Every finding on record at Orem Rehabilitation and Nursing Center

Based on observation, interview, and record review it was determined, for 2 of 28 sample residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two high fall risk residents did not have interventions put in place after multiple falls. Resident identifiers: 18 and 69. Findings included: Resident 69 was admitted to the facility on [DATE] with diagnoses which included but were not limited to dementia, hypotension, muscle weakness, morbid obesity, unsteadiness on feet, and need for assistance with personal care. Resident 69's medical record was reviewed 4/28/25 through 5/1/25. A Quarterly Minimum Data Set (MDS) dated [DATE] documented resident 69 was a one person physical assist with transfers, toileting and bed mobility. On 12/30/24, resident 69 was documented as a High Fall risk. A care plan focus dated 6/19/21 with a revision date of 2/16/25 revealed, [resident 69] has ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to]generalized weakness, obesity, confusion, forgetfulness, unspecified lack of coordination, need for assistance with personal care, unsteadiness on feet. ADL assistance level needs vary at times depending on resident behavior and needs. Resident 69's progress notes were reviewed and revealed the following: a. 1/31/25 at 11:40 PM, Pt [patient] was found lying next to bed requesting help to get up at 2320 [11:20 PM] on 01/31/2025. 4 employees assisted Pt back into bed where a skin and neurological assessment was performed. No skin alterations noted at the moment. Pt stated I'm okay when questions about pain. Pt is currently resting in bed with call light and water within reach. Neuros were restarted with current vitals of BP [blood pressure]: 146/77, Pulse: 100, Temp [temperature]: 97.9, Oxygen saturations of 93/3L [liters] and Respirations of 18. Family and Provider notified with no new orders at the moment. b. 2/1/25 at 6:50 PM, CNA [Certified Nursing Assistant] found resident on floor in his room. CNA reported that resident was trying to get from wheelchair to bed. RN [registered nurse] assessed resident, no injuries observed. Resident denies any pain. Helped resident back into bed. Vital sign monitoring started, neuro checks started. AAOx2 [alert and oriented times 2].PERRLA [pupils equal round reactive and accommodating]. VSS [vital signs stable]. c. 2/2/25 at 7:11 AM, Resident was yelling out this morning at 0605 [6:05 AM], RN went to assess resident and a second prior to walking in, RN heard a smack and found resident lying on the floor next to his bed. It appeared resident hit his head hard. RN and CNA's quickly helped resident back into bed. No injuries observed. Resident denied any head pain. HR [heart rate] was elevated at 124 and oxygen was 78% [percent] on 2L of O2 [oxygen]. RN increased oxygen to 3L and gave resident 1 dose of albuterol. Oxygen increased to 85%. On call provider [name omitted] notified, given that resident has fallen 4x in the last 40 hours provider wanted resident sent out to the hospital . No new fall prevention interventions were documented in the medical record after each of these falls. On 4/30/25 at 2:41 PM, an interview was conducted with RN 4. RN 4 stated she was the nurse who entered resident 69's room right after he had fallen o 2/1/25. RN 4 stated resident 69 was fighting a cold and was not feeling well. RN 4 stated resident 69 had fallen a couple of times the day before and she was unaware of any new interventions that had been put into place after the falls. RN 4 stated the resident was not on continuous observation. RN 4 stated resident 69 was a full assist at that time during his stay. On 4/30/25 at 2:54 PM, an interview was conducted with the Director of Nursing (DON) and the Corporate Resource Nurse (CRN) who stated neuro checks were done on any resident who fell and hit their head or had an unwitnessed fall. They stated the resident's was already in a low bed and in a room near the nurses station. They stated staff were always in resident 69's room but did not provide any new interventions that were put into place for the falls on 1/31/25 and 2/1/25. Per the resident record, resident 69's was in a room down the hallway from the nurses station. On 5/1/25 at 10:27 AM, a follow up interview as conducted with the DON and the CRN who stated resident 69 was sent to the hospital for a change of condition not for the falls. They stated they just did not have time to update the care plan since his falls happened so closely together. 2. Resident 18 was admitted to the facility on [DATE] with diagnoses which included, epilepsy, other deformity of the brain, unsteadiness on feet, difficulty walking, and muscle weakness. On 5/4/24 a fall risk assessment was completed in resident 18. Resident 18 scored a 12 which indicated a high risk for falls. A review of resident 18's medical records revealed the following falls and interventions: a. On 5/30/24 resident 18 slipped while in the shower and was assisted to the ground. The intervention that was put in place was to apply a non-slip shower mat in shower room. b. On 10/10/24 resident 18 was trying to reach for his electric razor and fell down. The intervention that was put into place was education on using the call light and proper footwear. c. On 11/12/24 resident 18 slipped out of his wheelchair while reaching for something on the ground. The intervention that was put into place was to have occupational therapy (OT) assist resident 18 with dynamic sitting and the use of a reacher. d. On 12/26/24 resident 18 fell out of his wheelchair while bending over to grab something. The intervention that was put into place was education on the use of the reacher that was previously given to him and to lock the brakes on his wheelchair. It should be noted that the use of the reacher was the intervention for the fall that occurred on 11/12/24. e. On 2/7/25 resident 18 experienced a fall when he ambulated on his own and slipped on the floor. The intervention that was put into place was to provide education on the use of non-skid socks and proper footwear. It should be noted that proper footwear was the intervention for the fall that occurred on 10/10/24. f. On 3/29/25 resident 18 experienced a fall while trying to reach for a garbage bag. The intervention that was put in place was to increase OT to focus on reaching out base of support. g. On 4/16/25 resident 18 experienced a fall he stood up and bent down to reach his activities punch card from under his wheelchair. The intervention that was put into place was to not store his punch care under the wheelchair and to have a rubber band provider for storage to the arm of the chair. On 4/30/25 at 11:09 AM, an interview was conducted with RN 1. RN 1 stated that resident 18 had undergone a brain procedure that caused cognitive delays. RN 1 stated that resident 18 was a fall risk and experienced multiple falls while at the facility. RN 1 stated that the resident often attempted to act independently, had difficulty following instructions, and struggled to retain education. RN 1 stated that resident 18 frequently forgot to use his call light and often fell while trying to bend over. On 5/1/25 at 8:31 AM, an interview was conducted with the DON. The DON stated that resident 18 required frequent prompting and was impulsive, which had contributed to some of his falls. The DON stated that resident 18 was unaware of his physical limitations and would often lean forward and fall. The DON stated that resident 18 liked to get up quickly and valued his independence, but needed constant reminders. On 5/1/25 at 8:42 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that resident 18 had the right to fall, but interventions needed to be done to prevent falls rather than be repeated. The RNC stated that resident 18 needed constant reminders because of his poor impulse control. On 5/1/25 at 10:31 AM, a follow-up interview was conducted with the RNC. The RNC stated that the facility should have implemented different interventions and resident 18's Plan of Care was not enough to prevent falls.

Based on interview and record review, the facility did not ensure that any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, was competent to provide nursing and nursing related services; and completed a training and competency program, or a competency evaluation program approved by the State. Specifically, Nurse Aides (NA) were employed at the facility, for over 4 months without completion of training and competency evaluation program. Findings include: On 4/30/25 NA 1's employee record was reviewed. NA 1 was hired on 9/3/24 as a NA. NA 1 was still employed as a NA and the last day worked was on 4/29/25. On 4/30/25 NA 2's employee record was reviewed. NA 2 was hired on 9/9/24 as a NA. NA 2 was still employed as a NA and the last day worked was on 4/11/25. On 4/30/25 NA 3's employee record was reviewed. NA 3 was hired on 5/3/25 and received his certification on 3/18/25. NA 3's last day of work as a NA at the facility was 3/16/25. On 4/30/25 NA 4's employee record was reviewed. NA 4 was hired on 9/4/24. NA 4 was still employed as a NA and the last day worked was on 4/10/25. NA's 1, 2, and 4 were not certified as nursing assistants. On 5/1/25 at 8:23 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the CNA (Certified Nursing Assistant) Coordinator was responsible for scheduling the Certified Nurse Assistants and the NA's. On 5/1/25 at 9:59 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that NA's have 120 days from their hire date to become certified. The CNA Coordinator stated that she had to take some of the NA's off the schedule for this week because they were not certified and had worked past their 120 days.

Based on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 7 out of 28 sampled resident, residents complained of the quality and temperature of the food, food was being fortified with a squirt of cold milk or splash of butter on the already prepared food, a test tray was not palatable and the food was cold. Resident identifiers: 19, 29, 35, 39, 41, 47 and 59. Findings include: 1. On 4/28/25 at 9:57 AM, an interview was conducted with resident 47. Resident 47 stated that she was on a specialized diet of minced and moist food. Resident 47 stated that the food tasted pretty gross. Resident 47 stated that she was given mashed potatoes in the shape of a hot dog that tasted bad and looked awful. 2. On 4/28/25 at 10:00 AM, an interview was conducted with resident 59 who stated the food was usually cold. 3. On 4/28/25 at 10:29 AM, an interview was conducted with resident 39. Resident 39 stated that sometimes the food served at the facility was pretty bad. 4. On 4/28/25 at 10:40 AM, an interview was conducted with resident 35 who stated the food is almost always cold, many times it doesn't have the heated plate underneath it. The chicken and the potatoes are ice cold, anything fried is never, ever warm. For breakfast the toast is not warm and the butter is not put onto the toast. 5. On 4/28/25 at 10:54 AM, an interview was conducted with resident 19. Resident 19 stated that the food was not that great and tasted very bland. 6. On 4/28/25 at 1:48 PM, an interview was conducted with resident 29. Resident 29 stated that the food was often cold. 7. On 4/28/25 at 2:27 PM, an interview was conducted with resident 41. Resident 41 stated that the food that is served is not the best and sometimes comes cold. During tray line service on 4/30/25 at 12:53 PM, [NAME] 1 was observed to squirt cold milk onto the prepared food that was already plated. An immediate interview was conducted with [NAME] 1 who stated a squirt of milk was put on those plates of the residents who needed fortification. [NAME] 1 stated the milk was kept cold in water while waiting to be used. On 5/1/25 at 12:30 PM, the DM was observed to serve the lunch tray line. The DM was observed to drizzle butter on the plates of those residents who needed fortification. On 5/1/25 at 12:22 PM, an observation was made of resident 47 tray. Resident 47 was given couscous, pureed chicken with gravy and pureed broccoli. The DM was observed to use a brush and drizzle butter over the meat two different times. The butter could be observed to pool on the plate around the meat and broccoli. On 5/1/25 at 8:09 AM, an interview was conducted with the DM. The DM stated they add butter, milk and sugar for fortification that is added while we are preparing the food. The DM gave the example that they would add a spoonful of butter for a cup of oatmeal. The DM stated for lunch or dinner they would add it over the top of the prepared food because they did not have enough space to add it prior. The DM stated they had a bottle of cold milk that they would squirt a little on the fortified plates. The DM stated it was not measured so they did not know exactly how many calories the residents were receiving. On 5/01/25 at 9:25 AM, a follow up interview was conducted with the DM. The DM stated for pureed diets they processed the chicken in the blender, resident 47 could not have rice so couscous was substituted, the vegetables were also processed in the blender. The DM stated the couscous would have added butter and the chicken will have whole milk added. The DM stated they had a bottle of the milk and they would squirt some milk over the food, the milk was not measured out. On 5/1/25 at 12:56 PM, an observation was made of the hall trays exiting the kitchen. A fortified pureed test tray was requested. At 12:59 PM, the following foods temperatures were obtained [Note: All temperatures were in degrees Fahrenheit.]: a. Chicken - 98.2 b. Couscous - 132.1 c. Broccoli - 100.8 The pureed chicken was cold to the taste and oily from the butter that was used for fortification. The couscous was bland. The broccoli was cool to the taste. On 5/1/25 at 1:25 PM, an interview was conducted with the DM. The DM stated that milk was not used as fortification today, only butter. The DM stated she was unaware that the residents did not like some of the food and that they thought the food was not warm enough.

Based on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were unlabeled and undated food items stored in the kitchen, there was food stored on the floor in the kitchen, meat was improperly stored in the walk-in refrigerator, staff cellphones and beverages were stored in food preparation areas, and staff did not serve food in a hygienic manner. Findings Include: On 4/28/25 at 8:41 AM, an initial observation of the kitchen was conducted. On 4/28/25 at 8:47 AM, an observation was made of the walk in refrigerator. There was an undated, unlabeled liquid in a 22 quart container. There was an opened box of bacon stored on a shelf above open boxes of bananas and oranges. There were multiplied carafes of juice that were not labeled or dated on the top shelf of the refrigerator. On 4/28/25 at 8:50 AM, an observation was made of the kitchen's dry storage room. There was a #10 can of beets sitting on the floor of the dry storage. There was a large rolling storage bin full of dry rice. The bin was not labeled or dated. On 4/28/25 at 8:52 AM, an observation was made of the food preparation area of the kitchen. There were 5 plastic bins full of cereal. The bins were labeled, cherios [sic], mini wheat, raisin brand, corn flakes, and rice crispy. None of the 5 bins were labeled with dates. There was a cellphone stored on top of a food preparation table. There were also two staff drink cups with no lids stored on a food preparation table. On 4/30/25 at 11:51 AM, a follow up observation of the kitchen was conducted. There was a cellphone and two staff drink cups stored on a food preparation table. There were cleaning supplies stored in the same room as potatoes, onions, and sweet potatoes. On 4/20/25 at 12:07 PM, an observation was made of staff plating meals for the lunch time meal service. [NAME] 1 was observed touching plates used to serve meals to residents with dirty gloves that had touched other surfaces. [NAME] 1 was observed touching food on the plates, the plate covers, meal tickets, and the faces of the plates. On 4/30/25 at 12:09 PM, water was observed dripping from a ceiling vent onto the plate warmer. On 4/30/25 at 12:25 PM, [NAME] 1 was observed touching a shelf that scoops were stored on, then touched the faces of several plates. [NAME] 1 then touched an electrical cord that was plugged into the ceiling and then touched the faces of several plates. On 5/1/25 at 8:01 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that when food is delivered to the facility, a staff member will date and label items with the received date. The DM stated that kitchen staff should not have drinks or personal items in cooking or preparation areas of the kitchen. The DM stated that food should not be stored on the floor of the kitchen. The DM stated that that meat should never be stored above produce in the refrigerator and that it should always be stored below everything. The DM stated that bins of rice or cereal should be dated and labeled. The DM stated that staff should not touch other surfaces before touching food or surfaces of plates.

Based on observation, interview and record review the facility failed to provide reasonable accommodations of needs and preferences except when to do so would endanger the health or safety of resident or other residents for 1 of 28 sampled residents. Specifically, a resident was not provided timely appointments to referred specialists for hand contractures and foot drop. Resident identifier: 41. Findings include: On 4/28/25 at 2:27 PM, an interview was conducted with resident 41. Resident 41 stated that she had to ask three different times to get an appointment with a specialist, she just barely got an appointment for the orthopedic hand surgeon. Resident 41 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, other reduced mobility, and major depressive disorder. Review of resident 41's records was completed on 4/28/25 through 5/1/25. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 41 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. On 2/3/25, an encounter note revealed, resident 41 was seen for hand and feet contractures. Resident 41 states that she is having significant and worsening contractures in her left hand and bilateral feet. She requested to see a specialist to see if there is anything that could be done from their standpoint. A referral requested that resident 41 follow up with an orthopedic hand specialist as well as a podiatrist to see if there are any surgical releases that could be done to help with these contractures. Diagnosis, Assessment and Plan: A referral placed to orthopedic hand as well as podiatry to see if there is any surgical releases that can happen with her contractures. Plan: Referrals placed to orthopedic and as well as podiatry. On 2/10/25, an encounter note revealed, resident 41 was seen for a follow-up for anxiety. Diagnosis, Assessment and Plan: A referral placed to orthopedic hand as well as podiatry to see if there are any surgical releases that can happen with resident 41's contractures. On 3/6/25, an encounter note for a follow-up visit revealed, resident 41 was seen for a follow-up visit for multiple specialist referral requests. Resident 41 presents today for a follow-up, expressing concerns regarding multiple specialist referral needs. Resident 41 specifically requests referrals to a orthopedic hand surgeon for evaluation of contractures and podiatry for drop foot management. Resident 41 reports these referral requests have been pending for some time. Diagnosis, Assessment and Plan: A referral placed to orthopedic hand as well as podiatry to see if there are any surgical releases that can happen with her contractures. Follow-up Plan: Hand contractures will refer to orthopedic hand surgery for evaluation and management. Pending specialist assessment for potential interventional options. Drop foot, referral to podiatry for comprehensive evaluation and management. On 3/11/25, an encounter note for an acute visit revealed, resident 41 was seen for follow-up visit for multiple specialist referral requests. Resident 41 presents with multiple complaints that have developed over recent weeks. Primary concerns included, hand issues requiring surgical evaluation, and drop foot. Resident 41 also demonstrated difficulty with ambulation due to drop foot, which is significantly impacting mobility. Diagnosis, Assessment and Plan: A referral placed to orthopedic hand as well as podiatry to see if there are any surgical releases that can happen with her contractures. Follow-up Plan: Hand contractures will refer to orthopedic hand surgeon for evaluation and management. Pending specialist assessment for potential interventional options. Drop foot, referral to podiatry for comprehensive evaluation and management. Follow-up Plan: Hand Condition, referral to hand surgeon for evaluation and treatment planning. Will request detailed documentation of specific hand symptoms and functional limitations. Drop foot, referral to podiatrist/orthopedist for evaluation and management. May need assistive devices or orthotics for ambulation safety. Follow-up: Schedule return visit after specialty consultations to coordinate care plan and monitor progression of symptoms. On 3/24/25, an encounter note for an acute visit revealed, resident 41 was seen for foot drop and macular degeneration. Resident 41 requested to see a podiatrist to evaluate her foot drop to see if surgical repair could be done. Resident 41 also requested to see an orthopedic hand surgeon for a finger contracture that she has been developing. Diagnosis, Assessment and Plan: A referral placed to orthopedic hand as well as podiatry to see if there are any surgical releases that can happen with her contractures. Follow-up Plan: A request for ortho and podiatry follow-ups. On 3/24/25 a physician's order was started for a referral to an orthopedic hand surgeon for an evaluation. One time only for finger deformity for 1 Day. On 3/24/25 a physician's order was started for a referral to outside podiatry for an evaluation related to drop foot. One time only for drop foot for 1 Day. On 3/24/25 at 5:20 PM, a nursing progress note revealed new patient orders for resident 41 for orthopedic hand for evaluation related to finger deformity. On 3/24/25 at 5:22 PM, a nursing progress note revealed that resident 41 to refer to outside podiatry for evaluation related to drop foot. On 3/24/25 at 6:00 PM, a nursing progress note revealed that medical doctor assessed resident 41 and wrote referral orders for outside podiatry evaluation related to drop foot. Also orders for orthopedic hand related to finger deformity. On 4/3/25, an encounter note for a follow-up visit revealed, resident 41 was seen for a follow-up visit for multiple specialist referral requests. Resident 41 expressed desire for multiple specialty referrals, specifically requesting evaluations from podiatry and orthopedics for assessment of bilateral foot contractures, and orthopedic evaluation for hand contractures. Diagnosis, Assessment and Plan: A referral placed to orthopedic hand as well as podiatry to see if there are any surgical releases that can happen with her contractures. Follow-up Plan: For hand contractures: Orthopedic referral initiated for evaluation and management. Continue the current physical therapy regimen. For foot contractures: Dual specialty approach with podiatry and orthopedic referrals initiated. Continue current physical therapy protocol. For general management: Transportation arrangements in process for specialty appointments. On 4/25/25 at 1:13 PM, an appointment/procedure note revealed that resident 41 was scheduled an appointment on 5/2/25 at 10:00 AM regarding referral for consult hand contractures and possible surgery options. Resident 41 and family notified. On 4/30/25 at 1:32 PM, an interview was conducted with the Director of Transportation (DT). The DT stated that she was the one who scheduled appointments and set up transportation for the residents. The DT stated that when a referral to a specialist was needed, the in-house physician would order it. The nurses would then create the order and print it out for the ordering physician to sign. The DT stated that when she received the signed order, she attempted to schedule an appointment as soon as possible, which could take from 24 to 72 hours. The DT stated that there could be delays during the scheduling process such as no prior relationship with the provider, getting the necessary documents sent over to the referred office, or finding a provider that would take the resident's insurance. The DT stated that she recalled getting the signed order for resident 41's referral to the orthopedic hand surgeon and was able to schedule her an appointment. On 5/1/25 at 9:30 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the in-house physician would give the floor nurse an order for the referral. RN 2 stated that she could find the orders in the communications tab in the electronic medical record. RN 2 stated she would then enter the order into the resident's medical chart. RN 2 stated that she was unaware if the order needed to be printed out. RN 2 stated that the DT would then look for any entered orders that needed to be scheduled and would schedule the appointment. On 5/1/25 at 11:03 AM, an interview was conducted with RN 1. RN 1 stated the in-house physician would let the floor nurse know that they had a referral request for a resident. RN 1 stated the floor nurse would enter the order and then printed the order out to have physician sign. RN 1 stated the signed order would then go to the transportation department. RN 1 stated that if they were not able to get the physician to sign the order prior to them leaving the building, the DT will follow up with the physician to get the order signed. On 5/1/25 at 11:26 AM, a request was made to Director of Nursing (DON) for the signed order for the referral to the orthopedic hand specialist. The DON provided the signed order dated 3/24/25. On 5/1/25 at 11:59 AM, an interview was conducted with the DON and Regional Nurse Consultant (RNC). The RNC stated that the DT needed to have a signed order before she could schedule an appointment with an outside provider. The DON stated that the floor nurse got the order from the physician when they were rounding on the residents. The DON stated that the floor nurse would enter the order then print the order to place it into the physician's box. The DON stated the physician would sign any orders that were in their box, once signed it was then placed in the transportation orders box located at the front nursing station. The DON stated that the DT looked in the box at least daily when she was in the facility. The RNC stated that only new appointments or referrals need to have a signed order. The RNC stated that residents that were already established with an outside provider did not need signed orders for any follow-up visits.

Based on interview and record review, it was determined that the facility did not prevent misappropriation of a resident's medications for 1 of 28 sampled residents. Specifically, a resident had a nurse tell him he was getting his pain medication but was replacing it with another medication on multiple occasions. Resident identifier: 170. Findings included: Resident 170 was admitted to the facility on [DATE] and discharged on 9/27/24 with diagnoses which included cerebral infarction due to embolism, acute and chronic respiratory failure, and chronic pain syndrome. Review of resident 170's records was completed on 4/28/25 through 5/1/25. A comprehensive Minimum Data Set (MDS) dated [DATE] revealed that resident 170 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. A grievance placed on 9/9/24, by resident 170 to the Director of Social Services (DSS) revealed, [Resident 170] states that he has some concerns about his medications, he feels that he is being given the wrong medications from a particular nurse, [Registered Nurse (RN) 3]. The grievance was resolved on 9/10/24, by the Director of Nursing (DON), the DSS and the Administrator (ADM). After further investigation, it was determined that this grievance will be a self-report. On 9/13/24 at 6:06 PM, the ADM submitted Form 358 to the State Agency (SA) which revealed the following. On 9/13/24 at 4:15 PM, During a scheduled Care Conference with [resident 170] and his Daughters, [sic] they alleged that [RN 3] had given a different colored pill when requesting his narcotic. The alleged incident happened on 8/31/24 at 12:30 PM. Adult Protective Services (APS) was notified on 9/13/24 at 6:08 PM. On 5/6/24, a physician's order for oxycodone hydrochloride (HCl) Tablet 20 milligram (mg), give 20 mg by mouth every 4 hours as needed (PRN) for pain related to chronic pain syndrome was started. On 9/20/24 at 4:55 PM, the ADM submitted Form 359 - Follow-Up Investigation Report to the SA which revealed the following: Resident 170 was interviewed and claimed that on 8/31/24, he was getting ready to go out with his family and ask for his pain pill. What RN 3 gave him was not the correct color of his oxycodone, it was a tiny white pill. Resident 170 said That's not my Oxy. RN 3 said Yes it was. RN 3 made a comment about not needing these, they are bad for you. Resident 170 stated that he did not report the first incident on 8/31/24, to anyone because he did not want to get the nurse in trouble. Resident 170 just thought it was off and did not realize at that time that it could be foul play. When a second incident happened on 9/9/24, he talked to his daughter over the phone. Resident 170 and his daughter requested a care conference. On 9/13/24, resident 170 reported the two incidents to the facility. On 9/17/24, resident 170 stated that he would notice an upset stomach when RN 3 worked and he had forgotten to ask for the PRN oxycodone. Resident 170 denied any uncontrollable or increased pain during the reported incidents. Resident 170's daughter claimed she had witnessed RN 3 giving resident 170 a white pill on 8/31/24, when he asked for his pain meds. Resident 170's daughter thought it was weird but did not think much about it until resident 170 claimed it happened again on 9/9/24. Resident 170's daughter then asked for a meeting. On 9/13/24, resident 170's daughter made the concern known to the Interdisciplinary team (IDT). An interview with the suspected perpetrator on 9/20/24 documented the following, RN 3 stated she was instructed to put the medications into separated pill packs and label when to take them and put his pain medication into a separate pack with six pills that would last for the requested 24 hours. RN 3 stated she did as was instructed and had another nurse sign to verify the pain pills and the number she was sending, and we both signed for them, I explained the medication to resident 170's daughter, who seemed confused as to why I was not just sending cards of meds. RN 3 stated she explained to resident 170's daughter that it was just easier to keep track of what resident 170 was taking. RN 3 stated that resident 170's daughter seemed upset but finished signing out Resident 170's daughter went to resident 170 room to get him, and they left. RN 3 stated I believe I only took care of resident 170 one more time after that and did not have any interactions with resident 170's daughter. That day, resident 170 did not express any concerns, confusion or have questions about the medications given throughout the shift. RN 3 stated the next time she worked, I was approached by several staff telling me that resident 170's daughter was filling a complaint about his pain medication, saying that I had been giving him heart medication and not his pain medication, and that resident 170's daughter had witnessed this. RN 3 stated that I was also told that resident 170's daughter and resident 170 were telling other staff they were out to get my license. RN 3 stated that on these days, I do not recall resident 170's daughter ever being present when medications were administered. The facility verified the allegation of misappropriation of resident 170's medications. During the investigation, camera footage was reviewed by the DON and CNA (Certified Nursing Assistant) coordinator. It was determined that it is probable that Resident 170 was not administered his narcotic as alleged. RN 3 was observed accessing the narcotic drawer, withdrawing a bubble pack of medication, placing medication into her hand and then placing her hand in her pocket. On 9/13/24 RN 3 was placed on suspension pending investigation. On 9/17/24, RN 3 was reported to Division of Professional Licensing (DOPL). On 9/18/24, RN 3 was involuntary terminated due to a Code of Conduct Violation for Drug Diversion. On 1/24/25, APS submitted a completed investigation to SA which revealed the following: The facility the [sic] [resident 170] is at, gave him the wrong medications. He was told by the nurse she was getting pain meds, but she was just giving him more of his heart medications. The bottle of pills went empty before it should have, His doctor stated that overdose of heart medication was messing with his heart rate. They said they were giving him pain meds. She [sic] gave him something else. It [sic] is messing with his heart rate a lot. [Resident 170] has also been on pain meds for 20 years and has been experiencing withdrawals, he is not being given his pain meds. Closure Statement Narrative: The allegation of financial exploitation is being supported. [Resident 170] is a vulnerable adult who at the time of the visit has full capacity as it relates to the allegation . On 5/01/25 at 12:11 PM, an interview with the DON was conducted. The DON stated that resident 170 and his daughter had an IDT meeting about resident 170's missing his medications. The DON stated that as soon as the allegations were known they placed RN 3 on suspension pending an investigation. The DON stated that her and the CNA coordinator reviewed hours of video footage to see if they were able to see any suspicious activity. The DON stated that there was video footage showing RN 3 accessing the locked narcotic drawer, pulling out a blister pack, placing medication in her hand, then placing her hand in her pocket. The DON stated that they reported RN 3 to DOPL, and they came and did an investigation. The DON stated that the incident was also reported to APS and the Police Department, they both came and did an investigation. The DON stated that once the investigation was completed it was decided that RN 3 needed their employment terminated and that was done on 9/18/25.

