Every finding on record at Mt Ogden Health and Rehabilitation Center

Based on interview and record review, the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, there were no interventions developed to prevent sexual abuse when 2 residents were in a relationship and one was cognitively impaired. This deficiency was found to have occurred at a past non-compliance. Resident Identifiers: 174 and 175. Findings included: 1. Resident 174 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy, and gastro-esophageal reflux disease. Resident 174's medical record was reviewed on 12/2/24 through 12/5/24. An admission Minimum Data Set (MDS) assessment revealed resident 174 had a Brief Interview for Mental Status (BIMS) score of 15, indicating this resident's cognitive status was mildly impaired. Progress notes for resident 174 revealed the following: a. On 5/2/24 at 1:25 PM, This nurse and a CNA [Certified Nursing Assistant] witnessed this resident asking another resident to help cut up her food, and to bring her items saying that she needs extra help. This was witnessed in the dining room on more than one occasion and also in her bedroom. b. On 5/2/24 at 8:20 PM, . A CNA reported to this nurse that the same male resident was found in this resident's bed of a different night. This resident has been told by staff, administration and social services that this behavior is inappropriate. c. On 5/7/24 at 7:57 PM, This nurse was notified by another resident that I should check on resident in her room. Upon entering the room resident was in her bed and another resident appeared to be 'tucking' her into bed. This nurse informed both residents that this is not acceptable behavior and that they are not allowed to enter each other's rooms. Resident was disgruntled and asked the other resident to 'give her a kiss before leaving'. This nurse reiterated that this was inappropriate behavior and that he needed to come with me. Residents' roommate was also upset that a male had entered the room. Resident was left safely in her bed with call light and hydration within reach. It was documented that both resident's rooms were down the same hallway in the facility. There was no documentation found or provided that either resident was relocated during the allegation period. The care plan for resident 174 was not updated during the allegation period. No capacity to consent for a relationship was located in the medical record. 2. Resident 175 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. On 12/18/23, a Montreal Cognitive Assessment (MOCA) was completed for resident 175. The resident was assessed as having a score of 10/30 indicating moderate cognitive impairment. On 4/25/24, a MOCA was completed for resident 175. The resident was assessed as having a score of 11/30 indicating moderate cognitive impairment. On 3/20/24, a BIMS score was completed for resident 175. The resident was assessed as having a score of 9 indicating moderate cognitive impairment. Progress notes for resident 175 revealed the following: a. On 3/22/24, a social service summary note revealed, . [Resident 175] has a diagnoses of dementia and needs staff to help anticipate needs. Resident can communicate with others but does have confusion. b. On 4/10/24, a provider note revealed, .Given his underlying dementia and need for assistance with ADLs [Activities of Daily Living] and ADLs [sic] I certify he is appropriate for skilled nursing facility level of care. c. On 5/2/24 at 9:54 AM, . This resident was seen in another resident's room early in the morning. This other resident is a female and she was asking this resident to do things for her and fetch things for her, like her remote or move her water closer to her. The CNA put a stop to this again reminding the female resident that she needs to do as much for herself, but also told this resident that he needs to focus on himself and the female resident needs to focus on herself. d. On 5/2/24 at 8:19 PM, Resident was asked by another female resident to borrow his phone. When this resident's son came to visit, they were looking for the phone. The resident's phone was found in the female resident's bed. Administration and social services were notified and both residents were told that this is inappropriate behavior. This nurse was also told by a CNA that they found this resident in the bed of the female resident the other night. e. On 5/7/24, Nurse was notified by another resident that this resident was in a female resident's room. Upon entering the room this nurse witnessed resident attempting to 'tuck' female resident in bed. This nurse explained to resident that he cannot be in another resident's room. Resident appeared irritable and stated that he did not understand and that he was only trying to help her. Female resident asked this resident to give her a kiss before leaving. This nurse explained to both resident's that this is not appropriate behavior and that he needed to come with me. Resident did exit the room. This nurse educated resident on common areas, and that he is not allowed to enter anyone else's room. Resident expressed understanding. f. On 5/21/24 a provider note revealed, . Dementia with behavioral problem. It was documented that both resident's rooms were down the same hallway in the facility. There was no documentation found or provided that either resident was relocated during the allegation period. The care plan for resident 175 was not updated during the allegation period. No capacity to consent for a relationship was located in the medical record. On 12/4/24 at 1:17 PM, an interview was conducted with resident 37 who was resident 174's roommate at the time of the incident. Resident 37 stated she remembered resident 175 coming into their room, a lot. Resident 37 stated I guess he liked her. Resident 37 stated that resident 174 would ask him to do things for her and he would do them. Resident 37 stated she did not see anything because she stayed on her side of the room. On 12/5/24 at 9:43 AM, and interview was conducted with CNA 1. CNA 1 stated resident 174 had a tendency to be manipulative and would ask others to do things for her that she could do for herself. CNA 1 stated resident 174 had the poor me act going most of the time. CNA 1 stated resident 174 was a little alert and oriented but sometimes confused. CNA 1 stated that she was aware of resident 174 and resident 175 being together a lot, they would go into each other's rooms and hold hands. CNA 1 stated resident 175 was pleasantly confused, he needed to be directed and shown where his room was because he would get disoriented. CNA 1 stated they were supposed to report any signs that residents may have been in a relationship to administration. CNA 1 stated she did not report anything to administration. On 12/5/24 at 9:45 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated she was working nights at the time resident 174 and 175 were residents. NA 1 stated resident 174 would ask resident 175 to do things for her most of the time and encourage him to go into her room with her. NA 1 stated resident 175 had sundowners really bad and when night time would come he would get really confused as to where he was or what you were talking about. NA 1 stated per policy we were supposed to see, stop, and report if we saw something. NA 1 stated administration was already aware of resident 174 and 175 being close so she did not bring it up again. On 12/5/24 at 10:04 AM, an interview was conducted with CNA 2. CNA 2 stated she did remember resident 174 and 175. CNA 2 stated that resident 174 would go into 175's room a lot. CNA 2 stated that she did see resident 174 and 175 being friendly with each other while they were in the facility. CNA 2 stated the staff were to see, stop, and report if they see something like that and CNA 2 stated that she told the administrator the resident 174 was seen going into resident 175's room. CNA 2 stated she did not remember any changes being made or any education being done when that happened. On 12/5/24 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did remember resident 174 and 175. RN 1 stated that resident 174 was alert and oriented and liked to manipulate another resident into doing things for her. RN 1 stated that resident was resident 175. RN 1 stated resident 175 was cognitively impaired and would get disoriented and need redirecting at times. RN 1 stated resident 175 would not usually go into other resident's rooms but he did go into resident 174's room. RN 1 stated she found resident 175 in resident 174's room a couple of times and asked him to leave. On 12/5/24 at 10:45 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 175 was alert and oriented but resident 174 would get confused and needed guidance to find his room. The ADON stated resident 175 did go into resident 174's room. The ADON stated there was one incident where resident 175 was tucking resident 174 into bed as you would a child. The ADON stated she asked resident 175 to leave, he became upset and resident 174 then asked him to give her a kiss before he left the room. The ADON stated she told them that was inappropriate and resident 175 left the room unhappy. The ADON stated if they saw any residents that appeared to be in a relationship they were to notify Social Services or the Administrator. The ADON stated she did not report the relationship to anyone. On 12/5/24 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she did remember resident 174 and 175. The DON stated residents were assessed to determine consent for a consensual relationship by having a conversation with them. The DON stated resident 174 was alert and oriented and able to make decisions for herself and the DON stated she felt resident 175 was able to make the decision because his cognitive level improved while he was in the facility and after he left. The DON stated a specific conversation to determine whether the residents were in a relationship or if they were able to consent did not happen. On 12/5/24 at 1:00 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated there were no residents in relationships in the facility currently and there were no staff in relationships with residents. The CRN stated she was unsure if the facility had a consensual consent policy. On 12/5/24 at 1:05 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was made aware of the alleged abuse allegation when another facility called and informed him. The ADM stated he was under the impression the residents were in a consensual relationship. The ADM stated while the residents were at the facility he was aware of the them being close but had no knowledge of any sexual abuse. The ADM stated he had a discussion with them about a relationship. The ADM stated the outcome from the discussion was that both of the residents were able to make the decision for themselves. The ADM stated to determine if a resident was able to consent to a consensual relationship a conversation was had with each resident to determine what a relationship means to them and determine what each resident wanted. The ADM stated if a resident was unable to make the decision due to cognitive ability the family was then involved. The ADM stated the family for either resident was not involved in this case because both residents seemed to be able to make the decision for themselves. The ADM stated after the allegation was brought to their attention a Quality Assurance and Performance Improvement (QAPI) plan was put into place and education with the staff was completed. Corrective action The exhibit 358 revealed that staff became aware of the incident on 10/18/24 at 11:00 AM. The exhibit revealed that resident 174 alleged, .[resident 174] was involved in an alleged incident that is sexual in nature during her stay . On 11/6/24, the DON and the ADM were unable to get in touch with resident 174 and 175 by telephone, so the DON and the ADM went to the residence of resident 174 and 175, two separate residences to interview the residents. Exhibit 359 revealed that the Administrator and Director of Nursing of the facility visited [resident 174] in her home with her family present. During interview DON asked [resident 174] about her relationship with [resident 175]. [Resident 174] relayed that she and [resident 175] were friends but at least on one other occasion they exchanged mutual affections including kissing. [Resident 174] stated that one night during bed time [resident 175] came to visit her in her room which he had done on other occasions that while she was in her bed he lifted her shirt up, touched her breast and put his hand down her pants. [Resident 174] said she yelled for him to stop and told him to leave her room which he did. Resident stated that this was an isolated incident. [Resident 174] states she did not report this to any staff. Further, [resident 174's] daughter said she was unaware of this alleged incident until the investigation. However, [resident 174] said that she told her friend [name omitted] and that her roommate [name omitted] was in the room at the time of the alleged incident and aware of the situation. [Resident 174] stated that she felt safe at the facility and would like to come back. A summary on interviews revealed, During our investigation, there were no known witnesses. [Resident 37] was [resident 174's] roommate at the time and [resident 174] stated that she was in the room during the time of alleged incident. Upon interview with [resident 37], she stated that she had no memory of [resident 174] yelling at or asking alleged perpetrator [resident 175] to leave their room. She just remembered both of them frequently enjoying the company of one another. A summary of the information from the investigation revealed, Inconclusive. After our investigation we were not able to verify or refute whether or not the allegation had occurred. After review of the charts of each resident, and also reviewing all interviews it was determined that former residents [175] and [174] did have some form of consensual relationship, where they spent time with each other and were affectionate. The two people that [resident 174] stated were aware of the alleged incident denied having knowledge of the incident. On 12/5/24, the facility provided the QAPI plan dated 11/8/24 which identified the issue as Resident and Relationships where All residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying and reporting to Administrator relationships between residents. Social services educated on appropriate follow-up to determine appropriateness of relationship and updating care plan per IDT [Interdisciplinary Team] discussion. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting or potential documentation of resident relationship. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. On 12/5/24, the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it, and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. On 12/5/24, the education slide show was provided to and reviewed by this surveyor. The education topics reviewed were Residents, Intimacy, and Sexual Contact and abuse scenarios with educational slides provided for each topic. On 12/5/24 an Assessment of Resident Capacity to Consent to Intimacy was provided by the facility and was part of the education given to the facility staff on 11/8/24. Inservices on abuse and reporting were documented as being given to the staff on the following dates: a. 6/20/24 b. 7/25/24 c. 8/30/24 d. 9/20/24 e. 10/17/24 f. 11/8/24 g. 11/14/24 h. 11/22/24 On 11/11/24 the Residents, Intimacy, and Sexual Contact slide education and abuse scenarios was reviewed again with the staff. On 12/5/24, the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

Based on interview and record review, the facility did not implement their written policies and procedures for investigation of abuse allegations. Specifically, an incident of potential sexual abuse was not investigated timely. Resident identifiers: 174 and 175. Findings include: 1. Resident 174 was admitted to 4/28/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy and gastro-esophageal reflux disease. 2. Resident 175 was admitted to the facility on [DATE] with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness and abnormalities of gait and mobility. The medical records for resident 174 and 175 were reviewed 12/2/24 through 12/5/24. The State Survey Agency (SSA) received a 358 report dated 11/6/24 indicating that another facility where resident 174 resided called on 10/18/24 and informed the previous facility that resident 174 had reported being in a sexual incident with resident 175 while a resident at the facility. On 12/4/24, an Incident Witness Interview Report dated 10/18/24 was conducted with four residents in the facility. No other investigation reports were located or provided. On 12/5/24, an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON). The ADM and DON were asked about the 358 report. The ADM stated he was made aware of the situation after being called by the other facility but did not do a full investigation at that time. The DON stated she did ask a few resident the questions on the Incident Witness Interview Report when she found out about the call but a complete investigation was not done. When asked why the incident was not reported to the SSA until 11/6/24 the ADM and DON stated they were unsure if it needed to be reported since the residents were not longer residents at the facility. The ADM stated he had talked with the long term care manager and was told they should report it. The ADM stated that is when it was reported to the SSA. The facility policy titled Abuse: Prevention of and Prohibition Against under the section labeled Policy revealed, It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Corrective action On 12/5/24 the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it , and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. Inservices on abuse and reporting were documented as being given to the staff on the following dates: 1. 6/20/24 2. 7/25/24 3. 8/30/24 4. 9/20/24 5. 10/17/24 6. 11/8/24 7. 11/14/24 8. 11/22/24 On 12/5/24 the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

Based on interview and record review it was determined, for 2 out of 26 sampled residents, that the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility, the State Survey Agency (SSA), and adult protective services (APS), and the results of all investigations were reported to the Administrator and the SSA within 5 working days of the incident. Specifically, allegations of abuse were not reported at the time of the allegation to the SSA or APS. Resident identifiers: 174 and 175. Findings include: 1. Resident 174 was admitted to 4/28/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy and gastro-esophageal reflux disease. 2. Resident 175 was admitted to the facility on [DATE] with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness and abnormalities of gait and mobility. The medical records for resident 174 and 175 were reviewed from 12/2/24 through 12/5/24. On 5/2/24 at 1:25 PM, a nurses note indicated that this nurse and a CNA (Certified Nursing Assistant) witnessed this resident [resident 174] asking another resident to help cut up her food, and to bring her items saying that she needs extra help. This was witnessed in the dining room on more than one occasion and also in her bedroom. This resident [resident 174] was already told that she needs to ask staff for help with these things. On 5/2/24 at 8:20 PM, a nurses note indicated that this resident [resident 174] asked a make (sic) resident [resident 175] to use his phone. When the other resident's son visited today, A search was conducted for his father's phone. It was found in this resident's bed. A CNA reported to this nurse that the same male resident [resident 175] was found in this resident's bed of a different night. This resident has been told by staff, administration and social services that this behavior is inappropriate. Review of the facility's form 358 for this incident indicated that although the facility was made aware of the incident on 10/18/24 at 11:00 AM, the facility did not report it to the SSA until 11/6/24 at 1:10 PM, approximately 19 days after the incident was reported to the facility. The facility policy titled Abuse: Prevention of and Prohibition Against under the section labeled Identification revealed, . Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This includes identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This also includes taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status with any type of device. Corrective action On 12/5/24 the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it , and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. Inservices on abuse and reporting were documented as being given to the staff on the following dates: 1. 6/20/24 2. 7/25/24 3. 8/30/24 4. 9/20/24 5. 10/17/24 6. 11/8/24 7. 11/14/24 8. 11/22/24 On 12/5/24 the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

Based on interview and record review, it was determined, for 2 of 26 sampled residents, that the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated. Specifically, an allegation of suspected sexual abuse was not thoroughly investigated. Resident identifier: 174 and 175. 1. Resident 174 was admitted to 4/28/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy and gastro-esophageal reflux disease. 2. Resident 175 was admitted to the facility on [DATE] with diagnoses which included athrosclerotic heart disease of native coronary artery without angina pectoris, anemia, unspecified dementia, cognitive communication deficit, reduced mobility, need for assistance with personal care, muscle weakness and abnormalities of gait and mobility. The medical records for resident 174 and 175 were reviewed 12/2/24 through 12/5/24. The exhibit 358 revealed that staff became aware of the incident on 10/18/24 at 11:00 AM. The exhibit revealed that resident 174 alleged, .[resident 174] was involved in an alleged incident that is sexual in nature during her stay . Exhibit 359 revealed that the Administrator and Director of Nursing of the facility visited [resident 174] in her home with her family present. During interview DON asked [resident 174] about her relationship with [resident 175]. [Resident 174] relayed that she and [resident 175] were friends but at least on one other occasion they exchanged mutual affections including kissing. [Resident 174] stated that one night during bed time [resident 175] came to visit her in her room which he had done on other occasions that while she was in her bed he lifted her shirt up, touched her breast and put his hand down her pants. [Resident 174] said she yelled for him to stop and told him to leave her room which he did. Resident stated that this was an isolated incident. [Resident 174]states she did not report this to any staff. Further, [resident 174's] daughter said she was unaware of this alleged incident until the investigation. However, [resident 174] said that she told her friend [name omitted] and that her roommate [name omitted] was in the room at the time of the alleged incident and aware of the situation. [Resident 174] stated that she felt safe at the facility and would like to come back. A summary on interviews revealed, During our investigation, there were no known witnesses. [Resident 37] was [resident 174's]roommate at the time and [resident 174]stated that she was in the room during the time of alleged incident. Upon interview with [resident 37], she stated that she had no memory of [resident 174] yelling at or asking alleged perpetrator [resident 175] to leave their room. She just remembered both of them frequently enjoying the company of one another. A summary of the information from the investigation revealed, Inconclusive. After our investigation we were not able to verify or refute whether or not the allegation had occurred. After review of the charts of each resident, and also reviewing all interviews it was determined that former residents [175] and [174] did have some form of consensual relationship, where they spent time with each other and were affectionate. The two people that [resident 174] stated were aware of the alleged incident denied having knowledge of the incident. On 12/5/24 at 1:30 PM, an interview was conducted with the Administrator (ADM)and the Director of Nursing (DON). The DON stated when they were informed of the incident she interviewed 4 residents about feeling safe in the facility but a full investigation was not done until a couple weeks later. The ADM stated the investigation was not completed immediately when the incident was reported to the facility. The ADM stated they were unsure if one needed to be completed since the residents no longer resided at the facility but after a discussion with the long term care manager it was determined an investigation was needed. The ADM stated a QAPI plan was then put into place improving the understanding of the types of abuse, how to report abuse, the investigation process and staff education was completed. The facility policy titled Abuse: Prevention of and Prohibition Against under the section labeled Investigation revealed, . 1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below). 3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPAA). Any such actual or potential violation will be managed as per the Facility's HIPAA policies and procedures. 5. The investigation will include the following: An interview with the person(s) reporting the incident; An interview with the resident(s); Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; A review of the resident's medical record; An interview with staff members (on all shifts) who may have information regarding the alleged incident; Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; An interview with staff members (on all shifts) having contact with the accused employee; and A review of all circumstances surrounding the incident. 6. To the extent there is evidence that could be used in a criminal investigation, staff will immediately notify the Administrator or his/her designee. Staff are not to tamper with or destroy any such evidence at any time. 7. At the conclusion of the investigation, the Facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred. 8. The investigation, and the results of the investigation, will be documented. 9. All phases of the investigation will be kept confidential in accordance with the Facility's policies governing the confidentiality of medical records and privilege of quality assurance/ quality improvement programs. Corrective action On 12/5/24 the facility provided the QAPI plan dated 11/8/24 which identified the issue as Recognizing Abuse where All Residents were identified as being at risk. The system correction that was put into place was, All staff to be educated on importance of identifying abuse and addressing it immediately and appropriately (stopping it , and notifying the administrator). In addition, staff will review specific abuse examples and go through the proper procedures when abuse is identified. Monitoring was done by, Administrator to do a review of the 24 hour report in the morning before morning meeting. LMS training assigned to all staff in the building on abuse. With a resolution date of 12/8/24. The QAPI plan was observed to be signed by the QAPI committee members. Inservices on abuse and reporting were documented as being given to the staff on the following dates: 1. 6/20/24 2. 7/25/24 3. 8/30/24 4. 9/20/24 5. 10/17/24 6. 11/8/24 7. 11/14/24 8. 11/22/24 On 12/5/24 the 24 Hour Report audits on abuse and relationships were reviewed by the administration from 11/11/24 through 12/5/24 with no concerns being documented.

