Every finding on record at Pine Creek Rehabilitation and Nursing

Based on observation, interview, and record review, the facility did not ensure the residents' environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 23 sampled residents, a resident sustained multiple falls with one fall resulting in a head laceration that required staples. This example of non-compliance was cited at a HARM level. Additionally, a resident eloped from the facility and was located by police approximately 3-4 hours after leaving the facility and resident had multiple falls without new interventions identified to prevent future falls. Resident identifiers: 12, 13, and 15.Findings included:HARM1. Resident 15 was admitted to the facility on [DATE] with diagnoses which included dementia, hypertension, muscle weakness, chronic pain, spondylosis, hyperlipidemia, heart failure,edema, and pneumonia. On 8/24/26 at 9:44 AM, an interview was conducted with resident 15. Resident 15 stated he had multiple falls at the facility. Resident 15 stated that he used a walker to ambulate and he has not had any falls recently. Resident 15's progress notes revealed the following: a. On 9/4/25 at 11:48 AM, the note documented, The CNA [Certified Nursing Assistant] reported they found [resident 15] sitting on the ground approx [approximately] 0650 [6:50 AM] this morning. He reports he fell. When asks [sic] he said his 'shoes were slippery' and that he 'reached to grab something'. he indicated he fell on his hands and knees 'oh and I hit my head'. No visible injuries. Neuro [neurological] assessments begun [sic]. Provider and DON [Director of Nursing] notified. Upon his second or third 15-min [minute] check he denied further pain in his head. b. On 9/15/25 at 10:00 PM, the note documented, No injuries or pain noted R/T [related to] the unwitnessed fall that happened on 9/15/25 in the morning. It should be noted that no other documentation was found of the fall on 9/15/25. Resident 15's care plan for falls did not have any new interventions identified after this fall. c. On 9/16/25 at 5:30 AM, the note documented, Resident was found sitting on the floor, next to the chair in his room. Resident denied any pain or injuries, and he denied hitting his head. Resident was assessed by this Nurse. No pain or injuries noted. Neuro checks were started and are WNL [within normal limits]. DON and MD [Medical Doctor] were notified. d. On 9/20/25 at 2:07 AM, the note documented, During report, residents roommate came to nursing station and stated 'my roommate is having a hard time getting up.' 2 LNs [licensed nurses] found resident sitting on his buttocks next to the left side of his bed w/ [with] his back facing the doorway. Resident was asked 'What happened?' [Resident 15] stated 'I tripped forward.' ROM [range of motion] performed, able to move all extremities. Resident was assisted back. e. On 9/20/25 at 2:32 AM, the note documented, CNA brought to my attention of resident being 'on the floor.' Resident was found sitting on his buttocks next to the end of the bed. Resident was noted to be holding the left side of his head. [Resident 15] stated 'I fell again and I hit my head on the floor.' Resident refused this nurse to access his head. Resident continued stating 'oww oww dont [sic] touch it.' . ROM performed, able to move all extremities. Resident was helped back intochair [sic]. Resident agreed on being sent to ER [emergency room] for evaluation. Resident 15's care plan for falls did not have any new interventions identified after this fall. f. On 9/25/25 at 10:51 AM, the note documented, [Resident 15] was found on the ground on his hands and knees approx 0630 [6:30 AM] this morning. When asked what happened he gave a rambling response. He was not clear if he fell or 'put himself there'. Assess, no injuries found. started neuro exams, alerted provider and DON. g. On 10/2/25 at 9:08 AM, the note documented, CNA reported [resident 15] was on the floor. He says he fell. He could not describe further other than he rubbed the floor to indicate it was slippery. He reports hitting his head and he has a tender, palpable goose egg. He became upset with staff when we tried to get his slippers on to get him off the ground. He was returned to bed safely and a walker was placed next to him. neuro [neurological] exams started. alerted provider & DON. Resident 15's care plan for falls did not have any new interventions identified after this fall. h. On 10/9/25 at 11:04 AM, the note documented, It has been noted that the resident continues to have frequent falls due to his recent visual changes and stating he sees 'shadows'. The DON made an appointment with an outside provider for a vision screening and exam. i. On 12/19/25 at 7:00 AM, the note documented, CNA notified nurse that resident was found on the floor in residents room. Nurse responded immediately. Upon assessment, resident was ambulating in the room and assisted to sit on the side of the bed. Resident was actively bleeding from a one inch laceration above his right eye hematoma to the right eyebrow and right cheek. pressure was applied to wound and bleeding was controlled. Resident remained alert and oriented and denied loss of consciousness. Vital signs obtained. Neurological assessment completed with no acute changes noted. Due to head injury and laceration, [name omitted] EMS [emergency medical services] was notified and resident was transported to [name omitted] hospital for further evaluation. On 12/19/25, resident 15's After Visit Summary from the hospital documented that the resident was seen for a ground level fall with a laceration to the forehead. The treatment documented that sutures were applied and the resident was to return for suture removal in 7-10 days. Resident 15's care plan for falls did not have any new interventions identified after this fall, despite an injury occurring. j. On 3/7/26 at 5:55 PM, the note documented, Another resident was heard 'he fell out of the chair' from the living room. Staff responded and [resident 15] was found laying on his side. Another resident reports he was asleep in a chair and tumbled out. He was assisted safely back into the chair, walker moved closer to him, assess [assessment], neuro exams started, alerted provider and DON. Resident 15's care plan for falls did not have any new interventions identified after this fall. Resident 15 had a total of 9 falls identified through record review with two of the falls resulting in evaluation and treatment at the hospital. On 4/28/25, resident 15 had a care plan initiated for at moderate risk for falls related to confusion, wandering, and recent history of falling. Interventions identified on the care plan included: Ensure walker was within reach during rounds and offer toileting during scheduled rounds. Date Initiated: 11/03/2025 Revision on: 05/12/2026. Offer toileting during rounds when resident 15 was awake. Date Initiated: 09/25/2025 Revision on: 05/20/2026. Put up a call don't fall sign. Date Initiated: 10/23/2025. Answer call lights promptly. Date Initiated: 04/28/2025. Encourage exercise and mobility to maximize and maintain strength, balance and coordination. Date Initiated: 09/23/2025. Examine all footwear for proper fit, repair and nonskid soles and replace if needed. Encourage non slip footwear Date Initiated: 09/04/2025 Revision on: 10/06/2025. Keep room free of clutter and ensure objects the resident may need are within use. Date Initiated: 09/16/2025. Resident 15's CNA Kardex documented under safety to ensure the resident's walker was within reach during rounds, offer toileting during scheduled rounds, and put up a call don't fall sign. The Kardex for mobility documented that the resident was weight bearing and used a front wheeled walker. On 8/26/26 at 11:05 AM, an interview was conducted with the Resident Care Coordinator (RCC). The RCC stated that resident 15 did not need much assistance and just needed reminders. The RCC stated that resident 15 was more independent, walked around the facility, and might use a walker. The RCC stated that she was not aware of resident 15 having had any falls and was not aware of any resident specific fall interventions. The RCC stated that general fall prevention interventions included visual checks on the resident every 2 hours, bed in the lowest position, call lights within reach, and reminders to call before they get out of bed. It should be noted that the RCC was a new hire and had been at the facility for approximately 2 weeks. On 8/26/26 at 11:35 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 15 had not had any falls that she was aware of. CNA 2 stated that resident 15 could ambulate independently with a walker slowly and she had never seen any signs of instability. CNA 2 stated that interventions for fall prevention were checking on resident 15 more frequently, but he mostly stayed in his room. It should be noted that CNA 2 was a new hire and had worked at the facility since May 2026. On 8/27/26 at 8:31 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that care plans were developed and revised by her. The DON stated that for residents who were at risk for falls she would put new interventions in place or revise them after each fall. The DON stated that she had to think outside the box to find new interventions. The DON stated that she tried to determine what interventions worked to prevent falls and what needed to be revised or added. The DON stated that this was done in an attempt to prevent a future fall from occurring. The DON stated that interventions were communicated to the CNAs by the Kardex and the nurses would tell the CNAs any new interventions. The DON stated that new hire CNAs were informed of fall interventions through training and should be informed of which residents were at risk for falls or who have had falls in the past. The DON stated this was communicated by word of mouth from other staff. On 8/27/26 at approximately 8:30 AM, resident 15 was observed ambulating independently with his walker towards the dining room. Resident 15 was holding his drink mug while pushing his walker. On 8/27/26 at 11:12 AM, a follow-up interview was conducted with the DON. The DON stated that resident 15 had advanced dementia and had short term memory and long term memory deficits. The DON stated that resident 15 was not using the walker consistently when he was falling. The DON stated that staff would give the walker to resident 15 and he would leave it behind. The DON stated that the other CNAs should be training the new CNAs with resident 15's fall prevention and they should obviously see he needed a walker. POTENTIAL FOR HARM2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, dementia, anxiety disorder, persistent affective mood disorder, personal history of other mental and behavioral disorders, alcohol dependence remission, and suicidal ideations.A care plan Focus documented that resident 13 was identified a risk for wandering/elopement initiated on 3/28/26.The Goals initiated on 3/28/26, included the resident will not leave the facility unattended and the resident's safety will be maintained. The interventions included clearly identify resident's room & bathroom; engage resident in purposeful activity; identify if there was a certain time of day wandering/elopement attempts occur; and schedule time for regular walks/appropriate activity.On 3/27/26 at 6:30 PM, an Elopement Evaluation documented that resident 13 was a high risk for elopement. Actioned clinical suggestions included monitor location frequently, notify staff of elopement risk, and utilize check in / check out log.On 4/6/26 at 10:30 PM, a Nurses Note documented DON [name redacted] was notified by the floor nurse [name redacted] that this resident was not able to be found during rounds. After searching the grounds and entire facility it was presumed that the resident had gotten out of the gate when another resident was letout [sic]. At this point I notified the administrator where he advised me to have the nurse call the police and file a missing person report. When the police arrived [name redacted] gave them all the necessary information and they started their search. [Name redacted] the administrator was on his way from home to speak with the family and police. At