Based on observation, interview, and record review the facility did not ensure that each resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, 1 out of 28 sample residents, did not have an order to change the oxygen tubing and humidifier. Resident identifier: 47 Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which included, acute respiratory failure with hypoxia, epilepsy, and subarachnoid hemorrhage. On 4/28/25 at 9:57 AM, a concurrent interview and observation was made with resident 47. Resident 47 was observed in bed with a nasal cannula attached to an oxygen concentrator delivering 3 liters of oxygen. The nasal cannula was undated. Resident 47's portable oxygen tank had a nasal cannula attached that was undated and wrapped around the left wheel of the resident's wheelchair. Resident 47 stated that she did use oxygen. On 4/29/25 at 10:46 AM, an observation was made of resident 47's oxygen cannulas. Resident 47's nasal cannula connected to the concentrator was undated. Resident 47's nasal cannula attached to the portable oxygen tank was undated and placed on the seat of the wheelchair. On 4/30/25 at 8:29 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 47 did use oxygen. RN 1 stated that resident 47 had both an oxygen concentrator and a portable oxygen tank. RN 1 stated that facility nurses were responsible for changing and dating the nasal cannulas. RN 1 stated that the medical record for resident 47 should contain orders for the nurse to change the nasal cannulas; however, RN 1 was unable to locate the order for weekly changes. On 4/30/25 at 12:00 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that CNA's were only permitted to replace oxygen tanks and adjust nasal cannulas that were already in place on the residents. CNA 1 stated that nurses were in charge of changing out the nasal cannulas. On 4/30/25 at 12:03 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that nurses were expected to change out nasal cannulas every Sunday and that there should be a physician's order to support that practice. The RNC stated that she would locate the order for changing the nasal cannulas for resident 47. It should be noted that no order for oxygen supplies was located in the medical record. On 4/30/25 at 12:04 PM, an interview was conducted with the Unit Manager (UM). The UM stated that the nursing night shift changed nasal cannulas on Sundays. The UM stated that all nasal cannulas should be dated. On 5/1/25 at 10:49 AM, a follow-up interview was conducted with the RNC. The RNC stated she had just entered the order for resident 47's nasal cannula to be changed. The RNC stated that the changes had not been occurring because no prior order was in the medical record.

Based on observation and interview, the facility did not have the nurse staffing information posted. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Specifically, nurse staffing information was out of date and not posted on weekends. Findings include: On 4/28/25 at 8:31 AM, during the initial tour of the facility, the nurse staff posting was dated 4/23/25. On 4/30/25 at 11:52 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the nurse staffing information was posted by the receptionist. On 4/30/25 at 11:55 AM an interview was conducted with the receptionist. The receptionist stated that she was out sick on 4/24/25 and 4/25/25 and no one else posted the daily staffing information during her absence. The receptionist stated that she worked Monday through Friday and that the daily nurse staffing information was not posted on weekends because the weekend receptionist did not know how. On 5/1/25 at 8:15 AM, a follow-up interview was conducted with the receptionist. The receptionist stated that for any weekend censuses or other daily censuses that were not posted, she completed them the following Monday and kept them in a binder.

Based on interview and record review it was determined for, 1 out of 28 sample residents, that the facility did not file, in the resident's clinical record, laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's laboratory results were not located in the electronic medical records. Resident identifier: 30 Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, congestive heart failure, essential hypertension, schizoaffective disorder, bell's palsy, anxiety disorder, and depression. Resident 30's medical record was reviewed 4/28/25 through 5/1/25. A physician's order, dated 9/9/24, ordered a Complete Blood Count (CBC) every day shift starting on the 10th and ending on the 10th every month for Plavix/Eliquis Use. A physician's order, dated 4/16/25, ordered a CBC one time only related to . possible UTI [urinary tract infection]. No laboratory results could be located on resident 30 ' s electronic medical record for the CBC ordered on 11/10/24, 4/10/25, and 4/16/25. On 4/30/25 at 12:09 PM, an interview was conducted with the Director of Nursing (DON) and Medical Records. The DON stated that the laboratory utilized two electronic health record (EHR) applications. The DON stated the laboratory uploaded the laboratory results to both EHR applications. Medical Records stated that he had access to one of the EHR applications, but not the other EHR application. Medical Records stated he filed the laboratory results on the facility's electronic medical records when the laboratory results were uploaded to the EHR application that he had access to. The DON stated that the missing laboratory results for resident 30 were uploaded by the laboratory to only one of the EHR applications, and it was the EHR application that Medical Records did not have access to.

Based on interview and record review, it was determined, for 2 or 28 sampled residents, the facility failed to keep an antibiotic stewardship program that included antibiotics use protocols and a system to monitor all antibiotic use for all residents. Specifically, residents with orders for prophylaxis antibiotics were not monitored for their antibiotic use. Resident identifier: 23 and 28. Findings include: 1. Resident 23 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included acquired deformity of left lower leg, type 2 diabetes mellitus, bipolar disorder, and personal history of urinary tract infections (UTI). Review of resident 23's records was completed on 4/29/25 through 5/1/25. A physician's order dated 10/20/24 documented, Keflex Oral Capsule 500 milligrams (mg) (Cephalexin) Give 1 capsule by mouth at bedtime for Prophylaxis for UTI. 2. Resident 28 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included borderline personality disorder, generalized anxiety disorder, major depressive disorder, and long term use of antibiotics. Review of resident 28's records was completed on 4/29/25 through 5/1/25. A physician's order dated 3/29/23 documented, Cephalexin Oral Capsule 250 mg. Give 250 mg by mouth one time a day for prophylaxis for history (hx) of chronic UTI related to long term use of antibiotics. On 5/01/25 at 12:35 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated that he did an antibiotic review for resident 28 about a year ago. The IP stated that resident 23 was recently put on prophylaxis antibiotics but unsure of when that was. The IP stated that when a resident was placed on a prophylaxis antibiotic he placed them on the infection tracking sheet for that month and that he did not carry the tracking over to future months. The IP stated that he did not have a tracking system for residents that are on long term antibiotics use. On 5/01/25 at 12:19 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she did not do any of the infection control monitoring. The DON stated the IP took care of all of the antibiotic stewardship.

Based on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse including involuntary seclusion. Specifically, the resident was seeking egress from a room and was denied the right to exit by facility staff. Resident identifier 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, congestive heart failure, atrial flutter, type II diabetes mellitus, chronic kidney disease, morbid obesity, chronic pain, difficulty with walking, polyneuropathy, hypertension, obstructive sleep apnea, and thrombocytopenia. Resident 2 was discharged from the facility on 3/30/24. On 12/30/23, resident 2's Minimum Data Set (MDS) assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that the resident was cognitively intact. The assessment documented that resident 2 required an extensive one-person assist for bed mobility, transfers, and toilet use. Resident 2's progress notes revealed the following: a. On 2/16/24 at 12:08 PM, the social service (SS) note documented, SS followed up with the pt [patient] about the recent self-report that the pt has opened. During this follow up, the pt mentioned that the incident triggered a deeper trauma for her. SS offered a safe space for the pt to share her thoughts and feelings. The pt proceeded to open up to SS about her past traumatic experiences. SS explained that it is standard practice for SS to update a pt's care plans (in PCC) when informed about pt's trauma triggers. The pt then requested that SS not document the trauma in her medical records. The pt stated she did not want to discuss this trauma with anyone else. SS offered the pt mental health counseling services, the pt declined the offer. Pt has not mentioned to SS previously about her trauma, pt has denied having trauma during her quarterly SS assessments. b. On 2/17/24 at 9:58 AM, the SS note documented, SS checked in on [resident 2]. She has been emotional the past few days. Discussed her feelings and her personal healing journey. Pt seems to be improving emotionally. Wants to move forward with forgiveness. On 2/14/24 at 11:00 AM, the facility reported an incident of mental/verbal abuse had occurred between resident 2 and the Assistant Director of Nursing (ADON). The facility abuse investigation documented that the ADON brought resident 2 into his office on 2/14/24 to address a concern brought up by a Certified Nurse Assistant (CNA). The concern was that [resident 2] was asking staff about a staff member who may have received disciplinary action that is not appropriate to discuss with a resident. [Registered Nurse (RN) 1] was present during the conversation between [ADON] and the resident. During this discussion, [resident 2] voiced she attempted to leave the office. [ADON] stood up and stood in front of the door stating , 'No we need to finish this conversation' [Resident 2] reported feeling distress as a result of this event. On 2/15/24, the Administrator (ADM) documented an interview with resident 2. Resident 2 stated that the ADON asked her to come into his office. He was talking over her and not letting her speak. She told him that if he wasn't going to let her talk then she was leaving. She said she started opening the door and he shut it. He blocked her from leaving. He told her she couldn't leave until they finished their conversation. She brought up her past trauma with her ex-husband and [ADON's] posture and demeanor reminded her of him and it triggered it to resurface. She stated [ADON] called her a 'gossip' and 'busybody.' She stated that [ADON] threatened he would give her a room change if she couldn't stop her gossiping. On 2/15/24, the ADM typed statement from the ADON documented, On 2/14/24 [Certified Nurse Assistant (CNA) 1] came to my office, visibly upset, and stated that the resident [resident 2] had been going around asking staff about an incident she was involved in. She said that another CNA, [CNA 2] had come to her and told her the information that the resident was asking about. [CNA 1] said that the resident was telling others that she should have been fired. I told her that I would speak with the resident. I asked the resident to come to my office. I had also asked [RN 1], another nurse manager, to attend with me. Because of the nature of the conversation, I closed the office door. The resident was in a power wheelchair and was sitting next to the door. [RN1] and I were in office chairs at the desks in the office. I started explaining to the resident that she is a resident here and anything that happens with staff discipline at the facility is not of concern to her. At this point, the resident was trying to interject and tell her side of the story, but I was not finished speaking and she felt that I was not letting her talk. She said she was done talking with us and wanted to leave. Not knowing her history of trauma, I stood up to go to the door to stop her from leaving so we could finish the conversation. I then sat back down, and she informed us that we were 'kidnapping me' and 'holding me against my will.' I told her I just wanted to finish the conversation so she could understand that disciplinary action of the staff cannot be discussed with the residents. She admitted that she asked the CNA for information. We also asked about her reasoning for asking staff for more information. [Resident 2] expressed that she felt like since she had been with us for so long, we were all like family and that she should be able to know what's going on in the facility. At that point, I got up out of my chair and assisted her in opening the office door. It was not my intention to upset [resident 2], I was only trying to address the concern that was upsetting to the staff member. I did not call her a 'gossip' or 'busybody.' We discussed gossip and the potential negative impact it can have. We discussed a possible room change as she referred to 'hearing nurses talk' if this was something she wanted to do. I did not threaten her with a room change because she gossips. On 2/15/24, the facility investigation documented an interview with RN 1 that was conducted by the Social Services Director (SSD). The interview documented that RN 1 reported, that the conversation was relatively passionate on both sides. She said that [ADON] was being stern and blunt in an attempt to address the above-mentioned staff concern. [Resident 2] responded in a verbally aggressive manner. Defensiveness on both sides was observed, due to both wanted to be heard. When asked about the conversation, contrary to what [resident 2] reported, [RN 1] said that [ADON] gave [resident 2] adequate time to respond and was not talking over her as [resident 2] reported. [Resident 2] felt like she wasn't being listened to and moved to leave out the door. [RN1] confirmed that [ADON] did move to stand in front of the door but reported it wasn't for more than 10 seconds and it wasn't done in a way to trap [resident 2], but to convey that he was hoping for resolution to the concern. She confirmed the door was shut as they entered the office due to the conversation's confidential nature. [RN 1] stated that at no time did she feel [ADON's] intentions were to cause distress to [resident 2]. She denied that [ADON] called [resident 2] a 'gossip' or 'busybody' as per [resident 2's] statement. [RN 1] also denied that [ADON] threatened [resident 2] with a room change if she can't control her gossiping. She stated that [ADON] offered a room change as an option if [resident 2] was concerned about staff conversations at the nurse's station. On 2/14/24, the facility investigation documented an interview with the SSD. The documentation did not specify who was conducting the interview. The interview documented that the Social Services Administrative Assistant (SSAA) was present as a witness. The interview documented, [Resident 2] came in and said she had a grievance. SS asked what was going on. She explained that she had an interaction with [ADON] that was uncomfortable and that she did not like his demeanor. From her report, the conversation got heated (she didn't go into many details during this first meeting), and voices were raised. At one point she tried to leave the conversation and [ADON] went to the door and said something along the lines of, 'No we're going to finish this conversation.' From there, she felt triggered because it reminded her of past trauma she has had with her son and her ex-husband. The posture [ADON] had reminded her of her ex-husband and standing in front of the doorway reminded her of why her son went to prison. The conclusion of the facility abuse investigation was not verified. The actions taken by [ADON] were found to be inappropriate. The investigation did not support, however, that his actions were malicious or that he intended to cause distress to the resident. Further, it is not supported that [ADON] called the residents names or that he threatened the resident with a room change if she cannot stop gossiping. On 5/22/24 at 11:40 AM, an interview was conducted with the SSD. The SSD stated that resident 2 reported the incident with the ADON to her. The SSD stated that the incident with the ADON had triggered resident 2 about an incident in her personal life with her ex-husband. The SSD stated that she offered resident 2 resources such as counseling, a trauma care plan, and informing other staff. The SSD stated that resident 2 mentioned a deeper trauma with her ex-husband, but the SSD refused to disclose what resident 2 stated to her. The SSD stated that the ADM was present when resident 2 reported her past trauma. The SSD stated that the incident with the ADON was when he stood in front of the door blocking her exit, and this action made resident 2 recall her husband's mannerisms. The SSD stated that resident 2 reported that the ADON blocked her from leaving the room. Her interpretation was that she was being held in the room and not allowed to go out. That is what triggered her PTSD [Post Traumatic Stress Disorder] about her husband. The SSD stated she asked resident 2 if she needed counseling services. The SSD stated that resident 2 had never mentioned in past assessments that she had this previous trauma, and she did not have any past mental health services. The SSD stated that she thought resident 2 felt frustrated by the situation and wanted to be able to express her feelings. The SSD stated that resident 2 was tearful when she talked about her ex-husband. The SSD stated that resident 2 reported that the interaction with the ADON made her feel trapped and she was being forced to stay in the room. The SSD stated that the deeper problem was that the incident triggered her past history of trauma and abuse. On 5/22/24 at 1:13 PM, an interview was conducted with RN 1. RN 1 stated that the ADON pulled her into the office to be a witness to the conversation with resident 2. RN 1 stated that the ADON shut the door to the office during the discussion with resident 2. RN 1 stated that resident 2 was asking about a staff member, and resident 2 wanted to get an aide fired because of an incident. RN 1 stated that the ADON told resident 2 that it was none of her business and why was she asking about it. RN 1 stated that resident 2 stated she was leaving, and the ADON stood in the doorway and said you're not leaving until we talk about this. RN 1 stated that the ADON stood in the doorway blocking resident 2 for maybe 3 seconds and then he sat back down. RN 1 stated that resident 2 and the ADON were both upset and talking loudly. RN 1 stated that they were not yelling but talked in raised voices. RN 1 stated that resident 2 seemed upset, she was uneasy and frustrated. RN 1 stated that at the end of the conversation resident 2 asked if she could go and the ADON opened the door for her to exit. RN 1 stated that in her opinion the ADON prevented resident 2 from leaving when she wanted to leave. RN 1 stated that the whole thing made her feel uncomfortable, and she did not like how either of them were talking to each other. RN 1 stated that the ADON meant business, but it was inappropriate for him to talk to her in that manner. RN 1 stated that she was not sure if resident 2 felt threatened but maybe intimidated. RN 1 stated that the ADON was trying to get his point across very seriously that it was not the resident's business to dig around in other people's business. RN 1 stated that resident 2 seemed upset. RN 1 stated that later that same day she asked resident 2 how she was and the resident replied by calling the ADON an expletive. RN 1 stated that resident 2's room was across from the nurse's station, and she was nosey and would ask about what she heard said. RN 1 stated that the ADON did call resident 2 a busybody. RN 1 stated that resident 2 responded with something like I want to know what's going on with the people taking care of me, and that it was her home. RN 1 stated that resident 2's excuse was that she knows things because her room was across from the nurse's station and he said okay we'll move your room. RN 1 stated that she did not think resident 2 would have wanted to move rooms, and it was possible that resident 2 could have interpreted that as a form of punishment. RN 1 stated that resident 2 had lived there for a while, and it would have been an inconvenience to move rooms. On 5/22/24 at 2:09 PM, an interview was conducted with the ADM. The ADM stated that it was reported that resident 2 was asking staff about situations with other residents and another staff, and she was trying to gossip. She liked to go around and know what was going on. The ADM stated that the ADON pulled resident 2 aside with RN 1 to address it. The ADM stated that the ADON reported he explained that he was addressing the situation with the resident to understand privacy and how it impacted other people. The ADM stated that the ADON basically stated what had happened, stood up and redirected resident 2, and sat back down and they talked. The ADM stated that resident 2 went to SSD to file a grievance against the ADON. The ADM stated that resident 2 told him about her ex-husband and how the ADON's posture reminded her of him. It resurfaced some past trauma. The ADM stated that resident 2 reported that the ADON had called her a gossip and busybody, and he threatened to move rooms if she did not stop gossiping. The ADM stated that resident 2 reported that the ADON had blocked her from leaving the room. The ADM stated, I don't believe they were yelling but there were raised voices. It was a conversation with some emotion. The ADM stated that the ADON's demeanor and how he was communicating with resident 2 triggered some past trauma responses of verbal abuse. The ADM stated that resident 2 had said that they were kidnapping her and this was in response to him blocking her exit and standing in front the door. The ADM stated that RN 1 reported that the ADON did step in front of the door to stop the resident from leaving but it was no more than 10 seconds. The ADM stated that he spoke with resident 2 afterwards and she wanted to know that it was being handled and investigated. The ADM stated that he told resident 2 that the ADON was suspended, and they were providing education based on the situation. On 5/22/24 at 2:36 PM, an interview was conducted with the ADON. The ADON stated that he had heard that resident 2 was going around talking about an incident that she was not involved in. The ADON stated that a staff member came to him upset and crying, she had heard on the floor that resident 2 was talking about her. The ADON stated that he brought resident 2 into the office to talk to her and it did not go well. The ADON stated that he had learned after the fact that resident 2 had been in an abusive relationship. The ADON stated that during his conversation with resident 2 he had the door shut and the resident felt trapped with the door closed. The ADON stated that resident 2 had said it was entrapment. She knew it because her son was in prison for it. The ADON stated that resident 2 did not want to stay, she wanted to go. The ADON stated that when he got up to go to the door resident 2 thought he was blocking her. The ADON stated he should have stopped the conversation and let her out. The ADON stated that resident 2 was name calling, and called him an asshole. The ADON stated that at the time he did not think to stop the conversation. The ADON stated that the conversation appeared to bother resident 2. The residents demeanor was fine when she entered, it changed when they told her what they were talking about. The ADON stated that he did not recall calling resident 2 a busybody. The ADON stated that resident 2's room was across from the nurse's station, and they talked about a room change so she would not be close to the nurses station. The ADON stated he did not tell her he would move her room if she did not stop gossiping, no I don't believe so. The ADON stated that while he spoke to resident 2 the tone of his voice was stern, and it could have been taken the wrong way. The ADON stated that he did not think his voice was threatening. The ADON stated that he should have left it for someone else to talk to her, and probably should not have done it in a closed area. The ADON stated that when resident 2 said she felt entrapped they should have ended the conversation and let her out. The ADON stated that he did not end the conversation because it was a problem they had with her since she had been there, the gossiping and wanting to know everything. The ADON stated that this situation had nothing to do with resident 2. I didn't feel like it was none of her business (sic). The ADON stated that resident 2 was probably not receptive to the conversation after she said that she was entrapped, stating I should have let her go. The ADON stated that resident 2 went and talked to SSD about it, and they came and talked to him. The ADON stated that the SSD told him that resident 2 had a previous history of an abusive relationship. The ADON stated that he was suspended the day of the incident and returned to work 3 to 5 days later. The ADON stated that he had training on the types of abuse and it covered involuntary seclusion. The ADON stated that involuntary seclusion was if you put someone in their room or locked them in a room but nothing covered a resident being held against their will. The ADON stated that management suggested that he write a letter of apology to resident 2, and he explained where he was coming from and why it may have gone the way it did. Review of the facility Policy and Procedure on Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment documented It is the policy of the Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy further defined involuntary seclusion as Separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's representative. The policy was last revised on 11/28/17.

Based on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse to the administrator of the facility, the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, an allegation of abuse was not reported to the SSA or APS within 2 hours of the allegation being made. Resident identifier 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, congestive heart failure, atrial flutter, type II diabetes mellitus, chronic kidney disease, morbid obesity, chronic pain, difficulty with walking, polyneuropathy, hypertension, obstructive sleep apnea, and thrombocytopenia. Resident 2 was discharged from the facility on 3/30/24. On 2/14/24 at 11:00 AM, the facility reported an incident of mental/verbal abuse had occurred between resident 2 and the Assistant Director of Nursing (ADON). The facility abuse investigation documented that the ADON brought resident 2 into his office on 2/14/24 to address a concern brought up by a Certified Nurse Assistant (CNA). The concern was that [resident 2] was asking staff about a staff member who may have received disciplinary action that is not appropriate to discuss with a resident. [Registered Nurse (RN) 1] was present during the conversation between [ADON] and the resident. During this discussion, [resident 2] voiced she attempted to leave the office. [ADON] stood up and stood in front of the door stating , 'No we need to finish this conversation' [Resident 2] reported feeling distress as a result of this event. On 2/15/24 at 2:30 PM, the SSA was notified of the allegation of abuse on form 358 Facility Reported Incidents. It should be noted that the incident was reported to the SSA 27.5 hours after the allegation was made. On 2/22/24 at 1:11 PM, APS was notified of the allegation of Suspected Dependent Adult/Elder Abuse. It should be noted that the incident was reported to APS eight days after the allegation was made. On 5/22/24 at 2:09 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he believed that he submitted the initial report to the SSA timely according to regulations. The ADM stated that he thought he had 24 hours to report because the allegation did not result in serious bodily injury. [Cross-refer F603]