Based on observation and interview, the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, one multi-dose vial was not labeled with an opened date, and a medication was taped back into the medication blister pack. Resident identifiers: 162. Findings included: Resident 162 was admitted to the facility on [DATE] with diagnoses which included fracture of lower end of left tibia, type 2 diabetes mellitus with diabetic neuropathy, Bell's palsy, muscle wasting and atrophy. On 12/4/24 at 8:16 AM, an observation was made of the 100-hall medication cart. An opened vial of Humulin 100 ml/units injection solution for resident 162 was located in the top right drawer of the medication cart and it did not have an opened date written on the vial. On 12/4/24, at 8:17 PM, an observation was made of a medication blister pack located in the locked drawer of the 100-hall medication cart. Resident 162's blister pack of Absenting 100 mg was observed to have a pill taped back into the 35 numbered space. On 12/04/24 at 8:17 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she did not see an opened date on the Humulin injection solution vial. LPN 1 stated there should be an open date on the vial. LPN stated that medications should not be taped back in blister packs, they should be disposed of properly. On 12/04/24 at 8:47 AM, an interview with the Director of Nursing (DON) was conducted. DON stated that when insulin vials were opened, they should be marked with an open date. DON stated that medication should not be taped back into the blister pill packs and that refused medications should be disposed of.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service. Specifically, food items in the walk-in refrigerator and walk-in freezer located in the kitchen were open to air, and the resident snack refrigerator was not clean. Findings included: 1. On 4/30/23 at 9:13 AM, an initial walk through of the kitchen was completed. In the walk-in freezer, a box of beef hamburger patties were found open to air. A box of mixed frozen vegetables was also found to be open to air. In the walk-in refrigerator, a box of uncooked bacon strips was observed to be open to air. On 5/3/23 at 10:09 AM, a second walk through of the kitchen was completed. In the walk-in freezer, a box with sausage patties was found to be open to air, a box of beef patties was open to air, a box with pre-made breakfast omelettes was open to air, and a box containing mixed frozen vegetables was open to air. On 5/3/23 at 10:30 AM, an interview was conducted with the Dietary Manager (DM). The DM stated staff had been educated about not only closing the boxes in the refrigerator and freezer, but securing the plastic the food items were being stored in within the boxes. The DM stated she would provide additional education to the kitchen staff about closing food items in the refrigerator and freezer. 2. On 4/30/23 at 9:40 AM, an interview was conducted with Dietary Aide (DA) 1, and DA 2 regarding the facility outside food policy. DA 1 stated if residents brought food into the facility from outside sources, the food was placed into the resident snack refrigerator that was located in the Certified Nursing Assistant (CNA) area in hallway 3. DA 1 stated that the facility required the food items to have a name, room number, and date on them. DA 2 stated the policy for keeping outside food was posted on the refrigerator. DA 1 stated the refrigerator was cleaned out every two weeks. DA 2 stated the refrigerator was cleaned out once each week. On 4/30/23 at 9:46 AM, an observation was made of the resident snack refrigerator. In the freezer section, a piece of popped popcorn was observed to be in the main area of the freezer. The refrigerator section was observed to be unclean with spilled orange juice on the bottom level and the middle glass shelf. Dried orange juice was also observed to be on the floor outside the refrigerator. Several small plates containing a small cup of covered cottage cheese and some with crackers were observed to be stacked on the bottom level of the refrigerator. On the outer part of the refrigerator door, the policy about outside food was taped to the door. The policy stated if food was placed in the refrigerator, it must be labeled with the resident's name, their room number, and the date it was placed into the refrigerator. The policy stated food would be discarded after three days in the refrigerator. Additionally, a flyer attached to the door contained information about safe food storage. A temperature log was also attached to the door and had been completed. On 5/1/23 at 2:50 PM, an observation was made of the resident snack refrigerator. Orange juice was observed to be on the bottom level of the refrigerator and on the shelf above it. Dried orange juice was also observed to be on the floor outside of the refrigerator. The plates containing the cottage cheese and crackers were no longer in the refrigerator. On 5/2/23 at 8:40 AM, an observation was made of the resident snack refrigerator. Orange juice was observed to be on the bottom level of the refrigerator and on the shelf above it. A piece of popped popcorn was observed to be in the freezer. On 5/2/23 at 11:26 AM, an interview was conducted with the DM. The DM stated the nursing staff were responsible to clean out the resident snack refrigerator of old food items and any messes that might have occurred. The DM stated the resident snacks were kept in the resident snack refrigerator for the evening snack offering. The DM stated residents did not keep food in the kitchen. The DM stated resident food brought from outside the building was kept in the resident snack refrigerator. The DM stated the policy for bringing in outside food was located on the outside portion of the refrigerator door. On 5/2/23 at 1:50 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated snack items were offered to every resident at night. The CNA Coordinator stated snacks were kept in the resident snack refrigerator. The CNA Coordinator stated the dietary staff were responsible for cleaning and cleaning out the resident snack refrigerator. On 5/3/23 at 8:10 AM, an observation was made of the resident snack refrigerator. Orange juice was observed to be on the bottom level and the shelf just above the bottom level. Dried orange juice was also observed to be on the floor outside of the refrigerator. A piece of popped popcorn was observed to be inside the freezer. On 5/3/23 at 8:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the Administrator (ADM) was responsible for emptying out the refrigerator. The DON stated the ADM had been doing this task since the previous DON had left. The DON stated the refrigerator should be cleaned out weekly. The DON stated the housekeeping staff should also be cleaning out the resident snack refrigerator. The DON stated she was not aware that the refrigerator was not being cleaned out. The DON stated she would provide more education to staff and be sure the task was put on the schedule to ensure the cleaning was completed.

Based on observation, interview, and record review, it was determined, the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, for 1 out of 24 sampled residents, a resident was not provided assistance with eating. Resident identifier: 48. Findings included: Resident 48 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, essential hypertension, hyperlipidemia, reduced mobility, cognitive communication deficit, dysphagia and lack of coordination. On 4/30/23 at 11:48 AM, an observation was made of resident 48. Resident 48 was sitting in his wheelchair with his bedside table in front of him. Resident 48 was observed to be drooling from his mouth, unshaven, hair disheveled, and his shirt was saturated with liquid with bits of uneaten food resting on his chest. Resident 48 was observed to not be wearing a clothing protector. No staff were observed in the room with resident 48. Resident 48 had a built-up spoon in his right hand which held oatmeal. Resident 48's hands were observed to tremble. Resident 48 attempted to bring the oatmeal to his mouth, the food fell off the spoon onto his shirt. Resident 48 took another spoonful and was observed to use both hands to bring the spoon to his mouth, half of the contents of the spoonful made it into resident 48's mouth. Resident 48 stated he had been trying to eat his breakfast for the past two and a half hours and no one had come in to help him eat. Resident 48 stated, The dining room is no place for a resident like me and they don't want to help me. On 4/30/23 at 12:07 PM, an observation was conducted of a staff member in the 300 hallway passing out beverages for the lunch meal to the residents. The staff member was observed to enter resident 48's room and asked resident 48 if he needed any other drinks. The staff member exited resident 48's room and did not offer resident 48 assistance with the breakfast meal. Resident 48 was observed with the breakfast meal tray in front of him on the bedside table. On 4/30/23 at 12:08 PM, an observation was conducted of Licensed Practical Nurse (LPN) 1 administering resident 48's medications. LPN 1 did not offer resident 48 assistance with the breakfast meal. On 4/30/23 at 12:13 PM, an observation was conducted of a staff member delivering the lunch meal tray to resident 48. The staff member was observed to remove the breakfast meal tray and placed the lunch meal tray on the bedside table in front of resident 48. Resident 48 was observed to hold onto the breakfast meal tray when the staff member tried to remove the tray. LPN 1 was observed to ask the staff member to get resident 48 a fresh bowl of oatmeal from the kitchen. The staff member exited resident 48's room with the breakfast meal tray and did not offer resident 48 assistance with the lunch meal. On 4/30/23 at 1:22 PM, a follow up interview was conducted with resident 48. Resident 48 sat in his chair with his bedside table in front of him. No staff were observed in the room with resident 48. During the resident interview the Corporate Resource Nurse came into the room and offered resident 48 oatmeal and asked if he would like some assistance with eating his lunch. Resident 48 stated he would like his grilled cheese warmed up and would like assistance after he had finished talking with this surveyor. [Note: Lunch was served at 12:15 PM, and resident 48 had not received help with eating until this surveyor entered the room at 1:22 PM]. On 5/1/23, resident 48's medical record was reviewed. A quarterly Minimum Data Set assessment dated [DATE], revealed resident 48 required one person physical assistance with eating. A care plan dated 9/26/22, revealed that resident 48 was at risk for altered Activities of Daily Living (ADL) related to decline in functional ADL activity such as eating. Resident 48 required supervision to limited assistance with eating. The goal was resident 8 would be able to participate in part of ADL activity and have needs met. Some interventions included provide assistance or cueing with meals as needed. Built up silverware was added to the care plan after the survey had commenced. On 5/2/23 at 12:54 PM, an interview was conducted with LPN 1. LPN 1 stated the facility did assign people to feed the residents who needed assistance. The Certified Nursing Assistants (CNAs) were assigned to the residents and they had a binder where they kept track of that information. LPN 1 stated they did not always have enough staff to provide assistance with feeding the residents that needed help everyday. On 5/2/23 at 1:05 PM, an observation was made of the CNA binder. There was an untitled form in the binder which documented which CNA would pass trays and assist residents with feeding. Resident 48 was not noted as a resident who required feeding assistance on 4/26/23, 4/27/23, 4/28/23, 4/29/23, 4/30/23, and 5/1/23, for the day and evening meals. In the CNA binder resident 48 was noted as a resident who required feeding assistance on 5/2/23 and 5/3/23, for the day and evening meals. [Note: These dates occurred after the survey commenced.] A form titled Breakfast/Lunch/Dinner had a list of all residents in the facility who required feeding assistance provided by the facility. Resident 48 was written in on the last copy provided, previous copies of the form did not have resident 48 listed as requiring feeding assistance. On 5/2/23 at 1:06 PM, an interview was conducted with CNA 1. CNA 1 stated there were a few CNAs that go to the dining room to help the residents at meal time. CNA 1 stated they encouraged all of the residents to go down but most wanted to stay in their room. CNA 1 stated the CNAs made sure the residents meals were all set up. CNA 1 stated we communicate with each other on which residents needed to be assisted with feeding and then one of the CNAs on the floor would help feed. CNA 1 stated resident 48 needed help with dressing, brief changes, and that he needed help every day with eating. CNA 1 stated resident 48 was doing pretty good then this April he had not been doing very good so the staff were helping him more now. CNA 1 stated resident 48 needed help with each meal. On 5/2/23 at 1:13 PM, an interview was conducted with CNA 2. CNA 2 stated that she had been assigned the 100 hallway and room [ROOM NUMBER] and 401. CNA 2 stated that her daily assignments included checking resident briefs and before 10:00 AM, CNA 2 was to get all resident vital signs. CNA 2 stated she was to provide assistance for residents that needed help to dining. CNA 2 stated that resident 38 required assistance with eating because resident 38's hands did not work at all. CNA 2 stated that resident 48 required assistance with eating and resident 48 required a hour and a half to eat breakfast today. CNA 2 stated that resident 34 required assistance with eating, but resident 34 would go to the main dining room for meals. CNA 2 stated there was a CNA book that would show which CNA was assigned for showers and to feed residents. CNA 2 stated she was not assigned to resident 48 today, but she was asked to provide feeding assistance to resident 48. CNA 2 stated that she was unsure which CNA was assigned to provide feeding assistance to resident 38 today. CNA 2 stated there were enough CNAs to provide assistance to residents with eating because there were not that many residents that required assistance. CNA 2 stated that most residents that require assistance with eating went to the dining room. On 5/2/23 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation of the facility was that the nurses and CNAs would provide the best possible care to each resident and treat them like they would their own family. The DON stated the staff would encourage the residents to go to the dining room for meals, if they were willing. The DON stated a quarterly nursing assessment was used to determine if a resident needed assistance with eating. The DON stated each nurse should also be able to determine if a resident had difficulty eating and required assistance. The DON stated if a resident required assistance the CNA should stay with the resident until they were done eating their meal. The DON stated resident 48 required assistance with eating and should have received it.

Based on observation, interview, and record review, it was determined the facility did not ensure residents who were unable to carry out activities of daily living (ADL), received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 24 sampled residents, a resident did not receive timely feeding assistance that she needed at meal time. Resident identifier: 38. Findings included: Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, wedge compression fracture, malignant neoplasm of colon, acute respiratory failure with hypoxia, secondary malignant neoplasm of liver and intrahepatic bile duct, major depressive disorder, generalized anxiety disorder, retention of urine, and history of falling. On 5/1/23 at 12:52 PM, resident 38 was observed to activate the call light system. The Health Information Management (HIM) staff member was observed to answer resident 38's call light. Resident 38 stated to the HIM that she needed help, she had been waiting over an hour, and she was not happy. Resident 38's lunch meal tray was observed on the bedside table against the wall and the bedside table was observed in the highest position. The lunch meal tray was observed to be out of reach from resident 38. The HIM was observed to provide feeding assistance to resident 38. [Note: The posted lunch meal time for the 100 and 400 hallways was 11:30 AM.] Resident 38's medical record was reviewed on 5/1/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 38 required extensive assistance of one person with eating. In addition, the MDS assessment documented that resident 38 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 suggests the patient was cognitively intact. A care plan focus initiated on 2/2/23, documented [Resident 38] has ADL Self Care Performance Deficit r/t [related to] new admission, Urinary Retention, Dehydration, Metastatic colon cancer of liver, spinal compression fx [fracture], DVT [deep vein thrombosis], obesity, weakness, deconditioning, right hip, right knee, right ankle, right elbow, right wrist, right fingers, right shoulder, left hip, left knee, left elbow, left wrist, left fingers, left shoulder contractures present on admission. Care plan interventions included, but were not limited to, EATING: requires assistance to eat. The intervention was initiated on 5/1/23. On 5/2/23 at 11:54 AM, an observation was conducted of resident 38's lunch meal tray being delivered to resident 38's room. At 12:02 PM, resident 38 was observed to return from therapy. The therapist was observed to position resident 38 in the wheelchair near the bed and placed the bedside table with the lunch meal tray in front of resident 38. The food was observed to be covered with the warmer dome. At 12:18 PM, resident 38 was observed to activate the call light system. At 12:22 PM, a nurse was observed to enter resident 38's room and resident 38 told the nurse that she needed help eating. The nurse was observed to provide resident 38 with feeding assistance. On 5/2/23 at 1:13 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she had been assigned the 100 hallway and room [ROOM NUMBER] and 401. CNA 2 stated that her daily assignments included checking resident briefs and before 10:00 AM, CNA 2 was to get all resident vital signs. CNA 2 stated she was to provide assistance for residents that needed help to dining. CNA 2 stated that resident 38 required assistance with eating because resident 38's hands did not work at all. CNA 2 stated that resident 48 required assistance with eating and resident 48 required a hour and a half to eat breakfast today. CNA 2 stated that resident 34 required assistance with eating, but resident 34 would go to the main dining room for meals. CNA 2 stated there was a CNA book that would show which CNA was assigned for showers and to feed residents. CNA 2 stated she was not assigned to resident 48 today, but she was asked to provide feeding assistance to resident 48. CNA 2 stated that she was unsure which CNA was assigned to provide feeding assistance to resident 38 today. CNA 2 stated there were enough CNAs to provide assistance to residents with eating because there were not that many residents that required assistance. CNA 2 stated that most residents that require assistance with eating went to the dining room. The CNA book was reviewed. CNA 2 was assigned to provide feeding assistance to resident 38 on 5/2/23. On 5/2/23 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation of the facility was that the nurses and CNAs would provide the best possible care to each resident and treat them like they would their own family. The DON stated the staff would encourage the residents to go to the dining room for meals, if they were willing. The DON stated a quarterly nursing assessment was used to determine if a resident needed assistance with eating. The DON stated each nurse should also be able to determine if a resident had difficulty eating and required assistance. The DON stated if a resident required assistance the CNA should stay with the resident until they were done eating their meal. On 5/2/23 at 1:55 PM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated that she would do active assistive range of motion with resident 38's upper body. The PTA stated that resident 38 could not move her arms or her legs much. The PTA stated that she had gotten resident 38 strong enough that resident 38 could use her motorized wheelchair independently. The PTA stated that resident 38 was not able to eat without assistance from staff. The PTA stated that Occupational Therapy was also working with resident 38. On 5/2/23 at 2:00 PM, an interview was conducted with resident 38. Resident 38 stated that typically she would have to push her call light to get assistance with meals. Resident 38 stated that she would usually have to wait 30 minutes to a hour for assistance. Resident 38 stated that she was not sure if the delay was a staffing issue, but it seemed like there were not enough staff. Resident 38 stated that some days the staff assisted here within 15 minutes. Resident 38 stated that the staff had to pass out all the meal trays before the staff could provide her with assistance.