approximately 1915 [7:15 PM] I was notified that this resident was found by police on 6th north 1200 w [West] in Salt Lake. Resident was brought back and oriented to the facility.It should be noted that resident 13 was found approximately 2.5 miles from the facility by the local police department. This was determined by the facility address and the location the local police department located resident 13.On 4/23/26 at 11:08 AM, a Social Services Note documented . Resident has a documented diagnosis of dementia associated with severe cognitive impairment. Cognitive testing via BIMS [Brief Interview for Mental Status] resulted in a score of 4/15, indicating severe impairment. Resident exhibits impaired short- and long-term memory, and his [sic] thought processes are often disorganized and disconnected.The Facility Incident Report form was reviewed. A Summary of interview(s) with the alleged victim documented that resident 13 had dementia and thought that her husband was coming to pick her up. She left on the coat tails of another guest that was leaving the facility through the gate. Staff realized she had left and immediately began looking for her. The police were notified and began the process of looking for her as well. The police found her down the road at a grocery store. They collected her and brought her back to the facility. On 8/27/26 at 8:31 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was the nurse on duty the night that resident 13 eloped and her shift started at 6:00 PM. LPN 1 stated it was shortly after shift change around 6:45 PM or 7:00 PM, that resident 13 got out of the facility. LPN 1 stated that staff noticed resident 13 missing around 7:30 PM, and she called the DON immediately. LPN 1 stated that resident 13 was brought back to the facility by 9:00 PM or 10:00 PM, by the local police department. LPN 1 stated that she had two CNAs that worked with her that night and one of the CNAs took a personal phone call outside of the locked front gate. LPN 1 stated that CNA 1 let resident 13 out of the locked front gate because she thought resident 13 was a family member. LPN 1 stated that she did not know why CNA 1 thought resident 13 was a family member because it was at night and family usually did not visit the facility. LPN 1 stated that CNA 1 finished her phone call, came back into the facility, and continued to work for approximately 20 to 30 minutes after she had let resident 13 out of the locked front gate. LPN 1 stated when CNA 1 realized that it was a resident that she had let out, CNA 1 reported to LPN 1 that she could not find resident 13. LPN 1 stated that the staff searched the facility and she was told to drive around to see if they could find resident 13. LPN 1 stated that she looked for resident 13 but could only go a couple blocks because she was the only nurse on duty and could not leave the facility for an extended time. LPN 1 stated that she returned to the facility and called the local police department. On 8/26/26 at 1:48 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the facility did not have cameras and the locking gate did not record the comings and goings of people. On 8/27/26 at 8:22 AM, an interview was conducted with the DON. The DON stated that she was notified that resident 13 had eloped after they all had left the facility for the day. The DON stated that LPN 1 called her and stated that she thought resident 13 had gotten out of the facility with somebody. The DON stated there was a three second delay before the locked front gate latched after it was opened and we found that out during this event. The DON stated that she did not recall when resident 13 was last seen by staff. On 8/27/26 at 8:57 AM, a telephone interview was attempted with CNA 1. Telephone message was not returned. On 8/27/26 at 11:00 AM, an interview was conducted with the ADM. The ADM stated that resident 13 was at the facility and someone was leaving, visitors, and resident 13 exited out of the facility on their coat tails. The ADM stated that he had received that information from LPN 1. The ADM stated that he did not remember what the specific times were that resident 13 was missing from the facility or when she was last seen.3. Resident 12 was admitted to the facility on [DATE] with diagnoses which included presence of left artificial knee joint and repeated falls.On 8/24/26 at 9:54 AM, an interview was conducted with resident 12. Resident 12 stated in the last two months she had fallen out of bed twice and bruised her knee. Resident 12 stated that her knee was still sore and she should have gotten an x-ray. Resident 12 stated an x-ray was not offered when she fell and she had to ask for everything.It should be noted that a care plan Focus for falls was not developed or implemented prior to resident 12 falling.On 6/10/26, a Fall Risk Evaluation was completed and resident 12 was documented as high risk for falls.On 6/22/26 at 6:01 PM, a Nurses Note documented Resident was preparing to shower and was transferring from the toilet to the shower chair with caregivers assistance. During the transfer, resident lost balance and began to fall. Caregiver attempted to assist but was unable to prevent the fall. Residentfell [sic] unto her right side.It should be noted there were no interventions implemented after the fall.On 7/5/26 at 1:23 AM, a Nurses Note documented Unwitnessed fall ~2300 [11:00 PM] tonight. Staff had barely left her room when she and her room mate [sic] started shouting for help. Staff responded immediately to find [name redacted] on the ground next to her bed, her room mate says she fell out of bed and may have hit her head on the concentrator. [Name redacted] denies any pain related to the fall but says she may have also hit her R [right] hip, no injuries immediately found.It should be noted there were no interventions implemented after the fall.On 8/27/26 at 12:23 PM, an interview was conducted with Regional Nurse Consultant (RNC). The RNC stated that she was unable to find a baseline care plan for resident 12 that addressed falls. The RNC stated yes there should have been a new care plan when resident 12 readmitted to the facility and yes falls should have been addressed. On 8/27/26 at 1:35 PM, a follow up interview was conducted with the RNC. The RNC stated there was nothing with resident 12's current care plan that addressed the falls. The RNC stated that with every incident there should be an update to the care plan with interventions.

Based on interview and record review, the facility did not use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Specifically, the facility did not always have a registered nurse at least 8 consecutive hours on certain weekends.Findings Included: Findings Included:The facility's staffing schedules from September 2025 to October 2025 were reviewed.-There was no RN scheduled on 9/14/25.-There was no RN scheduled on 9/28/25.On 10/8/25 at 2:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they did not need to have a registered nurse scheduled on every shift. The DON stated that they did not do admissions on the weekends and if the residents needed an assessment completed the nurse would call her. On 10/8/25 at 3:21 PM, an interview was conducted with the Administrator (Admin). The Admin stated if the residents needed intravenous therapy or a wound vacuum then they would send them out. The Admin stated they were not sure if it was necessary to have a registered nurse on every shift based on the type of facility they were and that they were trying to get guidance on whether they needed to have a registered nurse work 8 hours a day. On 10/8/25 at 3:47 PM, a follow up interview was conducted with the Admin who stated that there was only a Licensed Practical Nurse working on the 14th and the 28th of September, no Registered Nurse worked in the facility on those days.

Based on interview and record review, the facility did not ensure that the resident's transfer or discharge was documented in the resident's medical record and the information was communicated to the receiving provider to ensure a safe and effective transition of care. Specifically, for 3 out of 23 sampled residents, the resident's medical record did not contain documentation of what information was sent to the receiving provider and the transfer or discharge was not documented. In addition, a resident that was discharged to the hospital was not provided with a bed hold notice. Resident identifiers: 31, 33, and 38. Findings included: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, paranoid schizophrenia. Resident 31's medical record was reviewed. A discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE], documented that resident 31's discharge status was short-term general hospital. Resident 31's medical record revealed no documentation of a transfer/discharge summary, what information was sent to the receiving provider, a bed hold notice at the time of transfer, and there was no documentation regarding where resident 31 was transferred or discharged to. 2. Resident 33 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema. Resident 33's medical record was reviewed. A discharge return anticipated MDS assessment dated [DATE], documented that resident 33's discharge status was nursing home. On 8/8/25 at 5:06 PM, an Orders - Administration Note documented House Supplement two times a day for poor oral intake related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION Encourage resident to drink, document %m [percent] of intake discharged to other facility. Resident 33's medical record revealed no documentation of a transfer/discharge summary, what information was sent to the receiving provider, and there was no documentation regarding where resident 33 was transferred or discharged to. 3. Resident 38 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease. Resident 38's medical record was reviewed. Resident 38's face sheet revealed a date of discharge of 5/15/25. Resident 38's medical record revealed no documentation of a transfer/discharge summary, what information was sent to the receiving provider, and there was no documentation regarding where resident 38 was transferred or discharged to. On 10/8/25 at 9:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if a resident needed to go to the hospital she would make sure the resident was stable and call emergency services. LPN 1 stated she would print a face sheet and medication list. LPN 1 stated she would give the paramedics report when they arrived. LPN 1 stated she would document the hospital transfer in the medical record. On 10/8/25 at 10:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident discharged home the provider would see the resident to make sure they were safe or needed any services. The DON stated the Social Worker would set up any services and would notify the Ombudsman. The DON stated if the transfer was an emergency staff would call the doctor, print a face sheet, medication order summary, and call emergency services. The DON stated the staff should complete a discharge summary report and make a progress note. The DON stated a bed hold notice was provided to the residents on admission and when they were transferred to the hospital. The DON stated that the three residents were discharged to sister facilities. The facility Bed Hold Policy and Notification policy revised on 5/24/2023, documented It is the policy of this facility to provide any resident that is transferred to a general acute care hospital the right to exercise the bed hold provision. The resident or resident's representative has the right to exercise the bed hold provision of three (3) days. Medicaid will not cover the cost of the bed hold. Insurance plans may or may not cover for bed hold. Residents will be liable for the cost of the bed hold days. Upon transfer to a general acute care hospital the resident or resident representative shall notify the facility within twenty-four (24) hours after being informed of the right to have the bed held, if the resident desires the bed hold. If the resident's attending physician notifies the facility in writing that the resident's stay in the general acute care hospital is expected to exceed three (3) days, the facility shall not be required to maintain the bed hold.