Based on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators sexual behaviors and the facility failed to provide protection for the residents thereby allowing ongoing access to the residents by the alleged perpetrator. Finally, victims of the sexual abuse exhibited crying and expressed recurring fear of the perpetrator. Based on the resident(s) behavior, it can be determined that the resident(s) experienced psychosocial harm as a result of the sexual abuse. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. NOTICE On 7/12/23 at 5:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent abuse. Notice of the IJ was given verbally and in writing to the facility Administrator (ADM), Director of Nursing (DON), Assistant Director of Nursing (ADON), Clinical Resource Staff (CRS) 1, Minimum Data Set (MDS) Staff 1, Case Manager (CM) 1, and the Director of Therapy (DOT) and they were informed of the findings of IJ pertaining to F600 and F610 for residents 3, 10, 18, 24, 26, 34, and 136. On 7/13/23, the ADM provided the following abatement plan for the removal of the Immediate Jeopardy effective on 7/13/23 at 12:00 PM. Immediate Plan of Correction for F600 and F610 The facility submits this Plan of Correction to address the Immediate Jeopardy identified by the Survey Team on 7/12/2023. The facility feels that abatement outlined below will be in place as of 07/13/2023 by 12:00 pm. Medical Director was notified of IJ 7/12/2023 at 5:35 pm An aide/appointed designee that feels comfortable around [resident 10] will be one on one with [resident 10] 24 hours while he is up for the day. The aide/appointed designee will accompany him throughout the day to make sure he has no contact with any female residents. When resident is in bed, the assigned 1 on 1 staff can be doing other duties. This is because resident cannot get out of bed on his own. This started at 4:00 pm on 7/12/23 Additional education/training was done with all staff working with above resident. Education will be provided for on-going shifts. 7/13/2023 Q [every] shift charting of behaviors was adding to the resident record in PCC [point click care]. 7/13/2023 All residents were interviewed regarding concerns, abuse reporting, inappropriate contact or conversations. See attached form. Completed 7/12/23 and 7/13/2023 Social Services will conduct a Psychosocial assessment on the residents that have been affected and appropriate referrals for psychosocial follow up care will be made when indicated. 07/13/2023 Social Services will continue to attempt to find appropriate alternative placement for resident and will document attempts and outcomes. Social Services to help resident get on the New Choices waiver per resident request. This will be submitted no later than July 20, 2023 Behavioral Education was done with staff on 07/11/2023. Abuse education was done with all staff at an emergency all staff meeting on 7/13/2023. This also included education on facility wide communication regarding updates on residents The in-service includes the following information from the Abuse Prevention and Prohibition Policy: Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. We prevent by screening employees, training (upon hire, annually and with any allegation of abuse and neglect), investigating and reporting. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; Procedures for reporting incidents Education on reading the Kardex and Communication board to keep staff updated with resident information will be done. Department heads will be designated to inform their staff on updates in daily Stand Up meeting. Completed 7/13/2023 New hires will be educated on information in Orientation and upon hire. A QAPI [Quality Assurance and Performance Improvement] was held and IJ findings were addressed. 7/13/2023 The Abuse Coordinator will provide a summary of any investigations related to abuse/neglect/exploitation monthly at the QAPI meeting for review and recommendations weekly until facility is deemed to be in substantial compliance. F610 Abuse reporting training for the ED [Executive Director}, DON, ADON, Social Service will be completed by Governing Body on 7/13/23. The Administrator will review all current abuse allegation investigations with a member of the Governing Body to ensure timely reporting and completion of thorough investigations. This review will be weekly for 1 month, then monthly for 3 months. On 7/13/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 7/13/23. Findings included: IMMEDIATE JEOPARDY 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which consisted of but was not limited to type 2 diabetes mellitus, chronic kidney disease, cognitive communication deficit, morbid obesity, glaucoma, acquired absence of right leg above the knee, hypertensive heart disease, polyneuropathy, heart failure, hypertension, major depressive disorder, insomnia, anxiety disorder, and contracture of the left hand. On 7/10/23, resident 10's records were reviewed. On 7/7/22, resident 10's Pre-Admission Screening Applicant/Resident Review (PASRR) Level I documented psychiatric diagnoses as chronic anxiety and depression. On 10/15/22, the Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 12/15, which would indicate a moderate cognitive impairment. On 2/17/23, the Quarterly MDS Assessment documented a BIMS score of 7/15, which would indicate a severe cognitive impairment. On 5/20/23, the Quarterly MDS Assessment documented a BIMS score of 10/15, which would indicate a moderate cognitive impairment. On 7/27/22, a St. [NAME] Mental Status (SLUMS) exam documented a score of 10/24 which would place the resident at the cognitive level of dementia. On 9/6/22, the Montreal Cognitive Assessment (MoCA) documented a score of 26 out of 30, which would indicate a normal cognitive function. On 1/11/23, resident 10 had a physician order to monitor for sexual tendencies every 15 minutes to ensure safety of resident and others was initiated. Review of resident 10's behavior tracking for the last 30 days documented on 7/2/23 at 12:17 AM sexually inappropriate, and on 7/6/23 at 4:39 AM sexually inappropriate with grabbing. Review of resident 10's Kardex information for the aides revealed no documentation regarding sexual behaviors or monitoring. Resident 10's care plan revealed a focus area for had a behavior problem of touching female staff and female residents inappropriately. The care plan was initiated on 10/2/22. Interventions identified were: Administer medications as ordered; Approach in a calm manner; Assist to develop more appropriate methods of coping and interacting encourage to express feelings appropriately; Document behaviors, and resident response to interventions; If reasonable, discuss behavior and explain/reinforce why behavior is inappropriate; Intervene as necessary to protect the rights and safety of others; Divert attention and remove from situation and take to alternate location as needed; and Monitor behavior episodes and attempt to determine underlying cause. All interventions were initiated on 10/2/22. On 10/12/22, the care plan added an intervention to Notify Police, ombudsman, and families of behaviors, and the resident to eat in his room or be provided alternative social dining options away from female residents and staff provide supervision while out and about. Multiple allegations/incidents of sexual abuse by resident 10 were made as follows: A. On 10/2/22 at 1:38 PM, nursing progress notes for resident 10 revealed that the resident has been touching female patient's breasts during meal times. The progress note documented that the ADM/Abuse Coordinator, Medical Doctor, DON, and resident family members were notified of the incident. On 10/02/22 at 5:14 PM, the nursing progress note for resident 10 documented that the local police department was notified of the incident. On 10/03/22 at 6:24 PM, the social service progress note for resident 10 documented that the local police department informed the facility that none of the families wanted to press charges. On 10/2/22 at 2:57 PM, the State Survey Agency (SSA) was notified of an incident between resident 10 and resident 24. The entity report documented that a resident notified staff that resident 10 was inappropriately touching [resident 24] during lunch. The report documented that resident 10 touched resident 24's breast when she bent over to get her napkin from the floor. The report documented that residents 3, 18, and 24 were involved in the incident. However, no information regarding residents 3 and 18 was listed on the entity report. On 10/2/22 at 2:50 PM, the Adult Protective Service (APS) confidential report documented that A resident notified staff that [resident 10], A male LT (long term) resident, touched [resident 24] inappropriately during lunch on Sunday 10/2/2022. as reported, [resident 24] apparently dropped her napkin from the table, and while she was trying to recover it, [resident 10] 'touched' her (resident 24) breasts. The staff immediate (sic) moved [resident 10] to another table, and spoke with [resident 24] about it. [Resident 24] did not confirm or contradict what the other resident claimed. Until an investigation is completed, the facility will make sure that [resident 10] only sits at tables with other male residents, and that the staff will put him on 15 min (minute) checks. An incident report dated 10/2/22 did not provide any additional information regarding the event in question or the investigation. It should be noted that no final investigation into this allegation of sexual abuse was included in the facility's abuse file, nor was it submitted to the State Survey Agency. No evidence could be located to indicate that an investigation into the allegation was conducted. i. Resident 24 was initially admitted to the facility on [DATE] and again on 4/2/22 with medical diagnoses that included Parkinson's disease, history of transient ischemic attack, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ileus, generalized abdominal pain, major depressive disorder, dementia, cognitive communication deficit, dysphagia, and generalized anxiety disorder. On 9/20/22, the Quarterly MDS Assessment documented a BIMS score of 2/15, which would indicate a severe cognitive impairment. On 12/21/22, the Quarterly MDS Assessment documented a BIMS of 2/15, which would indicate a severe cognitive impairment. On 3/23/23, the Quarterly MDS Assessment documented a BIMS of 0/15, which would indicate a severe cognitive impairment. On 6/21/23, the Annual MDS Assessment documented a BIMS score of 9/15, which would indicate a moderate cognitive impairment. On 4/4/22, a SLUMS exam documented a score of 6/25, which would place the resident at the cognitive level of dementia. On 11/3/2020, resident 24 began receiving hospice services. On 10/6/22 at 2:16 PM, a nursing progress note documented, LN [Licensed Nurse] reports to DON that Hospice aide reported some minimal vaginal bleeding during resident shower this afternoon. LN and DON in to assess resident, vaginal bleeding is noted in very minimal amounts (appears 'splotchy' on the brief) the labia nor vaginal entry show any visual signs of trauma, redness, bruising, or irritation. There are no skin tears noted, resident reports that she has had a hx [history] of hemorrhoids but the bleeding appeared to be coming from the vaginal canal. Resident doesn't report any pain or irritation in the vaginal area, but did state that she sometimes has lower abdominal pain that comes and goes. When asked if resident had had any type of sexual intercourse with her husband [name redacted] or anyone else, she stated no. Resident does not appear in any distress at this time, and also notes that shes previously had a hysterectomy and is curious to know why she would be experiencing some bleeding. Hospice Nurse has been notified, NO [new order] to monitor as he will be in to see her tomorrow. COC [change of condition] completed, and monitoring in place. On 10/8/22 at 9:04 AM, a progress note documented, Resident is on alert charting for vaginal bleeding. She is still bleeding. It is a bit heavier and more consistent than yesterday. DON, Hospice and residents husband aware. Will continue to monitor. It should be noted that there was no sexual assault forensic exam conducted to determine the causative factors of the vaginal bleeding, or if trauma had occurred. ii. Resident 3 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included intracranial injury, aphasia, cognitive communication deficit and major depressive disorder. On 6/28/22, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 9/28/22, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 11/22/22, the Annual MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 1/20/23, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 4/22/23, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. Resident 3's progress notes did not document any investigation or follow up with regard to the incident with resident 10. iii. Resident 18 was admitted to facility on 5/29/18 and readmitted on [DATE] with diagnoses that included but not limited to subdural and subarachnoid hemorrhage, aphasia, dysphagia, cognitive communication deficit, apraxia, seizures, anxiety, muscle weakness, speech disturbances, lack of coordination, hypotension, history of falls, pseudobulbar affect, abnormal gait and mobility, and hypothyroidism. Resident 18's medical record was reviewed on 7/12/22. On 3/16/22, the Annual MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. On 9/20/22, the Quarterly MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. On 3/16/23, the Annual MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. On 6/16/23, the Quarterly MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. Resident 18's progress notes did not document any investigation or follow up with regard to the incident with resident 10. B. On 12/14/22 at 5:47 PM, resident 10's progress note documented, CNA [Certified Nurse Assistant] notified the nurse that the male resident inappropriately touched a female resident's breasts in the dining room without her consent. Male resident was immediately removed from the dining room. Resident was placed on q [every]15 checks. On 12/16/22 at 10:55 AM, the social service note documented, Resident asked if he wanted to be evaluated by [local] mental health as to be able to visit with them regarding things. [Resident 10] said no as he feels like he has done nothing wrong. On 12/14/22 at 5:28 PM, the initial facility entity report (Form 358) documented that resident 10 was witnessed to touch resident 34's breast in the dining room. The residents were separated, and resident 34 was provided emotional support and was able to calm down. The report documented that resident 34 was alert and oriented times 2. Resident 34 was initially distraught and did report that resident 10 had inappropriately touched her breasts without her consent. The report documented that resident 10 was alert and oriented times 4, and was educated on inappropriate behavior. The local police department was notified of the incident. Resident 10 was placed on 15-minute checks. The final investigation report (Form 359) documented that resident 34 reported that a male resident had been helping her get to the dining room by pushing her wheelchair with his powerchair. When they got to the dining room he brought her to the wrong side of the table, sat next to her, and proceeded to grope her breasts without her consent. Resident 34 reported that she told resident 10 to stop and he did. A CNA walked into the dining room and noticed that resident 34 was seated on the wrong side of the table. Resident 34 then reported the incident to the CNA who then reported it to the Licensed Nurse. The Licensed Nurse asked resident 10 to exit the dining room for victim safety. The report documented that resident 10 was educated to stay away from resident 34 and he would not be allowed to be alone with any other female residents. Review of the facility video footage revealed that the residents were alone in the dining room together, but both residents' backs were facing the camera. The report documented that the video footage did not determine whether the accusation actually occurred. The final report documented that the abuse allegation was unable to be confirmed by video footage and was deemed inconclusive. The report documented that the corrective action taken by the facility was to implement 15-minute checks, then every 1 hour check on resident 10. Resident 34 was provided Psychosocial follow up and was referred to behavioral health services. i. Resident 34 was admitted to the facility on [DATE] with diagnoses which consisted of but were not limited to unspecified dementia, mild cognitive impairment, morbid obesity, chronic obstructive pulmonary disease, cognitive communication deficit, bipolar disorder, anxiety disorder, major depressive disorder, and insomnia. On 7/10/23 at 11:03 AM, an interview was conducted with resident 34. Resident 34 stated that about 3 months ago resident 10 touched her breast. Resident 34 stated that it scared her and she panicked when this happened. Resident 34 stated that she did not feel safe from resident 10 unless she was with one of the aides or nurses that she knows. Resident 34 stated that when resident 10 passed her in the hallway he looked at her with a scowl crossed eyed. Resident 34 stated that the incident with resident 10 had caused her a lot of stress and worry. Resident 34's medical records were reviewed on 7/11/23. On 12/4/22, the Quarterly MDS Assessment documented a BIMS score of 7/15, which would indicate a severe cognitive impairment. On 3/6/23, the Quarterly MDS Assessment documented a BIMS score of 3/15, which would indicate a severe cognitive impairment. On 6/5/23, the Annual MDS Assessment documented a BIMS score of 15/15, which would indicate that the resident was cognitively intact. On 6/2/22, a SLUMS exam documented a score of 11/30, which would indicate a cognitive level consistent with dementia. On 6/7/23, a SLUMS exam documented a score of 14/30 which would indicate a cognitive level consistent with dementia. On 11/23/22, the MoCA exam documented a score of 23/20, which would indicate a mild cognitive impairment. On 6/28/22, resident 34's Preadmission Screening Resident Review (PASRR) Level II assessment documented an extensive history of mental health concerns since childhood. Resident 34 also struggled with a mild intellectual disability. The history of psychiatric symptoms documented that resident 34 had a long history of depression and anxiety, and that medications were helpful. Resident 34 reported she was in 3 marriages, all of which were abusive. Resident 34 reported that in her first marriage she found out that her husband and his mother were trying to poison her. Her husband was abusive and that was where her Post Traumatic Stress Disorder (PTSD) diagnosis came from. Resident 34's Progress notes revealed the following: a. On 12/14/22 at 4:58 PM, the social service note documented, Visited with patient. regarding incident of Another resident touching her innaproiatelym(sic). It caused the resident to be very upset. Says she felt violated. Administrator and DON made me aware. Resident assured that we will do all we have to, to take care of her. b. On 12/14/22 at 5:36 PM, the note documented, CNA notified the nurse that the resident was inappropriately touched by a male resident. The male inappropriately touched the patient's breasts without the patient's consent. Nurse removed the male patient from contact from the patient. Male patient was placed on q [every]15 checks. Facility DON, ADON, administrator, and [local] PD notified. c. On 12/15/22 at 10:12 AM, the social service note documented, Psychosocial follow up with patient. Still very upset and scared of another resident. We assured her we are watching him and keeping a close eye on him. Asked if she was feeling safe, being here? she replied yes as staff have been good to help and guide her as needed, reassure her and this has helped a lot. [Resident 34] expressed she was grateful. d. On 12/16/22 at 12:00 AM, the provider note documented, She reported that one of the residents had touched her breasts and that she has been raped 5 times in the past. She stated it was very scary. She has already reported the breast touching and it is being investigated. e. On 12/16/22 at 11:01 AM, the note documented, Alert charting r/t [related to] potential for trauma due. Resident c/o [complained of] having nightmares about being touched by male resident. Emotional support given and is stable. Social services notified of nightmares. f. On 12/16/22 at 1:15, the social service note documented, [Resident 34] said she is feeling sad and a little scared today. Saw the other resident in the hall and this caused her to be scared. I assured her everything would be ok. We are not going to let anything happen to her. Referral was made to [local mental health services] for some counseling. [Resident 34] felt this may help. g. On 12/16/22 at 9:01 PM, the note documented, Patient is on alert due to being inappropriately touched by a male resident. Frequent checks are continuing to be made to ensure that resident's wellbeing and mental health are WNL [within normal limits]. Patient tearful today, expressed some small amount of anxiety this evening. h. On 12/17/22 at 7:45 PM, the note documented, Patient is on alert due to being inappropriately touched by a male resident. Frequent checks are continuing to be made to ensure that resident's wellbeing and mental health are WNL. Patient tearful today, is cooperative with cares. Expresses how she is feeling. i. On 12/19/22 at 3:18 PM, the social service note documented, pyscho social follow up on patient. [Resident 34] has been getting out and coming to activities. [Resident 34] says she likes being involved and being able to participate. It also has been good for her to stay busy. Resident states she is still scared as well as nervous when she sees him, that it takes her to a not happy place. Has been having trouble sleeping. j. On 12/20/22 at 4:39 PM, the social service note documented, Psychosocial follow up . Resident is doing ok. Today during activity time, the resident came into to participate and the other resident that had touched her innapproiately (sic) also came in, this caused [Resident 34] to be upset. She began to cry, became very upset. We assured her we are here for her. The other patient left saying he was sorry. [Resident 34] was calmed down, reassured. she expressed she has a history of being attacked and not being treated nice, so this was very upsetting to her. I asked her if there was anything we could do while providing lots of love and support. [Resident 34] said no she was just glad we were there. k. On 12/22/22 at 11:06 AM, the social service note documented that resident 34 had stated that she was trying to be [NAME] and hang in there. l. On 12/31/22 at 11:44 AM, the social service note documented, Resident is doing ok, will still get upset when she sees the patient that touched her,. m. On 1/11/23 at 1:48 PM, the social service note documented, Met with resident to evaluate resident and provide psychotherapy. Resident states she is still upset about the incident with the male resident that happened about 3 weeks ago. She states it brought up memories of sexual trauma that happened with her ex husband. Resident has done therapy in the past at [local mental health provider] for PTSD but she is not interested counseling any longer. Resident avoids resident and male resident has not interacted with her since the incident. Resident states she would also feel more comfortable if her bedroom door is closed whenever she is in the room. Resident states she cannot always verbalize when she is anxious but if she starts crying if staff approach her and talk to her that often helps her calm down. Will update care plan. No further needs at this time. Resident was calm and didn't appear to be in any distress at the moment. n. On 01/11/23 at 5:34 PM, the social service note documented, Police met with [resident 34] regarding innaproitness (sic) with another resident, she related to the officer that she was fondled on her front chest and was not happy. Resident cried and expressed that she just did not want to see him. Her family did decide to press charges, so the officer was going to be submitting everything to the attorney. Ombudsman was notified as well as patients family and nursing. o. On 01/23/23 at 3:20 PM, the social service note documented, Resident isa [sic] doing well. Says as long as she does not see the patient that touched her, she will be fine. C. On 1/11/23 at 12:36 PM, the social service progress notes for resident 10 documented that resident 10 was being sent to a local emergency room to be evaluated by crisis worker and medically cleared. We believe he could benefit from a mental health evaluation and possible inpatient psych (psychiatric) stay. Resident exhibiting hypersexual behavior. Resident has been treated in the past for bipolar and may be experiencing a hypomanic episode. On 1/11/23 at 6:05 PM, the social service progress notes for resident 10 documented that the resident had been placed on 15 minute checks and all staff aware to monitor for hypersexuality and potential for inappropriate behavior. On 1/12/23 at 8:06 AM, the social service progress note for resident 10 documented, Resident returned last night from ER [emergency room ] visit, expressed he had no idea why he was even sent there as he is doing well with no issues and denied any problems. Said he is not sure why he went to begin with. On 1/17/23 at 12:15 PM, the social service note for resident 10 documented, Is still denying he did anything wrong. I said well it is important to not touch anyone and keep our hands to ourself. [Resident 10] said he does and has no idea why the cops were called or who called them. On 1/23/23 at 12:00 AM, the provider note for resident 10 documented, The patient has had reported interactions with other residents that were deemed inappropriate touching. I did discuss this with the patient and he does report that he has had no sexual conduct but has had episodes of inappropriate touching with other residents. We did discuss this and the patient states that he has been feeling increasingly depressed. On 1/11/23 at 10:34 AM, an initial facility entity (Form 358) was completed by facility staff. The form indicated that resident 26 reported to the local police department investigator while he was in the building conducting a separate investigation against [resident 10], that she had also been inappropriately touched by [resident 10]- another resident residing within the facility. [Resident 26] indicated that about a month ago, [resident 10] came into her room after dinner time, and placed his hand under her blankets and proceeded to run his hand up her thigh, then asked her if he could touch her breasts in which she told him 'No' and then he left. Facility to conduct formal investigation. It was also reported by investigator that resident [136] made an allegation to him as well - however resident out to dialysis at time of self-report and unable to be interviewed until she returns. [Resident 10] was sent to [local hospital] for Crisis Eval [evaluation] event that [resident 10] is not admitted [or transferred to another facility] he will be placed on [every 15 minute] checks to ensure that he is not potentially perpetuating other female residents within the facility. On 1/17/23 at 2:00 PM, a follow up investigation report (Form 359) was completed by facility staff. The form indicated that resident 10 denied any inappropriate actions were taken by him. The corrective actions taken documented, We have moved [resident 10] to another hall within the building, that at this time is consisting of more male in its residents. Staff has been educated for continual monitoring of [resident 10] in public spaces in the building, and [resident 10] is not allowed in any female resident's rooms unsupervised. We are alos (sic) trying to find placement for [resident 10] in a facility that is more appropriate for him. The form 359 indicated that the investigation was Inconclusive. The form 359 did not include any documentation of interviews with the alleged victims, or other residents who may have been at risk. i. Resident 26 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, diabetes mellitus, paraplegia, muscle weakness, generalized anxiety disorder, major depressive disorder, and chronic kidney disease stage 4. On 11/24/22, a Quarterly MDS Assessment documented a BIMS score of 14/15, which would indicate that resident 26 was cognitively intact. On 5/27/23, a Quarterly MDS Assessment documented a BIMS score of 12/15, which would indicate a moderate cognitive impairment. On 1/11/23 at 2:18 PM, a social services note documented that the facility Licensed Clinical Social Worker (LCSW) Met with resident to discuss incident with male resident. Resident does not feel unsafe and did not appear to be distressed over it but states she avoids resident now. No further needs at this time. On 7/10/23 at 10:14 AM, an interview was conducted with resident 26. Resident 26 stated that resident 10 had previously patted her leg, and moved his hand toward her genitals. Resident 26 stated that she stopped resident 10 from touching her genitals, but that resident 10 asked to touch her breasts, to which she replied no. Resident 26 stated that she avoids resident 10 at the facility because she feels [TRUNCATED]