Based on observation, interview, and record review, the facility did not ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance to residents. Specifically, for 1 out of 24 sampled residents, the Health Information Management (HIM) staff member was providing feeding assistance to a resident without having completed a state-approved training course. Resident identifier: 38. Findings included: Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, wedge compression fracture, malignant neoplasm of colon, acute respiratory failure with hypoxia, secondary malignant neoplasm of liver and intrahepatic bile duct, major depressive disorder, generalized anxiety disorder, retention of urine, and history of falling. On 5/1/23 at 12:52 PM, resident 38 was observed to activate the call light system. The HIM staff member was observed to answer resident 38's call light. Resident 38 stated to the HIM that she needed help, she had been waiting over an hour, and she was not happy. Resident 38's lunch meal tray was observed on the bedside table against the wall and the bedside table was observed in the highest position. The lunch meal tray was observed to be out of reach from resident 38. The HIM was observed to provide feeding assistance to resident 38. [Note: The posted lunch meal time for the 100 and 400 hallways was 11:30 AM.] Resident 38's medical record was reviewed on 5/1/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 38 required extensive assistance of one person with eating. In addition, the MDS assessment documented that resident 38 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 suggests the patient was cognitively intact. A care plan focus initiated on 2/2/23, documented [Resident 38] has ADL [activities of daily living] Self Care Performance Deficit r/t [related to] new admission, Urinary Retention, Dehydration, Metastatic colon cancer of liver, spinal compression fx [fracture], DVT [deep vein thrombosis], obesity, weakness, deconditioning, right hip, right knee, right ankle, right elbow, right wrist, right fingers, right shoulder, left hip, left knee, left elbow, left wrist, left fingers, left shoulder contractures present on admission. Care plan interventions included, but were not limited to, EATING: requires assistance to eat. The intervention was initiated on 5/1/23. On 5/2/23 at 2:06 PM, an interview was conducted with the HIM. The HIM stated that she was the medical records staff member. The HIM stated that she had not been trained to provide feeding assistance to residents, but she had worked with people that had disabilities. The HIM stated that she knew to be on the residents level when providing feeding assistance and that was why she had asked resident 38 if she could sit down next to her while she assisted resident 38 with eating. The HIM stated that she knew to make sure the food was in bite sized pieces. On 5/3/23 at 8:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the only staff in the facility allowed to provide feeding assistance to the residents would be the CNAs and nursing staff. The DON stated there were no paid feeding assistants in the facility.

Based on interview, observation, and record review, the facility did not notify the physician for 1 of 26 sampled residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, a resident experienced low blood sugar levels that were outside of physician-set parameters, and the physician was not notified. Resident identifier: 28. Findings include: Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 28's medical record was reviewed on 8/17/21. Resident 28's physician's orders were reviewed and revealed the following: a. On 12/21/20, [MEDICATION(S)] Inject as per sliding scale before meals and at bedtime: If 150- 200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units 351-400 = 10 units b. On 7/1/21, For blood sugar less than 65 or greater than 450 follow facility protocol. [Note: The physician's orders did not provide instructions for staff if resident 28 had a blood glucose (BG) level between 401 and 449.] On 8/17/21 at 11:09 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that for blood sugars less than 65 or greater than 450, the facility protocol was to notify the provider and get orders. Resident 28's July 2021 Medication Administration Record (MAR) and progress notes were reviewed and revealed the following: a. On 7/28/21 at 7:30 AM, resident 28's BG level was 56. There were no corresponding progress notes to indicate facility staff had contacted the physician. Resident 28's August 2021 MAR and progress notes were reviewed and revealed the following: a. On 8/1/21 at 7:30 AM, resident 28's BG level was 61. There were no corresponding progress notes to indicate facility staff had contacted the physician. b. On 8/8/21 at 7:30 AM, resident 28's BG level was 64. There were no corresponding progress notes to indicate facility staff had contacted the physician. c. On 8/13/21 at 7:30 AM, resident 28's BG level was 64. There were no corresponding progress notes to indicate facility staff had contacted the physician. d. On 8/16/21 at 7:30 AM, resident 28's BG level was 61. There were no corresponding progress notes to indicate facility staff had contacted the physician. e. On 8/17/21 at 7:30 AM, resident 28's BG level was 62. There were no corresponding progress notes to indicate facility staff had contacted the physician. On 8/18/21 at 1:10 PM, a follow up interview was conducted with the DON. The DON stated that when a resident's BG was outside of parameters, the protocol was to assess the resident, and then based on the nurses assessment, a determination could be made to notify the physician or not. The DON further stated that there was not a written facility protocol or policy regarding BG levels that were outside of parameters.

Based on observation, interview, and record review it was determined the facility did not develop and implement a comprehensive person-centered care plan. The care plan needed to include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 of 26 sampled residents, the care plan was not updated with suicidal ideation interventions after multiple expressions of suicidal ideations. In addition, a suicidal care plan was not initiated until approximately 4 months after the resident first expressed suicidal ideations and was readmitted from a Geropsych unit. Resident identifier: 45. Findings include: Resident 45 was admitted to the facility on [DATE] with a readmission on 12/20/20 and 5/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 45's medical record was reviewed on 8/19/21. A Care Plan Focus initiated on 8/5/20, documented [Resident 45] has Potential for mood problem r/t (related to) Admission. A Goal initiated on 8/5/20 and revised on 8/16/21, documented Will have improved sleep pattern by reporting adequate rest or documented episodes of [CONDITION(S)] less than weekly through the review dat (sic). The Interventions initiated on 8/5/20, included the following: a. Educate family and caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. b. Encourage to express feelings. c. Monitor, record, and report to Medical Director (MD) mood patterns signs and symptoms of depression, anxiety or sad mood. d. Monitor, record, and report to MD as needed (prn) acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleep patterns, diminished ability to concentrate, and change in psychomotor skills. [Note: The care plan was not updated with suicidal ideation interventions after resident 45 had multiple expressions of suicidal ideations.] On 2/8/21 at 1:45 PM, a Nursing Progress Note documented Pt (patient) has been making statements of feeling like he has poor quality of life and that he is depressed and lonely. His roommate had been out of the room for a couple weeks but was moved back into the room today. Pt doesn't have a plan to hurt himself. He said he would be willing to talk with someone about this. Referral made to [name of mental health services]. On 3/26/21 at 3:36 AM, a Nursing Progress Note documented resident is very depressed and made suicidal statements. stated he would cut his wrists but he didn't have a knife. he talked about his previous roommate and how he missed him since his death. kept stating he has no reason to live and no one cares. cried a little. asked if he would like to talk to someone. notified nurse manager on call. spent a lot of one on one emotional support time with this resident. On 3/26/21 at 1:02 PM, a Nursing Progress Note documented Res (resident) seen by NP (Nurse Practitioner) related to c/o (complaints of) and observed depressive statements. Upon assessment and medication review received new orders for [MEDICATION(S)] 60mg (milligrams) PO (by mouth) QAM (every morning) r/t depression r/t medical condition. On 4/6/21 at 10:50 AM, an Activities Progress Note documented . Resident is calling out less w/ (with) increased time out of bed w/ 1:1 (one-on-one) interventions. On 4/9/21 at 5:53 PM, a Nursing Progress Note documented Resident making statements about wanting to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry out any plan. Increased checks performed on resident. Resident has had suicidal thoughts in the past. Currently on [MEDICATION(S)]. Nurse managers notified. Social work notified. MD will see resident on Monday. [Note: Increased checks were unable to be located in the medical record. The one on one activity log was reviewed. A one on one activity was provided on 4/9/21 at 11:17 AM.] On 4/12/21 at 2:17 PM, a Nursing Progress Note documented Resident was seen today by NP d/t (due to) suicidal statements made without specific plan. Labs, meds (medications), vitals reviewed. Resident recently started on [MEDICATION(S)], increased dose during visit today. Social work working to arrange visit with psych (psychiatric) this week. [Note: There was no documentation located in the medical record indicating that a psych visit was arranged for resident 45. The last referral to a local mental health services was made on 2/28/21. The one on one activity log was reviewed. A one on one activity was provided on 4/12/21 at 11:48 AM.] On 4/16/21 at 5:56 PM, a Nursing Progress Note documented Resident made a comment earlier when going down to dining room for lunch. He stated: 'I just want to commit suicide.' Nurse asked resident if he had a plan. Resident stated he didn't have a plan. On 4/26/21 at 12:46 PM, a Nursing Progress Note documented Resident was seen today by NP for c/o anxiety, staff reports of yelling out and inability to redirect. Labs, meds, vitals reviewed. See order to obtain UA (urinalysis), titrate down [MEDICATION(S)], add [MEDICATION(S)]. Resident OK with plan of care. On 5/5/21 at 4:15 PM, a Nursing Progress Note documented CNA (Certified Nursing Assistant) called nurse into residents room due to suicidal thoughts. Resident stated they wanted to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry anything out physically. Stated they just feel sad all the time. Resident is on [MEDICATION(S)] 5 mg and [MEDICATION(S)] 30 mg. MD notified. Will continue to monitor resident and adjust medications as needed. Social work notified. Nurse managers notified. Will continue to monitor resident. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/5/21 at 12:06 PM.] On 5/11/21 at 8:30 PM, a Nursing Progress Note documented This evening pt. stated three times that he wanted to die and tried to wrap the call light cord around his neck. Nurse went in and visited with pt. and asked him what was wrong and pt. stated that he was bored. Nurse parked her cart by pt.'s room and visited with him will she pulled pills. This seemed to lift his spirits and pt. stopped making remarks about wanting to dye (sic). Pt. is asleep in bed. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/11/21 at 12:51 PM.] On 5/20/21 at 3:01 PM, a Social Services Progress Note documented Went and talked to [resident 45] about how he was currently feeling and the statements he had made. He stated that if the cord was around his neck it was an accident but he did want to die. He said if he could kill himself he would. I asked him if we could get him some help for this and he said I doubt anyone can help. I let him know we wanted to help and could send him out to get help and he agreed to go. EMS (Emergency Medical Services) was called. A message was left with [name of mental health services] as well to see if they had been seeing him since the referral was resent on 5/6/21. Awaiting call back. On 5/20/21 at 5:10 PM, a Nursing Progress Note documented This nurse was witnessed to EMS and [name of mental health services] crisis workers speaking with resident in regards to negative statements made by resident. He continued with active suicide statements resident did volunteer to go to hospital for psych assessment. Resident left with out struggle from center. On 5/20/21 at 5:20 PM, a Nursing Progress Note documented Res, with noted suicidal statements to social worker this day. But statements conflicting, resident stated he didn't want to die but if he could kill himself he would. Call light cord removed immediately from room due to this being a potential concern, and resident given alternative device to call for assistance and educated on how to use this, resident placed on q (every) 15minute watch. [name of MD] notified of this and stated to send resident to ER (emergency room ) for evaluation. EMS called, mobile crisis outreach team as well as EMTs (Emergency Medical Technicians) arrived and assessed resident. Resident left facility via EMS to [name of hospital] for evaluation at approx. (approximately) 1545. Resident emergency contact [name removed] called by floor nurse to notify of transfer and resident current situation. No answer, message left by floor nurse. On 5/21/21 at 10:53 AM, a Nursing Progress Note documented Clarification from previous note, resident taken to [name of local hospital] and admitted to their Geropsych unit. On 5/25/21 at 2:24 PM, a Social Services Progress Note documented [name of mental health services] called today in regards to psych eval referral. They are aware he is in a psych facility at this time. They will see him on 6/7/21 if he is back in the facility at that time. Resident 45 was a readmission from a Geropsych unit on 5/27/21. A Care Plan Focus initiated on 5/27/21 and revised on 6/3/21, documented Resident has a history of suicidal ideation. Resident returned from an inpatient psychiatric stay on 5/27/21. A Goal initiated on 5/27/21 and revised on 8/16/21, documented Resident will be free of any self injury and have a reduction of suicidal ideation by review date. The Interventions initiated on 6/3/21, included the following: a. If resident expresses suicidal ideation assess for suicide risk and plan. Provided Crisis number to call if resident was in crisis. Send for inpatient psych placement if resident was high risk. b. Monitor, record, and report to MD any risk for harming others: increased anger, labile [NAME] or agitation, feels threatened by others or thoughts of harming someone. c. Monitor, record, and report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, and impaired judgement or safety awareness. d. Resident referred to [name of mental health services] for mental health follow up. [Note: A suicidal care plan was not initiated until approximately 4 months after resident 45's first expression of suicidal ideation and resident 45 was readmitted from a Geropsych unit.] On 5/28/21 at 11:02 AM, a Social Services Progress Note documented [Resident 45] came back from psych hospital yesterday. He stated that he doesn't know if he feels any better but that he doesn't have a plan to hurt himself. Offered pt a new room with a new roommate that might be more talkative and he accepted. The room is closet (sic) to the nurses station as well. Pt does not have a call light in his room but is using a tab alarm to make his needs known at this time. Staff will be purchasing a bell today to use. On 5/28/21 at 12:11 PM, a Nursing Progress Note documented Resident is re-admit on 5/27. Was hospitalized for suicidal thoughts. Today resident stated they wanted to be dead. Asked resident if they wanted to kill themselves. Resident stated, 'They had been thinking about it'. Asked resident if they had a plan. Resident stated no. Resident also stated, 'It was all talk' and he would never do it. Nursing managers aware. On call MD made aware. Resident is on Q15 minute checks. They also have an alarm instead of a call button cord for safety measures. Will continue to monitor. On 6/3/21 at 4:07 PM, a Social Services Progress Note documented Pt reported to PASRR (Preadmission Screening and Resident Review) evaluator that he is still depressed and wants to die and he has a plan to overdose. He also told her he didn't have the courage to do it. I went and talked to him and he said he would if he could get enough 'equipment' to do it. National Suicide Hotline called. I was placed on hold while they called him. Awaiting next step. On 6/3/21 at 5:06 PM, a Social Services Progress Note documented MCOT (Mobile Crisis Outreach Team) came to assess pt. They don't feel he needs to return to psych hospital. They do want 15 min (minute) checks continued. They discussed his appointment with [name of mental health services] counselor coming up on Monday and pt willing to talk to him in hopes of making him feel better. He did say he has no way of stepping in front of train and cant (sic) get enough meds to harm himself so although he wants to die he cant (sic) kill himself. On 6/5/21 at 5:25 PM, a Nursing Progress Note documented Aide (CNA) came to me and said that the pt made a comment to her that he no longer wants to live. I went and discussed the statement with the pt and he stated that he does not have a plan and that he is not suicidal. When asked if he wanted to go to the hospital, he stated that 'it depends on if they are just going to put me on the back burner'. I also asked him if he was feeling anxious which he said that he was not. Pt is currently on 15min checks, NP was notified at 1505 (3:05 PM), no new orders were given. A review of the forms that the staff documented 15 minute checks for resident 45 revealed that 15 minute checks were not provided on 6/5/21. The last 15 minute check form provided was dated 6/7/21. A PASRR Letter Of Determination dated 6/6/21, documented to continue 15 minute checks until resident 45 was free of suicidal thinking or until a qualified professional has determined he was at low risk of self-harming. [Note: The mental health services worker on 6/8/21, was unable to remove the 15 minute checks for resident 45. The next documented qualified professional visit was conducted on 7/23/21, by the consulting Licensed Clinical Social Worker (LCSW).] On 6/8/21 at 1:54 PM, a Nursing Progress Note documented Pt seen by [name of mental health services] today. He will start seeing him weekly. He was not able to remove the q 15min checks at this time. They will continue until at least his next visit Wed. (Wednesday). On 7/23/21 at 3:29 PM, a Social Services Progress Note documented by the consulting LCSW documented Met with resident to assess his mental status. Resident was hospitalized in May after suicidal ideation. Resident has been seen by [name of mental health services] for follow up. Resident described that at the time of his hospitalization he just wasn't happy with where he was at in life but that he does not have any thoughts of suicide currently. He has been using a bell instead of a call light; however, this does not appear to be necessary any longer. Recommend monitoring for suicidal statements, stockpiling pills, talking about death and/or giving away items. [Name of mental health services] to continue to follow up with counseling. On 8/19/21 at 12:32 PM, an interview was conducted with the Patient Care Coordinator (PCC). The PCC stated that resident 45 did not feel any different when he was readmitted after his stay at the psych hospital. The PCC stated she had called the crisis team after resident 45 was readmitted and the crisis team told her that resident 45 was in no immediate danger and to follow up with mental health services. The PCC stated the resource Social Worker met with resident 45. The PCC stated the resource Social Worker initiates care plans. The PCC stated she had made the referral to mental health services but mental health services did not think they were allowed in the facility. The PCC stated mental health services were essential and allowed in the facility. The PCC stated resident 45's statements were more anxious then suicidal. The PCC stated the NP made the medication change based on resident 45 being anxious and not suicidal. The PCC stated resident 45's call light was removed and resident 45 was provided with a bell. The PCC stated the resource LCSW decided that resident 45 could have the call light back. On 8/19/21 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if mental health services was unable to come to the facility she would arrange a telehealth visit. On 8/19/21 at 1:52 PM, an interview was conducted with the DON, the PCC, the Administrator, and the Corporate Resource Nurse (CRN). The DON stated mental health services would schedule with the provider when a referral was made. The DON stated she was not sure if follow up on the referral to mental health services for resident 45 was done. The CRN stated the PCC would followup with referrals to mental health services. The PCC stated she could not remember if she followed up with mental health services and she was trying to get better at that. The DON stated they were not excluding providers from the facility. The DON stated if mental health services did not respond to a referral an in house provider would see the resident. The DON stated an in house provider would include the MD, NP, or the Physician Assistant. The CRN stated they were told by mental health services they were back logged and the provider was out a lot this year. The DON stated the LCSW would provide consultation with the resident care plans. The DON stated it would depend on the care plan and who would update it. The DON stated if resident 45 needed assistance he was able to use the call light and staff would go in and talk with resident 45. The DON was asked about interventions to keep resident 45 safe during the time he was making suicidal statements. The DON stated they were looking for a room mate that resident 45 enjoyed speaking with and would talk with resident 45. The CRN stated the nurses would talk with resident 45 a lot and make him feel better. The DON stated the staff would spend time with resident 45. The Administrator stated resident 45 was encouraged to participate in activities and they were offered daily. The CRN stated activities was providing 1:1 activities to resident 45. The CRN stated that resident 45 made statements that suicide would not be intentional and it would be an accident. The CRN stated resident 45 had changed his behaviors to calling out instead of the suicidal statements. The DON stated resident 45 was having some anxiety and was not always redirectable. The DON stated when the NP spoke with resident 45 he stated the [MEDICATION(S)] was making him to tired. The CRN stated other antidepressant medication had been tried. The DON stated the [MEDICATION(S)] was tapered to start the [MEDICATION(S)] because resident 45 told the NP that he was anxious. The DON stated when resident 45 was readmitted the call light was removed and 15 minute checks were initiated for a short time until resident 45 was safe. The DON stated the Crisis Team was called after resident 45 was readmitted and resident 45 had his room changed so he would be closer to the nurses station for visualization and interaction. The DON stated resident 45 had stopped the suicidal statements.