Based on interview and record review, for 3 out of 23 sampled residents, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, blood pressure medications were administered outside of the physician's ordered parameters. Resident identifiers: 1, 4, and 6. Findings included: 1. Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage, chronic obstructive pulmonary disease, chronic respiratory failure, dementia, paranoid schizophrenia, and pleural effusion. Resident 1's medical record was reviewed 10/6/25 through 10/8/25. A physician's order dated 9/25/24 indicated, Midodrine HCl [hydrochloride] Oral Tablet (Midodrine HCl) Give 5 mg [milligrams] by mouth three times a day for hypotension Hold for Systolic [blood pressure] over 110. The Medication Administration Record for October 2025 indicated that resident 1 received Midodrine 9 times when it should have been held due to a systolic blood pressure (BP) of more than 110: On 10/4/25, resident 1 had a BP of 120/76 and a BP of 126/83 two times; On 10/5/25, resident 1 had a BP of 120/79 two times; On 10/6/25, resident 1 had a BP of 158/81 and a BP of 120/80; and On 10/7/25, resident 1 had a BP of 130/79 two times. It should be noted that resident 1 received Midodrine when it should have been held due to a systolic blood pressure of more than 110, 23 times in September 2025 and 17 times in August 2025. 2. Resident 6 was admitted on [DATE] with diagnoses that included dementia, hypertension, hyperlipidemia, and chronic respiratory failure. Resident 6's medical record was reviewed 10/6/25 through 10/8/25. A physician's order dated 6/3/25 indicated, Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 12.5 mg by mouth two times a day for HTN [hypertension] Give 1 tablet by mouth one time a day for HTN hold for SBP [systolic blood pressure] under 110, HR [heart rate] under 60. The Medication Administration Record for October and September 2025 indicated that resident 1 received Metoprolol 9 times when it should have been held due to a systolic blood pressure of less than 110: On 10/5/25, resident 6 had a BP of 105/64; On 9/29/25, resident 6 had a BP of 97/59; On 9/27/25, resident 6 had a BP of 99/60; and On 9/18/25, resident 6 had a BP of 94/67. On 10/8/25 at 9:39 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated Midodrine raised blood pressure and should have been given within the parameters. LPN 1 stated if the systolic blood pressure was above 110, it should have been held because it would make the blood pressure go even higher and that could be bad. On 10/8/25 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Certified Nursing Assistants (CNAs) obtained the blood pressures but the nurses would review them before giving blood pressure medications. The DON stated that nurses were expected to review the parameters in the order before giving the medication. On 10/8/25 at 10:08 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the nurses may get confused with Midodrine because it raises the blood pressure instead of lowering it. The RNC stated that the parameters are very clear in the orders and that was something that they would need to educate nurses on. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, seizures, asthma, hypertensive heart disease and chronic obstructive pulmonary disease. Resident medical record reviewed 10/7/25. A physician order dated 4/20/21 indicated, Propranolol HCl Tablet Give 20 mg by mouth two times a day related to EXTRAPYRAMIDAL AND MOVEMENT DISORDER, UNSPECIFIED Hold for SBP < [less than] 110 and/or Pulse < [less than] 60. The Medication Administration Record for August, September and October 2025 documented resident 4 received Propranolol 28 times when it should have been held for a systolic blood pressure less than 110. Propranolol was given out of parameters on the following dates: On 8/8/25 for B/P of 109/75 and 98/58 On 8/10/25 for B/P of 102/62 On 8/15/25 for B/P of 98/57 and 90/67 On 8/16/25 for B/P of 101/53 On 8/17/25 for B/P of 105/79 On 8/18/25 for B/P of 106/65 On 8/19/25 for B/P of 105/65 On 8/24/25 for B/P of104/79 On 8/26/25 for B/P of 100/69 On 9/3/25 for B/P of 108/63 On 9/12/25 for B/P of 107/67 On 9/13/25 for B/P of 109/53 On 9/14/25 for B/P of 100/70 and 102/60 On 9/15/25 for B/P of 105/96 and 106/78 On 9/18/25 for B/P of 102/68 and 99/67 On 9/22/25 for B/P of 105/71 On 9/26/25 for B/P of 105/69 9/30 109/85 On 10/2/25 for B/P of 101/60 On 10/3/25 for B/P of 89/47 On 10/5/25 for B/P of 100/65 On 10/6/25 for B/P of 102/68 On 10/7/25 for B/P of 109/86 This surveyor interviewed LPN 1, on 10/7/25 at 10:15 AM, who stated the nurse should check the orders and the resident's blood pressure before giving a blood pressure medication. This surveyor interviewed the DON, on 10/8/25 at 10:01 AM who stated the nurses were expected to review the parameters before they administer the medications. The DON stated they expected the nurses to follow those parameters, and they should have held the propranolol for resident 4 when it was below 110. This surveyor interviewed the RNC, who stated the doctor had tried to get rid of blood pressure medication parameters with the residents at the facility. The RNC stated there were dates where resident 4 was given the medication out of the ordered parameters.

Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident with a referral to see a neurologist for evaluation was not completed. Resident identifier: 14.Findings included: Resident 14 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, arthropathies or the left and right hips, schizoaffective disorder, peripheral neuropathy, and spondylosis. Resident 14's medical record was reviewed. On 10/6/25 at 3:20 PM, an interview was conducted with resident 14 who stated he had asked to see a doctor about the numbness in his left hand but that had not happened yet. A physician order dated 7/11/25 documented, Neurology consult for left hand weakness for EMG [electromyography] A progress note dated 6/25/25 documented, Physical exam: Notable for mild degenerative changes in the right elbow and an olecranon spur in the left elbow. He reports occasional pain in his left arm, despite normal x-ray findings, and is scheduled for a podiatry [sic] consultation. A progress note dated 7/23/2025 documented, L. [left] Elbow: Olecranon spur. A progress note dated 8/19/25 documented, Patient was seen in room in bed. He reports pain mainly in his left hand and requests topical Diclofenac for relief . xray negative. he is now treating symptomatically . Diagnostic Result: On Jun 14, 2025 L. Elbow: Olecranon spur and minro [sic] arthritic change. On 10/7/25 at 2:48 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she was brand new so she did not know how it worked with referrals at the facility but she thought the doctor did those. LPN 1 stated she had not heard anything about resident 14 needing a referral. On 10/8/25 at 9:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if there is an appointment that needed to be made usually the doctor would let her know and she would reach out and make the appointment. The DON stated the order for resident 14's referral was faxed over to the other facility but they had not heard back from them. The DON stated there was not a set time to follow up on things like that, they would just wait for the other place to let them know when they could get the resident in to be seen. The DON stated usually she would have followed up in 2 weeks and she did not remember doing that and she should have.

Based on interview and record review, the facility did not prevent misappropriation of a resident's property. Specifically, for 1 out of 23 sampled residents, a resident gave a Nursing Assistant (NA) money and the NA did not return the money when the resident asked for the money back. Resident identifier: 38. Findings included: Resident 38 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease, generalized anxiety disorder, and adjustment disorder with mixed disturbance of emotions and conduct. Resident 38's medical record was reviewed. The facility Incident Report Form was reviewed. On 3/4/25 at 1:37 PM, resident 38 reported that she had learned that the (Nursing Assistant) NA was having some struggles financially and resident 38 offered to give the NA $100.00 to help. After multiple attempts resident 38 finally forced the funds in the NA's pocket and the NA accepted the funds. After a few days resident 38 texted the NA asking for the $100.00 back so resident 38 could pay for some personal storage expenses. The NA did not respond to resident 38 and resident 38 reported the issue to two different staff members to ask for help. The facility Follow-up Investigation Report was reviewed. Resident 38 reported that she wanted to do something nice for the NA and felt bad for the NA's situation. Resident 38 reported that she gave the NA $100.00 and was not hearing back from the NA now. Resident 38 reported it was getting to the point where resident 38 really needed her money back and had not heard from the NA. The summary of interviews with staff documented that multiple staff members commented on how upset resident 38 was and how worried she was getting. Many staff members agreed that resident 38 felt bad for the NA in question and that resident 38 was trying to do the right thing to help the NA. The alleged perpetrator statement dated 3/4/25 at 1:00 PM, documented that the NA was talking to resident 38 about her financial situation and talking about life. After resident 38 found out that she was struggling a little bit, resident 38 offered her $100.00 to help get her by. The NA reported that she did not accept the money at first but after she kept pressing and put the money in her pocket she kept the money. The NA reported that she did not know it was not allowed. A staff interview documented Spoke to her [the resident] in tears about the situation. She was upset that she wasn't hearing back from [name redacted]. An additional staff interview documented I know she is really upset she doesn't have her funds. The employee was terminated and the facility verified the allegation.On 10/8/25 at 11:22 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she did not currently work at the facility but she was the RA when she did. The RA stated that she was informed that resident 38 let a NA borrow $100.00, and the NA had not paid it back. The RA stated that resident 38 had no changes in behavior. The RA stated that she notified the Administrator (ADM) and Director of Nursing once she became aware of the incident. The RA stated that she did not help with investigating incidents. The RA stated that abuse training was provided to staff twice a year and the training included signs and symptoms of abuse, who to report allegations to, and the time frame of reporting. On 10/8/25 at 1:22 PM, an interview was conducted with the ADM. The ADM stated that he was not the ADM when the incident with resident 38 had occurred. The ADM stated he called the prior ADM and was told that he had not been completely in the loop regarding that incident. The ADM stated that the prior ADM spoke with corporate staff and was told to pay resident 38 back the money that was taken. The ADM stated that was all the prior ADM could say. The ADM stated that yes he would have called local law enforcement and reported the allegation. The ADM stated that he would investigate the allegation by speaking with the individual and the resident. The ADM stated that he would have assessed how the resident was doing. The ADM stated that he would have completed the typical investigation stuff and he would have asked for the money back from the individual that took it. The ADM stated that he had a curriculum of training that he presented at the all staff monthly meetings. The ADM stated that abuse was presented twice a year. The ADM stated if there was a unique case he would bring abuse up again. The ADM stated there was no training that he could find regarding the incident with resident 38.

Based on interview and record review, the facility did not ensure all alleged violations involving abuse, including misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, to Adult Protective Services (APS) and local law enforcement. Specifically, for 1 out of 23 sampled residents, an allegation of misappropriation of resident property was not reported to law enforcement and the report to APS was reported 17 days after the allegation. Resident identifier: 38. Findings included: Resident 38 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease, generalized anxiety disorder, and adjustment disorder with mixed disturbance of emotions and conduct. Resident 38's medical record was reviewed. The facility Incident Report Form was reviewed. On 3/4/25 at 1:37 PM, resident 38 reported that she had learned that the (Nursing Assistant) NA was having some struggles financially and resident 38 offered to give the NA $100.00 to help. After multiple attempts resident 38 finally forced the funds in the NA's pocket and the NA accepted the funds. After a few days resident 38 texted the NA asking for the $100.00 back so resident 38 could pay for some personal storage expenses. The NA did not respond to resident 38 and resident 38 reported the issue to two different staff members to ask for help. The alleged perpetrator statement dated 3/4/25 at 1:00 PM, documented that the NA was talking to resident 38 about her financial situation and talking about life. After resident 38 found out that she was struggling a little bit, resident 38 offered her $100.00 to help get her by. The NA reported that she did not accept the money at first but after she kept pressing and put the money in her pocket she kept the money. The NA reported that she did not know it was not allowed. The employee was terminated and the facility verified the allegation. The APS report included with the facility investigation was submitted on 3/21/25 at 1:51 PM. The facility Alleged Resident Abuse/Neglect Investigation Checklist documented Notification of Police was not applicable. On 10/8/25 at 11:22 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she did not currently work at the facility but she was the RA when she did. The RA stated that she was informed that resident 38 let a NA borrow $100.00, and the NA had not paid it back. The RA stated that resident 38 had no changes in behavior. The RA stated that she notified the Administrator (ADM) and Director of Nursing once she became aware of the incident. The RA stated that she did not help with investigating incidents. The RA stated that abuse training was provided to staff twice a year and the training included signs and symptoms of abuse, who to report allegations to, and the time frame of reporting. On 10/8/25 at 1:22 PM, an interview was conducted with the ADM. The ADM stated that he was not the ADM when the incident with resident 38 had occurred. The ADM stated he called the prior ADM and was told that he had not been completely in the loop regarding that incident. The ADM stated that the prior ADM spoke with corporate staff and was told to pay resident 38 back the money that was taken. The ADM stated that was all the prior ADM could say. The ADM stated that yes he would have called local law enforcement and reported the allegation. The ADM stated that he would investigate the allegation by speaking with the individual and the resident. The ADM stated that he would have assessed how the resident was doing. The ADM stated that he would have completed the typical investigation stuff and he would have asked for the money back from the individual that took it. The ADM stated that he had a curriculum of training that he presented at the all staff monthly meetings. The ADM stated that abuse was presented twice a year. The ADM stated if there was a unique case he would bring abuse up again. The ADM stated there was no training that he could find regarding the incident with resident 38.

Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility failed to ensure that the resident had adequate supervision and assistance devices to prevent accidents. Specifically, a resident was not secured inside the facility vehicle during transport and fell out of her wheelchair. The fall resulted in the resident sustaining a Thoracic (T)11-T12 fracture and a contusion of the abdominal wall. Based on the facility's investigation and corresponding corrective measures, this was cited at past non-compliance with a correction date of 8/1/23. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of Thoracic (T)11-T12 vertebra, type II diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. On 9/22/24 at 11:06 AM, an interview was attempted with resident 9. Resident 9 was not available for an interview due to a current hospitalization . Resident 9's medical records were reviewed. On 7/21/23, resident 9's Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that the resident was cognitively intact. The assessment documented that resident 9 required a 2 person extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The assessment documented that resident 9 was not steady moving from seated to standing position and used a wheelchair for a mobility device. Resident 9's progress notes revealed the following: a. On 7/31/23 at 12:27 PM, the Nurses Note documented, Family and provider were made aware of incident and transfer to hospital on 7/31/23 around 1500 [3:00 PM] by shift nurse. b. On 7/31/23 at 2:45 PM, the Nurses Note documented, [Resident 9] had a fall in the transport van on her way back from the [name omitted] hospital. [Resident 9] hit her head and was also complaining of back pain, staff decided to call the [name omitted] ambulance for her and have her taken to the hospital. c. On 8/1/23 at 12:39 PM, the Social Service Note documented, Called [name of hospital] to check on resident. Was informed that resident was at hospital but then was transferred to [name omitted] ER [emergency room ] dept. at 11:04 pm. Spoke with ER nurse who says they are waiting on bed to admit her. Waiting on Case management call to request medical records. d. On 8/5/23 at 4:18 AM, the Nurses Note documented, [Resident 9] returned to [name of facility] by [ambulance service]. via stretcher. She is wearing her Back brace as ordered. A&Ox3 [alert and oriented times 3]. Resp [respirations] even and unlabored. Heart regular rate and rhythm. Main concern is her lower back pain. She is incontinent of urine and extensive assist with brief changes. Limited assist with bed mobility. Reoriented her to her call light and room. Orders have been verified. She did have some nausea this evening . zofran given with good effect. She slept through the night at her normal baseline. e. On 8/6/23 at 9:10 AM, the MDS (Minimum Data Set) progress note documented, MDS note for 8/6/23 ARD [assessment reference date]: Res [resident] returned for (sic) hospital stay 7/31-8/4/23 after having being tipped forward in an unrestrained wheelchair in a moving transport vehicle. She sustained multiple spinal injuries including but not limited to a T12 burst fx [fracture], small epidural hematoma, spinal stenosis in cervical/lumbar regions. She also was noted to have an abdominal hematoma and a left diffuse adrenal enlargement. She returned w/ [with] TLSO [thoracolumbar sacral orthosis] brace and orders for PT/OT [physical therapy/occupational therapy]. She is alert and oriented to person place time and situation. She still requires extensive assist of 2 for all LLADLs [Activities of Daily Living] dressing and bathing, extensive assist of 1 for feeding upon return d/t [due to] mobility limitations while in brace. She still requires extensive assist with wheelchair mobility/locomotion on/off unit. Continues on O2 [oxygen] and CPAP [continuous positive airway pressure] w/ SOB [shortness of breath] on exertion. Hearing is adequate w/o [without] aids and vision is corrected lenses worn. On 7/31/23 at 2:57 PM, resident 9's incident report documented that resident 9 had a fall in the transport van while on her way back to the facility from an appointment. Resident 9 reported, I fell in the van hit my head and my back hurts. The report documented a vertebrae fracture as the injury type. The report documented under other information that the seatbelt did not secure. On 7/31/23, the hospital history and physical documented . the resident presented after her transport vehicle stopped suddenly while transporting her in her wheelchair, causing her to roll forward and fall out of her wheelchair. She was unfortunately not secured during transport and buckled forward. She reports hearing crunching and then reports severe low back pain. The resident was initially taken to another hospital where she was found to have an L [Lumbar]1 coronal split fracture as well as signs of possible bowel contusion. The Hospital Course documented the following: #T12 burst fracture with retropulsion and epidural hematoma #Lumbar spondylosis with anterolistesis of L3-L4 and moderate spinal canal stenosis Patient presented with back pain after wheelchair incident in which she was unrestrained in the back of a van and hit the van wall. In the setting of chronic back pain, she was reporting acute worsening of back pain. CT [Computed Tomography] T/L [Thoracic/Lumbar] Spine upon arrival was significant for coronally oriented fracture of T12 without retropulsion. There is widening of the bilateral T12-L1 facet joints suggestive of capsular injury and mild hyperdensity along the ventral epidural space a the L1 level may represent small volume epidural hematoma. The neurosurgical consult recommended a TLSO brace in place and to wear when HOB [head of bed] > [greater] 30 , out of bed or upright. Don/doff when sitting is ok. Review of the facility investigation documented that resident 9 had a fall during transportation that resulted in a fracture. The immediate steps taken were to have an off-site transportation company provide services until further safety training could be conducted. The facility investigation documented that resident 9 was picked up from a pulmonology appointment and the transportation driver, who was also the Therapeutic Recreation Specialist (TRS), secured her into the van in her wheelchair. While driving downhill resident 9 fell forward out her wheelchair. The summary of interviews documented, Upon investigation of this incident, we are reasonably relating the fall to the seatbelt not being fully latched. The wheelchair was still secured to the floor when she fell out of it. On 8/1/23, a Quality Assurance Committee Template Tool documented the identified problem as making sure residents and staff are safe when transporting. The corrective measures implemented were to test all seat belts to ensure safety equipment is working. check the lights and hazards. continue to monitor routine maintenance. The section for evaluation on the tool documented check marks next to seat belts, hazards, lights, and no lights on vehicle dashboard. On 8/1/23, an education acknowledgement form was signed by the TRS. The reason for the education documented, Understand the motor vehicle policy. The summary of the education documented, Finding out the safety equipment works, be careful when driving. The form documented that the expectations moving forward were, Review safety equipment before departing in the vehicle. The form was signed by the TRS. On 8/1/23, the TRS disciplinary form documented that the staff member had violated the company policy and the action taken was a final written warning. The explanation of the infractions documented, Understanding the motor vehicle policy specifically failed number six and seven. The form was signed by the TRS. Review of the Motor Vehicle Policy documented the following: 6. An employee who drives any car for facility business purposes must exercise due diligence in so doing. The employee must comply with all traffic laws. Such failure to comply with traffic laws could result in disciplinary action. 7. Employees and their passengers who are driving/riding in a car on facility business purposes must wear seat belts at all times in which the car is being operated. The policy was last revised in January 2008. On 8/1/23, a Performance Improvement Plan was initiated for the TRS. The corrective action documented that verbal/counseling was provided. The job standards that required improvement documented the policy of the motor vehicles. The specific improvement needed was checking all safety equipment before departing in the vehicle. The steps identified to achieve the improvement were training and referral back to the policy as needed. The plan documented that the consequence for not meeting the performance standard was termination. The plan was signed by the TRS. On 1/18/21, the TRS signed a copy of the Driver Safety Policy. The policy covered Basic Vehicle Operation Guidelines which documented, Always use seat belts. On 9/23/24 at 12:00 PM, an interview was conducted with the TRS. The TRS stated that he did a lot of the driving at the facility. The TRS stated that the training he was provided to be the transportation driver included inspecting the vehicle for tire air pressure and ensuring the tires were in good working condition, inspecting the windows, inspecting the locks and ensuring that the resident was seat belted in the vehicle. The TRS stated that it was a requirement that the driver be at least [AGE] years old. The TRS stated that he also had his Commercial Drivers License and use to drive the paratransit bus at the facility. The TRS stated that he had worked at the facility for a long time and had many training's on driver safety. The TRS stated that the training would be documented in the training log. The TRS stated that recently they implemented an additional measure of having a second person verify the safety checks were completed prior to transportation. The TRS stated that the process for securing a resident in a wheelchair inside the vehicle was to ensure that the 4 straps and the lap belt were secured. The TRS stated that the 4 straps were attached to the floor of the van and each strap was secured to the wheelchair frame on either side of the wheels in the front and back of the chair. The TRS stated that the straps were pulled tight to ensure that the chair did not move and that the straps were never attached to the wheels because the chair could then roll. The TRS stated that the floor straps were a ratchet that could be tightened. The TRS stated that the lap belt was positioned over the resident lap and was pulled tight. The TRS stated that he drove resident 9 on the date of the incident. The TRS stated that he was driving away from the hospital and when he came to a stop resident 9 fell out of the wheelchair. The TRS stated that she fell forward towards the front driver seat, impacted the drivers seat, and then fell to the floor. The TRS stated that the 4 floor straps were secured to the wheelchair, but the lap belt was not secured. The TRS stated that resident 9 was not seat belted at the time of the accident. The TRS stated that the van was modified and used to have rows of seats that were removed. The TRS stated that when those seats were in place the vehicle had shoulder seat belt straps that were connected to the sides of the vehicle. The TRS stated that those old seat belts were still present in the vehicle but did not connect to anything as the old seats had been removed. The TRS stated that he attempted to secure the old shoulder strap to the buckle but it would not clip in. The TRS stated that he was shown after the accident that the seatbelt did function. The TRS stated that at the time of the accident he did not see the lap belt. The TRS stated that after the accident he gave all this information to the insurance company. The TRS was asked why he departed the facility without securing a seat belt for resident 9. The TRS responded that it was the way he had done it for a long time and he was told that it was the straps securing the wheelchair that needed to be used. The TRS stated that after the accident it might have been the Maintenance Director that showed him the functioning lap belt. An immediate observation was made of the facility transportation vehicle with the TRS. The vehicle was observed with the wheelchair ramp located at the back of the van. The wheelchair floor straps were located in the back of the van where a previous third row of seats would have been located. The TRS confirmed that it was quite a distance that resident 9 came forward and hit the driver's chair. The TRS stated