Based on interview and record review it was determined, for 9 out of 40 sampled residents, that in response to allegations of abuse the facility failed to have evidence that all alleged violations were thoroughly investigated and further potential abuse was prevented. Specifically, the facility initial entity reports and final investigation reports filed with the State Survey Agency (SSA) contained incomplete summaries of incidents of sexual abuse, and the facility did not have supporting documentation of the summaries that were provided to the SSA. Additionally, not all reported incidents of alleged sexual abuse had evidence that suggested they were investigated by the facility. Multiple instances of resident to resident sexual abuse occurred with an insufficient investigation. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Furthermore, the facility did not conduct an independent investigation into a resident's missing Fentanyl patch but instead relied on the hospice companies investigation. Resident identifiers: 3, 9, 10, 18, 24, 26, 31, 34, and 136. NOTICE On 7/12/23 at 5:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent abuse. Notice of the IJ was given verbally and in writing to the facility Administrator (ADM), Director of Nursing (DON), Assistant Director of Nursing (ADON), Clinical Resource Staff (CRS) 1, Minimum Data Set (MDS) Staff 1, Case Manager (CM) 1, and the Director of Therapy (DOT) and they were informed of the findings of IJ pertaining to F600 and F610 for residents 3, 10, 18, 24, 26, 34, and 136. On 7/13/23, the ADM provided the following abatement plan for the removal of the Immediate Jeopardy effective on 7/13/23 at 12:00 PM. Immediate Plan of Correction for F600 and F610 The facility submits this Plan of Correction to address the Immediate Jeopardy identified by the Survey Team on 7/12/2023. The facility feels that abatement outlined below will be in place as of 07/13/2023 by 12:00 pm. Medical Director was notified of IJ 7/12/2023 at 5:35 pm An aide/appointed designee that feels comfortable around [resident 10] will be one on one with [resident 10] 24 hours while he is up for the day. The aide/appointed designee will accompany him throughout the day to make sure he has no contact with any female residents. When resident is in bed, the assigned 1 on 1 staff can be doing other duties. This is because resident cannot get out of bed on his own. This started at 4:00 pm on 7/12/23 Additional education/training was done with all staff working with above resident. Education will be provided for on-going shifts. 7/13/2023 Q [every] shift charting of behaviors was adding to the resident record in PCC [point click care]. 7/13/2023 All residents were interviewed regarding concerns, abuse reporting, inappropriate contact or conversations. See attached form. Completed 7/12/23 and 7/13/2023 Social Services will conduct a Psychosocial assessment on the residents that have been affected and appropriate referrals for psychosocial follow up care will be made when indicated. 07/13/2023 Social Services will continue to attempt to find appropriate alternative placement for resident and will document attempts and outcomes. Social Services to help resident get on the New Choices waiver per resident request. This will be submitted no later than July 20, 2023 Behavioral Education was done with staff on 07/11/2023. Abuse education was done with all staff at an emergency all staff meeting on 7/13/2023. This also included education on facility wide communication regarding updates on residents The in-service includes the following information from the Abuse Prevention and Prohibition Policy: Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. We prevent by screening employees, training (upon hire, annually and with any allegation of abuse and neglect), investigating and reporting. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; Procedures for reporting incidents Education on reading the Kardex and Communication board to keep staff updated with resident information will be done. Department heads will be designated to inform their staff on updates in daily Stand Up meeting. Completed 7/13/2023 New hires will be educated on information in Orientation and upon hire. A QAPI [Quality Assurance and Performance Improvement] was held and IJ findings were addressed. 7/13/2023 The Abuse Coordinator will provide a summary of any investigations related to abuse/neglect/exploitation monthly at the QAPI meeting for review and recommendations weekly until facility is deemed to be in substantial compliance. F610 Abuse reporting training for the ED [Executive Director}, DON, ADON, Social Service will be completed by Governing Body on 7/13/23. The Administrator will review all current abuse allegation investigations with a member of the Governing Body to ensure timely reporting and completion of thorough investigations. This review will be weekly for 1 month, then monthly for 3 months. On 7/13/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 7/13/23. Findings included: IMMEDIATE JEOPARDY 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which consisted of but was not limited to type 2 diabetes mellitus, chronic kidney disease, cognitive communication deficit, morbid obesity, glaucoma, acquired absence of right leg above the knee, hypertensive heart disease, polyneuropathy, heart failure, hypertension, major depressive disorder, insomnia, anxiety disorder, and contracture of the left hand. On 7/10/23, resident 10's records were reviewed. Multiple allegations/incidents of sexual abuse by resident 10 were made as follows: a. On 10/2/22 at 2:57 PM, the State Survey Agency (SSA) was notified of an incident between resident 10 and resident 24. The entity report documented that a resident notified staff that resident 10 was inappropriately touching [resident 24] during lunch. The report documented that resident 10 touched resident 24's breast when she bent over to get her napkin from the floor. The report documented that residents 3, 18, and 24 were involved in the incident. However, no information regarding residents 3 and 18 was listed on the entity report, and no information was obtained to identify the resident who reported the incident. On 10/2/22 at 2:50 PM, the Adult Protective Service (APS) confidential report documented that A resident notified staff that [resident 10], A male LT (long term) resident, touched [resident 24] inappropriately during lunch on Sunday 10/2/2022. as reported, [resident 24] apparently dropped her napkin from the table, and while she was trying to recover it, [resident 10] 'touched' her (resident 24) breasts. The staff immediate (sic) moved [resident 10] to another table, and spoke with [resident 24] about it. [Resident 24] did not confirm or contradict what the other resident claimed. Until an investigation is completed, the facility will make sure that [resident 10] only sits at tables with other male residents, and that the staff will put him on 15 min (minute) checks. It should be noted that no final investigation into this allegation of sexual abuse was included in the facility's abuse file, nor was it submitted to the State Survey Agency. No evidence could be located to indicate that an investigation into the allegation was conducted. b. On 12/14/22 at 5:28 PM, the initial facility entity report (Form 358) documented that resident 10 was witnessed to touch resident 34's breast in the dining room. The residents were separated, and resident 34 was provided emotional support and was able to calm down. The report documented that resident 34 was alert and oriented times 2. Resident 34 was initially distraught and did report that resident 10 had inappropriately touched her breasts without her consent. The report documented that resident 10 was alert and oriented times 4, and was educated on inappropriate behavior. The local police department was notified of the incident. Resident 10 was placed on 15-minute checks. The final investigation report (Form 359) documented that resident 34 reported that a male resident had been helping her get to the dining room by pushing her wheelchair with his powerchair. When they got to the dining room he brought her to the wrong side of the table, sat next to her, and proceeded to grope her breasts without her consent. Resident 34 reported that she told resident 10 to stop and he did. A CNA walked into the dining room and noticed that resident 34 was seated on the wrong side of the table. Resident 34 then reported the incident to the CNA who then reported it to the Licensed Nurse. The Licensed Nurse asked resident 10 to exit the dining room for victim safety. The report documented that resident 10 was educated to stay away from resident 34 and he would not be allowed to be alone with any other female residents. Review of the facility video footage revealed that the residents were alone in the dining room together, but both residents' backs were facing the camera. The report documented that the video footage did not determine whether the accusation actually occurred. The final report documented that the abuse allegation was unable to be confirmed by video footage and was deemed inconclusive. The report documented that the corrective action taken by the facility was to implement 15-minute checks, then every 1 hour check on resident 10. c. On 1/11/23 at 10:34 AM, an initial facility entity (Form 358) was completed by facility staff. The form indicated that resident 26 reported to the local police department investigator while he was in the building conducting a separate investigation against [resident 10], that she had also been inappropriately touched by [resident 10]- another resident residing within the facility. [Resident 26] indicated that about a month ago, [resident 10] came into her room after dinner time, and placed his hand under her blankets and proceeded to run his hand up her thigh, then asked her if he could touch her breasts in which she told him 'No' and then he left. Facility to conduct formal investigation. It was also reported by investigator that resident [136] made an allegation to him as well - however resident out to dialysis at time of self-report and unable to be interviewed until she returns. [Resident 10] was sent to [local hospital] for Crisis Eval [evaluation] event that [resident 10] is not admitted [or transferred to another facility] he will be placed on [every 15 minute] checks to ensure that he is not potentially perpetuating other female residents within the facility. On 1/17/23 at 2:00 PM, a follow up investigation report (Form 359) was completed by facility staff. The form indicated that resident 10 denied any inappropriate actions were taken by him. The corrective actions taken documented, We have moved [resident 10] to another hall within the building, that at this time is consisting of more male in its residents. Staff has been educated for continual monitoring of [resident 10] in public spaces in the building, and [resident 10] is not allowed in any female resident's rooms unsupervised. We are alos (sic) trying to find placement for [resident 10] in a facility that is more appropriate for him. The form 359 indicated that the investigation was Inconclusive. The form 359 did not include any documentation of interviews with the alleged victims, or other residents who may have been at risk. It should be noted that no facility investigation into the allegation of sexual abuse of resident 136 was included in the facility's abuse file, nor was it submitted to the State Survey Agency. No evidence could be located to indicate that an investigation into the allegation with resident 136 was conducted. d. On 6/30/23, the facility initial entity report (Form 358) was completed by facility staff. The form documented that Victim [resident 31] alleged that [resident 10] inappropriately touched her breast. She grabbed his hand and pushed it away. No other interactions occurred. Made sure [resident 31] felt safe and out of harms way. Addressed inappropriate behavior with [resident 10]. He agreed it was not ok. On 7/7/23, a follow up investigation report (Form 359) was completed by facility staff. The form indicated that resident 10 denied the allegation, and stated that he had only touched her arm. The form also indicated that two staff members witnessed the interaction, and also indicated that resident 10 touched resident 31's arm, but did ask to touch resident 31's breast. After interviews with staff and review of the incident on camera, the facility determined that the allegation was not verified. On 7/11/23 at 1:39 PM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that the dining room was used for residents who required assistance with dining. CNA 3 stated that resident 10 was not allowed into the dining room during meal times because resident 34 was in there, and this was due to resident 10 being inappropriate with resident 34. CNA 3 stated that resident 10 had touched resident 34's breast. CNA 3 stated that resident 10 goes into the dining room to obtain coffee and energy drinks. CNA 3 stated that resident 10 utilized a motorized wheelchair for mobility and that he was able to independently operate the wheelchair. CNA 3 stated that resident 10's room was located on the same hallway as resident 34. CNA 3 stated that resident 10 moved to another hallway away from resident 34 in January. CNA 3 stated that resident 10 had been sexually inappropriate with other residents and staff, but she was not aware of who those individuals were. On 7/11/23 at 2:08 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that none of the residents on his hallway ate their meals in the dining room. LPN 3 stated that resident 10 was not allowed to eat in the dining room because he had behaviors of being sexually inappropriate with women. LPN 3 stated that resident 10 had reached or touched resident 31's breasts, but he was not aware of resident 10 sexually abusing any other residents. LPN 3 stated that they conducted behavior monitoring for resident 10 every 30 minutes for any behaviors. LPN 3 stated that resident 10 was independent with mobility in his motorized wheelchair, and was social and in and out of his room. LPN 3 stated that resident 10 was not allowed to be around resident 31, but LPN 3 was not aware of any other resident restrictions. On 7/12/23 at 2:11 PM, an interview was conducted with the DON. The DON stated that resident 10 had inappropriate behaviors with women, and had touched resident 34's breast. The DON stated that there was a second incident in June with resident 10 and resident 31. The DON stated that the video footage did not reveal much, that you see resident 10's hand touch resident 31's arm and she shoos him away. The DON stated that resident 31 stated that resident 10's back of the hand touched her breast, but resident 10 said he just touched her arm, and they could not tell from the video. The DON stated that somebody laid eyes on resident 10 every 15 minutes and reported to the nurse any behaviors. The DON stated that this had been implemented since the incident with resident 34 and they had a physician order for it. It should be noted that the incident between resident 10 and resident 34 occurred on 12/14/22 and the order for 15-minute checks was initiated on 1/11/23, almost a month later. On 7/12/23 at 3:08 PM, an interview was conducted with the Administrator (ADM). The ADM stated that for any allegations of abuse they immediately reported it to the SSA and APS and then started the investigation process. The ADM stated that the investigation included calling staff and obtaining interviews. The ADM stated they also notified the resident's family and Ombudsman. The ADM stated that during the facility investigation they interviewed staff and residents who were noted to be present during the incident. The ADM stated that he did not document those interviews, but rather kept a mental note about the interview. The ADM stated that sometimes he kept an outline of the interview on his phone and he referenced this when writing the final investigation. The ADM stated that they did not have documentation or other notes from the investigation other than what was in the initial SSA notification (Form 358) and the final SSA investigation (Form 359). The ADM stated that not all investigation were expanded to interview other residents. The ADM stated that if it was a sexual abuse allegation they should expand the investigation to interview other residents. The ADM stated that they were not really consistent with the interview process. The ADM stated that he spoke with the previous ADM about the incident between resident 10 and resident 34. The ADM stated that the previous ADM reported that they had interviewed all the residents and asked if they had any interactions with resident 10. The ADM stated he was not sure if there was documentation of those interviews. On 7/12/23 at 3:32 PM, an interview was conducted with the MedTech. The MedTech stated she observed resident 10 grab resident 31's left forearm around the antecubital area, and his hand started to move up and down in a stroking movement with his fingertips. The MedTech stated that resident 10 asked resident 31, can I touch your breast while stroking with his fingertips. The MedTech stated that resident 10 was inappropriate with resident 34 and he groped her breast in the dining room. The MedTech stated that she was alerted to the incident when she heard resident 34 let out a blood curdling scream. The MedTech stated that resident 10 knows how to position himself without the cameras viewing what he was doing. The MedTech stated that she also witnessed an incident occur between resident 10 and resident 5. The MedTech stated that resident 10 groped resident 5's breast and it was an open handed stroke/caress. The MedTech stated that resident 5 stated, stop that, and when the MedTech asked her if she was okay she replied ya. The MedTech stated that she informed the previous ADM of the incident via text message. It should be noted that no documentation could be found of an investigation into the incident between resident 10 and resident 5. The MedTech stated that she had also heard that resident 10 had put his hand up resident 24's skirt, but her husband did not want to press charges. The MedTech stated that she did not recall when this incident occurred. The MedTech stated that she had also heard that resident 3 and resident 18 were also victims of resident 10, but she was not aware of the details of the incident. On 7/12/23 at 4:32 PM, a telephone interview was conducted with the previous ADM. The previous ADM stated that in October 2022 there was an incident with resident 10 touching resident 24's breast. The previous ADM stated that resident 3 and resident 18 were seated at the same table as resident 24 and resident 10. The previous ADM stated that he only had the initial entity report and he would have to locate his notes. The previous ADM stated that his investigation notes were located in the notebooks and were a part of the abuse investigation. It should be noted that no additional note documentation was found in the facility abuse investigation. The previous ADM stated that he would send to the SSA the final investigation report and that he did not have any notes outside of Form 359. The previous ADM stated that he did not document the date and times or who the other residents were that he interviewed, and that was something he needed to get better at documenting. The previous ADM stated that when he had an allegation of abuse he would talk to at least 2 other staff and 2 other residents on the same hallway as the victim. The previous ADM stated that the final investigation report documented that another resident who was not identified was interviewed and had stated she had seen resident 10 touch other residents. The previous ADM stated that those other potential victims were not identified nor investigated. The previous ADM stated that there was a second incident between resident 10 and resident 34. The previous ADM stated that the incident with resident 34 was unwitnessed, and that a CNA had reported to a LN that resident 10 was feeling up resident 34's breasts without her consent in the dining room. The previous ADM stated that it was his practice to talk to other residents, but he did not know if he documented it. The previous ADM stated that both resident 136 and resident 26 reported to the police similar incidents of sexual abuse. The previous ADM stated that at the time of the incidents resident 10, resident 34, resident 136, and resident 26 were all residing in the same hallway. The previous ADM stated that he did not interview all the residents on that hallway to determine if there were any other incidents of abuse, but instead focused on the residents that went to the dining room for meals. [Cross-refer to F600] 45470 47431 POTENTIAL FOR HARM 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus with diabetic neuropathy, other chronic pain, bipolar II disorder, borderline personality disorder, antisocial personality disorder, and dementia in other disease classified elsewhere with anxiety. Review of records was completed on 7/17/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 9 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. A Facility Reported Incident (FRI) dated 2/10/23 at 5:37 PM stated that on 2/10/23 at 11:30 AM, it was reported that during a fentanyl patch change resident 9's Tegaderm dressing was still on, but the fentanyl patch was cut out. An investigation has been initiated. An interview was conducted on 7/18/23 at 3:36 PM with Director of Nursing (DON). DON stated that Licensed Practical Nurse 3 (LPN 3) reported to her about missing fentanyl patch. The DON stated the facility used the hospice investigation as their investigation regarding the missing fentanyl patch. DON stated that there was not an additional investigation conducted with the facility staff. An interview was conducted on 7/18/23 at 3:36 PM with Corporate Resource Nurse 2 (CRN 2). CRN 2 stated that the facility requested an interview with Hospice Certified Nurse Assistant 1 (HCNA 1) at which time the Hospice Director of Nursing 1 (HDON 1) told her they would talk to the HCNA 1 regarding the missing fentanyl patch. CRN 2 stated they ended the investigation after receiving the hospice's findings. 48709

Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents were identified to be in Immediate Jeopardy for allegations of sexual abuse. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. Findings included: 1. Based on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators sexual behaviors and the facility failed to provide protection for the residents thereby allowing ongoing access to the residents by the alleged perpetrator. Finally, victims of the sexual abuse exhibited crying and expressed recurring fear of the perpetrator. Based on the resident(s) behavior, it can be determined that the resident(s) experienced psychosocial harm as a result of the sexual abuse. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 34, and 136. [Cross-refer F600] 2. Based on interview and record review it was determined, for 8 out of 40 sampled residents, that in response to allegations of abuse the facility failed to have evidence that all alleged violations were thoroughly investigated and further potential abuse was prevented. Specifically, the facility initial entity reports and final investigation reports filed with the State Survey Agency (SSA) contained incomplete summaries of incidents of sexual abuse, and the facility did not have supporting documentation of the summaries that were provided to the SSA. Additionally, not all reported incidents of alleged sexual abuse had evidence that suggested they were investigated by the facility. Multiple instances of resident to resident sexual abuse occurred with an insufficient investigation. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. [Cross-refer F610]

Based on interview and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not develop and implement policies addressing how they would use a systematic approach to determine underlying causes of problems impacting larger systems; how they would develop corrective actions that would be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and how the facility would monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Specifically, multiple residents were identified to be in Immediate Jeopardy for allegations of sexual abuse. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. Findings included: 1. Based on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators sexual behaviors and the facility failed to provide protection for the residents thereby allowing ongoing access to the residents by the alleged perpetrator. Finally, victims of the sexual abuse exhibited crying and expressed recurring fear of the perpetrator. Based on the resident(s) behavior, it can be determined that the resident(s) experienced psychosocial harm as a result of the sexual abuse. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 34, and 136. [Cross-refer F600] 2. Based on interview and record review it was determined, for 8 out of 40 sampled residents, that in response to allegations of abuse the facility failed to have evidence that all alleged violations were thoroughly investigated and further potential abuse was prevented. Specifically, the facility initial entity reports and final investigation reports filed with the State Survey Agency (SSA) contained incomplete summaries of incidents of sexual abuse, and the facility did not have supporting documentation of the summaries that were provided to the SSA. Additionally, not all reported incidents of alleged sexual abuse had evidence that suggested they were investigated by the facility. Multiple instances of resident to resident sexual abuse occurred with an insufficient investigation. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. [Cross-refer F610] On 7/18/23 at 11:55 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the entire Interdisciplinary Team along with the Medical Director met one time a month for a Quality Assurance and Performance Improvement (QAPI) meeting. The ADM stated that for any identified concern they would identify interventions and track and monitor the progress until it was resolved. The ADM stated that if a concern was not resolved they would revise the plan, obtain everyone's input on what they could change or do better, and then set up a new time period of tracking. The ADM stated that they had identified the allegations of sexual abuse through the process and they thought they had identified and implemented enough interventions through the QAPI process.

Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the resident had the right to self-determination through support of the resident's choices. Specifically, a resident requested a bathing schedule that would provide three showers a week and the facility did not accommodate the request. Resident identifier 34. Findings included: Resident 34 was admitted to the facility on [DATE] with diagnoses which consisted of but were not limited to unspecified dementia, mild cognitive impairment, morbid obesity, chronic obstructive pulmonary disease, hypertension, polyneuropathy, pain, cognitive communication deficit, bipolar disorder, anxiety disorder, major depressive disorder, and insomnia. On 7/10/23 at 11:19 AM, an interview was conducted with resident 34. Resident 34 stated that her showers were scheduled for Tuesdays and Fridays. Resident 34 stated that she would like a shower three times a week. Resident 34 stated that she felt dirty and that she sweated a lot. Resident 34 stated that the facility would not provide her with more showers. Review of the facility shower schedule revealed that resident 34 was scheduled to received a shower on Tuesdays and Fridays. Review of resident 34's bathing task for the last 30 days revealed the following: a. On 6/16/23 at 12:24 PM, a shower was provided. b. On 6/20/23 at 1:35 PM, a shower was provided. c. On 6/23/23 at 11:30 AM, a shower was provided. d. On 6/27/23 at 4:49 PM, a shower was provided. e. On 6/30/23 at 5:56 PM, a shower was provided. f. On 7/4/23 at 5:42 PM, a shower was provided. g. On 7/7/23 at 5:48 PM, a shower was provided. h. On 7/11/23 at 3:13 PM, a shower was provided. i. On 7/14/23, a shower sheet documented that a shower was provided. On 7/18/23 at 9:34 AM, a follow-up interview was conducted with resident 34. Resident 34 stated that the aides would not listen to her when she requested more showers. Resident 34 stated that the aide told her that she didn't know if they could give it [a shower] to her 3 times a week. Resident 34 stated that she breaks out in rashes under her breasts from sweat. On 7/18/23 at 9:54 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the shower binder contained the resident shower schedule for the aides. LPN 1 stated that the aides filled out a shower sheet for each shower provided and the licensed nurse reviewed and signed them. LPN 1 stated that they looked for any skin issues or care refusals that were documented on the shower sheet. LPN 1 stated that resident 34 was a one person assist with a sit to stand for transfers and mobility. LPN 1 stated that he was not aware that resident 34 had requested more showers than the scheduled 2 per week. LPN 1 stated that he did not think that the aides would give resident 34 more showers than the schedule because the schedule was set in stone and it was already a heavy load. LPN 1 stated that if resident 34 had requested more showers it would depend on the aide and if they had time to add any additional showers. LPN 1 stated that he did not think they could add another shower day to resident 34's schedule without talking to the Certified Nurse Aide (CNA) supervisor. On 7/18/23 at 10:01 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 34 was transferred with 2 staff by using the sit to stand mechanical lift. CNA 1 stated that she provided resident 34 with a shower today. CNA 1 stated that sometimes they did not have enough staff to provide extra showers and it was busy. CNA 1 stated that resident 34 had not requested more showers from her. On 7/18/23 at 11:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident shower schedule was 2 times a week with a possible 3rd day as needed. The DON stated that if a resident wanted more showers they would be given if the staff could accommodate it. The DON stated that the scheduled showers had to be completed first and then any additional request may be accommodated. The DON stated that there was no reason why a resident could not get additional showers if requested. The DON stated she was not aware if resident 34 had requested to have showers 3 times a week, but she should be able to get them. The DON stated that Sundays were supposed to be the day to provide additional requested showers.

Based on interview and record review, it was determined, for 1 of 40 sampled residents, that the facility failed to protect the residents from the right to be free from misappropriation of property. Specifically, a staff member at the facility used a resident's credit card for multiple personal purchases. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, borderline personality disorder, bipolar disorder, severe protein-calorie malnutrition, dysarthria and anarthria, muscle weakness, cognitive communication deficit, need for assistance with personal care, chronic pain syndrome, major depressive disorder, difficulty in walking, neuromuscular dysfunction of bladder, hypothyroidism, anxiety disorder, insomnia, gastro-esophageal reflux disease, dry eye syndrome, and muscle spasms. On 7/10/23 resident 1's medical record was reviewed. A quarterly Minimum Data Set from 5/6/23 revealed that resident 1 had a BIMS (Brief Interview for Mental Status) of 14 which suggests resident 1 was cognitively intact. On 7/10/23, a Form 358, also called a Facility Reported Incident (FRI), was reviewed. The FRI was reported to the state agency on 6/2/23. The submission reported that the alleged victim was resident 1 and the allegation type was marked as misappropriation of resident property/exploitation. The detailed account of the incident stated, During Medicaid Audit review, [Business Office Manager (BOM)] discovered suspicious transactions on resident's bank statement. The alleged perpetrator was identified as the previous Resident Advocate (PRA). The FRI stated, staff was suspended immediately, compliance notified and investigation started. The report revealed that the law enforcement agency was notified. On 7/10/23 at 11:32 AM, an interview with resident 1 was conducted. Resident 1 stated that she was happy with the care provided at the facility. Resident 1 stated that she does not have any concerns about the facility. Resident 1 stated that she did not have any issues regarding her personal finances. Resident 1 stated that she worked with the business office to talk about personal finances, and she received $45 a month from the facility. Resident 1 stated that most of the staff were able to help her with all her needs. Resident 1 stated that she hoped to return to assisted living once she regained her strength. Form 359, the follow-up investigation, was reported to the state agency on 6/9/23. Form 359 included the summary of the interview with the alleged perpetrator (the PRA). The interview stated, [The PRA] was interviewed extensively by facility administration in connection with the allegations. In response to specific questions posed to her, [the PRA] provided the following information: [The PRA] hypothesized that she may have mixed up her credit card with [resident 1's] credit card when presented with evidence of charge for purchases that would not have made sense for the resident to make. She further hypothesized that this 'mix up' may have happened more than once. [The PRA] stated that she accessed the vending machine for the resident several times a week. However, she could not be specific as to the actual number of times and had no explanation for individual days where there were as many as six (6) charges to the vending machine posted to the resident's credit card. [The PRA] admitted to withdrawing $100 in cash from the ATM in May, using [resident 1's] card. She was able to access the cash because [resident 1] provided her with the PIN [Personal Identification Number]. [The PRA] denied making any other ATM withdrawals beyond the one in May, and offered no explanation for the additional withdrawals from the resident's account in the amounts of $200, $300, and $500 dollars, respectively. [The PRA] had no explanation for credit card charges associated with clothing purchases, where the size of the clothing purchased was not the same size as that regularly worn by the resident. [The PRA] confirmed that she lives in [City name redacted], UT; however, and when asked about a $437 payment from the resident' account to [City name redacted] Utilities, [the PRA] was unable to provide an explanation. Likewise, [the PRA] had no explanation for charges to the resident's account in the amount of $537 (to [TV provider]) or for various restaurant charges ranging from $20-$100. [The PRA] asserted that she mistakenly used [resident 1's] card to pay her own car payment in the amount of $1,905.16. She stated that she will repay [resident 1] for this error. Form 359 reported a summary of the interview with other residents who may have had contact with the alleged perpetrator. The report stated, Facility conducted interviews with other residents who visited [the PRA's] office on a regular basis. They were asked about who they ask to help them when they need items purchased for them as well as if they have ever asked a staff member to use their card for purchases. All interviewed residents replied that they go to Rec [Recreation] Therapy, who are the designated shoppers in our segregations of duties. None of them have every [sic] asked staff to use their cash or debits cards besides through our authorized process. Form 359 revealed that the facility verified the allegation. Form 359 stated, Based on all of the information presented and analyzed secondary to the investigation, document review, and interviews, the Facility has concluded that there is evidence to support the allegation of misappropriation of resident funds. Included in the basis for this determination is documentary evidence (bank statements, receipts, etc.) as well as [The PRA's] admission that she improperly accessed and used the resident's funds. Although [the PRA] denies the extent of the claimed misappropriation, the evidence supports that she is responsible for more than she is admitting to. Form 359 revealed actions that were taken as a result of the investigation. The report stated, [1. [The PRA] has been terminated from her position. 2. The Facility is performing audits of all other resident accounts to which [The PRA] had access to ensure the absence of additional incidents of misconduct. 3. The Facility is validating the final amount owed to the resident in connection with the misappropriation, and will have her fully repaid and a deposit made to her account no later than Monday, June 12, 2023. 4. The Facility has prepared and is delivering education and in-services to its staff on the issues of financial abuse and misappropriation, and on the procedures surrounding the management of the resident accounts (including cash). 5. The Facility will partner with external resources to ensure that its internal processes and methods of accounting as related to the resident credit card use are reinforced and consistent with applicable standards in this area. The facility's investigation stated that $8,155.98 was the total amount that resident 1 needed to be repaid. On 7/17/23 at 10:00 PM, an interview with the Business Office Manager (BOM) was conducted. The BOM stated that she discovered the suspicious credit card activity when completing a financial review for resident 1. The BOM stated that there were charges that did not line up with resident 1's activities. The BOM stated that there was a charge to a car dealership and the BOM knew that resident 1 did not own a car. The BOM stated that she alerted the Administrator (ADM) right away. The BOM stated that she believed resident 1 asked the PRA to help her with making online purchases, and resident 1 gave the PRA her credit card and PIN number. Resident 1's credit card was found in the PRA's desk. The BOM stated that no other credit cards belonging to other residents were found in the PRA's desk. The BOM stated that the PRA was never supposed to have access to any resident's money. The BOM stated that the police were involved and took a report. The BOM stated that the facility added up all of the suspicious charges on resident 1's account, which totaled up to about $8,155. The BOM stated that the facility paid resident 1 that full amount. The BOM stated that she informed resident 1 of the incident, and resident 1 was confused by the situation. On 7/17/23 at 10:40 AM, an interview with the Administrator (ADM) was conducted. The ADM stated that the facility found out about the misappropriation of funds when the BOM was conducting a financial audit for resident 1. The ADM stated that the BOM notified him immediately. The ADM stated that the PRA was suspended right away. The ADM stated that staff and residents were interviewed to determine if the fraud went beyond resident 1. The ADM stated that they did not find any concerns with any other residents funds. The ADM stated that the facility totaled up the amount of money that appeared to be suspicious on resident 1's account and the facility paid resident 1 that amount. The ADM stated that if the facility was unable to prove if the charges were from the PRA or resident 1, the facility counted that as the PRA's spending, and included that as money to be paid back to resident 1. The ADM stated that the facility back resident 1 $8,155.98. The ADM stated that the PRA wrote a check for around $4,000 to the facility and the PRA claimed that was the amount she owed. The ADM stated that the PRA told the facility that all of the purchases on resident 1's card were accidents. The ADM stated that the PRA was never supposed to oversee resident's money. The ADM stated that the facilities protocol for handling money included a segregation of duties and a paper trail that showed exactly who had resident's money and what the money was used for. The ADM stated that the segregation of duties for handling funds was to prevent one person from being in charge, and it held multiple staff members accountable for the resident's money. The ADM stated that the facility informed resident 1 about what happened and resident 1 seemed confused. The ADM stated that she understood that there was an issue with her money and the facility fixed it. The ADM stated that resident 1 told staff that she asked the PRA for help with online purchases. The ADM stated that when resident 1 asked the PRA for help with purchases, the PRA should have explained that she was not in charge of helping residents with their shopping, and the PRA should have followed the facility policy on shopping for residents and contacted the appropriate staff members who were in charge of shopping for residents to assist resident 1. The ADM stated that the facility interviewed residents who were known to be frequently in contact with the PRA. The ADM stated that in-services regarding resident's money were provided to all staff members.

Based on interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, the facility did not notify the SSA and APS of an allegation of sexual abuse within the two hours of becoming aware of the the incident. Resident identifier 26 and 10. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, type 2 diabetes mellitus, paraplegia, chronic kidney disease, polyneuropathy, major depressive disorder, generalized anxiety disorder, insomnia, hyperlipidemia, gastro-esophageal reflux disease, hypertension, and flaccid neuropathic bladder. On 7/10/23 at 10:14 AM, an interview was conducted with resident 26. Resident 26 stated that she had a problem with another resident and she reported it to the police when they were already at the facility. Resident 26 stated that resident 10 got close to talk to her. Resident 26 stated that her leg fell off the foot rest of the wheelchair and resident 10 placed her foot back on the foot rest. Resident 26 stated that resident 10 then began to touch her upper thigh and was patting her leg while moving towards her genitals. Resident 26 stated that she stopped resident 10 by brushing his hand away. Resident 26 stated that resident 10 then asked her if he could touch her breast. On 7/11/23, the facility abuse investigation documentation was reviewed. On 1/11/23 at 10:34 AM, the facility initial report, Form 358, documented that the facility staff became aware of the incident between resident 26 and resident 10. On 1/11/23 at 3:30 PM, the APS report documented that they were notified of the incident between resident 26 and resident 10. It should be noted that the notification to APS was 5 hours after the facility staff became aware of the incident. On 1/11/23 at 4:11 PM, the SSA intake notes documented that the SSA was notified of the incident between resident 26 and resident 10. It should be noted that the notification to the SSA was approximately 5.5 hours after the facility staff became aware of the incident. On 7/12/23 at 3:08 PM, an interview was conducted with the Administrator (ADM). The ADM stated that with any allegations of abuse he would start the investigation process and immediately report the incident to the SSA and APS.

