain. Intervention was initiated on 11/30/17. b. Monitor pain q (every) shift, notify MD (Medical Doctor) if interventions are ineffective. Intervention was initiated on 11/30/17. c. Pain medications as ordered per MD. Intervention was initiated on 11/30/17. d. Watch for nonverbal signs or symptoms of pain. Intervention was initiated on 11/30/17. e. See Hospice Care Plan to coordinate care. Intervention was initiated on 5/9/18. Review of the hospice nursing notes revealed the following: a. On 6/7/18, the note stated, She is anxious, worrying about when her next dose of pain meds (medication) due. Resident 23 reported an acceptable pain level of 4 out of 10. b. On 6/5/18, the note stated, Pt. (patient) reports feeling pain not improved at all. Review of the nursing progress note on 6/19/18 stated, .observed using a wheelchair today per her request. (resident 23) continues to experience a decline r/t (related to) her [MEDICAL CONDITION]. Review of the nursing pain evaluation on 4/30/18 revealed that resident 23 reported left flank pain with a numeric pain score of 7 out of 10. The evaluation indicated that resident 23 reported that medications and heat packs makes the pain better. Resident 23 reported that the pain negatively impacts sleep and rest, social activities, appetite, physical activity and mobility, and emotions. On 6/19/18 at 1:15 PM, resident 23 was interviewed. The resident stated that she feels like she has injured her back and her pain was now a 10/10. Resident 23 requested pain medications from Licensed Practical Nurse (LPN) 3 and LPN 3 was observed to administer [MEDICATION NAME] and [MEDICATION NAME]. On 6/19/18 at 2:56 PM, resident 23 was re-interviewed. Resident 23 stated that her pain was currently still the same, at a 10 out of 10 in her lower back and it radiated all through. Resident 23 stated the medication did not alleviate the pain. On 6/19/18 at 3:00 PM, LPN 3 was interviewed. LPN 3 stated that resident 23's pain prior to the medication administration was a 4 and she obtained that number by observing facial grimacing. LPN 3 stated that resident 23 would not give a number score. LPN 3 stated that the follow-up pain score was a 2 based on the Wong Baker FACES pain rating scale. According to the Wong Baker scale, a score of 4 was Hurts a little more and a 2 was Hurts a little bit. It should be noted that the scale rates pain by asking the person to point to the face that depicts the pain they are experiencing and was originally developed for children to help them communicate about their pain. On 6/19/18 at 3:09 PM, resident 23 was observed stating to the Medical Records staff that her back went out and that she can not walk now. Resident 23 stated she can only walk to the bathroom. Resident 23 stated, it hurts like a [***] . The Medical Records staff was observed to ask resident 23 if the physician had seen her and resident 23 indicated no by shaking her head. On 6/20/18 at 11:37 AM, resident 23 was interviewed. Resident 23 stated that her back pain was a 10 out of 10 and not improving. Resident 23 stated that she can longer ambulate independently and now uses a walker or wheelchair to get around. The resident stated that she received [MEDICATION NAME] 3 to 4 times a day. Resident 23 requested this surveyor to inform the nursing staff that she would like some pain medication now. An immediate interview was conducted with LPN 2. LPN 2 stated that resident 23 only has a scheduled order for [MEDICATION NAME] 4 times a day. LPN 2 stated that resident 23 did not have a PRN (as needed) hourly order for [MEDICATION NAME] and that resident 23 refused liquid [MEDICATION NAME] because she does not like the taste. On 6/20/18 at 11:40 AM, resident 23 was re-interviewed. Resident 23 stated that she did not know she could have [MEDICATION NAME] every hour and that she did not refuse it. On 6/20/18 at 12:55 PM, LPN 2 was re-interviewed. LPN 2 stated that she administered [MEDICATION NAME] and [MEDICATION NAME] to the resident immediately after she requested it at 11:37 AM. LPN 2 stated that the resident reported her pain was a 8 out of 10 prior to the pain medication administration and a 4 out of 10 after administration. LPN 2 stated that the resident always rated her pain using the numeric pain scale. On 6/20/18 at 1:07 PM, a repeat interview was conducted with resident 23. Resident 23 stated that she received her [MEDICATION NAME] earlier and it did not help. Resident 23 stated her pain was still a 10 out of 10. Resident 23 stated that sometimes she got