that after resident 9 fell he pulled the vehicle over and checked on the resident. The TRS stated he called the facility and asked them to call the paramedics. The TRS stated that the paramedics transferred the resident from the floor of the vehicle to the ambulance, and that he did not move resident 9. The TRS stated that after the accident the facility implemented more training. The TRS stated that now the Administrator (ADM) and the Resident Advocate (RA) were also trained as backup drivers. The TRS stated that the RA scheduled the resident appointments and then notified him. The TRS stated that if he was not available to drive he would let the RA know. The TRS stated that he had one resident that had weekly appointments scheduled, and on average he had at least 2 resident appointments per week. On 9/23/24 at 12:58 PM, an interview was conducted with the RA. The RA stated that she was in charge of scheduling resident appointments and she notified the TRS of those appointments daily in the morning meeting. The RA stated that the ADM also drove residents if the TRS was not available. The RA stated that she had been trained to drive residents to appointment's but had not done it yet. The RA stated that if the facility could not transport a resident they contracted with an outside company for those services. The RA stated that after resident 9's accident the resident had requested that all her transportation needs be provided by the contracted company. On 9/23/24 at 1:12 PM, an interview was conducted with the ADM. The ADM stated that when he was first hired he was provided training on driving residents in the transportation van. The ADM stated that to drive the facility vehicle they had to be on the companies insurance, have had the driver training, and reviewed the company policy. The ADM stated that the TRS did a good job and helped with the transportation training. The ADM stated that the process for securing a resident in the van was to secure the wheelchair by centering it in the back of the van, hook all straps on the frame, and tighten them up. The ADM stated that they secured the seatbelt under the handle bar of the wheelchair and ensured that it was tight enough that the resident would not slide down. The ADM stated that he transported residents once a week if the TRS was not available. The ADM stated that all current drivers had training. The ADM stated that the TRS had one other incident with the van other than the accident with resident 9. The ADM stated that last week the TRS accidentally left the van door open while backing out and scratched the paint. The ADM stated that no residents were in the vehicle at the time. The ADM stated that the accident with resident 9, the TRS was confused that the seatbelt was not working. The ADM stated that the TRS secured the wheelchair but not resident 9 and the resident fell forward and hit her head on the seat. On 9/24/24 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that he had started working at the facility shortly after the transportation accident with resident 9. The DON stated that resident 9 was incorrectly secured and she slid out of the wheelchair. The DON stated that after the accident the changes that were made was an in depth training of the TRS by someone in corporate. On 9/25/24 at 8:37 AM, an observation was made of the TRS demonstrating how he secured a wheelchair in the vehicle for transportation. The ADM was the resident in the demonstration. The TRS stated that after he checked the van he would unlock the back door and lower the wheelchair ramp. The TRS placed the wheelchair on the ramp and locked the brakes on the wheelchair. The ramp was raised and the resident was pushed into the vehicle. The TRS secured two floor straps to the left side of the wheelchair frame, and ratcheted it down. The TRS then secured right side of the wheelchair with two floor straps to the bottom of the wheelchair frame. The TRS buckled the seat belt and secured the strap under the arm rests of the wheelchair. The TRS stated that some residents would request that the the seatbelt be loosened, and he would inform them that it needed to be secured firmly. The TRS stated that he made sure that the seatbelt was flush against the abdomen of the resident. The wheelchair was observed stationary and not movable when pulled or pushed on. All straps were secured tight.

Based on interview and record review it was determined, for 2 out of 28 sampled residents, that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility failed to promptly identify, monitor, and intervene for an acute change in condition after two residents sustained a fall. Additionally, one resident did not have neurological assessments completed status post fall, and the other resident did not have timely intervention after changes were identified on the neurological assessment. One resident was admitted to the hospital with sinus arrest and the other resident was admitted to the hospital with a subdural hematoma and brain compression. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) level. Resident identifiers: 9 and 87. NOTICE On 9/25/24 at 3:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to ensure that residents received treatment and care in accordance with professional standards of practice and to identify and intervene for an acute change in resident's condition. Specifically, the facility failed to ensure that monitoring and interventions were provided timely following the resident's fall and decline in condition. Notice of the IJ was given verbally and in writing to the Administrator (ADM), ADM 2, Director of Nursing (DON), Resident Advocate (RA), Corporate Licensed Clinical Social Worker (CLCSW) and the Corporate Resource Nurse (CRN) and they were informed of the findings of IJ pertaining to F684 for resident 9 and resident 87. On 9/30/24, the Administrator provided the following revised abatement plan for the removal of the Immediate Jeopardy effective 9/30/24 at 10:40 PM. Immediate action: Resident 9 is not in the facility; therefore an individualized plan of action is not possible. Facilities Plan to ensure compliance quickly: Identification of affected residents: A facility audit of all residents was completed by the Director of Nursing/Designee on 9/25/24 to identify residents who were having signs/symptoms of a change of condition. Residents who were identified as having a change from their normal baseline were addressed per facility protocol. This assessment was conducted by Registered Nurses who are familiar with the resident baseline. Systemic Changes: 1) An Ad-Hoc QAPI (Quality Assurance and Performance Improvement) was conducted on 9/24/2024 when quality of care concerns was brought up to the facility. Facility interventions were implemented: a. Licensed Nursing and CNA's (Certified Nurse Assistants) trained on 9/25/24 by the Director of Nursing regarding identifying changes of condition in residents and the appropriate action to take if a change is identified. This includes initiating emergency transport to the hospital, notification of physician, responsible party and Director of Nursing. b. Education was initiated for the facility nursing staff on 9/24/24 regarding Facility Change of Condition Policy - which was an up-to-date and applicable policy to the current functions of the facility - as well as normal vital sign ranges, neuro (neurological) checks, and timely interventions for abnormal assessments which include notification to Physician and initiating emergency medical treatment. This training outlined that neurological check procedures should be initiated following unwitnessed falls as well as witnessed falls with the resident striking their head during the fall. This training to clinical staff was validated by completion of a post-training test to assess understanding, and was completed by all clinical staff on 9/25/2024. c. Training provided to Licensed Nursing staff that emphasized urgency of intervention and procedure for notification of providers, seeking guidance from providers, and what to do should a provider not be able to be reached. Verbiage used in consideration of this subject stressed that an emergent change of condition does not warrant delaying emergency medical intervention via ambulance in order to seek a verbal order from a provider; standing order in place for a provider to be called no more than two times without answering before the nurse seeks emergency intervention for the resident without an order from said provider. For other changes of condition, it indicates that the nurse call - rather than text - a provider to seek further advice. The on-call provider schedule is available to nursing staff at the nurse's station. d. Licensed Nurse staff of facility received training on neurological status checks, including indications, completion and interpretation. Licensed Nurses educated on critical changes that warrant immediate, emergent intervention that must be initiated by the assessing nurse, including seeking immediate emergency care, proper notification of responsible party and physician, as well as proper documentation. Licensed nurses' understanding of this material was validated by completion of a post-training test that included, but were not limited to, question(s) referencing the responsibility of nurses - rather than CNAs -- to initiate and complete these examinations, scenario(s) in which the nurse would have to choose a course of action to assure the safety of a resident with abnormally-presenting neurological status, scenario(s) displaying symptoms and asking the nurse to determine which symptoms constitute a normal neuro status finding versus an abnormal finding, question(s) regarding typically-presenting vital sign trends with increasing intracranial pressure (Cushing's Triad) and the urgency of intervention should such vital signs present, question(s) regarding procedure for completing a neurological assessment, question(s) regarding scenarios under which a resident would be at increased risk of intracranial bleeding, and question(s) regarding interpretation of abnormal vital signs not necessarily associated with changing neurological status and how to respond appropriately. Director of Nursing made himself available for questions from Licensed Nursing staff regarding the source material after the initial training, and all nurses demonstrated understanding of the education. This training was completed by all Licensed Nursing staff before midnight on 9/25/2024. e. On 9/30/2024, the training confirmation examinations mentioned above were sent to management within the staffing agencies that the facility uses for emergency clinical staffing with the written understanding that all agency healthcare staff will need to complete prior to the beginning of their shift at the facility. All agency staff that had worked from 9/26 to 9/30 completed the examination(s) on 9/30/24. f. The night of 9/25, a resident was witnessed vomiting her medications after they were administered. The nurse confronted the resident and asked if they were ill, which she refuted. The documented note in question dictates this interaction as follows, (RESIDENT) took her evening medications whole with milk. She had swallowed them all then about 10 min later she was in the bathroom gagging over the toilet. Noted white emesis in the toilet. (RESIDENT) said she wasn't sick and then she said don't tell [name removed] (DON). The nurse chose not to notify the provider of this behavior, believing it to be a baseline behavior of her medication refusals, as she frequently and adamantly refuses her medications and has induced vomiting after swallowing her medications in the past as a behavior. Because this behavior did not represent a change of condition as was outlined in the policy or training provided -- either in significant behavioral change or refusal of medications or treatments twice consecutively -- the nurse determined this did not meet criteria as a change of condition, and thus did not follow report protocol. Additional resources to enforce understanding of situations that may warrant a change of condition requiring an immediate report provided to the nursing staff on 9/30/24. g. Staff who did not receive training by end of day 9/30/24 will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training, and this training will be implemented during onboarding of newly-hired nursing staff. 2) The Director of Nursing/Designee will communicate with the clinical staff from each shift to review if any changes of condition(s) were identified. If any changes occur, the Director of Nursing will review the situation(s) to verify that residents received care per facility protocols. This practice will occur until the Immediate Jeopardy conditions are abated. 