Based on interview and record review, it was determined for 1 of 40 sampled residents that the facility did not ensure the comprehensive care plan included the services needed to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident was found to be taking medications not prescribed by a physician on 3 different occasions which was not addressed in the comprehensive care plan. Resident identifier: 41. Findings included: Resident 41 was admitted to the facility on [DATE] with diagnoses which included but were not limited to traumatic subdural hemorrhage, cerebral infarction with right sided hemiplegia and hemiparesis, psychoactive substance dependence, depression, anxiety disorder, epilepsy, and hypertension. On 7/11/23 resident 41's medical records were reviewed. A. Suspected Self Harm On 1/16/23 a Change in Condition Evaluation indicated resident 41 had a change of condition with behavioral symptoms. The behavioral evaluation indicated social withdrawal and a danger to self or others with a described dangerous behavior of possible self harm to left leg and described behavioral changes of patient has been secluding herself. The document further indicated resident 41 was displaying a new skin condition described as a laceration not requiring sutures and without other symptoms. It was documented the new skin condition site was on the front of the right thigh, however, the description of the new skin condition documented, multiple lacerations to side of left thigh. It further indicated that patient denies self harm causing lacerations, could be in her sleep. A physician order dated 1/16/23 indicated resident 41 had lacerations to her right thigh. On 1/16/23 a Discharge Handout from an outside facility indicated resident 41 was seen in the emergency department on 1/16/23 with the diagnosis of History of non-suicidal self-harm which included Suicide Prevention Education Materials. Resident 41's care plan dated 1/17/23 revealed potential for .Self harm/scratching or cutting self. The goal was Will have no evidence of self harm by review date. An intervention was to assist to develop more appropriate methods of coping and interacting [and] encourage to express feelings appropriately. On 7/13/23 at 10:01 AM, an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated she looked for injuries when assisting residents with bathing and did not notice any bruising, cuts or pressure injuries on resident 41's skin during her shower on 7/13/23. CNA 2 stated that if she found any injuries or wounds on a resident's skin she would immediately tell the nurse and document the findings. On 7/13/23 at 10:30 AM, an interview was conducted with resident 41. Resident 41 nodded yes or no, mumbled simple words, and used other bodily gestures during interview to answer questions. Resident 41 nodded no when asked if she felt depressed, felt like hurting herself, or had felt like hurting herself in the past. Resident 41 indicated she remembered the incident when staff noticed scratches on her right thigh. Resident 41 pointed to her right thigh with her left arm, lifted up her right arm with her left arm, and gestured her scratching her right thigh with her fingernails on her right hand. Resident 41 indicated she scratched her right thigh with her right hand and she denied doing it on purpose. On 7/13/23 at 12:28 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she knew to watch for self harm with resident 41. RN 1 stated a whole body assessment was completed every week for each resident. B. Taking non-prescribed medications from roommate On 8/1/22 a Preadmission Screening Resident Review (PASRR) Level II was completed. The screening recommended for the facility to be aware of resident 41's substance use history and advised to make sure medications were not left out where resident would have access to them. The PASRR Level II revealed a recommendation for Specialized Services for mental illness treatment which included to monitor and assess mental health symptoms, monitor changes in mood and respond appropriately with medication and/or therapy if needed. On 5/31/23 an encounter progress note indicated, It has been found that patient [resident 41] has been receiving one 8-2mg [milligrams] film of Suboxone [a prescribed medication used to treat opioid addiction] every night for the last six months. This medication is not prescribed to her, but instead is prescribed her for roommate and the roommate has been giving this to the [sic] patient for the last six months. It further indicated that a non-prescribed anti-histamine sleeping medication was found in resident 41's room. The progress note also indicated, Patient appears to be in distress and begins to cry. On 7/2/23 a nursing progress note indicated resident 41 was found to have non-prescribed diphenhydramine (an antihistamine medication). On 7/9/23 a nursing progress note indicated an Advil PM [a sleep relief medication] gel cap was found on resident 41's floor and resident stated it was hers. The note further indicated resident 41 opened her backpack and pulled out 11 more gel capsules. On 7/10/23 at 1:51 PM, an interview was conducted with resident 5. Resident 5 stated that she used to share her Suboxone with her previous roommate, resident 41. Resident 5 stated that she used to receive two dissolvable films of Suboxone, and she would put one in her mouth and save the other one for her roommate. Resident 5 stated that she was able to do this without the nurses knowing. Resident 5 stated that resident 41 used to get upset and angry at her if she did not share the Suboxone. Resident 5 stated that it was easier to give resident 41 the Suboxone so resident 41 did not get angry at her. Resident 5 stated that, after a while of sharing the medication, she confessed to the nurses that she had been sharing her Suboxone with resident 41. On 7/13/23 at 10:01 AM, an interview was conducted with CNA 2. CNA 2 stated she was aware of resident 41's drug seeking behaviors. CNA 2 further stated that resident 41 got angry, frustrated, and went to her room when she was not understood by staff. On 7/13/23 at 10:30 AM, an interview was conducted with resident 41. Resident 41 nodded yes or no, mumbled simple words, and used other bodily gestures during interview to answer questions. Resident 41 indicated that she asked for, received, and ingested medications from her previous roommate, resident 5. Resident one further denied that she had asked for medications from any other residents. Resident 41 indicated the facility talked with her about the incident and that she agreed to not take any medications without the knowledge of the facility. On 7/13/23 at 12:28 PM, an interview was conducted with RN 1. RN 1 stated that she did a mouth check after administering Suboxone to ensure the resident took the medication. On 7/18/23 at 9:50 AM, an interview was conducted with the Licensed Clinical Social Worker (LCSW) Corporate Resource. The LCSW Corporate Resource stated that resident 41 was not receiving any mental health services. The LCSW Corporate Resource stated that if the PASRR Level II recommended services then the resident should be receiving those services. The LCSW Corporate Resource further stated that offering mental health services like 12-step meetings and substance abuse treatment should be considered if a resident was found to be taking non-prescribed medications from another resident. The LCSW Corporate Resource stated if there was a referral for mental health services there should be a progress note in the medical record. No documentation of mental health services was located in resident 41's medical record. On 7/18/23 at 10:02 AM, an interview was conducted with the Administrator (ADM). The ADM stated no psychiatric referrals were made based on the physician's recommendation. The ADM stated that if a social worker was involved and met with the resident it should be documented in a progress note. On 7/18/23 at 10:15 AM, an interview was conducted with Advanced Registered Nurse Practitioner (ARNP) 2. ARNP 2 stated she did not refer resident 41 to any mental health services because she was focused on resident 41's clinical health because of the medications. ARNP 2 stated she did not remember what resident 41's PASRR Level II recommended. ARNP 2 further stated she needed to consult with Social Work Services about resident 41 taking non-prescribed medications from another resident. ARNP 2 stated when resident 41 was suspected of cutting herself in January, an Interdisciplinary Team meeting should have been done to determine what resident 41 needed for overall health. On 7/18/23 at 11:40 AM, an interview was conducted with LCSW corporate resource. The LCSW corporate resource stated that the Resident Advocate completed the care plans and the consultant LCSW reviewed the care plans.

Based on observation, 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 staff were observed to reuse gowns and face shields without disinfecting between use, staff used the same Personal Protective Equipment (PPE) between resident rooms, staff entered quarantine/isolation rooms without gowns and N95 mask as indicated, masks were observed worn improperly, PPE was observed stored improperly, hand hygiene was not performed after resident care, and the quarantine/isolation unit was accessible by all facility staff and residents. The failure had the potential to expose and transmit COVID-19 to staff and residents. In addition, staff were observed in resident rooms without an N95 mask, gown, and gloves while an Aerosol Generating Procedure (AGP) was in operation and the resident door was observed open during the AGP. Additionally, a sick staff member reported to work and entered the facility with signs and symptoms (s/sx) that were consistent with COVID-19. Lastly, visitors were observed inside the facility without wearing a mask and staff monitoring was not observed. Resident Identifiers: 5, 7, 8, 9, and 10. Findings include: On 4/21/21 at 3:39 PM, an Immediate Jeopardy (IJ) was identified when the 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 reuse of gowns and face shields without disinfecting between use and sharing between resident rooms and staff members, the improper use and storage of PPE, the lack of PPE use when indicated in Transmission Based Precaution (TBP) rooms, and no hand hygiene between resident contact may result in serious illness, impairment or death among individuals in a congregant care setting. 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 4/21/21 at 6:04 PM, the Administrator, DON, and CRN 1 provided the following plan for the removal of the Immediate Jeopardy: IMMEDIATE ACTION TAKEN: 1. Medical Director was immediately notified on IJ status 2. Staff on duty was immediately educated on donning and doffing isolation PPE, hand hygiene, proper sanitization/storage of used PPE, proper use of PPE, isolation precautions to prevent the possible spread of COVID-19 and how to identify residents that are on isolation or quarantine precautions. Unit Manager/IP will educate staff on night shift 4/21/21 at beginning of shift. 3. All staff will be re-inserviced and demonstrate competency on donning and doffing isolation PPE, proper use of PPE, Hand washing procedures, sanitization and storage of used PPE, isolation precautions and procedures, identification of residents that are on isolation or quarantine area prior to next shift. 4. Staff will demonstrate and/or verbalize what PPE is indicated as they perform cares. Staff will be educated by IP (Infection Preventionist)/designee on the difference of Conventional, Contingency, and Crisis mode of PPE usage and the changes that need to be made with increased PPE supply availability. 5. Ongoing monitoring and education will be provided to staff as PPE changes identified based on Conventional, Contingency and Crisis needs. 6. Resident that were are (sic) admissions or on quarantine, were assessed on 4/21/21. Those identified as being fully vaccinated, had received a negative test on day 5 and day 7, or had passed the required isolation period and were not exhibiting any signs of COVID, will be relocated on 4/21 and 4/22 to other areas of the facility based with appropriate Infection Control procedures. 7. Resident identified as meeting criteria for quarantine needs are: 9, 10. Residents moved off new admission area: 13, 11, 7, & 5 8. New admissions that have not been vaccinated will be placed in the designated quarantine area on 200 hall. The area will be separated physically from the remainder of the facility by a distinct barrier. (Implemented 4/21/21) 9. PPE in quarantine area, will include: N95 mask with eye protection, gown and gloves for the duration of the 14 day quarantine. PPE supply will be readily available for staff to use and will be monitored by IP/designee. 10. Monitoring and system update implemented on new admissions to track those who have been vaccinated, or in 90 day recovered COVID-19 window to ensure proper room assignments of those residents in facility. 11. Facility outbreak testing ended on 4/21/21 with no new cases of COVID identified in past 14 days of testing. Due to the recent findings of non-compliance of PPE use and potential for increased exposure, the facility completed a facility wide testing of staff and resident son 4/21/21 with the rapid [MEDICATION(S)] test, with no positive cases identified. will continue withe facility wide testing weekly of residents and staff for the next 14 days. After the 14 days testing will continue per CDC and State guidance. On 4/23/21 at 12:46 PM, while completing the Focused Infection Control Survey, surveyors were onsite to verify Immediate Jeopardy had been removed. The surveyors determined the Immediate Jeopardy was removed, as alleged, on 4/23/21 at 12:00 PM. Findings include: 1. On 4/20/21 at 5:50 PM, an interview was conducted with the facility Infection Preventionist (in training). The IP stated that new admissions were quarantined on contact/droplet isolation precautions on the 200 hallway for 14 days. The IP stated that the resident was Polymerase Chain Reaction (PCR) tested on admission, on day 5 status post [MEDICAL RECORD OR PHYSICIAN ORDER] . If all PCR tests were negative the resident was taken off isolation precautions. The IP stated that if the new admission had been fully vaccinated and was 14 days past the second vaccine dose they were not quarantined on TBP. The IP stated that all residents and staff were currently past the 90 day post COVID-19 positive infection. The IP stated that the facility was currently in outbreak status due to a resident re-admission from the hospital with positive PCR test on 4/8/21. The IP stated that the resident had subsequent negative PCR tests and was no longer on quarantine. The IP stated that all staff universally wear a surgical mask and eye protection while in the facility. The IP stated that staff on the 200 hallway universally wore a N95 mask and eye protection as this was the new admission hall. The IP reported that the facility had a sufficient supply of all PPE and were not experiencing any shortages. The IP stated that they were utilizing reusable/washable gowns in the facility. The IP stated that they did have a sufficient supply of disposable gowns but were saving them for any future shortages. The IP stated that resident 7 was a new admission that had just arrived to the facility and the resident was placed on quarantine on TBP until the vaccination/COVID status could be determined. On 4/20/21 at approximately 5:45 PM, an observation was made of Certified Nurse Assistant (CNA) 8. CNA 8 was observed to donn a fabric gown that was hanging outside room [ROOM NUMBER]. CNA 8 was observed to exit the room with a fabric gown, N95 mask and face shield. CNA 8 was observed to walk through the hall past the nurses station into the utility room. CNA 8 was observed to doff the gown after exiting the utility room and entering a bathroom behind the nurse's station. CNA 8 was observed to have a N95 mask on. CNA 8 was observed to place her face shield on the nurses station desk. On 4/20/21 at 7:14 PM, an interview was conducted with CNA 8. CNA 8 stated she was a floating CNA between the 100 and 200 hall. CNA 8 stated the 200 hallway was for new admissions. CNA 8 stated that newly admitted residents had isolation precautions for 2 weeks after admission. CNA 8 stated that in the isolation rooms the staff wore goggles, face shield, N95 mask, gloves and a gown. CNA 8 stated that the gowns were changed out for clean ones every shift. CNA 8 stated that all staff members wore the same gown that was hanging outside the resident's room. CNA 8 stated that face shields were cleaned with bleach wipe after each use. CNA 8 stated that the gowns were worn into the rooms and were not to be worn in the hallways. CNA 8 stated all gowns needed to be removed prior to entering the hallway. CNA 8 stated that she used bleach wipes to sanitize the blood pressure cuff, pulse oximeter, thermometer between each resident. CNA 8 stated that she stored her N95 mask in her pocked when she used a surgical mask to enter resident rooms not on isolation. On 4/20/21 at approximately 7:10 PM, an observation was made of the 200 hallway. CNA 1 was observed to exit room [ROOM NUMBER] wearing a surgical mask and goggles. room [ROOM NUMBER] was observed with a sign posted on the door that stated isolation precautions to be maintained indefinitely, gowns-gloves-N95 mask. CNA 1 stated that room [ROOM NUMBER] had 2 gowns that were hung on the inside of the resident room on the back of the door, and that gloves were located inside of each resident room. CNA 1 stated that hand sanitizer was located in the hallway in wall mount dispensers. CNA 1 did not disinfect or clean the goggles upon exit of room [ROOM NUMBER]. On 4/20/21 at approximately 7:15 PM, an observation was made of RN 1 exiting room [ROOM NUMBER] wearing a reusable gown, N95 mask and goggles. The RN doffed the gown and hung it on the door room sign outside of room [ROOM NUMBER] in the hallway. RN 1 performed hand hygiene, spoke to CNA 1, and then donned the same gown again. RN 1 then entered room [ROOM NUMBER] wearing the same gown worn in room [ROOM NUMBER]. RN 1 exited room [ROOM NUMBER], doffed the gown and hung it on the room sign outside of room [ROOM NUMBER]. An immediate interview was conducted with RN 1 after he exited room [ROOM NUMBER]. RN 1 did not perform hand hygiene upon exit of room [ROOM NUMBER]. RN 1 stated that he mistakenly took room [ROOM NUMBER]'s reusable gown and entered room [ROOM NUMBER] with it on. RN 1 stated that the gowns were used for one room/resident only. RN 1 stated that the gowns were hung outside the resident room and each room had one gown. Staff would use the one gown for that resident room and the gowns were changed out daily. RN 1 stated gowns should not be used between resident rooms, and if more staff needed additional gowns for a room they could be obtained from the supply stock. Otherwise all staff utilized the same one gown per room. RN 1 stated that he was not sure why room [ROOM NUMBER] did not have signage posted on the door indicating that it was on contact/droplet isolation precautions. RN 1 stated that he knew that room [ROOM NUMBER] was on TBP because it had a gown hung outside the room, and that all rooms with gowns outside of them were on isolation precautions. On 4/20/21 at 7:25 PM, an observation was made of CNA 1 and CNA 2 donning reusable gowns obtained from the door sign of room [ROOM NUMBER]. Both CNAs donned an N95 mask over their surgical masks. On 4/20/21 at 7:31 PM, an interview was conducted with CNA 2. CNA 2 stated that he doffed the gown, gloves and N95 mask inside the doorway of room [ROOM NUMBER]. The CNA stated that the gown and N95 mask were left inside the resident room and he exited with only his surgical mask and goggles. CNA 2 did not disinfect or clean their goggles upon exit of the room. On 4/20/21 at 7:35 PM, an observation was made of CNA 1 exiting room [ROOM NUMBER]. CNA 1 doffed the reusable gown in the hallway and hung it on the room door sign on top of another reusable gown. CNA 1 was observed wearing a N95 mask over a surgical mask and the bottom elastic of the N95 mask was hanging down below the CNA's chin. An immediate interview was conducted with CNA 1. CNA 1 stated that she wore a N95 mask for the entire hallway. It should be noted that an earlier observation, at approximately 7:10 PM, CNA 1 was observed wearing only a surgical mask while entering isolation rooms. CNA 1 did not perform hand hygiene upon exit of room [ROOM NUMBER]. CNA 1 did not disinfect or clean their goggles upon exit of the room. On 4/20/21 at 7:45 PM, an observation was made of RN 1 donning the same reusable gown that was used by CNA 1. RN 1 noted that the gown was inside out, turned it right side out and donned the gown. RN 1 then entered room [ROOM NUMBER] to administer medication. On 4/20/21 at 7:59 PM a follow-up interview was conducted with RN 1. RN 1 stated that the facility had one nurse per hallway, but that the 100 hallway was floating and assisting on other hallways too. RN 1 stated that the PPE supply was good and that there was never a supply shortage. RN 1 stated that new admissions were in quarantine on contact/droplet isolation precautions for 14 days after admit unless they had a PCR test on admit, day 5 and day 7 that were all negative. On 4/21/21 at 12:17 PM, an observation was made of resident 10. A sign on resident 10's door revealed droplet precautions. Another sign revealed to wear a N95 mask, gown, face shield and gloves into the room. A sign revealed that the resident was off of precautions on 4/28/21. Resident 10 was in his room laying in bed. Nursing Assistant (NA) 1 was observed to be walking from one side of the bed to the other touching items on resident 10's over bed table. NA 1 did not have a gown on. NA 1 was observed to removed a meal tray from resident 10's room and take it through the hall to the kitchen. On 4/21/21 at 12:25 PM, an interview was conducted with NA 1. NA 1 stated that she worked the 100 and 200 halls. NA 1 stated that all newly admitted residents were on the 200 hallway for 14 days after admission with isolation precautions. NA 1 stated there were signs hanging outside resident rooms to indicate if they needed isolation precautions. NA 1 stated that she wore a KN95 mask, gown and face shield when in an isolation room. NA 1 stated that gowns were stored on the outside or inside of the isolation room. NA 1 stated that housekeeping staff placed new gowns every 2 to 3 hours outside resident rooms. NA 1 stated that each resident had a gown for the staff to wear. NA 1 stated that she removed the gown prior to exiting the room. NA 1 sated that her KN95 mask was not test fitted and she changed her mask every couple hours because she was a germophobe. NA 1 stated that all clothing and dishes had to be stored in red biohazard bags before removing from the resident room. NA 1 stated that she forgot to bag resident 10's meal tray. NA 1 stated that she told the dietary staff that the tray was from an isolation room. On 4/21/21 at 12:34 PM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated that CNAs placed all resident dishes from isolation rooms into red bags. DA 1 stated that she used gloves when touching anything in a red bag. DA 1 stated that if the dishes were not in the red bag she assumed the dishes were from non-isolation rooms. DA 1 stated that a CNA brought her a tray and did not tell her it was from an isolation room. An observation was made of the dish machine area and the tray was placed on top of other dirty dishes. On 4/21/21 at 12:18 PM, an observation was made of the 200 hallway. No gowns were observed in the hallway hanging on room signs. room [ROOM NUMBER] was observed with a door sign that stated N95, face shield, gown, and gloves must be worn prior to entry with a start date of 4/20/21 and an end date of 5/4/21. At approximately 12:20 PM an observation was made of Laundry Staff (LS)1 entering room [ROOM NUMBER] to deliver clean laundry, and the laundry was placed inside the resident closet. LS 1 was observed wearing a surgical mask and goggles. An immediate interview was conducted with LS 1. LS 1 stated that she identified rooms on isolation precautions by the gown hung outside the room on the door sign. LS 1 stated that her supervisor would also update her on the rooms on isolation precautions. LS 1 stated that there were no rooms on the 200 hallway that were on contact/droplet isolation precautions because there were no gowns observed outside any rooms. LS 1 stated that rooms on TBP had a yellow linen bag inside the room and she processed/washed this laundry separate from the other laundry. LS 1 stated that she read posted signs on resident doors and that she did not see the sign on room [ROOM NUMBER] prior to entering. On 4/21/21 at approximately 12:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that rooms on isolation precautions would have a sign on the door stating that and the type of PPE required. LPN 1 stated that the PPE would be located inside the resident room. LPN 1 stated that the 200 hallway was utilizing reusable gowns and the gowns were changed every shift. LPN 1 stated that the gowns were located inside the resident room on the back of the door. LPN 1 stated that everyone on the 200 hallway wore an N95 mask and either goggles or a face shield. LPN 1 stated that the eye protection was not cleaned in between contact/droplet isolation rooms. LPN 1 stated that he was not aware of any residents on the 200 hallway that had been vaccinated or had previously had COVID-19. On 4/21/21 at 12:36 PM, an observation was made of LPN 1. LPN 1 was observed in the 200 hallway. LPN 1 was observed to have an N95 mask that was below his nose. On 4/21/221 at 12:39 PM, an observation was made of CNA 10. CNA 10 was observed to have goggles and a mask on. CNA 10 was observed to open the door to room [ROOM NUMBER] and pull a disposable gown from behind the door. room [ROOM NUMBER] had a sign on the door that revealed the resident was on isolation precautions. CNA 10 opened the room [ROOM NUMBER] and removed the disposable gown and face shield. CNA 10 was observed to place the gown and face shield on the back door in room [ROOM NUMBER]. On 4/21/21 at 12:50 PM, an interview was conducted with CNA 10. CNA 10 stated that he was working on the 300 hallway. CNA 10 stated the he wanted to help the 200 hall and saw call lights alarming. CNA 10 stated that for residents in the 200 hall, he used whatever gown and face shield were on the back of the resident's door. CNA 10 stated that housekeeping cleaned the face shields and replaced the gowns every few hours. On 4/21/21 at 12:42 PM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] had a sign posted on the door that stated N95 mask, gown-face shield-gloves, must be worn prior to entry. On observation was made of the Community Liaison (CL) 1 donning PPE for room [ROOM NUMBER]. The CL 1 donned a reusable gown obtained from the back of the door in room [ROOM NUMBER] and gloves from inside the resident room. CL 1 was observed wearing an N95 mask and goggles. CL 1 delivered a lunch meal tray to the resident in room [ROOM NUMBER]. CL 1 was observed to touch objects on the bedside table to make room for the meal tray. CL 1 was then observed to touch their face, hair, placed an ear piece in ear, and called for assistance. CL 1 doffed the gown and gloves inside the resident room and the gown was hung on the back of the door. CL 1 was observed to obtain a drink for the resident and re-entered the room. CL 1 donned the reusable gown and new gloves. An observation was made of CL 1 inside room [ROOM NUMBER] with their N95 mask down under their chin. CL 1 doffed PPE inside room [ROOM NUMBER]'s doorway and hung the reusable gown on the back of the door. CL 1 did not disinfect or clean their goggles upon exit of the room. On 4/21/21 at 12:48 PM, an observation was made of NA 1. NA 1 was observed in resident room [ROOM NUMBER]. NA 1 was observed with a gown, N95, goggles, and a face shield on. [Note: room [ROOM NUMBER] had an isolation sign posted on the door.] NA 1 was observed to push the resident in room [ROOM NUMBER] in the wheelchair to the shower room. NA 1 was observed to exit the shower room and enter resident room [ROOM NUMBER]. NA 1 was observed to not doff PPE, perform hand hygiene, and donn PPE prior to entering resident room [ROOM NUMBER]. [Note: room [ROOM NUMBER] had an isolation sign posted on the door.] NA 1 was observed sitting at the resident bedside of room [ROOM NUMBER] assisting the resident with feeding. NA 1 was observed to exit room [ROOM NUMBER] and pour the resident in room [ROOM NUMBER] a drink from the cart in the hall. NA 1 was observed to not doff PPE and perform hand hygiene prior to exiting room [ROOM NUMBER]. NA 1 was observed to return to resident room [ROOM NUMBER] with the drink and assist resident with feeding. NA 1 was observed to exit resident room [ROOM NUMBER] and an interview was conducted. NA 1 stated that PPE should be changed each time she left an isolation room. NA 1 stated that hand hygiene should be performed prior to entering and exiting an isolation room. On 4/21/21 at 12:55 PM an observation was made of LPN 1 entering room [ROOM NUMBER]. LPN 1 donned the reusable gown from the back of the door and gloves from inside the room. It should be noted that the reusable gown was the same one worn by CL 1. LPN 1 was observed to doff the PPE and hang the reusable gown on the back of room [ROOM NUMBER]'s door. LPN 1 was observed exiting room [ROOM NUMBER] with their N95 mask down below their nose. An immediate interview was conducted with LPN 1. When LPN 1 was asked about the N95 mask being down below their nose, LPN 1 replied I can't breathe and I pull it down in the hallway. LPN 1 stated that if the mask slipped down while inside a TBP room he could not touch his face to pull it up so he left it down. LPN 1 stated that the N95 mask may not fit properly due to his big nose and this was causing the mask to continuously slip off his nose. LPN 1 did not disinfect or clean their goggles upon exit of the room. On 4/21/21 at 1:02 PM an observation was made of CNA 3 entering room [ROOM NUMBER]. CNA 3 wore a N95 mask and eye protection. CNA 3 approached the resident at the bedside and proceeded to have a conversation. The CNA was within six feet of the resident. CNA 3 was then observed to donn the gown from the back of the door along with gloves and a face shield. At 1:14 PM an interview was conducted with CNA 3. CNA 3 stated that resident 5 in room [ROOM NUMBER] had just been readmitted from the hospital and was on isolation precautions. CNA 3 stated that staff entering the room were to donn a gown and gloves in addition to their face mask and eye protection. CNA 3 stated that she would donn a face shield over her goggles. CNA 3 stated that doffing of PPE occurred inside the resident room and the gown was placed on the back of the door and the face shield on a separate hook. CNA 3 stated that anyone entering the resident room would use the same gown and face shield. CNA 3 stated that she initially entered the room without the required PPE on then noticed the sign on the door that stated N95, face shield, gown, and gloves. That's my fault, I didn't see the sign before I entered the room. CNA 3 did not disinfect or clean the reusable face shield. On 4/21/21 at 1:12 PM, an observation was made of LPN 1. LPN 1 was observed walking the the hallway outside of the dining room with an N95 mask that was below his nose. On 4/21/21 at 1:16 PM, an interview was conducted with Housekeeper 2. Housekeeper 2 stated that she cleaned resident rooms once a day and sanitized the gowns and face shields. On 4/21/21 at 1:43 PM, an interview was conducted with LS 1. LS 1 stated that she had already entered and isolation room without PPE. LS 1 stated that she looked for a yellow gown hanging outside the room to alert her it was an isolation room. LS 1 stated there were no yellow gowns this morning. LS 1 stated that she wore the gown and face shield outside the room to clean the room. LS 1 stated that she used the same gown as other staff for the same resident. On 4/23/21 at 11:14 AM, a follow-up interview was conducted with CL 1. CL 1 stated that resident 8's communication ability was limited to yes/no only. CL 1 stated that she would ask yes/no questions until she was able to identify what the resident needed. CL 1 stated that on 4/21/21 resident 8 was on isolation precautions in room [ROOM NUMBER] and staff were required to wear a N95 mask, face shield, gown and gloves. CL 1 stated that the face mask should be positioned over the nose and mouth and secured under the chin. CL 1 stated that sometimes the resident wanted to verbally read her mouth and that was why she had the N95 mask down under her chin. CL 1 stated that was not the process and that she should not take her mask off. The following resident's were reviewed following observations of their rooms and PPE usage: a. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5 resided in room [ROOM NUMBER]. Review of resident 5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility line listing for residents documented that resident 5 was not immunized for COVID-19, and had a positive COVID-19 infection on 2/22/21. No documentation could be found of the positive test result on 2/22/21, and [MEDICATION(S)] vs PCR test was unknown. Review of resident 5's COVID-19 testing revealed negative PCR results on 2/8/2021 and 2/24/21. b. Resident 7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 7 resided in room [ROOM NUMBER]. Review of resident 7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initiated on 4/21/21 and no end date was documented. c. Resident 8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8 resided in room [ROOM NUMBER]. Review of resident 8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It should be noted that resident 8 had a sign on his door that stated N95 mask, gown-face shield-gloves, must be worn prior to entry. Based on the admitted and 14 day quarantine period resident 8 should have come off isolation precautions on 4/20/21. It should be noted that resident 8 continued on isolation precautions during the observations on 4/21/21. Review of the facility line listing revealed that resident 8 was not immunized for COVID-19 and had never had COVID-19. On 4/22/21 at approximately 2:33 PM, an interview was conducted with the DON. The DON stated that the facility policy and procedures for COVID-19 were located in the COVID-19 Emergency Preparedness Plan. Review of facility COVID-19 Emergency Preparedness Plan documented under Patient Placement, (New admits will be placed away from other residents in the facility and will be monitored for 14 days for signs and symptoms of COVID (20 days if Resident is Immunocompromised). If no signs noted, the resident will be moved into a room into the other areas of the facility as appropriate. The Plan further documented under Transmission Based Precautions (use Standard, Contact, Airborne precautions plus eye protection for patients with confirmed or suspected COVID-19 cases): Personal Protective Equipment (PPE) and other infection prevention and control supplies (e.g., hand hygiene supplies) that would be used for both healthcare personnel (HCP) protection and source control for infected patients (e.g., facemask on the patient are located in sufficient supply including at patient arrival, triage, and assessment locations. Review of Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes documented under Personal Protective Equipment that Facilities should have policies and procedures addressing: Which PPE is required in which situations (e.g., residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, residents placed in quarantine) and Recommended sequence for safely donning and doffing PPE. Additionally, Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. The guidance further recommended under Implement Universal Use of Personal Protective Equipment that HCP (Health Care Personnel) working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other PPE. The guidance also recommended under New Admissions and Residents who Leave the Facility documented, In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#ppe Review of the CDC guidance on Strategies for Optimizing the Supply of Isolation Gowns, documented under Crisis Capacity Strategies that The risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. Similar to extended gown use, gown reuse has the potential to facilitate transmission of organisms (e.g., C. auris) among patients. However, unlike extended use, repeatedly donning and doffing a contaminated gown may increase risk for HCP self-contamination. If reuse is considered, gowns should be dedicated to care of individual patients. Any gown that becomes visibly soiled during patient care should be disposed of or, if reusable, laundered. The guidance further stated, Once gown availability returns to normal, healthcare facilities should promptly resume conventional practices. The guidance was last updated on January 21, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html# Review of the United States Food and Drug Administration (FDA) guidance on Personal Protective Equipment documented on questions about PPE, In general, most PPE cleared by the FDA is intended to be used only one time and by one person. Sharing PPE is not advised. The protective capabilities of single use PPE cannot be assured when it is reused by the same person or used by more than one person. Sharing PPE that is intended for single use may expose another person to infectious materials. PPE should be removed promptly after use and disposed of properly. The content was current as of March 11, 2020. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/questions-about-personal-protective-equipment-ppe 2. On 4/20/21 at 5:50 PM, an interview was conducted with the facility IP. The IP stated that staff screening was conducted in the lobby of the facility and consisted of a temperature check and a symptom screening questionnaire on the Simpliscreen kiosk. The IP stated that if staff were not feeling well they were instructed to not enter the building and a PCR test would be conducted in the lobby and then they would be sent home pending the results. It should be noted that the wall mounted thermometer and the Simpliscreen kiosk were located at the lobby desk directly past the doorway to the resident therapy gym, and the gym doors were observed open during daytime hours. On 4/21/21 at 6:04 PM, an interview was conducted with the Administrator and DON. The DON stated that housekeeper 1 was sent home ill with a cough and nasal congestion. The DON stated that the Simpliscreen identified the symptoms and it alerted the DON and Administrator by text. The DON stated that [TRUNCATED]