Based on observation, interview, and record review it was determined the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 of 26 sampled residents, a resident with [CONDITION(S)] was not provided interventions. Resident identifier: 45. Findings include: Resident 45 was admitted to the facility on [DATE] with a readmission on 12/20/20 and 5/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 45's medical record was reviewed on 8/19/21. A Care Plan Focus initiated on 8/5/20, documented [Resident 45] has Potential for mood problem r/t (related to) Admission. A Goal initiated on 8/5/20 and revised on 8/16/21, documented Will have improved sleep pattern by reporting adequate rest or documented episodes of [CONDITION(S)] less than weekly through the review dat (sic). The Interventions initiated on 8/5/20, included the following: a. Educate family and caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. b. Encourage to express feelings. c. Monitor, record, and report to Medical Director (MD) mood patterns signs and symptoms of depression, anxiety or sad mood. d. Monitor, record, and report to MD as needed (prn) acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleep patterns, diminished ability to concentrate, and change in psychomotor skills. [Note: The care plan was not updated with suicidal ideation interventions after resident 45 had multiple expressions of [CONDITION(S)].] The Order Summary was reviewed and the following medications were documented: a. On 7/24/20, [MEDICATION(S)] extended release 75 mg (milligrams) in the morning (QAM) for depression r/t medical condition. Discontinued on 12/17/20. b. On 12/20/20, [MEDICATION(S)] extended release 75 mg QAM for depression r/t medical condition. Discontinued on 1/5/21. [Note: No documentation was located within the medical record indicating why the antidepressant was discontinued.] c. On 1/5/21, [MEDICATION(S)] 7.5 mg at bedtime (QHS) for appetite stimulant for 30 days. Discontinued on 2/4/21. [Note: [MEDICATION(S)] was classified as an antidepressant medication.] d. On 3/24/21, [MEDICATION(S)] 50 mg QHS for sleep. [Note: [MEDICATION(S)] was classified as an antidepressant medication.] On 2/8/21 at 1:45 PM, a Nursing Progress Note documented Pt (patient) has been making statements of feeling like he has poor quality of life and that he is depressed and lonely. His roommate had been out of the room for a couple weeks but was moved back into the room today. Pt doesn't have a plan to hurt himself. He said he would be willing to talk with someone about this. Referral made to [name of mental health services]. On 3/26/21 at 3:36 AM, a Nursing Progress Note documented resident is very depressed and made suicidal statements. stated he would cut his wrists but he didn't have a knife. he talked about his previous roommate and how he missed him since his death. kept stating he has no reason to live and no one cares. cried a little. asked if he would like to talk to someone. notified nurse manager on call. spent a lot of one on one emotional support time with this resident. [Note: The one on one activity log was reviewed. No one on one activity was provided on 3/26/21.] On 3/26/21 at 1:02 PM, a Nursing Progress Note documented Res (resident) seen by NP (Nurse Practitioner) related to c/o (complaints of) and observed depressive statements. Upon assessment and medication review received new orders for [MEDICATION(S)] 60mg PO (by mouth) QAM r/t depression r/t medical condition. On 3/26/21 at 4:12 PM, a Social Services Progress Note documented Pt had made depressive statements and was put in the book for provider for possible med (medication) intervention. New order for [MEDICATION(S)] by NP. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/21 at 10:50 AM, an Activities Progress Note documented . Resident is calling out less w/ (with) increased time out of bed w/ 1:1 (one-on-one) interventions. On 4/9/21 at 5:53 PM, a Nursing Progress Note documented Resident making statements about wanting to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry out any plan. Increased checks performed on resident. Resident has had suicidal thoughts in the past. Currently on [MEDICATION(S)]. Nurse managers notified. Social work notified. MD will see resident on Monday. [Note: Increased checks were unable to be located in the medical record. The one on one activity log was reviewed. A one on one activity was provided on 4/9/21 at 11:17 AM.] On 4/12/21 at 2:17 PM, a Nursing Progress Note documented Resident was seen today by NP d/t (due to) suicidal statements made without specific plan. Labs, meds (medications), vitals reviewed. Resident recently started on [MEDICATION(S)], increased dose during visit today. Social work working to arrange visit with psych (psychiatric) this week. [Note: There was no documentation located in the medical record indicating that a psych visit was arranged for resident 45. The last referral to a local mental health services was made on 2/28/21. The one on one activity log was reviewed. A one on one activity was provided on 4/12/21 at 11:48 AM.] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/16/21 at 5:56 PM, a Nursing Progress Note documented Resident made a comment earlier when going down to dining room for lunch. He stated: 'I just want to commit suicide.' Nurse asked resident if he had a plan. Resident stated he didn't have a plan. [Note: The one on one activity log was reviewed. No one on one activity was provided on 4/16/21.] On 4/26/21 at 12:46 PM, a Nursing Progress Note documented Resident was seen today by NP for c/o anxiety, staff reports of yelling out and inability to redirect. Labs, meds, vitals reviewed. See order to obtain UA (urinalysis), titrate down [MEDICATION(S)], add [MEDICATION(S)]. Resident OK with plan of care. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinue [MEDICATION(S)] on 5/4/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinue [MEDICATION(S)] on 5/11/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinue [MEDICATION(S)] on 5/3/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A [CONDITION(S)] Monthly Review dated 4/27/21, documented [MEDICATION(S)] 90 mg daily was reviewed. Resident 45's target behaviors for the [MEDICATION(S)] were depressive statements. Resident 45 had 4 episodes and the recommended action was to discontinue. In addition, [MEDICATION(S)] 5 mg BID times 1 week then increase to TID was reviewed. Resident 45's target behaviors for [MEDICATION(S)] were anxious statements. Resident 45 had no episodes and the recommended action was to maintain. On 5/5/21 at 4:15 PM, a Nursing Progress Note documented CNA (Certified Nursing Assistant) called nurse into residents room due to suicidal thoughts. Resident stated they wanted to kill themselves. Asked resident if they had a plan and they stated they would not be able to carry anything out physically. Stated they just feel sad all the time. Resident is on [MEDICATION(S)] 5 mg and [MEDICATION(S)] 30 mg. MD notified. Will continue to monitor resident and adjust medications as needed. Social work notified. Nurse managers notified. Will continue to monitor resident. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/5/21 at 12:06 PM.] On 5/5/21 at 4:55 PM, a Social Services Progress Note documented Sent an email to [name of mental health services] to find out if they had been seeing pt since referral in Feb (February). Awaiting reply. On 5/6/21 at 4:58 PM, a Social Services Progress Note documented Received email from [name of mental health services]. They stated they remember receiving the referral and thought they had given to a case worker but wanted me to resend it. I resent referral. On 5/11/21 at 8:30 PM, a Nursing Progress Note documented This evening pt. stated three times that he wanted to die and tried to wrap the call light cord around his neck. Nurse went in and visited with pt. and asked him what was wrong and pt. stated that he was bored. Nurse parked her cart by pt.'s room and visited with him will she pulled pills. This seemed to lift his spirits and pt. stopped making remarks about wanting to dye (sic). Pt. is asleep in bed. [Note: The one on one activity log was reviewed. A one on one activity was provided on 5/11/21 at 12:51 PM.] On 5/20/21 at 3:01 PM, a Social Services Progress Note documented Went and talked to [resident 45] about how he was currently feeling and the statements he had made. He stated that if the cord was around his neck it was an accident but he did want to die. He said if he could kill himself he would. I asked him if we could get him some help for this and he said I doubt anyone can help. I let him know we wanted to help and could send him out to get help and he agreed to go. EMS (Emergency Medical Services) was called. A message was left with [name of mental health services] as well to see if they had been seeing him since the referral was resent on 5/6/21. Awaiting call back. On 5/20/21 at 5:10 PM, a Nursing Progress Note documented This nurse was witnessed to EMS and [name of mental health services] crisis workers speaking with resident in regards to negative statements made by resident. He continued with active suicide statements resident did volunteer to go to hospital for psych assessment. Resident left with out struggle from center. On 5/20/21 at 5:18 PM, a Nursing Progress Note documented Resident was sent to [name of hospital] ER (emergency room ) for suicidal statements via ambulance at approximately 1545 (3:45 PM). Message was left with contact [name removed]. On 5/20/21 at 5:20 PM, a Nursing Progress Note documented Res, with noted suicidal statements to social worker this day. But statements conflicting, resident stated he didn't want to die but if he could kill himself he would. Call light cord removed immediately from room due to this being a potential concern, and resident given alternative device to call for assistance and educated on how to use this, resident placed on q (every) 15minute watch. [name of MD] notified of this and stated to send resident to ER for evaluation. EMS called, mobile crisis outreach team as well as EMTs (Emergency Medical Technicians) arrived and assessed resident. Resident left facility via EMS to [name of hospital] for evaluation at approx. (approximately) 1545. Resident emergency contact [name removed] called by floor nurse to notify of transfer and resident current situation. No answer, message left by floor nurse. On 5/21/21 at 10:53 AM, a Nursing Progress Note documented Clarification from previous note, resident taken to [name of local hospital] and admitted to their Geropsych unit. On 5/25/21 at 2:24 PM, a Social Services Progress Note documented [name of mental health services] called today in regards to psych eval referral. They are aware he is in a psych facility at this time. They will see him on 6/7/21 if he is back in the facility at that time. Resident 45 was a readmission from a Geropsych unit on 5/27/21. A Care Plan Focus initiated on 5/27/21 and revised on 6/3/21, documented Resident has a history of suicidal ideation. Resident returned from an inpatient psychiatric stay on 5/27/21. A Goal initiated on 5/27/21 and revised on 8/16/21, documented Resident will be free of any self injury and have a reduction of suicidal ideation by review date. The Interventions initiated on 6/3/21, included the following: a. If resident expresses suicidal ideation assess for suicide risk and plan. Provided Crisis number to call if resident was in crisis. Send for inpatient psych placement if resident was high risk. b. Monitor, record, and report to MD any risk for harming others: increased anger, labile [NAME] or agitation, feels threatened by others or thoughts of harming someone. c. Monitor, record, and report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, and impaired judgement or safety awareness. d. Resident referred to [name of mental health services] for mental health follow up. [Note: A suicidal care plan was not initiated until approximately 4 months after resident 45's first expression of suicidal ideation and resident 45 was readmitted from a Geropsych unit.] The Hospital History of Present Illness note dated 5/21/21, documented that during a crisis evaluation, resident 45 continued to endorse [CONDITION(S)] and reported a plan to either use a knife to cut his wrists or overdose on his medications. The note further documented that since resident 45 arrived he has presented as anxious and dysphoric. Resident 45 has made several suicidal statements, and frequently repeats I want to die. Resident 45 had been prescribed [MEDICATION(S)] in the past, but was no currently prescribed any [CONDITION(S)] medications other than [MEDICATION(S)] for anxiety. Resident 45 denies he has ever experienced an adverse reaction to any medications. Resident 45 agrees to begin treatment with [MEDICATION(S)] to target his depressive symptoms. The Diagnosis, Assessment, and Plan documented resident 45 meets criteria for major depressive disorder. The Multi-Axial Assessment documented resident 45 with major depressive disorder, recurrent, severe without psychotic features with anxious distress. On 5/28/21 at 11:02 AM, a Social Services Progress Note documented [Resident 45] came back from psych hospital yesterday. He stated that he doesn't know if he feels any better but that he doesn't have a plan to hurt himself. Offered pt a new room with a new roommate that might be more talkative and he accepted. The room is closet (sic) to the nurses station as well. Pt does not have a call light in his room but is using a tab alarm to make his needs known at this time. Staff will be purchasing a bell today to use. On 5/28/21 at 12:11 PM, a Nursing Progress Note documented Resident is re-admit on 5/27. Was hospitalized for suicidal thoughts. Today resident stated they wanted to be dead. Asked resident if they wanted to kill themselves. Resident stated, 'They had been thinking about it'. Asked resident if they had a plan. Resident stated no. Resident also stated, 'It was all talk' and he would never do it. Nursing managers aware. On call MD made aware. Resident is on Q15 minute checks. They also have an alarm instead of a call button cord for safety measures. Will continue to monitor. A review of the forms that the staff documented 15 minute checks for resident 45 revealed that 15 minute checks were not provided on 5/28/21, 5/31/21, 6/1/21, 6/2/21, and 6/3/21. On 6/3/21 at 4:07 PM, a Social Services Progress Note documented Pt reported to PASRR (Preadmission Screening and Resident Review) evaluator that he is still depressed and wants to die and he has a plan to overdose. He also told her he didn't have the courage to do it. I went and talked to him and he said he would if he could get enough 'equipment' to do it. National Suicide Hotline called. I was placed on hold while they called him. Awaiting next step. On 6/3/21 at 5:06 PM, a Social Services Progress Note documented MCOT (Mobile Crisis Outreach Team) came to assess pt. They don't feel he needs to return to psych hospital. They do want 15 min (minute) checks continued. They discussed his appointment with [name of mental health services] counselor coming up on Monday and pt willing to talk to him in hopes of making him feel better. He did say he has no way of stepping in front of train and cant (sic) get enough meds to harm himself so although he wants to die he cant (sic) kill himself. On 6/5/21 at 5:25 PM, a Nursing Progress Note documented Aide (CNA) came to me and said that the pt made a comment to her that he no longer wants to live. I went and discussed the statement with the pt and he stated that he does not have a plan and that he is not suicidal. When asked if he wanted to go to the hospital, he stated that 'it depends on if they are just going to put me on the back burner'. I also asked him if he was feeling anxious which he said that he was not. Pt is currently on 15min checks, NP was notified at 1505 (3:05 PM), no new orders were given. A review of the forms that the staff documented 15 minute checks for resident 45 revealed that 15 minute checks were not provided on 6/5/21. The last 15 minute check form provided was dated 6/7/21. A PASRR Letter Of Determination dated 6/6/21, documented to continue 15 minute checks until resident 45 was free of suicidal thinking or until a qualified professional has determined he was at low risk of self-harming. [Note: The mental health services worker on 6/8/21, was unable to remove the 15 minute checks for resident 45. The next documented qualified professional visit was conducted on 7/23/21, by the consulting Licensed Clinical Social Worker (LCSW).] On 6/8/21 at 1:54 PM, a Nursing Progress Note documented Pt seen by [name of mental health services] today. He will start seeing him weekly. He was not able to remove the q 15min checks at this time. They will continue until at least his next visit Wed. (Wednesday). On 6/29/21 at 2:13 PM, a Social Services Progress Note documented Received email from [name of mental health services] that they have been backed up related to PASRRs and they will call to schedule an appointment to see [resident 45] again. On 7/9/21 at 12:00 PM, a Social Services Progress Note documented Email sent to [name of mental health services] to get update on when they will be in again to see patient as they have not been in since first assessment. On 7/23/21 at 3:29 PM, a Social Services Progress Note documented by the consulting LCSW documented Met with resident to assess his mental status. Resident was hospitalized in May after suicidal ideation. Resident has been seen by [name of mental health services] for follow up. Resident described that at the time of his hospitalization he just wasn't happy with where he was at in life but that he does not have any thoughts of suicide currently. He has been using a bell instead of a call light; however, this does not appear to be necessary any longer. Recommend monitoring for suicidal statements, stockpiling pills, talking about death and/or giving away items. [Name of mental health services] to continue to follow up with counseling. On 8/19/21 at 12:32 PM, an interview was conducted with the Patient Care Coordinator (PCC). The PCC stated that resident 45 did not feel any different when he was readmitted after his stay at the psych hospital. The PCC stated she had called the crisis team after resident 45 was readmitted and the crisis team told her that resident 45 was in no immediate danger and to follow up with mental health services. The PCC stated the resource Social Worker met with resident 45. The PCC stated the resource Social Worker initiates care plans. The PCC stated she had made the referral to mental health services but mental health services did not think they were allowed in the facility. The PCC stated mental health services were essential and allowed in the facility. The PCC stated resident 45's statements were more anxious then suicidal. The PCC stated the NP made the medication change based on resident 45 being anxious and not suicidal. The PCC stated resident 45's call light was removed and resident 45 was provided with a bell. The PCC stated the resource LCSW decided that resident 45 could have the call light back. On 8/19/21 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if mental health services was unable to come to the facility she would arrange a telehealth visit. On 8/19/21 at 1:52 PM, an interview was conducted with the DON, the PCC, the Administrator, and the Corporate Resource Nurse (CRN). The DON stated mental health services would schedule with the provider when a referral was made. The DON stated she was not sure if follow up on the referral to mental health services for resident 45 was done. The CRN stated the PCC would followup with referrals to mental health services. The PCC stated she could not remember if she followed up with mental health services and she was trying to get better at that. The DON stated they were not excluding providers from the facility. The DON stated if mental health services did not respond to a referral an in house provider would see the resident. The DON stated an in house provider would include the MD, NP, or the Physician Assistant. The CRN stated they were told by mental health services they were back logged and the provider was out a lot this year. The DON stated the LCSW would provide consultation with the resident care plans. The DON stated it would depend on the care plan and who would update it. The DON stated if resident 45 needed assistance he was able to use the call light and staff would go in and talk with resident 45. The DON was asked about interventions to keep resident 45 safe during the time he was making suicidal statements. The DON stated they were looking for a room mate that resident 45 enjoyed speaking with and would talk with resident 45. The CRN stated the nurses would talk with resident 45 a lot and make him feel better. The DON stated the staff would spend time with resident 45. The Administrator stated resident 45 was encouraged to participate in activities and they were offered daily. The CRN stated activities was providing 1:1 activities to resident 45. The CRN stated that resident 45 made statements that suicide would not be intentional and it would be an accident. The CRN stated resident 45 had changed his behaviors to calling out instead of the suicidal statements. The DON stated resident 45 was having some anxiety and was not always redirectable. The DON stated when the NP spoke with resident 45 he stated the [MEDICATION(S)] was making him to tired. The CRN stated other antidepressant medication had been tried. The DON stated the [MEDICATION(S)] was tapered to start the [MEDICATION(S)] because resident 45 told the NP that he was anxious. The DON stated when resident 45 was readmitted the call light was removed and 15 minute checks were initiated for a short time until resident 45 was safe. The DON stated the Crisis Team was called after resident 45 was readmitted and resident 45 had his room changed so he would be closer to the nurses station for visualization and interaction. The DON stated resident 45 had stopped the suicidal statements.