a heating pad for her back and it kind of helps. Resident 23 stated that optimally an acceptable pain level for her would be a 1. On 6/20/18 at 1:46 PM, LPN 2 was interviewed. LPN 2 stated that resident 23's acceptable pain level was none, or a 3 or less. LPN 2 stated that she was unaware of the PRN [MEDICATION NAME] order until this surveyor notified her. It should be noted that the PRN order for [MEDICATION NAME] was initiated on 5/4/18. On 6/21/18 at 8:00 AM, LPN 3 was interviewed. LPN 3 stated that resident 23 does not always provide a numeric pain score rating. LPN 3 stated that if the resident verbalized it's bad then she scored it as a 4 out of 10, verbalized horrible she scored it as 7 out of 10, and verbalized can't stand it scored it as a 9 out of 10. On 6/21/18 at 11:47 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 23 reported pain in her neck and that overall the resident has had a general decline and was not necessarily related to pain. The DON stated that she thought resident 23 had a PRN [MEDICATION NAME] order, and that it seems to be effective. The DON stated that the resident complains that the [MEDICATION NAME] tastes bad but they give her chocolate or coffee with it and the resident was able to tolerate it. The DON stated that she has had no reports that the pain medication was ineffective in managing resident 23's pain. The DON was informed of resident 23's decline in mobility, complaints of pain, and reports of ineffective pain control. No additional information was provided. 2. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 12:20 PM, resident 38 was observed crying during the lunch meal. The resident was observed to be wheeled to her room by the Medical Records staff. At 12:25 PM, resident 38 was observed to exit her room still visibly agitated and crying. Resident 38 was observed to be moaning and stating hurts repeatedly. At 1:00 PM, resident 38 was wheeled outside for a scheduled smoke break by the Social Service Worker (SSW). Resident 38 was observed to be agitated, crying, and moaning hurts. The Medical Records staff confirmed that the resident was in pain and then wheeled the resident to the nurses station to obtain medication. At 1:10 PM, the resident stated to this surveyor yes when asked if she was in pain. At 1:15 PM, LPN 1 was interviewed. LPN 1 stated that resident 38 suffers from chronic back pain, and that the resident only receives Tylenol for her pain. LPN 1 stated this was due to her history of a drug overdose. LPN 1 stated that the resident was due for her scheduled dose of [MEDICATION NAME] and Tylenol; and was observed to administer these medications. LPN 1 stated that they also alternate between ice and hot packs to try to alleviate resident 38's back pain. Review of physician orders [REDACTED]. a. Tylenol Tablet ([MEDICATION NAME]), Give 500 mg by mouth four times a day related to low back pain. The order was initiated on 7/31/2017. b. Tylenol Tablet ([MEDICATION NAME]), Give 500 mg by mouth every 4 hours as needed for pain. The order was initiated on 7/31/2017. c. Question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident is not able to answer, use PAINAD scale, every shift. The order was initiated on 7/5/2017. d. Resident to utilize cold packs PRN for comfort, as needed. The order was initiated on 7/5/2017. e. Resident to utilize hot pack PRN- monitor Q (every) 5-10 for skin redness/discoloration to avoid skin damage, as needed for Pain. The order was initiated on 7/5/2017. Review of the MAR/TAR for (MONTH) (YEAR) revealed that resident 38 received the scheduled Tylenol four times a day. No additional PRN doses of Tylenol were administered. Review of the Pain Level Summary for (MONTH) and (MONTH) (YEAR) revealed that resident 38 had 25 episodes of pain with a pain score of greater than 4 out of 10. The summary documented the episodes with a warning of High of 4 exceeded. Values were scored using the numeric pain scale and the Pain Assessment in Advanced Dementia (PAINAD) Scale. The PAINAD scale scores items a number of 1 or 2. Items scored include breathing, negative vocalization, facial expression, body language, and consolability. Total scores range from 0 to 10, with a higher score indicating more severe pain. Review of care plan revealed resident 38 .has pain related to Chronic back pain. She has a history of opioid abuse. Routine pain medication as ordered. Heat/cold packs for lower back. Intervention listed on the care plan include: a. Administer [MEDICATION NAME] as per orders. Give 1/2 hour