3) Any identified trends will be reviewed by the QAPI Committee for further interventions. On 10/1/24 at 12:13 PM, 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 9/30/24 at 10:40 PM. Findings included: IMMEDIATE JEOPARDY 1. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of Thoracic (T)11-T12 vertebra, type II diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. On 9/22/24 at 11:06 AM, an interview was attempted with resident 9. Resident 9 was not available for an interview due to current hospitalization . Resident 9's medical records were reviewed. On 9/19/24 at 4:41 PM, a nursing progress note documented, Resident was sent to the hospital via gold cross because of hypotension, lethargic and bradycardic. It should be noted that no additional documentation could be found of resident 9's assessment for the change in condition. On 9/20/24 at 2:35 PM, a nursing progress note document, DON [Director of Nursing] contacted [name of local hospital] for update on resident. Case manager indicated that resident admitted for Sinus arrest, and that she recovered her cardiac status quickly with IV (intravenous) fluid resuscitation. Case manager indicated an unclear cause for the sudden change in cardiac status, but that resident's lactate levels were elevated and may have contributed. Resident will be hospitalized through the weekend and may be ready for discharge early next week. On 9/18/24 at 4:15 AM, an incident report documented that resident 9 was found on the floor in the bathroom next to the toilet. The incident description documented, A different resident called CNA [Certified Nurse Assistant] and indicated that they heard a 'bump' on the other side of the shared bathroom door. Staff responded and found resident sitting up against the door on the ground, next to the toilet. She indicated that she did not hit her head. Voicemail left for primary contact. Resident Description: 'I couldn't hold my weight and slid off the toilet'. The report documented that the physician was notified on 9/18/24 at 9:22 AM. It should be noted that the physician notification occurred 5 hours after the initial fall. Additionally, the incident report was authored by the DON and not the licensed nurse on shift at the time of the incident. On 7/21/23, the Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that the resident was cognitively intact. The assessment documented that resident 9 required a 2-person extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The assessment further documented that resident 9 was not steady moving from seated to standing position and used a wheelchair for a mobility device. No documentation could be found of neurological assessments that were conducted after resident 9's unwitnessed fall on 9/18/24. On 9/7/24 at 7:28 AM, resident 9's last recorded blood pressure reading was 132/80. It should be noted that no other blood pressure readings were documented after this. On 9/18/24 at 7:09 AM, resident 9's heart rate (HR) was documented at 108 beats per minute (bpm). This was elevated from the previous reading on 9/7/24 at 7:28 AM when the HR was 68 bpm. It should be noted that no other HR readings were documented after 9/18/24. On 9/23/24 at 7:55 PM, a telephone interview was conducted with Registered Nurse (RN) 3. RN 3 stated that she worked the day shift on 9/19/24. RN 3 stated that resident 9 was drowsy during her shift on 9/19/24. RN 3 stated that she gave resident 9 her morning medication in the dining room with breakfast. RN 3 stated that after she gave the medication, resident 9 went back to her room and slept. RN 3 stated that she asked the CNA to take resident 9's vital signs (VS) and her blood pressure (BP) and heart rate were low. RN 3 was unable to recall what the blood pressure and heart rate readings were. RN 3 stated that she informed the DON and was instructed to send the resident to the emergency department. RN 3 stated that when the paramedics arrived resident 9's HR was 30 and they shocked the resident. RN 3 stated that she informed the Nurse Practitioner (NP) and she gave orders to transport the resident to the emergency department (ED). RN 3 stated that she did not document that she spoke to the NP. RN 3 stated that she was nervous and forgot to document that she notified the NP. RN 3 stated that she started the VS due to resident 9's drowsiness, and also completed a full neurological (neuro) check. RN 3 stated that she documented the neurological assessment on a flow sheet. It should be noted that no documentation could be found of the neurological flow sheet. RN 3 stated that resident 9 was not on neuro checks before she started declining that day. RN 3 stated that she was not aware of resident 9 having a recent fall, and no one had informed her in report when she arrived on shift on 9/19/24. RN 3 stated that if the resident had a fall it should have been reported to her and she should have had neurological checks ongoing. On 9/20/24 at 12:52 AM, a Medical Intensive Care Unit (MICU) attending physician documented, It is unclear how long she was down and who exactly called EMS [emergency medical services]. On arrival to the ED she was initially bradycardic with rates in the 30's due to complete heart block. Cardiology was consulted and she was started on transcutaneous pacing. Labs resulted and she was found to have hyperkalemia with a K [potassium] of 6.6 and AKI [acute kidney injury] with BUN [blood urea nitrogen]/Cr [creatinine] of 104/5.29 Facility where she resides was contacted and reportedly patient fell from toilet on the morning of 9/17 and had been lethargic since then. The MICU note further documented, She fell two days ago, unclear if she hit her head or not and had decreased PO [by mouth] intake since then and increasing lethargy. It is possible that she developed AKI due to decreased intake which resulted in hyperkalemia and CHB [complete heart block] with bradycardia. An alternative possibility is that she developed intermittent heart block and bradycardia which led to her fall, pre-renal AKI and resultant hyperkalemia. The resident was intubated for airway protection and had subsequently been extubated. The MICU note documented under assessment and plan for polypharmacy, Likely multifactorial with potential causes including multiple centrally acting medications (oxycodone, mirabegron, lurasidone, clonazepam, cyclobenzaprine, gabapentin, lamotrigine, haloperidol) i/s/o [equal, like or similar] AKI, metabolic encephalopathy (BUN 104) on admission), and recent fall. Fall from toilet two days ago, pt [patient] reports hitting her head. The history of present illness documented, EMS was called because [resident 9] had fallen off the toilet two days ago and was altered and confused. On arrival she had a HR of 35 and a pressure of 47/? States she hit her head when she fell , but unable to provide more information about the fall. She is having neck pain and back pain, neck pain is new and back pain is chronic and at baseline. Pt had difficulty answering questions. Called [name of facility] for more information; pt fell of (sic) toilet 2 days ago, unclear if pt had headstrike. Called EMS today because pt was more lethargic and BP was low. Facility states she reports being tired, having decreased PO water intake. On 9/23/24 at 9:16 AM, an interview was conducted with RN 1. RN 1 stated that for a change in condition she would check the vital signs, notify the DON and provider, and go from there. RN 1 stated that she would assess the resident and document the assessment in the progress note, along with everything that she did for the resident and if she had to call EMS. RN 1 stated that the progress note would detail the time of transfer and circumstance or details of event. RN 1 stated that resident 9 was transferred to the hospital due to hypotension and bradycardia. On 9/23/24 at 10:16 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 9 needed more assistance in the morning with transfers and bed mobility due to leg pain. CNA 1 stated resident 9 could stand and transfer to a wheelchair (w/c) independently. CNA 1 stated she was told in report that resident 9 had fallen and hit her head and that was why she was currently in the hospital. CNA 1 stated that for falls they did neuro checks and that the aide could fill out the entire assessment. CNA 1 stated that the assessment included vital signs, pupil response, grasp, and say or repeat anything. On 9/23/24 at 10:37 AM, an interview was conducted with CNA 7. CNA 7 stated that she was present when resident 9 was transferred to the hospital. CNA 7 stated that one of the aides was monitoring resident 9 and her HR was dropping. CNA 7 stated that she was informed that 2 days prior to resident 9's transfer to the hospital she had a fall on night shift. CNA 7 stated that resident 9 had fallen onto the floor from the toilet. CNA 7 stated that resident 9 required minimum assistance with toileting for cleaning and brief placement. CNA 7 stated that resident 9 was independent with transferring to the toilet, but it depended on the day and how she was feeling. On 9/23/24 at 1:56 PM, an interview was conducted with the DON. The DON stated a neurological assessments should be done with any unwitnessed falls or falls with injury to head. The DON stated neuro checks were done every (Q)15 minutes for 1 hour (hr), every 30 minutes for 1 hr, every hour times 4 hrs, then every 4 hrs times 24 hrs. The DON stated that the Neurological flowsheet documented VS, Level of Consciousness (LOC), movement, hand grasp, pupil, and speech response. The DON stated that the licensed nurses conducted the neuro checks and the aides could be delegated the VS. The DON stated that the aides cannot do the neurological assessment because they were not trained. The DON stated that the expectation was that the neuro checks should be filled out completely unless the resident was sent to the hospital. The DON stated that incidents reports were completed for falls, medication errors, suspicious injuries of unknown origin, and resident to resident altercation. On 9/24/24 at 1:19 PM, an interview was conducted with CNA 8. CNA 8 stated that she worked with resident 9 on 9/18/24 and she was mostly tired and in bed that day. CNA 8 stated that night shift reported resident 9 had a fall in the bathroom. CNA 8 stated that resident 9 was talking normally, she was awake and then asleep, but she was arousable. CNA 8 stated that she did not recall a neuro check sheet for resident 9, Don't think there was one. CNA 8 stated that neuro checks were done if a fall was unwitnessed or if the resident fell and hit their head. CNA 8 stated that she took resident 9's VS that morning, but could not recall what they were. CNA 8 stated that she documented VS in the electronic medical records and also wrote them down on a sheet of paper. CNA 8 stated that she took resident 9's oxygen saturation and heart rate the morning of 9/18/24, and her heart rate was 108. CNA 8 stated that if the resident was hypertensive with a blood pressure of greater than 120/60 she would inform the nurse. CNA 8 stated that a normal HR was 60-80 bpm. CNA 8 stated that she was not sure if she should have informed the nurse about resident 9's HR. CNA 8 stated that she only reported to the nurse if the resident had a low oxygen or a high or low blood pressure. On 9/24/24 at 1:49 PM, a follow up interview was conducted with the DON. The DON stated that for unwitnessed falls the staff should respond and verify the resident safety, assess for injury and initiate neuro checks. The DON stated that some nurses chose to document a progress note, but all the information was entered in an incident report. The DON stated that falls should be reported to the oncoming shift for continuity of care. The DON stated that any changes in behavior, dramatic shift of VS outside of normal range, change in LOC, or change in pupil should be reported to the provider. The DON stated that the most recent fall for resident 9 was in the bathroom on the toilet when she attempted a self transfer and fell backwards. The DON stated that no staff were present and she was found on the floor. The DON confirmed that the neurological assessment was not started and should have been completed. The DON stated that resident 9 had a change in condition on 9/19/24 in the early afternoon and she was not presenting the same way that she does. The DON stated that when they conducted VS the HR was in the 30s and the blood pressure was low at around 60/40. The