Based on interview and record review, it was determined the facility did not ensure residents' drug regimens were free from unnecessary drugs- an unnecessary drug is any drug when used without adequate monitoring. Specifically, for 1 of the 26 sampled residents, the facility provided a resident with blood pressure medication outside of the prescribed parameters for use. Resident identifier: 27. Findings included: Resident 27 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/21 at 11:41 AM, resident 27 was interviewed. Resident 27 stated he had issues with dizziness when going from laying down to standing, and resident 27 stated because of this reason, the facility was watching his blood pressure readings and medication. On 8/18/21, resident 27's medical record was reviewed. A Nursing Note from 7/20/21 documented, Res (resident) seen by NP (Nurse Practitioner) today r/t (related to) ongoing dizziness when sitting or standing . New orders given for: .add to [MEDICATION(S)] to hold if SBP (Systolic Blood Pressure) < (less than) 110. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <110- Start Date: 7/21/21. The July and August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 7/23/21, resident 27 had a blood pressure reading of 108/78 mmHg (millimeters of mercury) prior to [MEDICATION(S)] administration. The [MEDICATION(S)] was coded as provided to resident 27. b. On 8/6/21, resident 27's had a blood pressure reading of 96/52 mmHg prior to [MEDICATION(S)] administration. The [MEDICATION(S)] was coded as provided to resident 27. On 8/18/21 at 12:57 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated resident 27 received a [MEDICATION(S)] medication for high blood pressure in the mornings. RN 1 stated there were parameters to keep in mind when administering the medication, and resident 27 should not receive [MEDICATION(S)] if the systolic blood pressure was below 110 because resident 27 had trouble with low blood pressures. RN 1 stated the nurse who administered the medication would be prompted to check and record resident 27's blood pressure prior to providing the [MEDICATION(S)], and the nurse should know if the systolic blood pressure was too low and resident 27 should not be provided [MEDICATION(S)]. On 8/18/21 at 1:23 PM, the Director of Nursing (DON) was interviewed. The DON was asked about the administration of resident 27's [MEDICATION(S)] medication. The DON stated the medication was given to resident 27 outside of the prescribed parameters on 7/23/21 and 8/6/21, and the DON stated the facility would have to complete some re-education with staff.

Based on interviews and record reviews, it was determined the facility did not maintain medical records on each resident that are complete and readily accessible. Specifically, for 2 of the 26 sampled residents, the facility did not have all recent physician or nurse practitioner visit notes within the residents' electronic medical record. Resident identifiers: 15 and 39. Findings included: 1. Resident 15 was most recently readmitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/21 at 12:25 PM, resident 15 was interviewed. Resident 15 stated he had experienced an issue with fluid accumulation in his ankles for the past couple months, and resident 15 stated nothing was being done at that time for the fluid accumulation in his lower extremities. Resident 15's medical record was reviewed on 8/19/21. An initial history and physical was available within resident 15's medical record dated 6/16/21. On 8/18/21 at 2:30 PM, the Director of Nursing (DON) was interviewed. The DON was asked about the location of other physician assessments of resident 15. The DON stated having to locate the assessments. An email received on 8/18/21 at 2:44 PM, from the DON included the following documents: a. A physician visit documented by a Nurse Practitioner (NP) dated 6/21/21. b. A physician visit documented by a NP dated 6/28/21. c. A physician visit documented by a NP dated 7/15/21. d. A physician visit by a Medical Doctor dated 7/15/21. [Note: The physician visit notes were unable to be located within resident 15's medical record for review.] The physician note completed by a NP dated 6/28/21 documented, [CONDITION(S)] BLE (bilateral lower extremities) 2.6% weight gain and 1 week Tubigrips [compression stockings] on the morning off at bedtime. On 8/18/21 at 12:57 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated being unaware of any interventions resident 15 had in place for fluid accumulation. RN 1 stated if there was an intervention it would be located within resident 15's Order Summary. A review of the Order Summary did not include orders for, 1 week Tubigrips on the morning off at bedtime, as expressed in the 6/28/21, NP visit note. [Note: The 6/28/21, NP visit note was unable to be located within resident 15's medical record.] 2. Resident 39 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 39's medical record was reviewed on 8/19/21. The medical record was reviewed regarding medication adjustments to anti-anxiety medication and included the following documentation: a. A Nursing note dated 7/26/21, documented, Note text: Res (resident) seen by NP, new order given for [MEDICATION(S)] to be scheduled TID (three times a day), b. A Nursing note dated 7/29/21 documented, Note Text: Pt (patient) seen by NP today. Vitals, orders, labs assessed. See new orders. On 8/17/21 at 2:42 PM, the DON was interviewed. The DON was asked the location of NP visit notes and assessments from 7/26/21 and 7/29/21. The DON stated she would have to locate the documentation. On 8/17/21 at 2:51 PM, an email was received from the DON which contained documentation of NP visits dated 7/26/21 and 7/29/21. [Note: The NP visit notes were unable to be located within resident 39's medical record for review.] On 8/17/21 at 10:48 AM, the Medical Records manager was interviewed. The Medical Records manager stated there was a pile of documents to be filed. The Medical Records manager stated that she tried to sort the documents and upload the records by category. The Medical Records manager stated It can get behind. On 8/19/21 at 10:31 AM, the DON was interviewed. The DON stated the facility was aware of an issue with having all physician's visits timely placed into the residents' medical records. The DON stated the facility had thought to either have the physicians document directly within the residents' medical record or have documentation sent directly to the Medical Records manager through a secure e-mail. The DON stated, at this time, the physician would see residents, documentation of visits occurs off-site and the physician then sends the documentation to the facility or brings in a paper copy. The DON was unable to quantify the time between a physician visit, when the facility received documentation of the visit, and when the documentation was accessible within the residents' medical record. On 8/19/21 at 10:39 AM, RN 2 was interviewed. RN 2 stated it had been an issue being able to locate physician visit notes within residents' medical records. RN 2 stated if she had a physician note to go back to it would help her better understand the residents' care. RN 2 reported at this time once the NP came to the facility any orders would be provided to the Assistant Director of Nursing, and then the orders would be communicated to the nurses.

Based on interview and record review it was determined, for 1 of 6 sampled residents, that the facility did not immediately notify the resident's physician when there was a significant change in physical status; a need to alter treatment; or a need to transfer or discharge the resident from the facility. Specifically, the facility did not inform the physician when a resident had a new onset of signs and symptoms and a change in condition. Resident identifier 6. Findings include: Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/14/2021 resident 6's medical records were reviewed. Review of resident 6's progress notes revealed the following: a. On 1/12/2021 at 5:46 AM, the night nurses' note documented Nurses collected a UA (urinalysis) this morning from pt (patient). When nurses called [resident's name] by her name she opened her eyes and looked towards us. Pt.'s left eye is drooping and not tracking objects with the other eye. When nurse asked pt. a question, pt. had an extremely hard time answering. Pt. is very weak. Nurse cleaned out pt.'s mouth and tried to get pt. to suck from a straw and pt. could not do this, she just bit down on the straw. When nurse put a small amount of water into pt.'s mouth pt. could not swallow, water just ran out the side of her mouth. Pt. also has a slight jerk all the time. Pt. is more alert then evening shift but defiantly not at her normal LOC (level of consciousness) two day ago when she could hold a conversation and sit up in her w/c (wheelchair). Morning meds (medication) where (sic) held r/t (related to) poor swallowing. Pt. needs to have a swallow evaluation done again if she could. The note was authored by Licensed Practical Nurse (LPN) 2. b. On 1/12/2021 at 9:55 AM, the day nurse note documented Pt showing decline in cognition and swallowing for the past 48 hours. NP (Nurse Practitioner) ordered hospital for assessment and evaluation due to increased speed of testing. Sent by non-emergent to [name of hospital]. Nurse admin (administration) notified, Family notified. The note was authored by Registered Nurse (RN) 2. On 4/15/21 at 11:22 AM, a telephone interview was conducted with LPN 2. LPN 2 stated that she recalled 6's name. LPN 2 stated she would notify the doctor if a resident had a decline in LOC or a change in condition. LPN 2 stated she would document the physician notification in the progress notes along with any new orders. The LPN stated that she would attempt to notify the doctor in a messaging application inside the electronic medical records. LPN 2 stated that the doctor did not always reply to the message due to the time of the night. LPN 2 stated that if she was unable to reach the doctor by the messaging app. she would call them directly. LPN 2 stated she would pass off any changes in the resident's condition to the nurse on the next shift. LPN 2 stated that signs and symptoms consistent with a stroke were drooping in the face, slurred speech, chest pain, and vital sign changes. LPN 2 stated that she would notify the doctor after calling 911, and would immediately send the resident to the emergency department. LPN 2 stated that the signs and symptoms that were documented in the progress note on 1/12/21 at 5:46 AM could be consistent with a stroke. LPN 2 stated that if the doctor was notified she would have documented it in the progress note as they are required to document everything that they witness. LPN 2 stated that she thinks she notified the day shift nurse, but was not able to recall. On 4/15/21 at 2:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the signs of a stroke were increased weakness, change in LOC, drooping of one side, unequal pupils, flaccidity on one side, face drooping, tongue shift midline, garbled speech or inability to speak, and a change in normal speech pattern. The DON stated that if a stroke was suspected that the resident would need to get to the hospital as soon as possible so that the hospital could diagnose and treat according. The DON stated that the window for thrombolytic treatment was 3 hours after onset of symptoms. The DON stated that the doctor should be notified of any change in resident condition. The DON stated that notification to the doctor would depend on the urgency of the situation, and notification could be made after an event. Decisions sometimes warrant more speed than waiting for a physician.

Based on interview and record review it was determined, for 1 of 6 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, staff identified new signs and symptoms (s/sx) consistent with a stroke and the facility did not treat the change in condition for 4 hours after it was first identified. Resident identifier 6. Findings include: Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/14/2021 resident 6's medical records were reviewed. Review of resident 6's progress notes revealed the following: a. On 1/12/2021 at 5:46 AM, the night nurses note documented Nurses collected a UA (urinalysis) this morning from pt (patient). When nurses called [name omitted] by her name she opened her eyes and looked towards us. Pt.'s left eye is drooping and not tracking objects with the other eye. When nurse asked pt. a question, pt. had an extremely hard time answering. Pt. is very weak. Nurse cleaned out pt.'s mouth and tried to get pt. to suck from a straw and pt. could not do this, she just bit down on the straw. When nurse put a small amount of water into pt.'s mouth pt. could not swallow, water just ran out the side of her mouth. Pt. also has a slight jerk all the time. Pt. is more alert then evening shift but defiantly not at her normal LOC (level of consciousness) two day ago when she could hold a conversation and sit up in her w/c (wheelchair). Morning meds (medication) where (sic) held r/t (related to) poor swallowing. Pt. needs to have a swallow evaluation done again if she could. The note was authored by Licensed Practical Nurse (LPN) 2. b. On 1/12/2021 at 9:55 AM, the day nurse note documented Pt showing decline in cognition and swallowing for the past 48 hours. NP (Nurse Practitioner) ordered hospital for assessment and evaluation due to increased speed of testing. Sent by non-emergent to [name of hospital]. Nurse admin (administration) notified, Family notified. The note was authored by Registered Nurse (RN) 2. It should be noted that the notification to the NP was not made until 4 hours after the identification of a drooping eye and difficulty answering questions. On 4/15/2021 at 10:01 AM, an interview was conducted with LPN 1. LPN 1 stated that she had worked at the facility for approximately 7 months, and had worked with resident 6. LPN 1 stated that she recalled that prior to resident 6's transfer to the hospital she was sleepier. LPN 1 stated that the s/sx of a stroke were weakness, facial drooping, vital sign changes, and difficulty with speech. LPN 1 stated that the time from identification of symptoms to treatment was important because it would affect the treatment. LPN 1 stated that she can't remember how long but there is a mediation that can be given within a few hours for the clot. LPN 1 stated that facial drooping, difficulty talking with increased confusion, and not tracking with the eyes could indicate a stroke. LPN 1 stated that a delay of 4 hours would be prolonged because you would want to get treatment as soon as possible. On 4/15/21 at 10:45, a interview was conducted with Registered Nurse (RN) 2. RN 2 stated that he recalled resident 6 but did not recall the specifics of her care as it was so long ago. RN 2 stated that he imagined that she was having a change in condition or abnormal lab value from the review of progress notes. The RN stated that based off the progress note it appeared that resident 6's decline was passed off in report from the night shift on 1/12/21. After review of the progress note on 1/12/21 at 9:55 AM, RN 2 stated that he would have notified the doctor at the time the note was documented, and that would have been towards the end of morning medication pass. RN 2 stated that a non-emergent transfer meant that the resident was not in immediate peril, but they would still arrive quickly. RN 2 stated that he did not recall the specific time that the resident was transferred out of the facility, but he recalled that it was in the morning. RN 2 stated that he should have documented the time of transfer in the progress note. RN 2 stated that the s/sx of a stroke were new confusion, flaccidity on one side, decreased LOC, drowsiness, drooping on one side of face with eye or lip, gait imbalance, and trouble speaking. RN 2 stated that there was a time frame for the administration of TPA (tissue plasminogen activator) with a stroke and it needed to be administered within 2 hours or as fast as possible. If he suspected a stroke he would have sent her emergent transport. RN 2 did not recall if any of those s/sx were passed off in report from the night nurse. RN 2 stated that resident 6 was kind of confused at baseline, she was speaking prior to the change in condition, but not very with it. RN 2 stated that the decrease in LOC was she went from smiling to mostly sleeping. RN 2 reviewed the night nurse progress note that was documented prior to his on 1/12/21. RN 2 stated that drooping of the eye, not tracking objects, having a hard time answering questions, not being able to drink from a straw, decrease LOC from holding a conversation and sitting up in a wheelchair were symptoms that could indicate a stroke. RN 2 stated that he imagined that the night nurse reported those symptoms to him if it was in the progress notes, but that he did not recall. On 4/15/21 at 11:22 AM, a telephone interview was conducted with LPN 2. LPN 2 stated that she recalled resident 6's name. LPN 2 stated she would notify the doctor if a resident had a decline in LOC or a change in condition. LPN 2 also stated she would pass off any changes in the resident's condition to the nurse on the next shift. LPN 2 stated that signs and symptoms consistent with a stroke were drooping in the face, slurred speech, chest pain, and vital sign changes. LPN 2 stated that she would notify the doctor after calling 911, and would immediately send the resident to the emergency department. LPN 2 stated that notification would be made after a transfer out of the facility because don't have time to wait for the doctor to respond. LPN 2 stated that there was probably a timing element with the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 2 stated that she thinks she notified the day shift nurse, but was not able to recall. LPN 2 stated that she would call 911 if she suspected a stroke and not non-emergent transport. LPN 2 stated that the response time for 911 was 1-5 minutes and non-emergent was a couple of minutes longer. LPN 2 stated that the response time was pretty fast due to the facility's close proximity to the hospital. It should be noted that the facility was directly across from the local hospital. On 4/15/21 at 2:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the signs of a stroke were increased weakness, change in LOC, drooping of one side, unequal pupils, flaccidity on one side, face drooping, tongue shift midline, garbled speech or inability to speak, and a change in normal speech pattern. The DON stated that if a stroke was suspected that the resident would need to get to the hospital as soon as possible so that the hospital could diagnose and treat according. The DON stated that the window for thrombolytic treatment was 3 hours after onset of symptoms. The DON stated that the doctor should be notified of any change in resident condition. The DON stated that notification to the doctor would depend on the urgency of the situation, and notification could be made after an event. Decisions sometimes warrant more speed than waiting for a physician.

Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility failed to ensure that a symptomatic Department Head (DH), who subsequently tested positive for COVID-19, was screened accurately and notification and evaluation was completed per the facility protocol, that negative [MEDICATION NAME] tests were followed with a molecular confirmation test, and that the symptomatic DH was excluded from work pending the results of the molecular Polymerase Chain Reaction (PCR) tests. The failure had the potential to expose 10 facility residents who have continued to test negative for COVID-19. In addition, staff and visiting essential personnel who have continued to test negative for COVID-19 were also at an elevated risk. Additionally, the facility policy and procedures for COVID-19 did not address staff screening, monitoring and eye protection use. Staff were also observed without a face shield in areas of the facility where resident encounters occurred. Resident identifiers: 1, 2, 3, 6, 9, 10, 11, 12, 13, and 14. On 2/11/2021 at 2:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Specifically, the facility failed to ensure that a symptomatic DH was fully evaluated and excluded from work until a confirmation PCR test result was obtained. Notice of IJ was given verbally to the Administrator, Director of Nursing (DON), Corporate Resource Nurse (CRN) 1, and CRN 2 and they were informed of the findings of IJ pertaining to F880. On 2/12/2021 the Administrator and DON provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 2/12/2021 at 11:00 PM: · Medical Director was notified at 1500 (3:00 PM) on 2/11/2021 of IJ. · (Title omitted) immediately educated on proper reporting of symptoms and recording of symptoms in screening log. · Contact tracing completed for employee exposure to positive employee, known contacts had PCR testing on 2/10/2021 with negative PCR results. · Residents identified as exposed are on quarantine with increased symptom monitoring. Both had negative PCR test on 2/10/21. · All staff on shift were immediately trained on 2/11/2021-2/12/2021 and all subsequent staff will be trained PRIOR to working their next shift on the following: o All staff will enter the building through a single door (breakroom door) for screening purposes. If screening reveals symptomatic persons, testing will be completed outside and symptomatic persons will not enter facility. If employees are coming for testing because they are symptomatic, testing will be completed outside of the facility. o Employee screening will be completed electronically using 'Simpliscreen' to identify COVID-19 symptoms. This software will automatically notify nurse managers and administrator of failed screening with positive symptoms as well as prompt employee to contact nurse manager in the event symptoms are reported. o Education on the proper reporting of symptoms and procedure if symptoms are present. This education to include not minimizing illness or symptoms, proper utilization of our sick policy, encouragement of staff that if they do not feel well they should not come in, and education on procedure to follow if peers are symptomatic. o If a staff member develops symptoms during their shift the nurse manager on-call will be notified immediately and give further guidance. o Staff will demonstrate competency related to COVID-19, a POC (point of care) test will be performed. In the event that the POC test was negative but symptoms are consistent with COVID-19, a PCR test will be performed, and staff will not be allowed to work until these results are obtained. o Updated policy and procedure will be reviewed. · Posting on staff entrance providing notice and direction for new Policy and Procedure, algorithm for testing and screening posted throughout the building. · Audits performed daily on accuracy for those working in the facility. · IDT (Interdisciplinary Team) QA (Quality Assurance) to review monthly. On 2/16/21, while completing the Focused Infection Control survey, surveyors conducted an onsite revisit to verify immediate jeopardy had been removed. The surveyors determined the immediate jeopardy was removed, as alleged, on 2/12/2021 at 11:00 PM. Subsequent to the removal of immediate jeopardy, the remaining non-compliance was determined to pose a potential for more than minimal harm to residents who have continued to test negative for COVID-19. Findings include: 1. On 2/8/2021 at 10:12 AM, an interview was conducted with the DON. The DON stated that one DH tested positive for COVID-19 on 2/4/2021 with the [MEDICATION NAME] Point of Care (POC) test. The DON stated that the DH complained of cold-like symptoms. The DON stated that the DH was tested with both the BD Veritor and(NAME)BinaxNOW [MEDICATION NAME] tests. The DON stated that on 2/4/2021 the DH entered the facility, marked that she had a sore throat on the symptom screening questionnaire, and reported that she felt like it was cold symptoms. The DON stated that she screened in the employee break room off the 200 hallway, entered the 200 hallway and walked to her office at the end of the 300 hallway, and then went to the conference room for morning meeting. The DON stated that the meeting had not started yet and the DH was removed from the conference room immediately. The DON further stated that to her knowledge the DH did not have any contact with residents on 2/4/2021. The DON stated that the DH was inside the building for approximately 30 minutes. The DON stated that she conducted contact tracing for the 72 hours prior to the DH testing positive and identified 2 residents that the DH had contact with, resident 1 and resident 2. The DON stated that resident 1 and resident 2 were on contact/droplet precautions due to the exposure to the DH. The DON stated that the DH was quarantining at home as of 2/4/2021. The DON stated that all staff self-screened at the beginning of their shift in the break room and screening consisted of a temperature check at the beginning of the shift and at the end of the shift and a symptom screening questionnaire. The questionnaire asked the following Yes/No questions; shortness of breath (SOB), cough, sore throat, contact outside the facility with someone suspected of having or diagnosed with [REDACTED]. The DON stated that typically staff should call before coming to the facility if they had any symptoms. The DON stated that staff were educated on the signs and symptoms of COVID-19 and to call their direct supervisor should they have any symptoms. Then they would be directed to come to the facility to be COVID-19 tested . The DON stated that she conducted the POC test outside the building, and did not allow symptomatic staff to come inside the building. The DON stated all the residents on the 300 hallway were COVID recovered and within the 90 day post recovery window. The DON stated that they did not have any COVID recovered residents that were past the 90 day post infection window. The DON stated that residents that had never tested positive for COVID were located on the 100 and 200 hallway. The DON stated that all the COVID negative residents were in private rooms with the exception of resident 1 and resident 2, who were cohorting. The DON stated that prior to exposure to the DH, resident 1 and resident 2 had been COVID negative. On 2/9/2021 at 1:14 PM, a telephone interview was conducted with the DH. The DH stated that she went to the facility and was tested on Monday (2/1/2021), Tuesday (2/2/2021), and Wednesday (2/3/2021). The DH stated that on Monday (2/1/2021) she entered the facility for surveillance testing and did not work that day. Testing was conducted in the lab room. The DH stated that on Tuesday (2/2/2021) and Wednesday (2/3/2021), she conducted the [MEDICATION NAME] test herself in the lab room. The DH stated that she had been trained on how to perform the [MEDICATION NAME] test. The DH stated that if they had any signs and symptoms (s/sx) they needed to be tested . The DH stated that on Monday (2/1/2021), Tuesday (2/2/2021), and Wednesday (2/3/2021) she had a head cold with nasal congestion, runny nose, allergies [REDACTED]. The DH stated that on Thursday (2/4/2021), the sore throat was more pronounced from drainage. The DH stated that she was not sure if the process was to notify management if she had symptoms so they could test her. The DH stated that on Tuesday (2/2/2021) and Wednesday (2/3/2021) she did not notify management but instead tested herself. The DH stated that this was common practice. The DH stated that on Thursday (2/4/2021) she entered the building in the break room and clocked in. The DH stated that she then conducted a self-screen with a temperature check, and symptom screening questionnaire. The DH stated that she checked the boxes for a head cold, cough and sore throat on the questionnaire. The DH stated that she then donned a clean surgical mask and face shield and took her purse and coat to her office at the end of the 300 hallway. The DH stated that she did not come into contact with any residents on the 300 hallway. The DH stated that she was supposed to go get tested or go notify the head nurse. The DH stated that because she had been tested 3 days in a row, and all three [MEDICATION NAME] tests were negative, she did not notify anyone. The DH stated that after she went to her office she went to the morning meeting. The DH stated that she did not conduct an [MEDICATION NAME] test prior to going to the morning meeting because she was in a hurry to make it to the meeting. The DH stated that at the meeting all of the management team was present and included the Medical Records staff whom the DH sat next to, the Marketing Director, Administrator 1, Certified Nurse Assistant (CNA) Coordinator, the Housekeeping Director, the Dietary Manager, the DON and the CRN 1. The DH stated that the DON came in and asked if she had been tested yet, and she replied no. The DH stated that she walked down the 100 hallway to the testing/lab room, and conducted her own tests. The DH stated that both the BinaxNOW and Veritor [MEDICATION NAME] tests were positive. The DH stated she proceeded to her office to gather her belongings and then left the building immediately. Review of the line listing for COVID testing of staff for January 2021 revealed that 6 out of 8 staff members present in the morning meeting were COVID negative. The DON subsequently provided a list of 10 COVID negative residents and an email stating that there were 35 COVID negative staff currently in the building. The 10 COVID negative residents were documented as resident 1, 2, 3, 6, 9, 10, 11, 12, 13, and 14. Review of the employee screening log revealed the following for the DH: a. On 2/1/2021 no documentation was provided for an employee screening log for the DH. It should be noted that during the telephone interview the DH had reported entering the building for surveillance testing. b. On 2/2/2021 the DH temperature at the beginning of the shift, time unknown, was documented as 98.2 degrees Fahrenheit (F) and at 5:00 PM was 98.7 degrees F. The DH checked No to shortness of breath (SOB), cough, sore throat, contact outside the facility with someone suspected of having or diagnosed with [REDACTED]. It should be noted that during the telephone interview the DH reported having symptoms on this day. c. On 2/3/2021 the DH temperature at the beginning of the shift, time unknown, was documented as 98.2 degrees F and at 5:22 PM was 98.3 degrees F. The DH checked Yes to a cough and sore throat. d. On 2/4/2021 the DH temperature at the beginning of the shift, time unknown, was documented as 98.2 degrees F. The screening log did not have an end of shift temperature documented. The DH checked Yes to a cough and sore throat. Review of the testing results revealed that on 2/1/2021, 2/2/2021, and 2/3/2021 the DH tested negative on the(NAME)BinaxNOW [MEDICATION NAME] test. On 2/4/2021 the(NAME)BinaxNOW [MEDICATION NAME] test results for the DH was positive for COVID-19. Review of the facility's Policy and Procedure for Emerging Infectious Disease (EID): Coronavirus Disease 2019 (COVID19) under Monitor and Manage III and Exposed Healthcare Personnel provided a link to the CDC; https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. The policy and procedure did not address the facility's specific practice of screening Healthcare Workers (HCW), exclusion from work for symptomatic HCW, and testing practices for symptomatic HCW. Review of the education that was provided to staff in a staff meeting on 8/4/2020 documented, Please ensure that you are filling out the symptom tracker accurately at work when you are temping in and temping out. Remember if you have symptoms you are not allowed to work the floor until you have clearance by the on call nurse. Review of the attendance log revealed that the DH had attended the meeting. On 2/9/2020 at 1:40 PM, a telephone interview was conducted with the DON. The DON stated that the process for screening staff when they were symptomatic was the staff member should notify the direct manager or nurse manager to test them. The DON stated that ideally notification should be made by telephone. They do have a mask and face shield on so they can come to the office to notify. The DON stated that they did not have a specific policy stating to notify the manager if the HCW was symptomatic. The DON stated that the reasoning behind telephone notification was so that symptomatic HCW were not exposed to other staff members. The DON stated that the DH should have notified her. The DON stated that on 2/4/2021 she accompanied the DH to the testing room and rechecked her temperature to see that she was temping accurately and then tested her. On 2/10/2021 at 4:10 PM, a follow-up telephone interview was conducted with the DON. The DON stated that the DH did not notify her that she had symptoms on 2/3/2021 or 2/4/2021, but she went and tested herself on 2/3/2021 and notified Administrator 1 that she had tested negative. She was negative at that point and continued to work for the day. The DON stated that resident 1 and resident 2 had contact with the DH on Tuesday (2/2/2021). The DON stated that the DH was wearing a gown, gloves, surgical mask and face shield during that contact. The DON stated that the residents were already cohorting prior to having exposure on 2/2/2021. The DON stated that the DH reported that she was going over a shopping list for resident 2. The resident had items that she wanted the DH to buy for her. The DON stated that the DH went shopping for resident 2 and delivered those items to the resident. The DON stated that on 2/4/2021 a staff member came in behind the DH and noticed that the DH had marked yes to symptoms on the screening log. That staff person then informed the DON that the DH had marked yes to s/sx. The DON stated that she could not recall who the staff member was, but that it was someone in the morning meeting. The DON stated that Administrator 1 did not inform her that the DH was symptomatic on 2/3/21, but she was negative so he wouldn't have thought there was a problem. The DON stated 10 residents in the facility have not had COVID-19 or have not recoved from COVID-19 within the previous 90 days. Those 10 residents were identified as resident 1, 2, 3, 6, 9, 10, 11, 12, 13, and 14 On 2/11/2021 at 1:49 PM, a telephone interview was conducted with Staff 1. Staff 1 stated that she shared an office with the DH. Staff 1 stated that the office was located at the end of the 300 hallway, past all the resident rooms. Staff 1 stated that she had contact with the DH on Tuesday (2/2/2021) through Thursday (2/4/2021) and the DH had said she had a cold on all three days. Staff 1 stated that the DH looked like she wasn't quite herself, and she complained of a sore throat. Staff 1 stated that every day the DH was COVID tested and they said she was fine. Staff 1 stated that she did not mention to management that the DH was not feeling well because the DH was already talking to other members of the management team. On 2/11/2021 at 12:15 PM, a telephone interview was conducted with the DON. The DON stated that if a staff member was symptomatic with symptoms consistent with COVID they would perform an [MEDICATION NAME] test. If the [MEDICATION NAME] test was negative, the staff was allowed to work if the symptoms were minor such as a tickle in the throat. If the staff member's symptoms were major such as a fever greater than 100.4 F they would be sent home and not allowed to work. The DON stated that if the [MEDICATION NAME] test was negative, a confirmatory PCR test was not performed. The DON stated that the DH reported the negative results of her [MEDICATION NAME] test on 2/2/2021 and 2/3/2021 to the Administrator 1. The DON stated that this information was not reported to her. Review of the CDC's guidance on Preparing for COVID-19 in Nursing Homes documented under Evaluate and manage Healthcare Personnel stated As part of routine practice, ask HCP (Healthcare Personnel) (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. The guidance further stated to Remind HCP to stay home when they are ill, and HCP with suspected COVID-19 should be prioritized for testing. Additionally, the guidance stated that if HCP developed symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace immediately. The guidance was last updated on November 20, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Review of the CDC's guidance on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 stated .symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. The guidance further stated to Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19. And Properly manage anyone with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection or who has had contact with someone suspected or confirmed with [DIAGNOSES REDACTED]-CoV-2 infection: Healthcare personnel (HCP) should be excluded from work The guidance was last updated on December 14, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html. Review of the CDC's guidance on [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Testing in Long Term Care Facilities documented under Considerations for interpreting [MEDICATION NAME] test results in long-term care facilities stated for testing of symptomatic HCP, If an [MEDICATION NAME] test is presumptive negative, perform NAAT (nucleic acid amplification tests) immediately (e.g. within 2 days) and .symptomatic HCP should be excluded from work until NAAT results return. The guidance was last updated on January 7, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-[MEDICATION NAME]-testing.html. Review of the State Agency guidance on Guidelines for Using Point-of Care [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Tests in Long-Term Care Facilities documented under When to use the [MEDICATION NAME] test and interpreting results stated The POC [MEDICATION NAME] test is most useful for testing a symptomatic patient or HCW However, false negatives may occur, so negative tests need to be followed up with a standard PCR test. The guidance was last updated on 8/8/2020. https://coronavirus.utah.gov/long-term-care-facilities/. 2. Review of the facility employee screening log for January and February 2021 revealed the following staff had marked yes to s/sx consistent with COVID-19: a. On 1/11/2021, Housekeeper (HK) 1 checked yes to a cough on the symptom screening questionnaire. Review of the surveillance testing log revealed that HK 1 tested negative with the(NAME)BinaxNOW [MEDICATION NAME] test on 1/11/2021, 1/14/2021 and 1/18/2021. Housekeeper 1 was not listed on the employee positive list for COVID-19. b. On 1/13/2021, Registered Nurse (RN) 1 checked yes to contact outside the facility with someone of having or diagnosed with [REDACTED]. No test results could be found for 1/13/2020. RN 1 was not listed on the employee positive list for COVID-19. c. On 1/15/2021, CNA 3 checked yes to a cough on the symptom screening questionnaire. On 1/21/2021 CNA 3 checked yes to a cough and a sore throat on the symptom screening questionnaire. Review of the surveillance testing log revealed that CNA 3 tested negative with the(NAME)BinaxNOW [MEDICATION NAME] test on 1/18/2021, 1/23/2021, and 1/25/2021. CNA 3 was not listed on the employee positive list for COVID-19. On 2/10/2021 at 12:20 PM, a telephone interview was conducted with CNA 3. CNA 3 stated that she entered the building through the laundry area and conducted the screening in the break room. The CNA stated that screening consisted of a temperature check and a symptom screening questionnaire. The CNA stated that if they checked yes on any s/sx. they were to call the on call nurse and see what they said to do. The CNA stated that she has never had to notify the on call nurse. The CNA stated that she had not tested positive for COVID-19. The CNA stated that on 1/15/2021, the symptom screen was accidentally checked. CNA 3 stated that she did not have a cough and she did not notify the nurse. The CNA stated that on 1/21/2021 that she contacted the CNA Coordinator before coming into work to notify of the cough and a sore throat. The CNA stated that she was instructed to come to the facility to get tested . CNA 3 stated that she entered the break room and filled out the symptom screening questionnaire. The CNA stated that the CNA Coordinator then instructed her to go to the DON's office for testing. CNA 3 could not recall who conducted the COVID-19 test. CNA 3 stated that she stayed in the office and waited for the results, and no one else was present. It should be noted that the CNA had to pass through the 200 hallway with COVID negative residents to reach the DON's office for testing. CNA 3 stated that she tested negative and was allowed to work a shift. On 2/10/2021 at 5:08 PM, a telephone interview was conducted with HK 1. The housekeeper stated that the screening process was a temperature check and to log it on the symptom screening questionnaire. HK 1 stated that if staff mark yes to any symptoms, they were supposed to call the on call nurse and notify your supervisor. The housekeeper stated that she marked yes to a cough, and it was on a testing day. HK 1 stated that she took the test before the shift and it was negative. HK 1 stated that she informed the the manager of housekeeping and she told her what the protocol was. HK 1 stated that the test was done in the lab room located on the 100 hallway. HK 1 stated that she waited until the test result came back before going back into the building to work. On 2/11/21 at 9:00 AM, an interview was conducted with RN 1. RN 1 stated that staff entered the building through the 200 hall break room. RN 1 stated that staff filled out the questionnaire about symptoms and their temperature, and should notify the nurse on call from the management team if they had symptoms. RN 1 stated that staff tested on Mondays in the lab on the 100 hall. RN 1 stated that staff would wait there for their results, then begin their shift. RN 1 stated that some staff did not screen for COVID-19 symptoms if they were just coming in to get tested , because they were not working directly with patients. RN 1 stated that at times, the nurse manager on call was not listed in the break room. RN 1 stated that the information of the on-call nurse manager was available in the employee report room, in the center of the 300 hall. RN 1 stated that if staff had symptoms, they should not enter the building, but should wait in the break room or outside for a manager. 3. Review of the facility's COVID-19 symptom screening form revealed the following omissions: a. On 1/9/21, one staff member did not report their temperature. b. On 1/11/21, two staff members did not complete the question about cough. c. On 1/12/21, one staff did not complete the sore throat section. d. On 1/20/21, two staff members did not complete the contact section. e. On 1/25/21, one staff member did not complete the international travel section. 4. On 2/15/2021 at 1:55 PM, an observation was made of Licensed Practical Nurse (LPN) 1. LPN 1 was observed wearing a face mask and eye glasses. No face shield was present. LPN 1 was immediately interviewed and stated that she came to the facility for surveillance testing. LPN 1 stated that she entered the facility through the break room, conducted screening, and walked to the lab for testing. It should be noted that the LPN had to walk through the 200 hallway and 100 hallway to reach the lab room located at the end of the 100 hallway. Residents were residing in both hallways. On 2/15/2021 at 2:14 PM, an interview was conducted with the DON. The DON stated that staff who entered the building were to wear a surgical mask and a face shield or goggles for eye protection. The DON stated that LPN 1 was wearing her prescription glasses without a face shield or goggles that covered the sides of her glasses. The DON stated that LPN 1 should have worn a face shield or goggles over her glasses. On 2/15/2021 at approximately 2:17 PM, an observation was made of the Speech Therapist (ST). The ST was walking a resident down the hallway next to the lab room and waiting area. The ST was observed wearing a surgical mask and no face shield. The DON stopped the ST and asked her to place a face shield on. The ST was observed to walk back to the therapy gym and obtain a face shield. An immediate interview was conducted with the ST. The ST stated that she had just removed her face shield to wipe her eyes and had forgotten to place it back on. The ST stated that she universally wore a surgical mask and eye protection from the time she entered the facility and while working with residents. The ST stated that as part of her duties as a ST, she conducted cognitive therapy, swallow therapy, and evaluated therapeutic diets for residents based on their assessed swallow ability. The ST stated that during swallow therapy the resident would remove their mask and would swallow different types of food with various consistencies. The ST would observe the swallow technique and any observed difficulties, such as coughing or choking. The ST stated that during her evaluation with residents she wore gloves in addition to the mask and face shield. The ST stated that she only wore a gown if the resident was on any type of transmission based precautions, but did not universally wear a gown while conducting swallow therapy. Review of the staff audits for PPE usage in January 2021 revealed that two staff members were not wearing gowns when required. A housekeeper did not have not have a gown on inside of an isolation room, and a CNA did not have a gown on in a room identified as requiring one. The audit revealed that education was provided to both staff members. Review of the facility's Policy and Procedure for Emerging Infectious Disease (EID): Coronavirus Disease 2019 (COVID19) under Personal Protective Equipment (PPE) stated HCP must receive training on and demonstrate an understanding of when to use PPE; what PPE is necessary; how to properly don, use and doff PPE in a manner to prevent self-contamination; how to properly dispose of or disinfect and maintain PPE; and the limitations of PPE. The policy and procedure further broke down PPE into gloves, gowns, respiratory protection, use of caution when performing aerosol-generating procedures, diagnostic respiratory specimen collection, and duration of isolation precautions for PUIs (person(s) under investigation) and confirmed COVID-19 patients. The policy stated that for gown use to Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. The policy also stated Some procedures performed on COVID-19 patients could generate infectious aerosols. In particular, procedures that are likely to induce coughing .should be performed cautiously and avoided if possible. The policy and procedure did not address the use of eye protection nor the use of gowns outside the resident room and during aerosol-generating procedures (i.e. therapy room with swallow studies). Review of the CDC guidance on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions. The guidance was last updated on February 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html#useppe .