Based on observation, interview, and record review it was determined, for 3 of 16 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, three residents had multiple falls with inadequate interventions in an attempt to decrease the number of falls. Resident identifiers: 1, 6, and 10. Findings include: 1. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included but not limited to end stage [CONDITION(S)], diabetes mellitus type 2, dependence on renal [CONDITION(S)], acquired absence of unspecified leg below knee, unspecified lack of coordination, muscle weakness, dysphagia, need for assistance with personal care, major depressive disorder, and essential hypertension. Resident 1's medical record was reviewed on 4/21/2021. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 1 was requiring extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident 1 was further documented as requiring supervision of one person for locomotion on and off the unit. A Quarterly MDS assessment dated [DATE], documented that resident 1 had a Brief Interview for Mental Status (BIMS) of a 10. A BIMS score of a 8 to 12 indicates a moderate cognitive impairment. A care plan Focus initiated on 11/14/2017 and revised on 10/22/2020, documented FALL RISK: [Resident 1] is at risk for falls r/t (related to) bilat (bilateral) lower amputations, incontinence, weakness, and depression w/ (with) anti-depressants. Resident chooses to be as independent as possible with mobility. A care plan Goal initiated on 11/14/2017 and revised on 10/25/2019, documented Will not sustain serious injury through the review date. Care plan Interventions initiated on 11/14/2017, documented Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Bed in lowest position. Educate resident/family/caregivers about safety reminders and what to do if a fall occurs. Educated [resident 1] to ask for assistance when reaching down to grab items. A care plan Intervention initiated on 7/24/2018, documented Needs a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach On 10/16/2020 at 11:16 PM, a Nursing note documented Resident had an unwitnessed fall in her room from her w/c (wheelchair) at 1600 (4:00 PM). Resident complained of head pain and left knee pain. Resident has a hematoma to her left forehead, but no injury noted to her knee. Neuros started and resident placed on alert. MD (Medical Doctor) and family notified. On 10/16/2020, a Fall Risk Evaluation documented resident 1 as High Risk for falls with a score of 11. Care plan Interventions initiated on 10/16/2020, documented Keep needed items, water, etc, in reach. Care plan Interventions initiated on 10/22/2020, documented Avoid rearranging furniture. Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility On 10/23/20 at 9:29 PM, a Nursing note documented Patient fell from her wheelchair to the floor while self-transferring. a fall witnessed however Sn (skilled nursing) was unable to get to pt n (sic) time to prevent the fall. Patient did not hit her head however she did suffer a skin tear on her right forearm. Sn placed steri-strips on laceration. Patient's assessed. Al (sic) vitals WNL (within normal limits). SN to notify PO (Power of Attorney). DON (Director of Nursing) and MD. Nursing to continue to monitor pt (patient) On 10/23/2020, a Fall Risk Evaluation documented resident 1 as High Risk for falls with a score of 15. [Note: No new fall interventions were implemented.] On 11/17/2020 at 1:24 PM, a Fall Committee IDT (Interdisciplinary Team) note documented [Resident 1] had a fall on 10/23 transferring her self from her w/c to another chair when [resident 1] went to sit she missed the chair, [resident 1] did receive a skin tear to R (right) forearm that wound nurse is following. [Resident 1] had a [CONDITION(S)] med (medication) review on 10/27 as well as provider coming in and assessing her d/t (due to) her falling. No new orders. Care Plan and assessment have been updated. On 12/5/2020 at 11:29 AM, a Social Services Summary note documented that resident 1 had scored a 10 on her most recent BIMS assessment. On 12/21/2020 at 8:13 PM, a Nursing note documented Nurse notified that patient was found on floor at 1340 (1:40 PM). Nurse assessed and noted patient laying on the ground, on her back, while still in wheelchair. Patient reported pain in back of head and neck as well as pain in neck with movement. Neuro assessment completed and patient A&Ox2 (alert and oriented times two). PA (Physician's Assistant) notified and orders given to send patient to [name of Hospital] for further evaluation regarding head and neck pain. Patient sent to [name of Hospital] via facility transport. MD, NP (Nurse Practitioner), DON and family notified. Continue to assess for changes in condition. On 12/21/2020, a Fall Risk Evaluation documented resident 1 as High Risk for falls with a score of 16. [Note: No new fall interventions were implemented.] On 12/29/2020 at 10:53 AM, a Fall Committee IDT note documented [Resident 1] fell on ,d+[DATE] when she was wheeling herself around the unit and she bumped into something and she slid out of w/c. She did hit her head on the floor and c/o (complaints of) headache no other neurological deficits noted On 2/5/2021 at 1:11 AM, a Nursing note documented Patient was found on the ground. Vitals taken and neuro checks performed, patient transferred back into w/c and into bed. Skin assessed, small abrasion on right center lateral back, and skin tear on right proximal thumb. Wound on thumb cleaned and bandage applied. Patient complained of the back of her head being sore, neuro checks performed pupils are equal and reactive, will continue to monitor. Vitals stable and will continue to monitor. On 2/5/2021, a Fall Risk Evaluation documented resident 1 as High Risk for falls with a score of 17. A care plan Focus initiated on 2/5/2021, documented Has had an actual unwitnessed fall with injury (Abrasion to back and thumb) r/t Unsteady gait 2/5/21 A care plan Goal initiated on 2/5/2021, documented Will resume usual activities without further incident through the review date. (Abrasion to back and thumb) will resolve without complication by review date. Care plan Interventions initiated on 2/5/2021, documented Continue interventions on the at-risk plan. Monitor/document/report t MD for s/sx (signs and symptoms): Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks as ordered. WC Assessment On 2/7/2021 at 3:56 PM, a Fall Committee IDT note documented Pt experienced an unwitnessed fall 2/5/21, pt found on the floor in the doorway to her room. Small abrasion noted to right center lateral back, and skin tear to right proximal thumb. Pt stated her w/c (wheelchair) slipped and she fell on the floor. VS (vital signs) srable (sic), neuro checks performed, wounds cleansed and dressed. Cont (continue) to educate pt on requesting assistance as needed. MD, DON, and family notified. On 2/18/2021 at 3:09 AM, a Nursing note documented Patient was found by [name of Certified Nursing Assistant (CNA)] CNA on the ground on her right side, she had a approximately 1 inch hematoma on her right eyebrow that increased in size within 15 minutes. Her right arm was behind her, patient complained of pain in her head, left hand and right arm. Patient would not follow commands. Patient moaning. Patient unable to open her right eye and wouldn't let nurse look open her eye to assess her pupils. Respirations are shallow and increased rate of 20-22 breaths per minute. Patient was transferred to [name of hospital]. Charge nurse [name of nurse] called and reported that CT (computed tomography) scan resulted in intracranial bleeding and patient will be admitted . On 2/27/2021 at 4:11 PM, a Fall Committee IDT note documented Pt experienced an unwitnessed fall w (with) injury on 2/18/21. Pt was found on her R hand side on the floor by CNA, nurse called to assess immediately. Hematoma to R eyebrow noted increasing in size within 15 min (minutes), pt expressed confusion, pain of head l (left) hand and r arm. Pt unable to follow commands and moaning out in pain, neurological assessment unable to be completed as patient was not able to follow simple commands. Orders from on call MD to send pt out to hospital for CT scan. Pt did not return to facility. On 4/22/2021 at 12:11 PM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that he would evaluate a resident's wheelchair for position and size. The DOR stated that he would assess for wheelchair operation and customizations. The DOR stated the day after a resident had a fall the staff would have a fall risk meeting and he would be informed if an assessment would need to be conducted on the resident. The DOR stated that he was not aware that resident 1 needed a wheelchair assessment after her fall on 2/5/2021. The DOR provided this surveyor a Physical Therapy Note dated 8/19/2020, in regards to resident 1 and her wheelchair. Physical Therapy Note signed 8/19/2020, documented Skilled services included assisting and instructing pt using visual, verbal and tactile cueing to improve w/c mobility, focussing (sic) on improving centering, keeping distance from objects to improve safety with functional w/c management. Physical Therapy Note signed 8/26/2020, documented Skilled services included instructing pt with visual and verbal cueing for improved safety techniques, maneuving (sic) obstacles to progress pt with functional w/c mobility independence. On 4/23/2021 at 9:56 AM, an interview was conducted with the DON. The DON stated if a resident had a fall the CNA or staff member was expected to stay with the resident and call the nurse to do a complete assessment on the resident prior to moving them. The DON stated if the resident fall was witnessed the staff would identify if the resident hit their head. The DON stated if the resident fall was unwitnessed the staff would assume the resident hit their head and neuro checks would be initiated. The DON stated that a full head to toe assessment would be completed and the resident would be assessed for injuries. The DON stated the MD, DON, and nurse manager would be notified. The DON stated the nurse would complete a fall risk assessment and pain management assessment on the resident. The DON stated that nursing staff would be encourage to provide interventions and interventions would be reassessed. The DON stated the interventions were documented on the care plan and on the fall IDT progress notes. The DON stated an at risk care plan and a new fall care plan for each fall would be developed. The DON stated that an investigation would not be conducted to determine interventions unless the resident had an injury. The DON stated that she would only have an on the spot conversation and provide education to staff on the floor. The DON stated that she thought resident 1 was changed from a powerchair to a manualchair for safety but could not remember. The DON stated that resident 1's wheelchair was not changed or assessed related to her falls. The DON stated she could not remember if resident 1 was evaluated after her fall on 2/5/2021. The DON stated that interventions were not put in place for resident 1 sliding out of her wheelchair. The DON stated that resident 1 was not evaluated for a self release belt. The DON stated that herself, the Administrator, the DOR, and Licensed Clinical Social Worker attended the fall committee IDT meetings. 2. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included subdural hemorrhage, pseudobulbar affect, dysphagia, cognitive communication deficit, seizures, lack of coordination, and history of falling. On 4/20/21 at 5:35 PM, an observation was made of resident 6. Resident 6 was observed in a wheelchair in the dining room eating the dinner meal. Resident 6 was observed to have a large red area on the right side of her forehead. On 4/20/21 at 7:54 PM, an observation was made of resident 6. Resident 6 was sitting outside of her room in a wheelchair with a blanket over her lap. At 7:55 PM, resident 6 was observed patting her lap with her hand. CNA 5 was observed to tell resident 6 You still have 30 minutes. At 7:57 PM, resident 6 was observed patting her lap with her hand. CNA 5 stated I can't take you yet [resident 6's name]. At 8:03 PM, resident 6 was patting her lap with her hand and CNA 5 stated 30 more minutes and we will toilet you and get you into bed, okay? Resident 6 was observed to close her eyes. At 8:04 PM, resident 6 patted her lap and stated Please. At 8:14 PM, CNA 4 stated to resident 6 it isn't time yet. At 8:23 PM, resident 6 was patting her lap and CNA 6 stated just a minute my dear, just a minute. At 8:26 PM, CNA 6 stated, Okay it's time. Are you excited? I'm excited. CNA 5 asked resident 6 if she wanted to use the bathroom before she went and resident 6 moved her head up and down. On 4/22/21 at 2:13 PM, an observation was made of resident 6. Resident 6 was observed in her wheelchair in the hallway outside of her room. Resident 6 had an alarm on the back of her wheelchair and a seatbelt across her lap. Her wheelchair seat was observed tilted. There was a small box at the top of her bathroom door. There was a large mat against the wall in her room. Resident 6's medical record was reviewed on 4/21/21 through 4/23/21. A care plan dated 5/30/18 and revised on 9/4/20 revealed, FALL RISK: At risk for falls r/t Gait/balance problems, confusion, history of falls, and transferring self without using the call light or waiting for assistance. [Resident 6] is At risk for falls r/t R sided weakness, generalized weakness, R hand contractures, R foot drop (wears a brace), confusion, hx (history) of fall, impulsive behaviors, cognitive impairment, [CONDITION(S)], h/o (history of) multiple falls. Resident chooses to transfer self without asking for assist. The goals developed were resident 6 would be free from injury, free from minor injury, and would not sustain serious injury. Interventions developed in 2018 were patient screened for Part B therapy, therapy evaluation and treatment, safe environment, maintain clear pathway, keep needed items within reach, bowel/bladder tracking initiated to establish bowel/bladder program to prevent falls, staff were to stay with resident while on the toilet, bed in lowest position, call light within reach, and ongoing education to wear appropriate footwear. An intervention developed on 9/9/2020 was bathroom door alarm in place. An intervention developed on 2/16/21 was floor mat. An intervention on 4/8/19 was Wireless alarm to bed and pressure alarm to wheelchair, door alarm. A care plan dated 3/3/21 revealed Has had an actual staff-assisted fall with No Injury, r/t Poor Balance, Poor communication/comprehension, Unsteady gait. on 3/3/21. The goal developed was to resume usual activities without further incident. The intervention included continue interventions on the at-risk plan, educate resident and staff to transfer slowly, determine and address causative factors of the fall, neuro-checks as orders and vital signs as ordered. A care plan dated 3/30/21 revealed, Has had an actual fall with no injuries 3/29/21. The goal was to resume usual activities without further incident. The interventions included to continue intervention on the at-risk plan, door and chair alarm in place, encourage resident toileting program, monitor for change in condition, neuro (Neurological) -checks and vital signs as ordered. [Note: Bed, chair and door alarms were implemented on the at risk care plan on 4/8/19. In addition, a toileting plan was developed in 2018.] A care plan dated 4/5/21 revealed, Has had an actual fall on 4/4/21 with no injury. The goal was to resume usual activities without further incident. The interventions included to continue interventions on the at-risk plan, determine and address causation factors of the fall, monitor for change of condition, pressure alarm in bed and wheelchair and door alarm, neuro-checks and vital signs as ordered. [Note: Bed, chair and door alarms were implemented on the at risk care plan on 4/8/19.] A care plan dated 4/9/21 revealed, Has had an actual fall on 4/8/21 with minor injury (Small amount of blood noted to back of head with hematoma). The goal was (injured areas: head) will resolve without complication by review date. The interventions were continue interventions on the at-risk plan, bed lowest position, CNA education on removing chair foot rest before transfers, floor mat, monitor for change in condition, neuro-checks and vital signs as ordered. In addition, alarm in bed, wheelchair and door. [Note: The bed in the lowest position was an intervention on the at risk care plan that was developed in 2018. Bed, chair and door alarms were implemented on the at risk care plan on 4/8/19.] Another care plan dated 4/9/21 revealed, Has had an actual fall with injury laceration to right side of head Poor communication/comprehension. The goal was to resume usual activities without further incident and laceration to right side of head will resolve without complication by the review date. The interventions were continue interventions on the at-risk plan, bed in lowest position, check range of motion, floor mat, neuro-checks and vital signs as ordered. [Note: The bed in the lowest position was an intervention on the at risk care plan that was developed in 2018. The floor mat intervention was developed on the at risk care plan on 2/16/21.] Another care plan dated 4/9/21 revealed, Has had an actual fall on 4/8/21. Pt (patient) hit right side of head. Pt taken to ER (emergency room ) and had 4 staples put to right side of head. The goal developed was (head injury) will resolve without complication by review date. The interventions were to continue interventions on the at-risk plan, bed in lowest position, continue alarms, floor mat, monitor for change in condition, neurochecks and vital signs as ordered. A new interventions were medication management due to her anxiety, will work with therapy for strengthening and room assignment close to the nurses station. There were physician's orders for alarm while in bed and chair dated 2/16/21 and another physician's order dated 4/8/19 revealed Pressure alarm to bed and wheelchair. According to resident 6's progress notes and incident reports the following falls were documented: a. On 1/31/21, a nursing progress note revealed Resident noted at 1730 (5:30 PM) sitting on her bathroom floor with her back and head resting against the wall. VSS (vital signs stable). Assessed for injury with none noted.Neuro checks initiated. According to the incident report resident 6's alarm (was) sounding staff running down hallway with resident sitting on floor with legs extended and head resting against wall. The report further revealed, resident attempted to transfer self and fell in bathroom with wheelchair alarming. b. On 2/3/21, a nursing progress note revealed that staff heard alternate resident yelling out for help from the hallway. Staff rushed to resident 6's room and the chair alarm began sounding. Resident 6 was found on the bathroom floor of an alternate resident room. Resident 6 had attempted to transfer herself from her chair to his toilet independently. Neurological assessments were initiated and there were no injuries observed. The incident report did not have additional information. c. On 3/3/21, a nursing progress note revealed that at 11:00 AM resident 6 was transferred to the toilet by a CNA with 1 person extensive assist. Resident 6 stood up quickly and lost her balance and she hit her head on the floor with restrained force. Resident 6 was assessed and there was no injury observed. Neurological checks were initiated. The staff and resident were educated to transfer slowly and ensure appropriate footing and balance. There was no additional information on the incident report. d. A nursing progress note dated 3/29/21 at 5:59 PM, revealed that Resident was attempting to self transfer onto toilet. Found on floor by nurse. No injuries noted during assessment. Vital signs stable. Family contacted. MD notified and ADON. Placed on alert charting. [Note: There was no documentation regarding if alarms were alarming.] There was no additional information on the incident report. e. A nursing progress note dated 4/4/21 at 4:29 PM, revealed that resident 6 slid out of her wheelchair at the nurses station. Resident 6 was very agitated and anxious regarding her restroom schedule. Resident 6 had been taken to the restroom on time according to her schedule. No injuries were observed and vital signs were stable. There was no additional information on the incident report dated 4/4/21 at 4:23 PM. f. A nursing progress note dated 4/8/21 at 11:46 PM, revealed that Nurse called into resident room with small amount of bleeding noted to back of head with hematoma. Aide states he was transferring resident into her bed when her leg got caught in wheelchair and they both fell on to the bed. Unsure what she hit the back of her head on. Area cleaned. ROM (range of motion) at baseline. Neurological assessment initiated. Aide education on removing leg rests before transferring. The incident report dated 4/8/21 at 7:45 PM, did not have additional information. g. A nursing progress note dated 4/9/21 at 12:25 AM, revealed Resident was sitting up on the side of her bed with nurse and aide cleaning her hair and changing her clothing. Aide stepped away to get a gown for resident and right then resident lunged to her right falling very quickly hitting her head and right shoulder to floor. Residents right side of head immediately began bleeding profusely. Nurse held pressure with sterile gauze and notified other LN (Licensed Nurse) to call 911. Resident awake and alert with no loss of consciousness. The incident report dated 4/8/21 at 8:00 PM, revealed other info: Resident to not sit on the side of bed without being directly held to a sitting position. A nursing progress note dated 4/9/21 at 12:33 AM, revealed that resident 6 returned from local emergency department with 4 staples to the right side of head. Resident was assisted into bed in low position with mat to floor. A restorative nursing note dated 4/16/21 revealed, [Resident 6] had a fall recently and required some stitches on right side of her forehead. She needed assistance with feeding r/t recent fall and weakness. She worked with Restorative aid on feeding and now able to self-feed. On 4/22/21 at 2:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that after being notified or witnessing a fall, he entered the room and observed the area. LPN 3 stated that he looked to see where the walker or wheel chair were. LPN 3 stated he assessed the resident for injuries. LPN 3 stated if no injuries, then a CNA assisted him in getting the resident into a wheelchair or bed. LPN 3 stated that he completed an incident report, notified the DON and resident's family. LPN 3 stated after a fall there was alert charting for 3 days to assess for bruising and other changes. LPN 3 stated that the nurses gave a report to each other at the start and end of every shift. LPN 3 stated that the nurse reported falls to the next nurse on shift. LPN 3 stated that resident 6 asked to use the bathroom over and over. LPN 3 stated that resident 6 had tried to get herself to the bathroom in the past. LPN 3 stated staff monitored resident 6 to make sure she did not go to the bathroom alone. On 4/22/21 at 2:13 PM, an interview was conducted with CNA 7. CNA 7 stated that she had not worked at the facility for a while. CNA 7 stated that the CNA lead gave her information about each resident when she started her shift. CNA 7 stated that resident 6 was a 1 person assist with transfers and toileting. CNA 7 stated resident 6 had a low bed, a pad next to her bed, seatbelt, chair alarm and an alarm on her bathroom door. CNA 7 stated she did not know if resident 6 was able to release her seatbelt. CNA 7 was observed to ask resident 6 to remove her seatbelt and resident 6 removed it. CNA 7 opened resident 6's bathroom door and there was a loud alarm sound. On 4/23/21 at 9:31 AM, an interview was conducted with the DON, Administrator, and Corporate Resource Nurse (CRN) 1. The DON stated that after a resident fell the nurse was notified. The DON stated if it was a witnessed fall then the witness reported if the resident hit their head to the nurse. The DON stated if it was an unwitnessed fall then a neurological assessment was completed along with vital signs. The DON stated after the nurse assessed the resident then the resident was moved if there were no injuries. The DON stated that a fall risk assessment and pain assessment were completed after a fall by the nurse. The DON stated that there was a fall meeting with management the next day to determined new interventions and update the care plan. The DON stated there was an actual fall care plan initiated for each fall that resolved a month after the fall. The DON stated that there was no written investigation into falls but the DON asked staff if interventions were in place. The DON stated that she then provided verbal education onsite to staff regarding new interventions. The DON stated that resident 6 had a bathroom alarm, so if the bathroom door opened an alarm went off. The DON stated there was no process to ensure the door alarm was functioning properly. The DON stated that the fall committee had not discussed the need for increased assistance for resident 6 during transfers. The DON stated that she did not know if alarms were alarming when resident 6 was found in the bathroom or had slid out of her wheelchair. The DON stated that resident 6 was anxious and jumped up and fell when she was assisted to the toilet. The DON stated that she was constantly fixated on using the bathroom. The DON stated resident 6 was on a 2 hour toileting program and had not re-evaluated the need to change the toileting program. The DON stated she did not know when the toileting program was implemented. The DON stated that it must have been implemented on 7/9/18 because according to the care plan that was the date it was initiated. The DON stated that resident 6 had 2 falls on 4/8/21. The DON stated that the first fall resident 6 was being transferred with 1 staff member when their feet caught in the footrests. The DON stated that the staff and resident both fell on the bed. The DON stated that the nurse was completing an assessment when the CNA stepped out to get a gown and resident 6 lunged forward and fell hitting her head. The DON stated that Emergency Medical Services was called and resident 6 was transferred to the hospital and returned with staples. The DON stated she had not complied all the falls with resident 6 since January to determine if resident 6 needed increased assistance, if the alarms were working, or the possible root cause of the falls. The DON stated she did not assess where the falls were and where the staff members were. The DON stated she did not know that resident 6 had fallen twice in her bathroom and 3 times when being assisted by 1 staff member. 3. Resident 10 was admitted to the facility on [DATE] with diagnoses which included pneumonia, hypoxemia, urinary tract infection, and chronic kidney disease. On 4/21/21 at 12:17 PM, an observation was made of resident 10. Resident 10 was observed to be laying in bed. The bed was positioned about 3 feet above the floor. A care plan dated 4/15/21, and revealed that resident 10 was at risk for falls related to weakness. The goal developed was that resident 10 would be free of falls through review date. The interventions developed were be sure call light is within reach and encourage to use it to call for assistance as needed. Education resident/family/caregivers about safety reminders and what to do if a fall occurs. Keep needed items, water, etc in reach. Maintain a clear pathway, free of obstacles. Needs safe environment: bed in low position at night. A nursing progress note dated 4/17/21 at 6:52 PM, revealed Resident found on the floor in his bedroom. Unsure if he had a fall, or put himself on the floor as he was covered up with his sheet and blanket. He was found lying on his back with his feet under his desk and his head by the foot of the bed. Assessment completed and resident assist back to the bed. He had some redness to his right shoulder blade and in the middle of his back. No complaints of pain. No injuries noted. Educated resident on the use of his call light when he needs help. MD and on call nurse notified. Placed on alert status. A care plan dated 4/21/21, revealed that resident had an actual fall on 4/16/21 with no injury. The goal was to resume usual activities without further incident through the review date. The intervention was bed in lowest position, continue interventions on the at-risk plan, monitor/document/report to MD changes, neurological checks as ordered and vital signs as ordered. On 4/23/21 at 9:35 AM, an interview was conducted with the DON. The DON stated that she did not have additional information regarding why resident 10's bed was not in the low position.