DON stated that the nurse reported that resident 9 was lethargic and confused. The DON stated that the EMTs administered two injectable medications and they were going to start to pace resident 9. The DON stated that he was not aware that the EMT's shocked resident 9. On 9/25/24 at 9:52 AM, an interview was conducted with Nurse Assistant (NA) 1. NA 1 stated that she was not present during the fall but reported resident 9's change in condition. NA 1 stated that she worked the 6:00 AM to 6:00 PM shift on Thursday 9/19/24. NA 1 stated that she was informed in report that resident 9 had a fall. NA 1 stated that she noticed that resident 9 was different than usual. NA 1 stated that resident 9 loved to feed the birds and NA 1 would often take the resident outside to do this. NA 1 stated that resident 9 did not want to do this that day. NA 1 stated that resident 9 could not stay awake longer than 5 minutes and was having random jerks that she had never had before. NA 1 stated that when resident 9 would rouse she would be loopy and would say random things that did not make sense. NA 1 stated that she noticed the changes within the first hour of her shift. NA 1 stated that resident 9 also typically ate and drank a lot and she did not want anything to eat or drink that day. NA 1 stated that resident 9 did not eat her breakfast that morning and could not stay awake long enough to eat. NA 1 stated that she reported these changes to the nurse. NA 1 stated that when she did not receive a response from the nurse she reported the change in condition to the Administrator (ADM). NA 1 stated, I don't think she was okay, she was acting different. NA 1 stated that she informed the ADM that the nurse was not listening to her and not responding. NA 1 stated that she took resident 9's VS every 30 minutes and documented them on a neuro flow sheet. NA 1 stated that she began monitoring resident 9's VS at approximately 7:30 AM to 8:00 AM. NA 1 stated that she documented the VS on a neuro sheet. NA 1 stated that resident 9's blood pressure and heart rate were dropping and every 30 minutes it went down. NA 1 stated that she checked the VS with different equipment, in both arms and with the arm positioned at heart level. NA 1 stated that the readings were all low and that was when she notified the RN. NA 1 stated that the RN checked resident 9's VS and the HR was reading 50 and kept dropping. NA 1 stated that was when they notified EMS. NA 1 stated that when EMS arrived they were in resident 9's room for a long time. NA 1 stated that resident 9 was transported to the hospital between 11:00 AM and 12:00 PM. NA 1 stated that she informed resident 9 that they were sending her to the hospital because her blood pressure was low and the resident responded, I don't want to die. On 9/25/24 at 10:18 AM, a follow-up interview was conducted with the DON. The DON again confirmed that the neurological assessments were not initiated after resident 9's fall. The DON stated We dropped the ball on those. The DON stated that he was not present at 4:15 AM on 9/18/24 after resident 9's fall, but confirmed that he authored the incident report. The DON stated that the details on the incident report were obtained from the staff on shift, both licensed nurses and aides. The DON stated that the procedure was that the nurse was supposed to fill out the incident report, but the nurse on shift that day, RN 2, failed to complete it. The DON stated that was why he filled the report out after the fact. The DON stated that he recognized that RN 2 failed to follow the policy for a resident change in condition and that education had been provided to RN 2 back in October 2023 for the same reason after resident 87 had a fall. 50200 2. Resident 87 was admitted to the facility on [DATE] with diagnoses which included diffuse traumatic brain injury, vascular dementia, traumatic hemorrhage of cerebrum atrial flutter, atrial fibrillation, anxiety disorder, generalized muscle weakness, other lack of coordination, cognitive communication deficit, other toxic encephalopathy, unsteadiness on feet, essential hypertension, hyperlipidemia, hypermagnesemia, hypomagnesemia, insomnia, other symptoms and signs involving cognitive functions and awareness, other reduced mobility, and long term (current) use of anticoagulants. On 10/5/23 at 7:50 PM, a nursing progress note documented, CNA brought to nurses attention that patient had a fall from wheelchair. Head to toe assessment completed. Upon assessment, superficial laceration noted on top of scalp and abrasions on his back. Steri strips placed on laceration. Patient assisted back into wheel chair and brought to nurses station for more frequent checks. Neuro status at baseline. Patient alert and oriented, speech clear, PERRLA [pupils are equal, round, reactive to light, and accommodation]. Passive and active range of motion at baseline. Friend [name redacted] notified who informed nurse that patient has hx [history] of brain bleeds. DON notified. Called LM [left message] for Dr. [name redacted] informing him of the above and to call back if any further orders. Passed onto NOC [night] nurse, [name redacted] of this information and to follow up with patient. Nurse stated understanding. On 10/6/23 at 1:39 AM, a nursing progress note documented, Resident continues at baseline. Neuro checks continued. Night medication was given. Resident refused to remain in bed, fearing the possibility of more falls, resident was placed in recliner in dayroom. VSS. [vital signs stable] Resident fell asleep. On 10/6/23 at 1:54 AM, a nursing progress note documented, Resident is in the recliner, sleeping. He doesn't look or sound well. Vitals are B/P 155/81, pulse 129, Temp. (temperature) 98.2, oxygenation 94%, Respirations are 24. His mouth is dry, because of open mouth breathing, and his eyes look slightly milky. The DON, MDs, have been alerted through [name of messaging system]. The Medical director was notified. Voice mail left. On 10/6/23 at 3:03 PM, a nursing progress note documented, Resident with a notable medical history of atrial fibrillation, atrial flutter, hypertension, traumatic brain injury, traumatic hemorrhage of cerebrum, and vascular dementia moved into the community from a sister community at approximately 1300 [1:00 PM] via wheelchair. Resident had been assessed the day prior by DON, RNC [Regional Nurse Consultant] and Admin [Administrator], and found to be a pleasant, conversational but slightly confused individual with slightly impaired gait, but good balance once walking and able to ambulate long distances with standby assistance. Resident was on a 1:1 at the sister facility due to an elopement attempt, prompting the necessity to relocate him to a secured facility. When resident arrived at the community, he began observing behaviors outside of his reported baseline; shouting at staff, making incoherent angry comments, kicking off the wall as staff were assisting him with ambulation via wheelchair, becoming agitated and attempting to stand but having very poor balance and needing redirected back into his wheelchair. At approximately 1500 [3:00 PM], resident was in the hallway when he attempted to stand himself up, resulting in him falling backward against the wall, scraping his back as he slid down and creating an abrasion on the top of his scalp from where it made contact with thewall [sic]. The scrape on his back was superficial and required no intervention, though the abrasion to the top of his head was cleaned and steri-strips were applied. Resident was immediately assessed and found to be without major injury. Resident was found [NAME] [sic] hypertensive at 157/82 and tachycardic at 109, all other vitals unremarkable. Neuro checks remained unremarkable, though his agitation continued. At 2200 [10:00 PM], resident was assisted to bed, but he continuously attempted to stand back up from bed. Staff asked if he would prefer to be in the common area to minimize his agitation, which he agreed, and staff assisted him into a chair in the common area to avoid isolation. At approximately 0200 [2:00 AM], the nurse performed another neuro check on the resident and found him to be hypertensive at 155/81, tachycardic at 129, and his respiratory rate was 24, utilizing accessory muscles for respirations, though his oxygen saturation was 94% and had an appropriate temperature, also noting that the resident takes Eliquis. Nurse reached out to providers for guidance, but received no response from them. At 0558 [5:58 AM], the nurse reached out to the DON, indicating at the last neuro check at 0545 [5:45 AM], it appeared that resident's pupils were not symmetrical. DON immediately contacted theprovider [sic], who provided an order to send the resident to [name redacted] via ambulance. 911 was called, and EMS left with the resident at approximately 0655 [6:55 AM]. On 10/6/23, the hospital history and physical documented the resident .presented via EMS for altered mental status change with Glasgow Coma Score [GCS] of 3, and approximately 8 falls over the course of the last 24 hours . On 10/6/23, the hospital assessment and plan documented, a. subdural hematoma b. brain compression c. required emergent intubation . On 10/6/23 a CT [cat scan] Spine Cervical without contrast revealed: a. Large mixed attenuation left subdural hematoma resulting in approximately 2.2 cm [centimeters] of rightward midline shift and left-sided uncal herniation. b. Dilation of the occipital and temporal horns of the right lateral ventricle with surrounding transependymal edema, suggestive of entrapment. c. Additional intraventricular blood products in the fourth ventricle. d. No acute fracture or malalignment of the cervical spine. On 10/5/23 at 2:37 PM, the incident report documented, CNA brought to nurses attention that patient fell out of wheelchair. On 10/5/23 at 4:00 PM, neuro checks were begun on the patient. The neuro sh [TRUNCATED]

Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident with a history of suicidal ideations (SI) was hospitalized for a suicidal attempt and did not have behavioral health services provided for more than 2 months after the hospitalization . Resident identifier 14. Findings included: Resident 14 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. Resident 14's physician orders revealed the following: a. Aripiprazole Tablet 2 milligram (mg), give 1 tablet by mouth one time a day for supplemental treatment for major depressive disorder. The order was initiated on 3/8/24. b. Duloxetine Hydrochloride Capsule Delayed Release Particles, give 120 mg by mouth one time a day related to major depressive disorder. The order was initiated on 12/19/22. c. Escitalopram Oxalate Tablet, give 20 mg by mouth one time a day related to major depressive disorder. The order was initiated on 11/13/2023. Resident 14's progress notes revealed the following: a. On 3/7/24 at 2:27 PM, the nurse note documented, Resident is at hospital for trying to hurt himself. b. On 3/9/24 at 9:20 AM, the nurse note documented, Resident state that he is having suicidal thought but dont have any plan. He refused to go hospital. Thank you DON [Director of Nursing] notified. c. On 5/31/24 at 3:08 PM, the resident advocate note documented, [Resident 14] has began Mental health therapy with [name omitted] therapy. It should be noted that more than 2 months had passed since resident 14 was hospitalized for SI to when behavioral health services were implemented. d. On 6/4/24 at 2:04 PM, the Social Services Assessment documented, Social Services has reviewed resident's psychosocial needs and created initial care plan. On 12/29/21, the Pre-Admission Screening and Resident Review (PASRR) Level II evaluation documented that in 2018 the resident began to experience increasing depressive symptoms due to his memory loss and due to fears of being put out on the street as he did not have a place to live. He was having suicidal thoughts and eventually cut on both of his wrists; hospital records state that pt reported 'so rather than living on the street, I decided to end it'. After cutting his wrists he fell and hit his head and ribs as well. Pt [patient] was taken to the ER [emergency room ] at [hospital name omitted] and had his wrists bandaged, and due to his severe depression he was admitted to [hospital name omitted] for psychiatric evaluation and stabilization. The assessment documented that the resident may be a substantial danger to himself or others. The assessment documented the recommendations as Pt would likely benefit from counseling services to learn ways to cope with his psychiatric sxs [signs and symptoms]. On 5/25/23, resident 14's