Based on interview and record review it was determined, for 2 of 8 sampled residents, that the facility did not ensure that the resident was free from abuse, neglect, and misappropriation of resident property. Specifically, a Certified Nurse Assistant was reported to have taken money from two residents and one resident's missing wallet was located inside the CNA's car. Resident identifiers: 7 and 8. Findings include: 1. On 2/8/2021 the facility abuse investigation documentation was reviewed. Review of the facility Resident Abuse Investigation Report Form documented that the incident was reported on 10/25/2020 at 10:30 AM by Receptionist 1. The form identified Certified Nurse Assistant (CNA) 1, CNA 2 and CNA 4 as witnesses to the incident. The report identified CNA 5 as the name of the person accused of misappropriating money from Resident 7 and Resident 8. Resident 7 stated that she had $200 in her wallet, in her purse, but the wallet and money were missing on 10/25/2020. The report documented that resident 7's family member was contacted and stated that the resident had closer to $500 dollars in her wallet ($315 from Social Security and $200 before COVID). Resident 8 stated that on the evening of 10/24/2020, she had $40 in her room. Resident 8 stated that sometime on the morning of 10/25/2020, the money went missing. The summary of the investigator's findings on the report documented that, based on statements from staff and the fact that Resident 7's wallet was found in CNA 5's car after her 10:00-10:30 AM lunch break, the facility determined that abuse did occur. The corrective action documented on the report was that CNA 5 was terminated and $500 was reimbursed to Resident 7 and $45 was reimbursed to Resident 8. Review of the daily schedule for 10/25/2020 revealed that CNA 5 was scheduled for the day shift and was assigned to rooms 305 to 311. It should be noted that CNA 5 was assigned to provide care for resident 7 and resident 8 on 10/25/2020. Termination paperwork for CNA 5 documented date of termination was 10/28/2020 and the last day worked was 10/25/2020. Termination was documented as due to misconduct. Resident 7 was reimbursed by the facility $500, and it was deposited into her trust account at the facility on 12/11/2020, almost 7 weeks after the money went missing. Resident 8 was reimbursed by the facility $45 on 10/25/2020. Review of the witness statements revealed the following: a. Receptionist 1 provided a typed statement with a signature. The statement was not dated or timestamped. The statement read as follows, I arrived at work at 9:15 am and was approached by (CNA 2), the cna. She told me that they had found [MEDICATION NAME] in 305B purse but she didn't want to give them to staff. (Staff 4) came up to me right after and told me that 309 was missing money out of her envelopes. I told her to have the resident fill out a grievance form so that I can give it to (Administrator 1) to handle this. She told me the resident didn't want to fill one out because she didn't want to get anyone in trouble or be in trouble herself. I took the paper to the resident and she still refused to fill it out. Resident was not sure how much there was. She did state that the money must have gone missing between the hours of 7 am and 10 am. 309 stated this was the time she was asleep. Staff asked if there was any other places the money maybe at. She stated there was not and she knows she had the money around 7 am because she seen it. Staff did look in the places where 309 stated the money was and there was nothing. Staff filled out the form to give to (Administrator 1) regarding missing money that was around $40 to 50. I went back to the front desk and was approached by (CNA 4). I was told 305 B wallet was missing now and she had over $200 dollar in it, including pictures. I was also told that there was a staff member, (CNA 5) who was crying earlier in the morning by (CNA 2) that was in need of money to buy diapers for her child. I received a call a few minutes later from (CNA 5) stating she was going to be late from her break because she had to buy diapers for her child since he only had three left. This raised a red flag of two people missing money so I filled out a paper for 305 B about her missing money. I was approached by (Staff 4, CNA 4 and CNA 2) telling me that they had found the wallet of 305 B. I asked where did they find it and told it was in CNA 5's car. I asked how they got it and was told (CNA 4) was walk by the car. She noticed the wallet on the floor of CNA 5's car. She tried the door and it was unlocked so she took a picture of the wallet. (CNA 4) took the wallet because it matched the descriptions of the wallet 305 B was missing.The police officer arrived around 12:05 PM. We first went to 305 B. she told him that staff came into her room looking for pills and she was confused on why they were doing this. She than (sic) looked in her purse and noticed the wallet was missing after staff left her room. 305 B told the officer she (sic) this is not the first time of this happening. She stated there was over $200 in the wallet with family pictures. He told her there would be a report filed for his investigation. Next, we spoke with 309 A, regarding her missing money. She stated first she didn't want to be in trouble and that maybe someone needed the money more than she did. she also said to the officer it was the only money she had .He asked if we had cameras in any part of our building. I told him they are along the halls and in the back by the dumpster. He told me to have someone look at the cameras from when all the staff arrived until the time (CNA 5) had left for the day. b. CNA 4 provided a hand written statement with a signature. The statement was dated 10/26/2020 without a timestamp. The statement read as follows, I got to work at 10 am, and around 11 am I heard over the radio (CNA 5) asking the nurse if 305 b can have aspirin in her purse. about 30 min later I hear from (Receptionist 2) that 2 residents are missing money. one of the residents that is missing money is the one that (CNA 5) had been in her purse to find the meds, so me and another co worker (CNA 2) go to the parking lot to look inside her car windows to see if we can see the wallet that is missing (we did). I go back outside to get the wallet that fits the description of the wallet that is missing. I take it directly to (Receptionist 2) and she takes a picture to show 305 b. It is then locked up. c. CNA 1 provided a typed written statement. The statement was dated on 10/27/2020 without a timestamp. The statement read as follows, Sunday at 8:35 am we are passing hall trays down the 300 hall for breakfast. I overheard (CNA 5) talking to (CNA 2) stressed because she did not have the money to buy her son diapers. Before breaks at 10:00 (CNA 5) calls over the headset asking (RN 3), the nurse, if 305B is allowed to have 800 mg [MEDICATION NAME] pills in her purse. I walked into 305B to see (CNA 5) standing at the end of the bed and (Resident 7) looking through her purse. Before (CNA 5) left to go on break she claimed to have seen another pill bottle in her purse, and asked me to find it. I proceeded to ask (Resident 7) if she had anything. She stated she could not find her wallet, so I began helping her try to find it. While in the room she called her daughter on the phone, and I got to talk to her. She described it as a brown wallet, with one button on the side, and very worn and old. When I went on break it wasn't exactly, but close to 10:30. While on break I heard on the headset that 309A had also had money missing from her room. From my understanding (CNA 4) had permission to look in her car, and she found it (the wallet) on the passenger side floor. She took the wallet to (Receptionist 2) who took a picture and locked it up. d. CNA 2 provided a hand written statement with a signature. The statement was dated on 10/26/2020 without a timestamp. The statement read as follows, On Sunday October 25th 2020, (CNA 5) was complaining to me about not having any money to buy diapers for her baby and she had absotuley (sic) no money. At about 7:45 - 8:00 we were passing breakfast trays on the floor. I noticed (CNA 5) was out in her car. She came back in and helped with the trays that where (sic) left and started complaining to me about she had no money. Shortly after 9:00 she came over the radio and asked if 305 B could have [MEDICATION NAME] 800 in her room - she said she had found them in her purse. (CNA 1) had told us that while she was in 305 b the patient was telling her that her wallet was missing. (CNA 5) returned back from lunch around 11:00. I said to (CNA 4) we should go look in her car and see if we could see the wallet that 305B had described. I opened the drivers door and seen nothing, I opened the backdoors and didn't see anything. (CNA 4) and I went back inside (CNA 5) was sitting in the CNA Room. (CNA 4) went back out and in front of (CNA 1) and her boyfrien (sic) opened the passanger (sic) side door and found the wallet ( I was not out there at the time). (CNA 4) texted me to come to the end of the 100 hall. She had an empty wallet - (Receptionist 2) to (sic) a picture of it. and then went and asked the patient if it was hers. (Receptionist 2) texted me to let me know it was hers. e. CNA 5 provided an email written statement from the iPhone. The statement was dated 10/26/2020 at 1:15 PM. The statement read as follows, This is (CNA 5) so I went into a room she wanted a candy bar I looked in her wallet I could only find one there was two dollars in there and so I called (CNA 1) to come in there she looked in the wallet and there is only one Walet (sic) Walet (sic) she said that she only had $200 in there and then (CNA 1) came in and she said I had $100 an hour and then (CNA 1) said he (sic) just said 200 so which on is it So I left the room and let (CNA 1) handle it because I had to go on break I just went to Maverik (sic) and look into my car and my car is a Chevy white Chevy and it was locked and somebody took all of my money all of my socials my kids socials everything that was in there even their Medicaid cards and insurance cards even (CNA 1) search for another wallet but there was no other wallet I had a gray wallet in there a pink wallet in there and a brown wallet in there there was change it and some candy I contacted the police because I was (sic) all the money that I had left because I just had surgery I thought I locked my car but I guess I didn't so somebody took my daughter Wallet and also my wallet I wasn't sure if there was 450 in there or $600 in there but now I have nothing less for me or my children I contacted the police because somebody stole my wallet it is illegal to go into somebody's vehicle and go through it without permission that is a police his job somebody should've asked me to take me with them to go into my car and and then I would've allowed them to search through it to make sure that the wallet was in there I would never steal from a resident I have worked hard at this facility and I have tried my best to help everybody else this is not fair to me and now I have nothing left for me and my children because somebody stole my wallet with everything in it all of my important information Review of the facility Final Investigation Summary stated that the report allegations were that Resident 7 and Resident 8 had money missing from their rooms on 10/25/2020. It was reported that (CNA 5) was witnessed looking through (Resident 7's) purse. The police were notified and (CNA 5) has been suspended and an investigation was started. The investigation findings documented that Resident 8 reported having money taken from her over-the-bed table, while she took a nap between 8:30-10:00 AM. The resident said she didn't remember anyone coming into the room, but knew the money was there the night before because she got some change for a soda. Resident 7 reported money missing from her wallet and the entire wallet missing. The wallet was described as old, worn, and with a nickel type button on it. Resident 7 stated that CNA 5 was the only person she saw get into her purse. CNA 5 denied any taking of resident money, but had inconsistent stories. (CNA 5) had been complaining to other staff members during the morning of 10/25/2020 that she didn't have any money for her kid's food or diapers. When (CNA 5) went on her lunch break, she left the facility and told staff she was going to get food and diapers for her kids, and was late getting back for her shift. Later that morning (Resident 7's) wallet was seen, by other staff members, in the front seat of (CNA 5's) car. CNA 5 was terminated on 10/28/2020 and both residents were reimbursed the missing money. On 2/9/2021 at 12:43 PM, a telephone interview was conducted with CNA 2. CNA 2 stated that CNA 5 was acting funny, wondering how she was going to get money for diapers. One of the other CNAs (CNA 1) heard her in a pt. room asking the resident why she had [MEDICATION NAME] in her purse. The nurse went to investigate and then money came up missing. Cannot recall the nurse. CNA 5 was waiting for her mom to transfer her money. The CNA left for lunch and was gone for 45 minutes and lunches are only 30 minutes. When she came back, CNA 4 had been outside and had noticed that the wallet was in CNA 5's car. CNA 2 stated that she did not see it in the car, but she saw a wallet on the passenger's seat and it was brown, but doesn't recall what it looked like. CNA 2 stated she saw it through the window. CNA 2 stated she was talking to CNA 1 and her boyfriend outside while with CNA 4. Stated that neither she nor CNA 4 went inside the car at that time. It should be noted that this contradicted CNA 2's written statement. After that they came back inside the facility. CNA 4 and Receptionist 2 called her back down to the hall, and they had resident 7's wallet at that time. Receptionist 2 took a picture of the wallet. Receptionist 2 asked the patient if that was her wallet and she said yes. CNA 2 stated that this wallet was not the same wallet that she saw on the seat, it was bigger. CNA 2 stated she did not see this wallet inside the car when she was looking. CNA 2 stated that when she was looking inside the car she looked through the passenger window and the back window. CNA 2 stated she was not aware of where CNA 4 found the wallet. All she said was that she found it in the front, not sure where. CNA 2 stated that she only spoke to Administrator 1 about the incident, but never spoke to the police. On 2/10/2021 at 11:56 AM, an interview was conducted with CNA 1. The CNA stated that the incident occurred on a Saturday or Sunday and no management was in the building. CNA 1 stated she was covering for CNA 5's break and she went to room [ROOM NUMBER]B and answered some questions. The resident in 305B couldn't find her wallet. CNA 1 stated that while she was assisting resident 7 in searching for her wallet she discovered bottles of pills and medicated cream in the resident's room. At that time the resident's daughter was calling, and she gave a description of the wallet. It was an old brown wallet with a zipper on one side with a button. CNA 1 stated that while CNA 5 was on break she went to buy diapers. CNA 1 stated that she had found out that CNA 5 was asking other CNAs for money in the morning to pay for diapers. To her knowledge none of the CNAs had given her money. All the CNAs talked while she was on break and no one said they gave CNA 5 money. CNA 1 stated that she saw CNA 5 in room [ROOM NUMBER]B with the resident looking through the resident's purse. CNA 1 stated that she never saw CNA 5 take the wallet. The CNA did not know why CNA 5 was looking inside resident 7's purse. CNA 1 stated that she spoke with CNA 4, CNA 6, and CNA 7 and none had given CNA 5 any money. CNA 1 stated that Receptionist 2 was involved and was contacting management. CNA 1 stated she went on her break when CNA 5 got back. CNA 1 stated that her boyfriend brought her lunch. Over the headset, CNA 5 said she was going to be late returning from her break because she was in traffic. CNA 1 stated that she observed CNA 5 in the car next to her and the boyfriend when she said this over the headset. CNA 1 stated that she called CNA 4 and told her that CNA 5 was in the parking lot. CNA 4 went to talk to the resident and resident in 305B had reported CNA 5 went through the purse while she was in the room. When CNA 5 went inside the building, CNA 4 came outside and looked in CNA 5's car window and saw the wallet was sitting on the floor of the passenger side. CNA 1 stated that only CNA 4 came out and looked in the window. CNA 1 was told that CNA 4 had permission from Receptionist 2 to open the passenger side door and grab the wallet. CNA 1 stated that CNA 4 looked through the driver and passenger window, saw the wallet on the floor, opened the car door, and took the wallet inside the facility. Receptionist 2 took a picture of ithe wallet and showed the picture to the resident and the resident confirmed that it was her wallet. CNA 1 stated that CNA 5 confronted her saying you saw me in 305. I didn't take the wallet. I didn't see the wallet while I was in the room. CNA 5 wanted CNA 1 to talk to Administrator 1 with her. CNA 1 told CNA 5 that she had not seen anything. When she arrived in resident 7's room, the wallet was already gone and the resident was complaining of it being lost. CNA 1 stated that she spoke to the police and reported that she didn't see anything in the resident's room, but witnessed CNA 4 finding the wallet in CNA 5's car. CNA 1 stated from her position in the parking lot she could not see the wallet in the car. CNA 1 stated that CNA 4 showed the wallet to her after she pulled it out of the car. CNA 4 asked if it looked like the wallet that the daughter had described on the phone and CNA 1 stated that it did. CNA 1 stated that she did not speak to the Administrator about the incident. CNA 1 stated that a month after the incident happened she went into the Administrator's office and gave a written report and then discussed the report. CNA 1 stated that CNA 5 left the facility the day of the incident and she never saw her again. CNA 1 stated that resident 7 had dementia and was a little confused. CNA 1 stated that the resident had some short term memory deficits, but long term memory was intact. CNA 1 stated that resident 7 was able to perform all Activities of Daily Living (ADL's), but needed reminders to eat and drink throughout the day. On 2/16/2021 at 9:28 AM, a telephone interview was conducted with Receptionist 2. Receptionist 2 reported that on the day of the incident a couple of the staff had reported that money was missing from 2 residents. Receptionist 2 stated that she reported this to the Administrator, and was instructed to call the police. CNA 4 and CNA 2 were involved in reporting the missing money to her. Receptionist 2 stated that she found it strange that 2 residents were missing money, especially since CNA 5 had been asking co-workers for money to buy diapers, and then two residents reported missing money. The receptionist stated that CNA 5 was assigned to both residents that day. Receptionist 2 stated that she thought maybe there was a connection between the missing money and CNA 5 needing money. Receptionist 2 stated that resident 8 was missing a smaller amount of money. The larger amount of money was resident 7's. Resident 7's family gave her a large amount of money. Receptionist 2 stated that resident 7 had previously shown her the wallet when resident 7 was removing photos to show her. Receptionist 2 stated that was how she knew what the wallet looked like. Receptionist 2 stated that CNA 4 found the wallet either next to or inside CNA 5's car. The receptionist stated that she recognized the wallet as belonging to resident 7. The receptionist took a picture of the wallet, and locked the wallet in the front desk. Then she asked resident 7 to describe what the wallet looked like and resident 7 described the wallet that was found. The receptionist stated that the wallet was empty; no money or pictures were located inside it. Receptionist 2 stated that resident 8's money was located in envelopes sitting on her table. Receptionist 2 stated that after she notified the Administrator and police, she did not have any more involvement in the investigation. Receptionist 2 stated she provided a statement to Administrator 1 and to the police. The police came back to the facility later and interviewed her. The receptionist reported that they said that there was probably nothing that they could do about it because there was no proof that CNA 5 took the money. On 2/16/2021 at 12:26 PM, an interview was conducted with CNA 4. The CNA stated that on the day of the incident she came to the facility at 10 AM. CNA 4 stated that CNA 5 was begging everyone for money because she needed to buy diapers. CNA 4 stated then CNA 5 was going to lunch, got money, and CNA 5 returned saying she had bought diapers. CNA 4 stated that at around the same time two residents reported missing money. CNA 4 stated that she suspected a connection between CNA 5 asking for money and the residents' missing money. CNA 4 stated that she went outside with CNA 2 to view CNA 5's car. CNA 4 stated that she noticed the wallet, which was later identified as belonging to resident 7, inside CNA 5's car. CNA 4 stated that the wallet was located on the passenger side on the floor board. CNA 4 stated that the wallet was visible from the window. The CNA 4 stated that she came inside to ask Receptionist 2 what resident 7's wallet looked like. CNA 4 stated that she went outside, opened the car door, and took the wallet out of CNA 5's car. CNA 4 then gave it to Receptionist 2. CNA 4 stated that she did not open the wallet and check the contents. CNA 4 stated that resident 7 described the wallet as brown, older and long, kind of beat up. The CNA stated that she took a picture of the wallet and sent it to Receptionist 2. CNA 4 stated that the police came to the facility and spoke with her. CNA 4 stated that she provided a statement to the Administrator and the police. The CNA stated that CNA 5 left the facility that day and then came back later to drop off her radio. CNA 4 stated she did not see CNA 5 again. On 2/22/2020 at 4:04 PM, a telephone interview was conducted with Administrator 1. The Administrator stated that staff reported that money was missing from 2 residents. The Administrator stated that he talked with the residents and staff that day. Administrator 1 reported that no one had witnessed the money being taken, but CNA 5 had been asking for money for diapers. It was reported that CNA 5 went on break and let everyone know that she was going to buy diapers, but had previously been asking staff for money for said diapers. The Administrator stated that he asked the staff if anyone had given CNA 5 money and they all had said no. The Administrator stated that this did not add up. Administrator 1 stated that one staff had notified him that they had seen the wallet in CNA 5's car, and that it was brown and had a clip. Resident 7 also identified the wallet as belonging to her. It was CNA 4 that found the wallet. The Administrator stated that resident 7 was a reliable source, and fairly alert. The Administrator stated that there was other staff in the parking lot at the time the wallet was found, but he could not recall who. The Administrator stated that when he spoke to CNA 5 she had said which residents she had worked with that morning. The Administrator stated that the topic of a wallet was brought up by CNA 5 before he had even mentioned it. The Administrator stated that CNA 5 mentioned that resident 7 had wanted her to obtain an item from resident 7's purse for her, and this was said prior to him mentioning the missing wallet. The Administrator stated that CNA 5's demeanor was the same as always, she was naturally a nervous/antsy person, and no other abnormal behavior was noted. The Administrator stated that he suspended CNA 5 that day and sent her home. The Administrator stated that he remembered CNA 5 repeatedly calling both himself and the facility Director of Nursing that day after being sent home. The Administrator stated that after gathering information he called CNA 5 and informed her of the allegation and why she was being suspended. The Administrator stated that CNA 5 said she never touched the wallet and was just getting the other item out of the purse for resident 7. The Administrator stated that CNA 5 had reported that she had money all along in her car. The Administrator stated that CNA 5 had reported that the wallet was one of her daughter's play wallets, and was given to her as a gift from a family member. The Administrator stated that CNA 5 denied that the wallet belonged to resident 7. The Administrator stated that CNA 5 had suspicious behavior of asking other staff for money and tardiness, but no other allegation of abuse or theft of money. The Administrator stated that resident 8 had reported that for her missing money was previously on her bedside table that morning. Resident 8 reported that CNA 5 had come into the room to provide cares, the resident had dozed off, and then the money was missing. Resident 8 recognized that she had missing money a few hours later and did not recall anyone else coming into her room. The Administrator stated that he had a short conversation with the detective, but does not recall much from the encounter. The Administrator stated that he was not aware of any action taken against CNA 5 by the police department. 2. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical records were reviewed. Review of resident 7's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/23/2020 and 1/27/2021 documented a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. The resident was unable to recall the day of the week, and needed cueing for all three recall items listed on the assessment. The resident did not have any behaviors present for inattention, disorganized thinking or altered level of consciousness. On 2/16/2021 at 12:09 PM, an interview was conducted with resident 7. The resident was observed seated in a recliner next to the bed. The resident appeared, clean and well groomed. The resident stated that she had been at the facility for 3-4 years. Resident 7 stated that staff treated her good and she had no concerns with the staff. The resident stated that she currently had no missing property, and if something was lost the staff had found it. The resident stated that she did have money go missing last year. The resident stated, she stole it, and she got fired. The resident stated that one of the CNAs took her money. The resident stated that she knew who the CNA was but declined to reveal her name, I don't want to say. Resident 7 stated that the facility refunded money. The resident stated the CNA ran to her car, and put her wallet in her car. They went out to get it and it was completely empty and that was when they fired her. The resident stated that she got her wallet back with nothing in it, her drivers license and all documents were gone. The resident reported that no other incidents like that have occurred since. The resident was observed to reach under the bed and pulled out her purse. The resident showed her wallet. The wallet was rectangle shaped, was brown leather, and had a silver/nickel snap closure. The resident stated that she did not see the CNA take the wallet out of her purse, but they found it in her car, completely empty. All papers and pictures were gone. Resident 7 stated that she gave the police the information and told them who the girl was. The resident stated that the police said they did not have enough information to pursue charges against the CNA. The resident stated this with observed frustration and said, they gave them all the information here at the facility. They found the wallet in her car. 3. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 8's medical records were reviewed. Review of resident 8's MDS with an ARD of 11/6/2020 documented a BIMS score of 15 out of 15 which indicated cognitively intact. The resident did not have any behaviors present for inattention, disorganized thinking or altered level of consciousness. On 2/16/2021 at 12:18 PM, an interview was conducted with resident 8. The resident stated that she had been at the facility for months. The resident stated that she had all her belongings and was not missing any personal property. Resident 8 stated that she had money go missing, and the previous Administrator, Administrator 1, paid it back. The resident declined to answer any questions regarding the incident, It doesn't matter. It got stolen. The resident appeared agitated and did not want to talk about the incident of missing money. Resident 8 stated that the money was reimbursed.