Based on observation, interview, and record review it was determined, for 2 of 16 sample residents, that 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. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident with behaviors of refusing to have brief changes, showers, and his room cleaned was not provided interventions from all departments. In addition, a resident with [CONDITION(S)] was not provided interventions. Resident identifiers: 3 and 10. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/22/21 at 10:08 AM, an interview was conducted with resident 3. Resident 3's call light was alarming. Resident 3 stated that he wanted his brief changed. Resident 3's room was observed to have an odor with soiled and sticky floors. Resident 3 stated that housekeeping staff came by his room once a day. Resident 3 stated that his sheets were changed on his bed daily. Resident 3 stated that from the waist up he was really healthy and very rarely refused his medications. Resident 3 stated the Licensed Clinical Social Worker (LCSW) had talked to him about the voices in his head that told him to self mutilate. Resident 3 stated that the LCSW down played his concerns. Resident 3 stated that he reported the voices in his head to a nurse and the nurse administered medications that helped. Resident 3 stated he asked the Nurse Practitioner for that medication but had not received it. Resident 3's medical record was reviewed on 4/20/21 through 4/23/21. Resident 3's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 3 had a Brief Interview of Mental Status (BIMS) score of 14 which revealed resident 3's cognition was intact. Resident 3 received his antipsychotic medications 7 days out of 7 days. In addition, resident 3 did not have psychological therapy provided. A Preadmission Screening Resident Review (PASRR) Level II was signed by an evaluator on 12/6/2019. The PASRR revealed that within the last 2 years resident 3 experienced an episode of significant disruption to the normal living situation which required supportive services due to serious mental illness. Resident 3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The recommendations for services to be provided by the nursing facility were to Encourage participation in group activities. Reassurance, support. Verify the factuality of what he says, especially if it benefits him in some way. Monitor for depression symptoms, oral intake, and encourage medication compliance, especially regarding an antidepressant and a [MEDICATION(S)], which would benefit him. A letter of determination dated 12/10/2019 revealed resident 3 was approved for Nursing Facility Services and to see the PASRR evaluation for recommended specialized services. A care plan initiated on 8/1/19 and updated on 8/4/19 revealed, [Resident 3] is at risk for impaired cognitive function/dementia, or impaired though process r/t (related to) use of opioid analgesics, oxygen dependence and non-compliance refusal of care, weakness. Goals developed were to maintain level of cognitive function and remain oriented. Interventions developed were PASRR level II recommendations: Encourage participating in group activities. Reassurance, support. Check facts of what he says, especially if it gives him a benefit in some way. Monitor for depression symptoms. Monitor oral intake. Pt (patient) is very depressed, will help support pt in any needs that he expresses A care plan dated 8/4/19 and updated on 4/12/21 revealed, BEHAVIOR: [Resident 3] is resistive to care at times r/t non-compliance with shower, refusing to use oxygen when SpO2 (oxygen saturation) is below 90%. Pt. denies having [CONDITION(S)] even when SpO2 is in 70s. The goals were Will cooperate with cares through next review date and Will participate in care through next review date. Interventions developed were Allow to make decisions about treatment regime, to provide sense of control. If possible, negotiate a time for ADLs (activities of daily living) so that the resident participates in the decision making process. Return at the agreed time. Another care plan dated 4/12/21 revealed Potential for behavior problem r/t [CONDITION(S)] aeb (and) hallucinations and delusions. PT being seen by [local mental health] services. The goal was to have fewer episodes of hallucinations and delusions by review date. Interventions included were to observe for side effects and adverse reactions of psychoactive medication, praise any indication of progress/improvement in behavior, provide a program of activities that is of interest and accommodates residents status, referral to an appropriate psychiatric provider as needed, intervene as necessary to protect the rights and safety of others, approach/Speak in a calm manner, divert attention, remove from situation and take to alternate location as needed, monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations, document behavior and potential causes, and assist to develop more appropriate methods of coping and interacting, and encourage to express feelings appropriately. Resident 3's March 2021 Treatment Administration Record (TAR) revealed the following number of psychotic behaviors: a. 3/1/21 through 3/15/21, No behaviors documented b. On 3/16/21, 10 episodes c. On 3/17/21, 13 episodes d. On 3/18/21, 30 episodes e. On 3/19/21, 20 episodes f. 3/20/21 through 3/31/21, there were a total of 7 episodes Resident 3's April 2021 TAR revealed the following number of psychotic behaviors: a. On 4/5/21, 5 episodes b. On 4/11/21, 4 episodes c. On 4/21/21, 4 episodes Resident 3's April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 refused the medication on 4/2/21 and 4/3/21. Progress notes revealed the following entries: a. On 2/12/21, an MDS note revealed Pain interview conducted. Resident denied having any pain in the last 5 days. Resident stated that he sometimes has SOB (shortness of breath) when lying flat and keeps his HOB (head of bed) elevated. He denied having SOB when sitting or when transferring. He denied having any difficulties swallowing. He understands and is understood. He stated his vision and hearing was adequate and he doesn't have any glasses, hearing aids or dentures. Resident denied having pain in his mouth. b. On 3/4/21, a [CONDITION(S)] Interdisciplinary Team (IDT) note revealed no new orders at this time and continue to maintain due to patient doing extremely well with room change and medication management, no episodes of depression, hallucinations or delusions noted this month. c. On 3/6/21 at 8:59 PM, a pharmacy review revealed Medications and chart reviewed. Stable mood. No ASE reported. No irregularities noted. d. On 3/19/21 at 10:13 AM, Social Services note revealed LCSW attended to patient per patient request. Patient is having active delusions and hallucinations (visual, and auditory). In our conversation we discussed how he would like to go to room [ROOM NUMBER], to which he was already in. He reported he needed to be in 102 because the people in his room (he pointed to the wall) are trying to hurt him. Patient then pointed to his bed and stated that he needed someone to hold him so that they don't attack him and gouge his eyes out of his head. LCSW assured him that he was safe and that she would get him the help that he would need. He then started yelling 'help' at the top of his lungs, to which he was doing when LCSW entered his room. When the aide came in, she realized LCSW was present in his room, made sure there was nothing she could do and left his room when he started screaming out 'help' as loud as he could and told the LCSW that she was part of them and that she was there to hurt him, that she was part of the people going to gouge his eyes out, and rip off his testicles. LCSW assured him that she was only there to help. He said, 'then go and get me some help!' LCSW exited the room and met with the nurse who stated she talked with. [local behavioral health] and he requested we send documentation regarding being able to see him. Patient refused to sign the documents for [local behavioral health]. Which [local behavioral health] couldn't accept double caregiver signatures, he needed to sign it personally. LCSW talked with the NP (Nurse Practitioner) and got a blue slip filled out and signed since he wouldn't talk with the Nursing Home Therapist with [local behavioral health]. Patient received IM (intramuscular) [MEDICATION(S)] via doctors orders to help him calm down and relax. [Local behavioral health] went in to try and talk to him about signing the documents to assist him further. Patient agreed to sign documents with [local behavioral health], when SSA (Social Services Assistant) went in to attempt to get signatures he was experiencing this same stimuli and was unable to sign as he was trying to find room [ROOM NUMBER] again, even though he was in 102. LCSW waiting 10 minutes and then attempted once more, to which he started screaming help, and stated that if he signed he would be signing approval for them to gouge his eye balls, rip out his testicles and attack him. LCSW assured him that she was still getting him the help that he requested. He thanked LCSW but told her she wasn't a very good Social Worker because she wouldn't get rid of these people attacking him. LCSW then called the ER (emergency room ) to let them know he was coming via blue slip. LCSW then called emergency personnel to transport him to [Local] ED (emergency department). e. A NP note dated 3/19/21, -acute visit for hallucinations - pt in bed, anxious, yelling, screaming - pt has had significant mental health history at the facility, mostly dealing with [CONDITION(S)], and [CONDITION(S)], and depression - was able to hold small conversation in between these episodes - pt reports increased frequency of both auditory and visual hallucinations. - Auditory - hearing people try to convince him of self mutilization, demanding he poke his eyes out or rip off his genitals - also complains of some SOB, and cough but says 'been happening for a while' - Visual - seeing 'three men in checkered shirts, from the club come into his room and try to take me' - asks to be chained to the bed so they can't take him - pt goes in and out of yelling and screaming - pt is difficult to talk down, or talk through the situation - 2MG of IM [MEDICATION(S)] was administered, due to pt being a risk to himself and staff - pt needs emergent transfer for evaluation and does not have the mental capacity to consent, for the safety of the patient and staff,will sign blue slip. f. On 3/19/21 at 11:58 AM, a Social Services note revealed LCSW conducted an online report as the fire-chief stated this may be a way to get his patient additional help with getting him in a safer setting for his benefit. g. On 3/19/21 at 2:36 PM, a Social Services note revealed LCSW received a call from APS (Adult Protective Services) stating they were unable to open a case for patient as he was in a SNF (Skilled Nursing Facility). h. On 3/19/21 at 5:08 PM, DON (Director of Nursing) received a call from ER Nurse at [name of hospital] with concerns of patient hygiene and bathing, stating they were able to give him a bed bath while he was there as he was very calm and cooperative with them. She expressed that the ER staff was very concerned about his care and hygiene. DON explained to ER that patient is behavioral and refuses cares frequently, LCSW sent a Self Neglect report to APS prior to pt transfer to the ER for this. Pt also has recorded shower 3/16. DON to cont (continue) to educate staff on cares and encouraging hygiene for pt. WCTM (will continue to monitor). i. On 3/21/21 at 11:33 AM a Social Services note revealed, SSA assisted client to complete necessary portions of Treatment contact with [local] Behavioral Health. j. A NP visit dated 4/9/21, for a regulatory visit revealed discussed consult with local mental health service, should be coming to evaluate soon. k. On 4/12/21 at 4:38 PM, DON into discuss multiple RvB (risks verses benefits) w (with) patient, including; ADLS: Showers, Brief Changes, Oral Hygiene, Proper Urinal use, PRN (as needed) Supplemental O2 (oxygen) Use, and Obtaining Weight and Height. See RvB in Misc for details. According to the local hospital Emergency Department note, [AGE] year-old male sent over from . nursing and rehabilitation with concerns of increasing hallucinations. Patient apparently has been fairly noncompliant with any medications or any kind of care that may try to get him over there now over the last 3 days reportedly has had increasing visual and audio hallucinations. Patient otherwise feeling well and is comfortable at this time. The report further revealed Patient also shows obvious evidence of being unkempt and concern for underlying medical conditions may be exacerbating his hallucinations. The ED course was Patient underwent labs that are fairly reassuring. Does show a little bit of hemoconcentration which I think is likely related to some dehydration given his unkempt state. He was given some IV fluids here.Patient is actually been fairly cooperative with his (sic) here although he will not let us clean up his head and face but we were able to clean up the soiled sheets and linens that it appears as if he been laying in for days with break down of the skin. Concerns for his care have been raised and a report has been filed with DCFS (Division of Child and Family Services). Patient has been seen and examined by our care manger and crisis worker and arrangements were made for him to be getting go (sic) to the facility but with much closer follow-up and family involvement. On 4/22/21 at 12:00 PM, an interview was conducted with the LCSW. The LCSW stated that prior to resident 3's admission to the facility a PASRR was provided to the LCSW to review. The LCSW stated that the PASRR contained information regarding resident 3's past. The LCSW stated that a PASRR evaluator determined if a level II was needed. The LCSW stated typically behavioral health was recommended. The LCSW stated a staff member from the local behavioral health met with residents on Fridays at the facility. The LCSW stated that the staff member and her emailed back and forth regarding resident's. The LCSW stated that the staff member from the local behavioral health did not provide notes for resident records. The LCSW stated that resident 3 was admitted about 2 years ago to the facility. The LCSW stated that he was homeless and resistive to cares. The LCSW stated that over time resident 3 has learned to trust the LCSW. The LCSW stated that resident 3 stated to her that he was having audio/visual hallucinations and would tell her that was why he did not want a roommate and why he did not want staff in his room. The LCSW stated that he had behavioral health services involved prior to the ED visit on 3/19/21. The LCSW stated that when resident 3 was taking his medications he was willing to let staff shower, shave, and change him but not often. The LCSW stated that resident 3 had a daughter that was hit and miss with her dad's care. The LCSW stated that recently resident 3 was screaming that he was not in the right room and he was having delusions. The LCSW stated that the local behavioral health staff member and NP were at the facility and tried to talked to him. The LCSW stated that the behavioral health staff member wanted him to sign a contact for services and he refused. The LCSW stated that staff worked together and obtained a blue slip for resident 3 to go to the emergency room . The LCSW stated that she did not know how often resident 3 refused showers, medications, and room cleaning. The LCSW stated that if a resident was refusing then the IDT came together to discuss the use of outside providers. The LCSW stated that she was not sure why resident 3's room was dirty with an odor. The LCSW stated that psychosocial support from resident 3's care plan would mean that she would check on the resident if see if they were okay. On 4/22/21 at 1:54 PM, an interview was conducted with the Environmental Services Director (ESD). The ESD stated resident rooms were cleaned daily. The ESD stated that he knew that resident 3 did not like to have his room cleaned. The ESD stated he did not know how often resident 3 refused to have his room cleaned. The ESD stated that housekeeping staff did not document rooms that were not cleaned. The ESD stated that he has talked with resident 3 about cleaning his room. The ESD stated that resident 3's room was to be cleaned at least every 2 days. On 4/22/21 at 2:30 PM, an interview was conducted with CNA 11. CNA 11 stated that if a resident refused cares he asked three different times through out the shift. CNA 11 stated resident 3 refused to have his brief changed more than twice per shift. CNA 11 stated resident 3 was usually willing to take showers. CNA 11 stated that he noticed an odor when entering resident 3's room. CNA 11 stated he was not sure when resident 3's room was cleaned. CNA 11 stated if resident 3 refused cares three times he reported it to the nurse on duty. On 4/23/21 at 9:35 AM, an interview was conducted with the DON. The DON stated that staff were provided behavioral health training as part of their orientation and annually. The DON stated that resident 3 had consistently refused cares. The DON stated that resident 3 wanted certain things done at certain times and did not want staff to interfere. The DON stated that resident 3 went to the ER for a psych evaluation and was soiled because of refusing cares. The DON stated that the LCSW filed an APS report for self-infliction of abuse because he was not allowing for cares. The DON stated that she reviewed all progress notes from the day before. The DON stated that she was not aware of when residents were refusing cares except from the progress notes. The DON stated that there was a Tiger Text system that nurses, LCSW, DON and NP used to communicate about resident's care. 2. Resident 10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 10's medical record was reviewed on 4/20/21 through 4/23/21. Progress notes revealed the following entries: a. On 4/16/21 at 10:52 AM, [Resident 10] has been refusing brief changes this morning. Multiple staff members attempted go in and try to help him get cleaned up. Patient is nice when staff talk to him and explain that his bedding needs to be changed but becomes combative and agitated every time staff attempt to start the change. b. On 4/17/21 at 3:06 PM, Resident has refused all medications this shift. He has refused cares as well, and fights us when trying to change his brief or bed. He will not allow us to take vitals. He told this LN that he just wants to die. MD (Medical Doctor) and team notified. c. On 4/17/21 at 4:28 PM, Resident on alert for PO (oral) ABO (antibiotics). Resident has refused all medications since admission and has not received any doses of ABO. Will continue to encourage.States he just wants to diet. Will continue to monitor. d. On 4/18/21 at 2:01 PM, Pt continues to refuse medications. Combative with cares.Will continue to monitor. e. On 4/19/21 at 4:51 AM, Pt on alert charting for ABX (antibiotics) . for pneumonia. Pt continues to be resistant to cares and refuses meds (medications). f. On 4/19/21 at 4:14 PM, While speaking with the resident, SSA was made aware by the resident that they believe they would be better off dead. After further assessment with LCSW and the floor nurse it was determined that Q15 (every 15 minute) checks are not necessary at this time as their desire was deemed passive. SSA will follow up as needed. g. On 4/20/21 at 6:49 AM, .Pt refuses meds continually. On 4/23/21 at 11:48 AM, an interview was conducted with the LCSW. The LCSW stated that when a resident expressed wanting to die, then she would do an assessment to determine if the resident had active or passive [CONDITION(S)]. The LCSW stated that if the resident was determined active then 15 minute checks were indicated. The LCSW stated if the resident was determined to have passive then she would ask the resident if there was something she could do to help. The LCSW stated that she involved a local behavioral health service to evaluate residents that expressed wanting to die. The LCSW stated she did not provide interventions for resident's that were determined to have passive [CONDITION(S)]. The LCSW stated that she determined resident 10 was having passive [CONDITION(S)] because it was common for resident 10 to say he wanted to die according to his history and physical. The LCSW stated she had been notified of the statement once. The LCSW stated that she asked the resident What is it that I can help you with? The LCSW stated resident 10 did not have anything that she could do for him. The LCSW stated she referred resident 10 to the local behavioral health service, who were scheduled to see him on 4/23/21. The LCSW stated she was aware that resident 10 was refusing his medications. The LCSW stated she did not know a resident with pneumonia refusing an antibiotic medication could be considered a suicidal ideation. The LCSW stated that the behavior of refusing medications would not be passive but was active.

Based on interview and medical record review it was determined, for 1 of 17 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, facility staff waited approximately 20 hours before notifying the physician regarding a resident's lab results. In addition, facility staff delayed administration of prescribed medication and did not coordinate care with radiology and other providers in attempt to initialize intravenous (IV) port site. Resident identifier: 8. Findings include: Resident 8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] and [DATE], resident 8's medical records were reviewed and revealed the following information. On [DATE] at approximately 2:20 AM, an order summary report revealed that a telephone order was made for following: a. [MEDICATION NAME] 500 milligrams (mg), give 500 mg via gastrostomy tube ([DEVICE]) three times per day (TID) for [MEDICATION NAME] for teeth extraction for 10 days. b. Urinary analysis (UA) with Culture and Sensitivity (C&S) one time only for 2 days. Medical records revealed that resident 8's urine sample was collected on [DATE] at 8:05 PM and was sent to the lab for analysis. (Note: Facility waited more than 40 hours to collect urine sample for resident 8.) On [DATE] at 12:47 PM, lab results for urinary analysis were available, with results for C&S pending. On [DATE] at 7:15 AM, lab results revealed that lab was not able to provide C&S results due to sample being contaminated. The facility Nurse Practitioner (NP) placed an order for [REDACTED]. (Note: There was delay of at least 9 hours in reporting to NP that the urine sample was contaminated for C&S.) On [DATE] at 11:58 PM, order summary report revealed that the telephone order for UA with C&S was entered by night shift nurse. This order was supposed to be collected on [DATE] at 7:00 AM. (Note: There was delay in staff entering the order of 7 hours, from 4:30 PM to 11:58 PM). The UA sample for order placed on [DATE] on 11:58 PM was never collected. On [DATE] at 4:21 PM, facility NP assessed resident 8. NP ordered a STAT repeat UA with C&S, blood sample for Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential (Diff) and a bolus of IV normal saline to be administered. In a progress note dated [DATE], the NP documented the following: Disorientation-repeat UA ordered yesterday ([DATE]). Result not available currently. Give 2 liters NS bolus now ASAP (as soon as possible) then NS (normal saline) at 100 ml/hr (milliliters per hour) X additional liter. Chronic UTI-Awaiting urine results. [MEDICATION NAME] currently. Poorly controlled diabetes-[MEDICATION NAME] in urine. IVF (Intravenous Fluids) Monitor closely. Patient had large fluctuations from [DIAGNOSES REDACTED] to severe [MEDICAL CONDITION]. (Note:[MEDICATION NAME] ordered on [DATE] at 8:00 PM for infection. Unsure what kind of infection resident had, no confirmation of UTI or other kind of infection were found in nursing progress notes.) Samples for this order after an assessment were collected on [DATE] between 4:37 PM and 5:37 PM. On [DATE], the following STAT lab results were received. a. At 7:32 PM, the completed CBC with differential revealed that resident 8 had elevated White Blood Cells (WBC) at 19.7 k/uL (kilo per microliter), reference range: 3.6 - 10.8 k/uL; Red Blood Cells (RBC) at 5.21 m/uL (million per microliter), reference range: 4.00 - 5.20 m/uL; platelets at 490, reference range: 130 - 400 K/uL; and [DIAGNOSES REDACTED]s at 17.8, reference range: 1.8 - 7.0 k/uL. b. At 7:43 PM, the completed CMP revealed that resident 8 had an elevated Anion Gap at 22.0, reference range: 3XXX,[DATE].0; glucose 265 milligrams/deciliter (mg/dL), reference range: ,[DATE] mg/dL; Blood Urea Nitrogen (BUN) at 39 mg/dL, reference range: 7 - 20 mg/dL; and creatinine at 2.45 mg/dL, reference range: 0.60 - 1.30 mg/dL. c. At 7:46 PM, the completed UA revealed the presence of glucose, [MEDICATION NAME], protein, white blood cells and yeast. Final results on urine C&S were released on [DATE] at 11:33 AM. Lab results revealed that resident 8 had yeast infection in urine. On [DATE], nursing progress note revealed the following information. a. At 12:31 AM, Results received for CBC, CMP, and UA. Will notify facility provider. Attempted to insert IV this evening. Attempt X 1 (one time) to L (left) hand. Unsuccessful. No other viable veins able to be seen or palpated. Liquids administered frequently via [DEVICE]. Will continue to monitor. (Note: There was no documentation showing that the NP was notified of the critical lab values. There is no documentation that the NP was notified of the failed attempt to start an IV. There was no order to give fluids via [DEVICE], if unable to start an IV.) b. At 5:15 AM, res (resident) having severe anxiety throughout the evening, despite being given PRN [MEDICATION NAME]. Possibly related to d/c of [MEDICATION NAME]. Will continue to monitor. c. At 12:41 PM, Res has some anxiety and increased agitation this shift. Res encouraged to increase fluids. Will continue to monitor and treat. d. At 13:11 PM, Pt (patient) c/o (complaints of) anxiety and pain. Pt states she 'cannot do it anymore,' and she is 'dying.' Pt keeps yelling 'help me.' Pt has c/o in different areas every time she is asked, whole body, R (Right) arm, stomach, head and neck, etc. PRN pain and anxiety medication administered, and pt calmed down a little bit. Bowel sounds active x4. Able to make needs known. (Note: No order was found to administered liquid through resident 8's [DEVICE].) On [DATE] at 1:45 PM, the NP assessed resident 8 and reviewed her lab results. At that time, NP had resident 8 transferred to a local hospital emergency room (ER). Resident 8 was subsequently diagnosed with [REDACTED]. Per hospital discharge summary, resident 8 was placed on hospice before she deceased on [DATE]. On [DATE] at 2:52 PM, Director of Nursing (DON) 1 was interviewed. DON 1 stated that resident 8 was a very difficult patient with many [DIAGNOSES REDACTED]. DON 1 stated that resident 8 had a habit of slipping into Diabetic Ketoacidosis (DKA) and had behaviors. DON 1 stated that after resident 8's death, the facility did an investigation. DON 1 acknowledged that the facility did not complete labs on time or provide care/orders as they were prescribed. DON 1 stated that facility had a delay in collecting lab samples and treatments with bolus IV fluids administration. DON 1 stated that facility had a delay for more than 12 hours in finding resident 8's IV port. DON 1 stated that facility staff were expected to notify the IV team if they were unable to successfully place an IV. DON 1 stated that facility staff failed to notify the IV team when they did not successfully establish an IV for resident 8. DON 1 stated that facility staff tried to find a vein for IV fluid bolus and the nurse was not able to find a vein. DON 1 stated that staff called physician when resident 8 started to show signs of increased confusion and agitation and then resident 8 was transported to local hospital ER. DON 1 stated that in the hospital resident 8 was diagnosed with [REDACTED]. DON 1 stated that resident 8 died in the hospital the same day. On [DATE] at 1:47 PM, NP was interviewed. NP stated that he ordered a repeat UA on [DATE] through the facility's secured messaging system. NP stated that he was not sure who entered the order after his message was submitted. NP stated that he was not sure why the UA order was discontinued on [DATE], or who discontinued it. NP did not know why the UA was not collected. NP stated that he reordered the UA along with CMP, CBC and IV bolus to be done STAT on [DATE]. He stated that all STAT results, especially critically high results, should have be reported to the physician on call. NP stated that he did not receive call from MD or facility and he was not sure if MD was notified after facility received lab results. (Note: No nursing progress notes were found about MD or NP being notified after facility received lab results.) NP stated that his expectation was to be called with critical results. He stated that he expected facility staff to notify radiology team or to send resident to ER to have an IV port placed if facility staff was not able to find an accessible port. NP stated that he was not aware of the critical STAT lab results until he came to the facility on [DATE] around 1:00 PM for regular daily rounds. He stated that after he saw resident 8 and her lab results, he ordered resident 8 to be sent to local hospital ER. NP stated that his opinion was that residents 8 teeth extraction did not contribute to resident 8's death, since she was receiving antibiotics as a [MEDICATION NAME] which should help with urinary infection as well. NP stated that per his opinion facility staff failed to do following: a. Obtain urine sample as ordered on [DATE]. b. Notify radiology/ IV team to start an IV port when facility staff attempt did not work. c. Notify him or MD of STAT lab results in timely manner. On [DATE] at 2:15 PM, Assistant of Director of Nursing (ADON) was interviewed. ADON stated that standard protocol for IV placement was for every nurse to try to find an IV access two times. If one RN was not able to find an accessible vein then she would call another nurse. If no nurses were able to do it, then the facility should call IV/Radiology team from the hospital or they should send resident to ER to have the IV placed. On [DATE] at 2:54 PM, DON 2 was interviewed. DON 2 stated that nurse have an access to the secured messaging system on the facility computer system. DON 2 stated that sometimes things did not get ordered because they were not ordered STAT or staff could wait for order verification from physician. DON 2 stated that during the night shift, staff would not do UA sample collection because resident 8 would need to be straight cathed, so the staff did not want to wake resident 8 up. DON 2 stated that this order should have been completed the following morning (Note: It was not until NP came to see resident 24 hours after.) DON 2 stated that she did not know why the day shift nurse did not collect resident 8's UA sample on [DATE] between 4:30 PM and 7:00 PM. DON 2 stated that she did not know why resident 8's UA samples was not collected on [DATE] before the NP placed a second order at 4:30 PM.