before treatments or care. The intervention was initiated on 2/6/18. b. Anticipate (resident's name) need for pain relief and respond immediately to any complain of pain. The intervention was revised on 3/21/18. c. (resident's name) prefers to have pain controlled by: Heat packs. Is able to request heat packs from nurses. The intervention was revised on 3/21/18. Review of the nursing progress notes revealed the following: a. On 6/15/17, the note stated, Pt (patient) with increased anxiousness and leaning forward in her W/c (wheelchair) Ice pack placed on back and 1:1 provided X (times) 30 minutes offering reassurance. b. On 5/20/18, the note stated, .Frequent requests for pills/ice/heat/smokes, often within minutes of receiving the same item requested Struggles to communicate by typing with phone which was her easiest way to communicate until recently. Few words are spoken clearly enough to understand. Staff attempts to anticipate needs and she is able to answer yes no questions. c. On 5/2/18, the note stated, Call in to (doctors name)r/t (related to) increase in falls. Resident also states she has increased pain and is unable to stay upright in her chair. Awaiting response. It should be noted that no documentation could be found for a response from the doctor. d. The post pain intervention follow-up documented 8 episodes of hot pack utilization that were effective and 2 episodes that were ineffective for (MONTH) (YEAR) and (MONTH) (YEAR). Review of the nursing Pain Evaluation on 6/17/18 revealed a numeric pain score of 7 on a scale of 0 to 10, with increasing numbers indicating an increase in pain. The evaluation indicated that resident 38 was able to verbalize pain and has a history of back pain, and that medications and heat make the pain better. The evaluation also documented that the pain negatively impacts sleep and rest, social activities, appetite, physical activity and mobility, and emotions. No documentation could be found in the evaluation section of Describe all methods of alleviating pain and their effectiveness. On 6/19/18 at 10:44 AM, resident 38 was observed. Resident 38 was observed to use her legs to wheel herself out of her room in her wheelchair. Resident 38 stated to the DON hurt, hurt. The DON stated that she was asking for her chapstick. The DON was observed to ask Certified Nursing Assistants (CNAs) to get her chapstick. Resident 38 was observed to wheel herself through the hall crying, Hurt, Hurt, Hurt. There were no staff observed to provide interventions for resident 38 when she stated, Hurt, Hurt. Resident 38 was also observed to lean self forward in wheelchair and place hands flat on the floor. A CNA immediately ran down the hall and resident 38 was taken back to her room. Prior to placing her hands palm down on the floor, resident 38 leaned forward, causing a staff member to grab the back of her shirt. Resident 38 then crossed the hall and was using the handrail to propelled self up the hallway while using her right fist to hit the arm rest and side of the wheelchair. On 6/20/18 at 2:05 PM, CNA 6 was interviewed. CNA 6 stated that the resident would repeatedly state it hurts. CNA 6 stated that when she really wanted something she will text or write it for the staff. CNA 6 stated she applied heat packs to the resident's lower back for pain, and stated it's hard to tell if it helps her pain, but it keeps her calm. CNA 6 stated that if it did not alleviate her pain then resident 38 would keep repeating heat. On 6/20/18 at 2:08 PM, LPN 2 was interviewed with LPN 1 present. LPN 2 stated that resident 38 has chronic pain in her back. LPN 2 stated that the resident was bathing her injured husband and slipped and fell , injuring her back. LPN 2 stated that resident 38 was on narcotic pain medication for her back injury and accidentally overdosed resulting in her [MEDICAL CONDITIONS]. LPN 2 stated that interventions for pain control included hot/ice packs and scheduled Tylenol. LPN 2 stated that nothing took away the pain and she had informed the doctor on multiple occasions but the doctor stated she can only be on Tylenol. LPN 2 stated that it is documented in numerous nursing notes. LPN 2 stated that this has been going on for at least 2 years. LPN 2 stated that she has not seen where any intervention has alleviated resident 38's pain and its really sad. LPN 1 stated its just heartbreaking. It should be noted that the nursing progress notes were reviewed from 7/5/17 to 6/19/18 and only one progress note was identified as having informed