Based on interview and record review it was determined, for 1 of 22 sampled residents, that the facility did not ensure that a resident who uses [MEDICAL CONDITION] drugs received gradual dose reductions, and behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, the facility did not conduct a gradual dose reduction for an anti-anxiety medication. Resident identifier: 12. Finding include: Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 12's medical record was reviewed on 6/19/19. A physician's orders [REDACTED]. Give 1 tablet by mouth two times a day for anxiety r/t (related to) medical condition. A care plan dated 7/19/18, revealed '(Resident 12) has anti-anxiety medication use for Anxiety disorder R/T medical condition. The goals developed were, Will be free from discomfort or adverse reactions related to antianxiety therapy through the review date. Will show decreased episodes of s/sx (signs and symptoms) of anxiety through the review date. Some of the interventions developed were, Educate resident, family/caregivers about risks, benefits and the side effects of antianxiety medication drugs being given. Give anti-anxiety, Monitor/record occurrence of for target behavior symptoms Anxious statements and document per facility protocol. Non-pharmalogical interventions done: back rub, redirection, . Monthly pharmacy reviews were completed and there were no recommendations. The facility [MEDICAL CONDITION] medication review meetings were reviewed and there was no information regarding the [MEDICATION NAME] having a gradual dose reduction or there being a clinical contraindication. On 6/19/19 at 7:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 12 had not had a gradual dose reduction since the medication was started in (MONTH) of (YEAR). The DON stated that resident 12 was admitted to the facility with the [MEDICATION NAME] medication. The DON stated that she contacted the facility Pharmacist and the Pharmacist told her they did not have to start a gradual dose reduction until after a year.

Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 6/17/19 at 6:55 AM, an initial tour of the kitchen was conducted. The Dietary Manager (DM) was interviewed. The DM stated that she started at the facility as the DM in (MONTH) of 2019. The DM stated that the former DM quit unexpected. The DM stated that she did not have the qualifications but was in school working on her Certified Dietary Manager (CDM). The DM provided documentation that she was currently enrolled in a CDM course. On 6/19/19 at 11:43 AM, an interview was conducted with the facility Registered Dietitian (RD). The RD stated that she was at the facility 12 hours per week. The RD stated that the former DM had a CDM and quit unexpected. The RD stated that the DM was in classes to complete her CDM but had not completed her CDM.

Based on interviews and record review, it was determined the facility had not monitored, as prescribed by physician order, the PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) for 2 of 8 sampled residents, who had been receiving the anticoagulant medication [MEDICATION NAME]. Resident identifiers: 4 and 5. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/30/10, resident 4's medical record was reviewed. Review of resident 4's hospital discharge instructions, dated 12/8/09, documented that resident 4 was to be on [MEDICATION NAME] (anticoagulant) therapy for 4 weeks post surgery. The discharge instructions also documented that resident 4 was to receive no non-steroidal anti-[MEDICAL CONDITION] drugs (NSAIDS) while receiving [MEDICATION NAME] therapy. Review of resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This medication is classified as an NSAID medication. Further review of resident 4's MAR indicated [REDACTED]. Resident 4 received six days of [MEDICATION NAME] before being discharged to the hospital. Nursing 2009 Drug Handbook, Lippincott Williams & Wilkins 2009 pg. 505, Celecoxib ([MEDICATION NAME]), [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] ([MEDICATION NAME]) and NSAIDS "may increase anticoagulant effect. Monitor patient carefully for bleeding. Reduce anticoagulant dosage as directed." On 12/8/09 a physician's telephone order was written for resident 4 to be administered 3 milligrams of [MEDICATION NAME] each day and have her PT/INR rechecked on 12/10/09. On 12/10/09 resident 4 had a PT/INR collected in which her levels were 52.7/4.25, both of which were higher than the recommended range printed on the laboratory results sheet. The laboratory results sheet had handwritten documentation that resident 4's [MEDICATION NAME] dose was to be changed, and a PT/INR rechecked in one week. No documentation could be located that indicated resident 4's PT/INR had been checked after 12/10/09. On 3/31/10 at 8:30 AM an interview was held with resident 4. Resident 4 stated that while she was at the facility, she was aware that her PT/INR should be drawn every week, and that it was checked once, on 12/10/09. Resident 4 stated that on 12/28/09, she had an appointment with her physician, at the physician's office. Resident 4 then stated that her physician admitted her to an acute care hospital on that day due to her elevated PT/INR laboratory values. Resident 4's medical records from the acute care hospital were obtained and reviewed. On 12/28/09 resident 4's physician documented that resident 4's lower extremity "pain and [MEDICAL CONDITION] is concerning for a bleed, given abrupt onset of worsening 12/24, in a patient on [MEDICATION NAME] with no apparent checking of INR. She could have bleed (sic) into her back, hip, or RP (retroperitoneal), causing some of her myriad of symptoms. . . will admit this patient from clinic." The hospital physician then performed a scan of resident 4's right hip and low back "to evaluate for bleed." The hospital physician also ordered that a PT/INR be drawn. The results of the PT/INR were 97.4/11.9, both of which were higher than the recommended range on the laboratory results sheet. The results sheet documented that an INR of 11.9 was "critical." On 3/31/10 at 10:20 AM, an interview was held with Registered Nurse (RN) 2. RN 2 stated that when resident 4's PT/INR laboratory results were received on 12/11/10, she wrote a physician's telephone order to change resident 4's [MEDICATION NAME] dose, but because it was the end of her shift, she "forgot" to include the order to recheck the PT/INR in one week. 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 3/30/10. On 2/7/10 resident 5 had a PT/INR collected in which her levels were 22.2/1.87, with the PT being higher than the recommended range printed on the laboratory results sheet. The laboratory results sheet had handwritten documentation that resident 5's [MEDICATION NAME] dose was changed, and that an additional PT/INR level was to be drawn in one week. On 2/21/10 resident 5 had a PT/INR collected in which her levels were 74.4/5.92, both of which were higher than the recommended range printed on the laboratory results sheet. The laboratory results sheet documented that resident 5's PT/INR levels were at a "critical high." The laboratory results sheet had handwritten documentation that resident 5's [MEDICATION NAME] dose was to be decreased. On 2/22/10 a physician's telephone order was written for resident 5 to have her PT/INR rechecked in one week. On 2/28/10 resident 5 had a PT/INR collected in which her levels were 56.9/4.57, both of which were higher than the recommended range printed on the laboratory results sheet. The laboratory results sheet had handwritten documentation that resident 5's [MEDICATION NAME] was not to be administered for one day. A document entitled "[MEDICATION NAME] Tracking Sheet" for resident 5 was reviewed. The tracking sheet also documented that resident 5 had a lab drawn on 2/7/10, but not again until 2/22/10. On 3/31/10 at 3:08 PM an interview was held with the facility Director of Nursing (DON) regarding resident 5's missing lab. The DON stated she did not know why the lab had not been drawn for two weeks. No documentation could be located that indicated why the lab had not been drawn for two weeks. 3. On 3/31/10 at 10:00 AM an interview was held with a facility corporate resource nurse. The resource nurse stated that in December 2009 the facility was aware of the missing lab for resident 4 and had implemented a new system, including a new policy and procedure, to prevent further incidents from occurring. On 3/31/10 the facility corporate resource nurse provided surveyors with a document entitled "Investigation." The investigation form documented that RN 2 "forgot to order a follow up [MEDICATION NAME] order on 12/11/09. States she talked to (physician) and she does not recall him giving her any follow up labs for (resident 4). States she was leaving when (physician) walked in and she obtained the order and wrote a telephone order for the on coming (sic) nurse." The facility's policy and procedure regarding anticoagulation medication was reviewed. The policy included the following: "Upon admission, each resident receiving anticoagulation therapy will have anticoagulation labs drawn, and will have subsequent weekly anticoagulation time labs drawn. . . Weekly anticoagulation time labs will only be discontinued with the ordered discontinuation of anticoagulation medication or patient discharge from the facility." The facility's corporate resource nurse also provided surveyors with a document entitled "Quality Improvement Team (QIT) Tracking Form." The QIT form documented that facility staff were re-evaluating the issue regarding missing anticoagulation labs on 1/5/10, 1/12/10, 1/19/10, 1/26/10, 2/9/10, 2/27/10, 3/9/10, and 3/23/10 and that the "system in place is working. No issues."