Based on interview, observation, and record review it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. Specifically, hot water temperatures in the Garden Dining Room were observed to range in temperatures from 167.7 degrees to 176 degrees Fahrenheit. The deficient practice identified, in regards to the hot water, was found to have occurred at an Immediate Jeopardy level due to the potential for thermal injury to the residents residing within the facility. Additionally, 3 sinks in resident rooms were observed with hot water temperatures ranging from 120.3 degrees to 123.6 degrees Fahrenheit. Resident identifier: 28, and 33. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 2/19/15. The Administrator was asked to develop an immediate plan to ensure resident safety related to hot water temperatures. PLAN: On 2/19/15 at 10:15 AM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated February 19, 2015 stated the following: " RE: Action Plan for Immediate Jeopardy February 19, 2015 Orem Rehabilitation is alleging the Immediate Jeopardy is abated at 10:15 a.m. 2/19/15. We allege this is abated by the following plan of action that was implemented immediately: 1) Sink in rehab dining was immediately disabled after the first initial temperature indicated out of range. 2) Facility staff was immediately in-serviced to not use that sink until further notice. 3) This sink is not deemed for resident used. (Name) Director of Nurrsing, at a sister facility, stated that she washed her hands in that sink yesterday (Feb. 18, 2015) and did not notice any unusually hot water. She ran the for at least 5 minutes as she was washing an oxygen filter. (Name) The Director of Clinical Services for also washed her hands in sink on 2/17/15, in question and did not notice excessive hot water. 4) Maintenance determined that mixing valve failed and needed replacement. 5) Maintenance director installed new mixing valve immediately. 6) Facility initiated 30 minutes water temp checks on that sink starting at 10 am to ensure that new water valve is functioning properly times 2 hours. 7) Facility has not experienced any issues with residents, or staff reporting concerns with water being to hot, nor has any resident been injured or burned by hot water. 8) Facility had a system in place prior to this annual survey process where water temperatures were and are checked weekly in multiple locations randomly. 9) Facility created a Quality Assurance process on February 19, 2015 where temeratures are now checked daily including the sink in the rehab dining room. 10) Mixing valve has been replaced and has been checked by both administrator (name) and maintenance director (name). Temperatures were running at 105 degrees after 5 minutes. Facility will continue to check water temps every 30 minutes for 4 hours, then randomly, to ensure proper water temperate is maintained. Thanks for your time and consideration in lifting this Immediate Jeopardy." Prior to leaving the facility on 2/19/15, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 2/19/15 the surveyors confirmed removal of the Immediate Jeopardy situation as of February 19, 2015. Deficient practice with the potential for more than minimal harm remained for the risk of injury. Findings include: Immediate Jeopardy: A. On 2/18/15 at 2:00 PM to 2:45 PM, water temperatures were checked in resident rooms. The following water temperatures (all temperatures are listed in degrees Fahrenheit) were observed: Surveyor Thermometer readings (calibrated, State issued, digital, probe thermometer) 1. Room 215 - 122 degrees 2. Room 308 - 123 degrees 3. Room 317 - 120 degrees 4. Room 208 - 119 degrees 5. Room 102 - 118 degrees Facility thermometer readings (laser thermometer) 1. Room 215 - 108 degrees 2. Room 308 - 116 degrees 3. Room 317 - 104 degrees 4. Room 208 - 108 degrees 5. Room 102 - 104 degrees The above listed temperatures were taken with both a digital and a laser thermometer in the presence of two surveyors and the Director of Maintenance (DOM). On 2/18/15 at 2:45 PM, 2 surveyors and the facility DOM observed 4 hot water tanks stored on the lower level of the facility. The DOM stated that 2 tanks were for "domestic" use and the other 2 tanks were for kitchen/laundry use. The thermostat on the water heater for the tanks that supplied the kitchen/laundry was observed at 180 degrees Fahrenheit. The thermostat for the water tanks associated with resident use was observed at 150 degrees Fahrenheit. The mixing valve for the resident use water tanks was observed at 125 degrees Fahrenheit. The DOM was immediately interviewed and stated he did not know for sure what temperature the mixing values should have been set. The DOM further stated that he randomly checked water temperatures on a weekly basis. On 2/18/15 the temperature logs were requested for review. Review of the temperature logs revealed that the water temperatures for resident rooms, shower rooms, and the kitchen were checked on 1/22/15, 2/2/15, and 2/10/15, and 2/16/15. No other documentation could be found to show that the water temperatures had been checked more frequently or weekly as stated by the DOM. No documentation could be found to show that facility staff were checking the temperature on the thermometer above the mixing valve and no documentation could be found to show that the water in the garden dining room sink had been checked. On 2/19/15 at 8:45 AM, hot water temperatures where randomly rechecked. The water in the garden dining room was observed to be 167.3 degrees Fahrenheit with the facility administrator present. The facility administrator turned off the water to that sink. On 2/19/15 at 9:16 AM, the administrator and 2 surveyors rechecked the water temperature in the garden dining room sink with a digital and analog thermometer. The following results revealed water temperatures in the garden dining room: After 1 minute, the water temperature was 128 degrees Fahrenheit. After 3 minutes the water was observed to be 161 degrees Fahrenheit. After 5 minutes the water was observed to be 176.7 degrees Fahrenheit. The administrator was immediately interviewed and stated that the water should not be that hot and he would take care of it immediately. (Note: The facility was no longer using the laser thermometer because they questioned the accuracy of the laser thermometer.) On 2/19/15 at 5:50 AM, an observation of Certified Nursing Assistant (CNA) 3 using the sink in the garden dining room. When she placed her hands under the water, she stated "ouch, that's too hot", and then proceeded to adjust the water temperature. On 2/19/15 at 5:55 AM, CNA 4 was interviewed and stated that resident 33 ate with family in the garden dining room. On 2/19/15 at 5:56 AM, an interview with CNA 5 revealed that resident 33 sometimes ate in the garden dining room with his family. On 2/19/15 at approximately 10:30 AM, CNA 4 was reinterviewed. CNA 4 stated that resident 33 sometimes ate in the garden dining room with his family. She also stated that the garden dining room was used by residents for dining and activities. On 2/17/15 during initial tour, resident 28 was observed in the garden dining area. Resident 28 stated that he liked to sit in the sun in the garden dining room. On 2/18/15 resident 28 was observed to be alone in the garden dining room. On 2/19/15 at 9:17 AM, the Activities Director (AD) was interviewed. The AD stated that she used the garden dining room for activities 1 to 2 times per week. The AD further stated that she had not been told not to use the sink in the garden dining room. On 2/19/15 at 9:55 AM, the administrator was interviewed and stated that the mixing valve for water tanks associated with resident use should not be more than 115 degrees Fahrenheit and water for resident use should not be more than 120 degrees.

Based on observation, interview and record review, it was determined the facility did not ensure that all employees had been trained in emergency procedures. Specifically, multiple nursing staff, both licensed and unlicensed, reported they were unaware of where to locate emergency equipment; such as a suction machine, or even if the facility had such a device. Findings include: On 9/3/11, resident 3 passed away in the facility following a change in condition in which facility staff noted the resident to be having difficulties and sounding "gurgly". During the period of time that resident 3's medical condition deteriorated, facility staff did not activate Emergency Medical Services or obtain emergency equipment. Cross-Refer to F-309. An initial tour of the facility was conducted on 9/7/11 at 10:00 AM. Emergency equipment, including suction equipment, was not at either nursing stations or otherwise in open view. The facility Policy and Procedures for emergency equipment and "Crash Cart" was reviewed. Procedures included the following: "(1) The modified crash cart will routinely be stored at each nurse's station; (2) The Central Supply designee will check the modified crash cart every A.M. (morning) and restock as necessary; (3) the night shift nurse will check crash cart nightly to ensure all supplies are stocked; (4) Equipment to be included on the modified crash cart at all times: (a) 1 (one) size "E" oxygen tank, (b) Oxygen gauge, (c) Oxygen mask and nasal canula, (d) extra length oxygen tubing, (e) BP (blood pressure) cuff, (f) stethoscope, (g) Ambu bag, (h) flashlight, (i) scissors, (j) padded tongue blade, (k) oral airway, (l) suction machine, (m) suction catheters, (n) sterile gloves, (o) sterile water, (p) first aide dressings, (q) gloves, (r) Yonkers; (5) Upon employment, all licensed nurses will be oriented and instructed in the use of the modified crash carts; and (6) After each use, supplies will be cleaned and re-stocked as needed." On 9/7/11 between 11:43 AM and 3:00 PM, facility licensed and unlicensed nursing staff were interviewed related to the location of the facility "crash carts" and/or suctioning equipment. Those results were as follows: 1. Certified Nurse Aide (CNA) 1 at 11:42 AM stated that she did not know where the crash cart or suctioning equipment was located. 2. CNA 2 at 11:55 AM stated she did not know where the crash cart or suctioning equipment was located. 3. CNA 3 at 11:43 AM demonstrated to the surveyor that the treatment cart (used to store a variety of lotions, creams, over-the-counter medications, and a variety of bandages) was the crash cart. 4. CNA 4 at 12:07 PM, stated the crash cart was located in the "Med (medication room) Room behind the north nurse's station. Upon demonstration of the location, no crash cart was observed. 5. CNA 5 at 2:36 PM, stated she did not know where the crash cart was located. 6. CNA 6 at 2:40 PM, stated the crash cart was located in the "Med (medication room) Room behind the north nurse's station. Upon demonstration of the location, no crash cart was observed. CNA 6 further stated that "there should be another crash cart in the oxygen supply room by room [ROOM NUMBER] close to the other nurse's station." CNA 6 was asked to demonstrate the location of the crash cart in the "oxygen supply room". The crash cart was not observed in the "oxygen supply room" as stated by CNA 6. 7. CNA 7 at 2:43 PM, stated that the crash cart is located at the nurse's stations. CNA 7 was asked to demonstrate the location of the crash cart on the North nurse's station. A crash cart was not observed 8. CNA 8 at 2:50 PM, stated that she did not know where to get the crash cart from. 9. Registered Nurse (RN) 1 at 2:40 PM stated he thought the crash cart was located on the north nurse's station. 10. RN 2 at 11:48 AM, stated that the crash carts were located behind the north and east nurse's stations. RN 2 demonstrated where the crash cart was on the east nurses station. The crash cart was found in a corner, behind a medical record stand. The crash cart did not have a suction machine or suctioning equipment. RN 2 stated that she had identified earlier in the day that the crash cart did not have a suction machine or suctioning supplies and that she was going to notify Central Supply of the missing equipment, but had not notified central supply that the equipment was missing or needed to be replaced. 11. RN 3 at 11:55 AM, stated that the crash cart with suctioning equipment was located in the storage room next to the north CNA desk. Two suction machines were observed but no cannisters or catheters were available. 12. RN 4 at 12:02 PM, stated that the crash cart was located in the med room behind the north nurse's station. On 9/7/11 at 2:35 PM, the Corporate Clinical Resource Nurse stated on that day the facility crash carts were serviced and that equipment (canisters and [MEDICATION NAME]) had been replaced. This Corporate Nurse stated she did not know when the emergency equipment had been previously serviced. However, stickers on each of the facility's three suctions machines documented a service date of June 2008. On 9/7/11 at 3:07 PM, the facility DON was interviewed. The DON stated that on 9/3/11 she was not aware the suctioning equipment was not readily available for emergency situations. She further stated she did not locate or obtain any emergency equipment on 9/3/11 when resident 3's medical condition deteriorated. The DON stated that subsequent to the incident with resident 3 on 9/3/11, she located the facility's suction equipment. She stated the equipment was located in the facility's central supply room. On 9/8/11 at 10:30 AM, the DON was interviewed again by telephone. The DON stated the central supply room was locked and that the charge nurse for the North Nursing Station would have a key to access the room. The DON stated that she had been employed as the Director of Nursing since January, 2011. She further stated that since the beginning of her employment, she was not aware of any training of emergency procedures given to staff, including identification and location of emergency equipment.

Based on interview and record review it was determined, for 1 of 4 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, facility staff identified that a resident was experiencing respiratory distress. The respiratory distress was not assessed nor acted upon by facility staff, rather facility staff attempted and continued to feed and place both liquids and solid food in the residents mouth despite the resident's inability to swallow or manage her own secretions. When the resident began to experience a more significant level of respiratory distress, facility staff placed the resident in her room and did not reassess the resident nor activate Emergency Medical Services. (EMS) Resident Identifier: 3. Findings include: Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on [DATE]. Review of resident 3's medical record revealed a physician's orders [REDACTED]. It was documented on the POLST that resident 3 indicated that her desire was to have no attempt of Resuscitation (DNR) if she was found to have no pulse and not be breathing. The POLST form completed and signed by resident 3 indicated that if resident 3 was not in cardiopulmonary arrest the orders in B and C should be followed. In section B, resident 3 indicated that she wanted "Comfort Measures Only: Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of [REDACTED]. Antibiotics only to promote comfort. Transfer if comfort needs cannot be met in current location." Review of nurse's notes revealed the following entry dated [DATE]. "At 8:38 AM I gave (resident 3) her 8:00 AM medications. After which she was having a hard time breathing and was gurgling while trying to breath. We were preparing to call the doctor by getting VS (Vital Signs) and preparing to suction when a fast onset of not breathing. (sic) I gave only 30 ml (milliters) of Megase (sic) (liquid medication) to drink. Her pills were crushed and went down with one swallow. I did not give any other fluids. I listened to her lungs and was unable to determin (sic) if she had asparated (sic) do to her gurgling with the liquid [MEDICATION NAME] that she hadn't swallowed. The DON (Director of Nursing) (name) tried to help (resident 3) swallow whatever was causing the gurgling. She gave her a small drink of med/pass (liquid nutritional supplement) in hopes to get whatever was causing it down. I had left the room to call the Doctor. We were thinking a chest x-ray might be needed and I was calling for some orders. Thats (sic) when help was called to the dinning room (sic) for help with (resident 3) not breathing. Because she is a DNR no CPR was done. She was pronounced dead at 9:06 AM. ..." On [DATE] the DON documented the following entry on an Interdisciplinary Team Note: "Nurse reported to me that res (resident) seemed to be not doing well. She was in the Dining Room eating Bkfast (Breakfast) when I arrived. Res. sounded like she was slightly gurggling (sic) like she had phelgm in her throat - Like she needed to swallow. She wasn't coughing or choking. I encouraged the CNA (Certified Nursing Assistant) to place a small bite of pureed food in her mouth and I began working with her to try and get her to swallow. The bite of food sat on her tongue. I gave her a small drink of Med Pass (because it was thickened) to see if she could clear her throat. I asked the nurse to listen to her lungs to see if possible aspirition (sic) and to get her VS and notify M.D. (Medical Doctor) and then I left Dining Room. Minutes later I was called back down stat (immediately) and the nurse had her on her bed - Her eyes were glazed over, she was Cheyne Stoke breathing - pulse almost unpalpable and she was a DNR. please follow nurse's note for the rest." According to Taber's Cyclopedic Medical Dictionary the definition of Cheyne Stokes respirations is "a breathing pattern marked by a period of apnea [MEDICATION NAME] 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations (hyperventilation). It occurs in dysfunction or depression of the cerebral hemispheres (e.g., in coma), in basal ganglia disease, and occasionally in patients with [MEDICAL CONDITION]. It often indicates a grave prognosis in adults ..." On [DATE] the facility's policy and procedure for Emergency Procedures was reviewed. The facility's policy for Emergency Procedures was as follows: "It is the policy of this facility when an emergency situation occurs, the person finding the situation should implement emergency procedures." The purpose: "To provide immediate medical care to a resident whose condition indicates a need." The Procedures were as follows: "1. Stay with the resident 2. Call for assistance by using the call bell and by calling out if needed. 3. Check for the ABC's: A. Airway B. Breathing C. Circulation - if indicated, begin CPR procedures 4. Take Vital signs 5. Contact the resident's attending physician or alternate immediatley 6. If the attending or alternate physician is not available, call the medical director 7. If the services of the paramedics are needed, activate facility emergency notification system 8. ... 9. ..." On [DATE] at 11:42 AM, CNA 1 was interviewed regarding the incident that occurred with resident 3 on [DATE]. CNA 1 stated that resident 3 was "not doing good" the morning of [DATE] and that resident 3 had not eaten lunch on [DATE]. CNA 1 stated that because resident 3 sounded "gurgley" all morning that CNA 1 had not given resident 3 her scheduled shower. CNA 1 stated that she took resident 3 to the Dining Room and put her at the table so CNA 2 could assist resident 3 with eating. CNA 1 reported that sometime later when she entered the Dining Room resident 3 was not eating and still sounded "gurgley". CNA 1 stated that RN (Registered Nurse) 1 and the DON asked CNA 1 if resident 3 would drink through a straw. CNA 1 stated that she told the DON and RN 1 that resident 3 liked cranberry juice and would drink through a straw. CNA 1 stated that she left the Dining Room to retrieve the cranberry juice. CNA 1 stated that when she returned to the Dining Room the DON was "pouring med pass" into resident 3's mouth. CNA 1 further stated that she then heard CNA 2 ask the DON if the facility had a suction machine. CNA 1 stated that she then left the Dining Room. CNA 1 stated that a little while later a call came over the radio from LPN (Licensed Practical Nurse) 1 that she needed help. CNA 1 stated that she then saw LPN 1 and CNA 1 wheeling resident 3 down the hall toward resident 3's room. CNA 1 further stated that LPN 1 was asking RN 1 what resident 3's "code status" (whether the resident is DNR) was. CNA 1 stated that RN 1 told LPN 1 that resident 3 was a DNR. CNA 1 stated that she did not know where the facility's emergency equipment was located or if the facility even had emergency medical equipment including a suction machine. No evidence could be found to show that facility unlicensed staff had reported to licensed staff about resident 3 "not doing good" the morning of [DATE] or that resident 3 had not eaten lunch on [DATE]. No evidence could be found to show resident 3 was assessed for her change of condition prior to being taken to the Dining Room for breakfast on [DATE]. On [DATE] at 11:55 AM, CNA 2 was interviewed regarding the incident that occurred with resident 3 on [DATE]. CNA 2 stated that she began to feed resident 3, who was normally a good eater, but stopped after giving resident 3 just three bites of food because resident 3 "was not doing well." CNA 2 stated that RN 1 came into the Dining Room and gave resident 3 [MEDICATION NAME]. CNA 2 stated that resident 3 immediately started coughing. CNA 2 stated that she told RN 1 that she was afraid to feed resident 3 because resident 3 had not been swallowing well. CNA 2 stated that RN 1 rubbed resident 3's back a couple of times and then left the Dining Room. CNA 2 stated that resident 3 sounded like she was "gurgling" and that resident 3 sounded like she had phlegm in her throat that she could not get out. CNA 2 stated that she called on the radio and reported to RN 1 that resident 3 was coughing and had phlegm stuck in her throat. CNA 2 further stated that she asked RN 1 over the radio if the facility had a suction machine. CNA 2 stated that the DON's voice came over the radio and stated that she, the DON, would have to look for the suction machine. CNA 2 stated that RN 1 then returned to the Dining Room to get resident 3's vital signs. CNA 2 stated that resident 3's respirations were 39 and resident 3's oxygen saturation was 85% (normal oxygen saturation is ,[DATE]%). CNA 2 stated that RN 1 left the Dining Room and returned with the DON. CNA 2 stated that the DON asked if resident 3 had eaten anything. CNA 2 stated that she told the DON that resident 3 had not had anything to eat because it seemed like resident 3 could not swallow. CNA 2 stated that she told the DON that she was afraid to feed resident 3. CNA 2 stated that the DON asked if resident 3 could drink anything out of a straw. CNA 2 stated that CNA 1 left the Dining Room and came back with some cranberry juice. CNA 2 stated that the DON took a cup full of Med Pass and poured it into resident 3's mouth. CNA 2 reported that CNA 1 left the Dining Room. CNA 2 stated that the Med Pass stayed in resident 3's mouth. CNA 2 stated that resident 3 did not swallow the Med Pass. CNA 2 stated that the DON then told CNA 2 to give resident 3 a bite of food. CNA 2 stated that she told the DON that she was afraid to feed resident 3 because resident 3 could not swallow. CNA 2 stated that the DON told CNA 2 to give resident 3 a bite of food. CNA 2 stated that she then placed a bite of food into resident 3's mouth. CNA 2 further stated that resident 3 could not swallow and that resident 3's eyes were "watering". CNA 2 stated that both RN 1 and the DON then left the Dining Room. CNA 2 stated that she was getting upset because the nurses were "not doing anything." CNA 2 stated that she stepped out of the Dining Room to grab LPN 1. CNA 2 stated that upon returning to the Dining Room, resident 3 had her head back and CNA 2 heard resident 3 take two short gasps of air. CNA 2 stated that LPN 1 and CNA 2 moved resident 3 down the hall and into resident 3's room. CNA 2 reported that when they placed resident 3 on her bed resident 3 was "silently gasping" for air. CNA 2 reported that facility staff did not activate EMS nor perform any emergency procedures. CNA 2 stated that she did not know where the suction machine was located in the facility nor where to locate the emergency equipment. Both CNA 1 and CNA 2 stated that at no time did the facility nurses talk with resident 3. No evidence could be found to show that facility staff assessed resident 3 while she was in the Dining Room or that facility staff reassessed resident 3 after returning her to her room. On [DATE] at 2:40 PM, RN 1 was interviewed regarding the incident that occurred with resident 3 on [DATE]. RN 1 stated that he had given resident 3 her medications on [DATE] crushed in pudding. RN 1 stated that CNA 1 was feeding resident 3 and had reported to him that resident 3 was "gurgling". RN 1 reported that resident 3's VS were stable and he was going to call the MD. RN 1 stated that while he was in the Dining Room with the DON that he listened to resident 3's lungs and her lungs sounded clear. RN 1 stated that he and the DON were considering suctioning resident 3 and the DON was locating that equipment while he notified the physician. RN 1 stated that he checked resident 3's mouth while he was in the Dining Room and that resident 3's mouth was "all clear." RN 1 stated that resident 3 appeared to be stable and he had no concerns with her breathing. RN 1 further stated that if a resident was experiencing breathing problems that they should not be left alone. On [DATE] at 3:07 PM, the facility DON was interviewed. The DON stated that she was in the building when the incident with resident 3 occurred. The DON stated that RN 1 called and told her that resident 3 was acting funny. The DON stated that she went into the Dining Room and resident 3 was gurgling with what appeared to be phlegm. The DON stated that the CNA gave resident 3 a bite of food and the food just sat on resident 3's tongue. The DON further stated that she felt like resident 3 just needed to swallow and clear her throat. The DON stated that she then gave resident 3 a drink of Med Pass and resident 3 swallowed the first drink of Med Pass but the second drink of Med Pass just ran out of the corners of resident 3's mouth. The DON stated that she instructed RN 1 to get a stethoscope and listen to resident 3's lungs to check for aspiration and then she left the Dining Room. The DON stated that RN 1 left the Dining Room also to get the Vital Sign equipment. The DON further stated that she did not see RN 1 assess resident 3. The DON stated that the next call she heard was from LPN 1, over the radio, calling for help immediately in the Dining Room. The DON stated that when she got to resident 3's room that resident 3's eyes were glazed over and resident 3 was Cheyne-Stoke breathing and gasping silently for air. The DON stated that when she felt for a pulse on resident 3 she thought she had felt a pulse but was unsure because it was very faint. The DON stated that her and RN 1 were thinking of suctioning resident 3 during the episode in the Dining Room but that she just felt if resident 3 would swallow it would have cleared her airway. The DON stated that the suction machine had been missing off of the crash cart so she was on her way to Central Supply to look for it there when the call came over the radio for the assistance. The DON stated that none of the staff had thought about activating EMS because resident 3 was a DNR status. The DON stated that she had not done any emergency preparedness training with the staff. The DON further stated that CPR should only be initiated when a person is found without a pulse or with no respirations. The DON stated that if a resident has a change in condition the facility staff should do all they can for the resident and only initiate CPR (CardioPulmonary Resuscitation) if the resident is a full code and found without a pulse or respirations. The DON further stated that if a resident is having trouble clearing their airway facility staff should suction the airway or try to manually remove the obstruction.

Based on interview and medical record review it was determined, that for 1 of 16 sample residents, the facility did not ensure that residents are free of any significant medication errors. Specifically, a resident did not receive his prescribed dose of [MEDICATION NAME] thus causing the resident to be sent to the hospital and treated for [REDACTED]. Findings include: Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/16/10, resident 15's medical record was reviewed. Review of resident 15's medical record revealed physician's orders [REDACTED]. Review of the medication administration record (MAR) revealed the [MEDICATION NAME] was written on the MAR with the dosage underlined and a note that indicated facility staff should check the dose. It was documented on the MAR that resident 15 received the 30 mg of [MEDICATION NAME] on 8/20/10 at 8:00 PM and 8/21/10 at 8:00 AM and 8:00 PM. The dose for the the morning of 8/22/10 was circled, indicating that resident 15 did not receive that dose. (Note: The same facility nurse administered the [MEDICATION NAME] to resident 15 on 8/20/10, 8/21/10, and 8/22/10). Review of facility medication error report forms revealed an "Incident Report for Medication Errors" dated 8/22/10. According to the report, the error was discovered by the facility nurse on 8/22/10. The facility nurse documented that she had given the incorrect dose of medication to resident 15 which resulted in an under dosage of 40 mg. The facility nurse documented, "I neglected to check the correct dose on the med. (medication) card. The pill was larger than other 10 mg [MEDICATION NAME] tablets I had administered in the past and I assumed the larger pill was a larger dose. It was a 10 mg pill. So I only gave 20 mg for a 24 hr. (hour) period instead of 60 mg." Review of Nurses Notes revealed an entry dated 8/21/10. It was documented in the nurses notes that resident 15 was, "Alert, oriented X3 (person, place, and time). Complain of chest tightness due to [MEDICAL CONDITION] hypertension. Also experienced nausea this evening. Upset due to extensive time taken to have call light answered." (Note: No evidence could be found in resident 15's medical record to indicate resident 15 had [MEDICAL CONDITION] hypertension.) On 8/22/10 at 11:20 AM, it was documented in the nurses notes that, "Pt. (patient) had nausea this AM. Pt. had dry heaves. ... Pt. request pain medication due to chest pain. Went to administer [MEDICATION NAME]. Pt. able to keep that down. No pain relief. Pt. continued with nausea. ... Pt. unable to take morning meds. Pt. requested to be sent to (Local Hospital). (Name of Ambulance Company) transported pt. Called and spoke with ER (emergency room ) nurse and gave report. Pt.'s wife was notified and she had also requested pt be sent to ER." It was documented on the Hospital Discharge instructions given to resident 15 when he left the local emergency room that resident 15 had been evaluated for, "Probable Narcotic Withdrawal." It was documented under "Additional Information" that, "Narcotic withdrawal occurs in persons who have used narcotics on a daily basis for at least three weeks. Symptoms usually begin about 12 hours after the last dose of narcotic. Withdrawal symptoms last 3-5 days and may include yawning, sweating, runny nose, restlessness, stomach cramping, diarrhea, nausea, vomiting, hot and cold flashes and difficulty sleeping." On 12/16/10 at 3:00 PM, the facility DON (Director Of Nursing) and the facility Corporate Nurse (CN) 1 were interviewed regarding the dose of [MEDICATION NAME] administered to resident 15 on 8/20/10. The DON and CN 1 both stated that by looking at the MAR and the fact that the same nurse who made the medication error worked on 8/20/10 and 8/21/10, they would assume that resident 15 did not get the correct dose of [MEDICATION NAME] on 8/20/10, even though the 30 mg had been signed out by the nurse. On 12/16/10 at 4:00 PM, CN 2 stated that resident 15 could not have gotten addicted to pain medication because he had only been taking the [MEDICATION NAME] for four days before being admitted to the nursing facility. The CN 2 further stated that she felt resident 15 had just had a "big anxiety attack". On 12/16/10 at 5:00 PM, resident 15's primary care physician was interviewed regarding resident 15's visit to the emergency room . The primary care physician stated that resident 15 had been taking the 30 mg of [MEDICATION NAME] twice daily for at least 8 months prior to his stay at the nursing home. The primary care physician stated that resident 15 had also been receiving high doses of pain medication in addition to the [MEDICATION NAME]. The primary care physician stated that the emergency room doctor who had treated resident 15 had not wanted to send resident 15 back to the nursing facility because he was angry that resident 15 was not receiving the appropriate amount of pain medication. The primary care physician further stated that not receiving the prescribed amount of [MEDICATION NAME] possibly could have contributed to resident 15's narcotic withdrawal. The primary care physician stated that [MEDICATION NAME] was a very "tricky" drug when it came to withdrawals.