the doctor of resident 38's pain. On 6/21/18 at 8:00 AM, LPN 3 was interviewed. LPN 3 stated that she scored resident 38's pain by observing her body movements, and back pain was displayed with side to side movements. LPN 3 stated that resident 38 was sometimes able to provide a numeric pain scale, but mostly she utilized the PAINAD scale if I can't understand her. On 6/21/18 at 8:05 AM, LPN 2 was interviewed. LPN 2 stated that she used the PAINAD scale to score the residents pain because she was nonverbal. On 6/21/18 at 9:26 AM, resident 38's physician was interviewed. The physician stated that it was hard to assess the resident's pain and she's really all over the map with her communication. The physician stated that he believed that resident 38's pain was well controlled. The physician stated that it was difficult to assess the resident's pain with her [MEDICAL CONDITIONS], but that he thought the pain was well managed. The physician stated that resident 38 had not exhibited a lot of problems with pain. The physician stated that resident 38 had no complaints of chronic pain and was in the facility for an opioid overdose. The physician further stated that he did not have any problems with ordering pain medications for resident 38 in a clinical setting, but he did not see a need or indication for more pain management. On 6/21/18 at 9:34 AM, the DON was interviewed. The DON stated that resident 38 suffered from chronic low back pain. The DON stated that the resident had Tylenol ordered to cover the pain and it was effective. The DON further stated that resident 38 can have a heat pack and cold pack for pain. The DON stated that the nursing staff had not reported that her pain was not well controlled. The DON stated that staff assessed for pain by asking the resident, and the resident will state hurt. The DON stated that the resident's behavior would also indicate the need for other things such as smoking, chap stick, ice cream, pills (just states pills). The DON stated that the MAR indicated [REDACTED]. On 6/21/18 at 9:56 AM, resident 38's spouse was interviewed. The spouse stated that resident 38 has chronic pain in head and back, and that the facility gave her Tylenol for pain management. The spouse stated that the medication was not effective to alleviate the pain. The spouse stated that he talked to the facility staff about resident 38's pain, all the time. The spouse further stated that he had a discussion with the resident's physician on 6/18/18 and that the physician did not want to prescribe anything stronger with the resident's past history of abuse and an overdose. On 6/21/18 at 10:30 AM, the SSW was interviewed. The SSW stated that resident 38 exhibited behaviors of repeatedly asking for smokes, pills, heat pack, cold pack, and phone. The SSW stated that the heat and cold pack can indicate lower back pain, but it can be a behavior if she already has a heat pack in place. The SSW stated that the resident's short term memory loss required frequent reminders that the heat pack was in place. The SSW stated that requests for a heat pack were considered a complaint of pain if a pack was not already present. The SSW stated that resident 38 had a high level of anxiety and increased behaviors when her needs were not being met. The SSW stated that when resident 38 had 1:1 care her behaviors were reduced, and that the facility administration helped with her care. The SSW stated that resident 38 can communicate verbally, by typing on a phone, or by a written message. The SSW stated that resident 38 was able to communicate her level of pain and the location of the pain. Additionally, the SSW stated that resident 38 was able to state if the interventions was alleviating her pain if asked specifically about it. The SSW stated that she had wondered if the current interventions of Tylenol and heat packs alleviated her pain. The SSW stated that she believed that resident 38's [MEDICAL CONDITIONS] amplifies her request. The SSW stated that resident 38 had an accidental opioid overdose, and that the opiates were for chronic back pain. On 6/21/18 at 11:47 AM, the DON was re-interviewed. The DON was informed of the multiple observations of resident 38 crying and stating hurts, the interviews with facility staff that stated the pain was not well controlled, and the interview with the physician stating he had not been informed of uncontrolled pain. The DON stated, sound like we are not all on the same page, we have a communication problem. No additional information was provided.