care plan for meets PASRR Level II determination was initiated. The goal was that resident 14 would receive specialized services as recommended by the PASRR Level II evaluation. On 5/25/23, interventions initiated included: Assist case worker with obtaining any needed information; Coordinate services with habilitative coordinator; Invite the habilitative coordinator to the quarterly care plan meeting; and Report any need to re-evaluate for specialized services. On 5/27/24, an intervention was initiated for PASRR Recommendations for specialized services treatment: Pt would likely benefit from counseling services to learn ways to cope with his psychiatric sxs. and PASRR Recommendations for services to be provided by facility: Medical Management, Assistance with ADL?S [Activities of Daily Living], Therapies for rehabilitation/to improve memory, support from SNF [skilled nursing facility] staff. On 5/29/24, an intervention was initiated for a Gradual Dose Reduction (GDR) contraindication given the patients significant depressive symptoms. On 1/1/23, resident 14's care plan for at risk for suicidal impulsive/ideations of self harm related to depression was initiated. The goal was that resident 14 would remain safe from self harm. Interventions identified on the care plan were: allow time for expression of feelings; provide empathy, encouragement and reassurance; encourage participation in activity preferences; ensure medications were swallowed after administration; familiarize resident with own belongings and surroundings; monitor and report to the charge nurse, nursing supervisor, and physician any behavior changes; and immediately report to nurse and provider any verbalizations of hurting self. On 3/7/24, resident 14's hospital history of present illness documented that resident 14 was seen for suicidal thoughts. Patient reports that just he has declined to the point where he just feels like there is no reason to live anymore and was talking about cutting his wrist to end his life. Patient is not actually hurt himself at this point but just more in the thought process The physical exam documented that resident 14 had a flat affect, stated SI and that had a sense of hopelessness at this time that his life is not worth living due to the fact that he is staying any (sic) rehab facility and has no family or friends as well as his health is deteriorating to the point where he is not functional The report documented that resident 14 was evaluated by a psychiatric crisis counselor. Patient did have some issues with the facility and was acting out this morning due to anger due to restrictions of his smoking and the crisis worker felt that patient is not truly suicidal but just more acting out due to worsening dementia and other concerns with the facility. The hospital discharge note documented that resident 14 was transferred back to the facility to discuss with the provider the possibility of increasing his dose of antidepressant medication as well as incorporating counseling to help alleviate some of his suicidal thought and end-stage concerns. Patient will follow through on safety plan that was established by him and the crisis worker. On 6/5/24, the behavioral health provider progress note documented that resident 14 reported passive SI at intake, today adheres to same passive SI without intent or thought of planning. Safety plan documented, attempted to create a safety plan due to the shift in emotional lavility today, however pt [patient] adamantly refused to safety plan. Staff were notified of the presence of SI and the pt to safety plan. They were given recommendations based of protective factors identified during last weeks assessment. He reported that I wish I would die because I don't want to be here anymore. When asked whether he had any plans to harm himself or others he replied no I can't do anything here when therapist tried to draw out more information he became more labile and so therapist opted to end the session and discuss the situation with the staff at the facility. He was given a SafeUt card with 988 information if he wanted to talk later on with someone. On 10/2/24 at 1:14 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 14 was blue sheeted a couple of months back. The DON stated that something upset resident 14 and he believed it had to do with the resident being out of cigarettes. The DON stated that resident 14 walked away and said might as well get a body bag. The DON stated that he went and talked to resident 14 and he was holding a butter knife. He looked like he was about to cut himself, one arm extended like he was going to cut himself. The DON asked resident 14 to give him the knife and he did. The DON stated that he asked resident 14 if he was actively suicidal and he responded yes. The DON stated that he asked if he had a plan and resident 14 replied what do you think?. The DON stated that resident 14 did not want to go to the hospital so the provider blue sheeted him. The DON stated that resident 14 did not have a psychosocial assessment after the incident. The DON stated that resident 14 reported to the hospital that he was doing the SI behavior in an attempt to obtain cigarettes and that was why they did not admit resident 14. The DON stated that the provider ordered Abilify for resident 14 after his re-admission. The DON stated he could not recall if resident 14 was evaluated by a Social Service Worker (SSW) after his re-admission. The DON stated that a SSW should evaluate a resident after any suicidal ideations or suicidal attempts. The DON stated that resident 14 was receiving behavioral health services but did not know when those services began. On 10/02/24 at 1:37 PM, a telephone interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 14 was very depressed, and was trying to hurt himself. RN 3 stated that she was not aware of what happened to initiate the depression. RN 3 stated that resident 14 did not have therapy services prior to being sent to the hospital for SI in March 2024. RN 3 stated that she thought resident 14 had therapy since the SI and hospitalization , but does not know who provided it or the frequency of the visits. On 10/02/24 at 1:57 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that resident 14 did not have any behaviors that she was aware of and she was not aware of a history of SI. On 10/02/24 at 1:59 PM, an interview was conducted with RN 1. RN 1 stated that resident 14 did not have any behaviors that came to mind. RN 1 stated that she felt like since she had been at the facility there had been some talk of behaviors for resident 14 but she could not recall what was said. RN 1 stated that resident 14 did not have a safety plan that she was aware of. On 10/02/24 at 2:00 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 14 had behaviors of yelling or screaming at the staff. On 10/02/24 at 2:05 PM, an observation was made of resident 14's room. The room contained the following items that could be used for self harm: a fork on the bedside table; a candle in glass jar; push pins in wall holding up the calendar; pens on the table; multiple cords; and a nasal cannula.

Based on interview and record review it was determined, for 4 out of 28 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the transfer or discharge was documented in the resident's medical record and that all the information was communicated to the receiving provider. The information provided to the receiving provider should include contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found to demonstrate what information was communicated to the receiving provider. Resident identifiers 8, 9, 14, and 19. Findings included: 1. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. On 9/19/2024 at 4:41 PM, resident 9's nurse note documented, Resident was sent to the hospital via gold cross because of hypotension, lethargic and bradycardic. On 9/23/24 at 9:16 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she would document a resident change in condition, everything she did for the resident, and if the resident was transferred to the hospital in a progress note. RN 1 stated that the progress notes would detail the time of transfer, circumstance or details of event, and where they transferred to. RN 1 stated she would send the resident face sheet and medication list with the resident to the hospital. RN 1 stated that they do not send a copy of the resident's Physician Order for Life Sustaining Treatment (POLST) to the hospital. RN 1 reviewed a random resident's face sheet and confirmed that the POLST or Advanced Directives were not listed on the form. RN 1 stated that she would also document in the progress note what was sent with the resident to the hospital. On 9/23/24 at 7:55 PM, a telephone interview was conducted with the RN 3. RN 3 stated that resident 9 was drowsy in the morning when she administered her medication. RN 3 stated that later in the day resident 9's vital signs changed and she had a low blood pressure and a low heart rate. RN 3 stated that she informed the Director of Nursing (DON) and the decision was made to send resident 9 to the emergency department. RN 3 stated that she gave the paramedics a copy of resident 9's medication list and face sheet. RN 3 stated that the paramedics shocked resident 9 before they transported her to the emergency room . On 9/24/24 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 had a change in condition in the afternoon on Thursday. The DON stated that Nursing Assistant (NA) 1 brought it to his attention. The DON stated he asked for a full set of vital signs and resident 9 had a heart rate in the high 30's and a blood pressure around 60/40. The DON stated that when the paramedics arrived they took resident 9's vital signs again. The DON stated that the paramedics asked him for a copy of resident 9's POLST form because they were going to start pacing her. It should be noted that no documentation could be found of the transfer paperwork for resident 9 or what information was sent to the receiving provider. 2. Resident 14 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. On 3/7/24 at 2:27 PM, resident 14's nurse note documented, Resident is at hospital for trying to hurt himself. It should be noted that no documentation could be found of the transfer paperwork for resident 14 or what information was sent to the receiving provider. 50200 3. Resident 8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, metabolic encephalopathy, diabetes mellitus, chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, pulmonary hypertension, paranoid schizophrenia, and anxiety disorder. Resident 8's medical record was reviewed on 9/22/24. A review of the progress notes documented the following: a. On 1/7/24 at 3:56 AM, Nurses Note Note Text: Resident was re-admited [sic] to facility after being at the hospital. She has been hit and miss with keeping her NC [nasal cannula] on for additional oxygen. She doesn't like wearing it, and will sit in the hallway without it, or sit outside. Resident has not had a fall, [NAME] [sic] she exhibiting involuntary arm movements like before her hospital visit. She is compliant with taking her medications and with her ADLs. [activities of daily living] b. On 1/15/24 at 2:36 AM, Nurses Note Note Text: Late entry for 1-14-2024 @ 1855 [6:55 PM]: Re-admit from [name of hospital] hospital. Arrived back to facility at 1855 in ambulance. DX [diagnosis]; Acute on 1)chronic respiratory failure with hypoxia and hypercapnia 2)Pneumonia. Ambulated from ambulance into facility with assistance from CNA [certified nursing aide] staff. Alert and oriented X3 [times 3] with verbal and nonverbal behavior congruent. New order for BS [blood sugar] checks to be done before and after meals QD [daily]. New order for DME [durable medical equipment] Compressor and for Nebulizer. Order faxed to [name of DME company] medical for DME equipment. VS [vital signs]: Temp [temperature] 97.9, B/P [blood pressure]138/74, Resp [respirations] 20, SPO2 [oxygen saturation] 90% on 3L [liters], Pulse 94. Lungs sounds diminished in all lobes. Wet cough noted with no sputum expelled. c. On 2/22/24 at 2:34 AM, Nurses Note Note Text: [resident 8] voiced she came back to [name of facility] from the hospital today at 4PM. Voiced she is happy to be back and that she missed her friends here. She is alert and oriented X3 and compliant with all meds and cares. Took all HS [bedtime] meds whole with water without any problems. SPO2 90% on 3.5L O2 [oxygen]. Assisted her to call her husband at 2000 [8:00 PM]. She is in bed sleeping without any signs or symptoms of distress. d. On 3/25/24 at 10:44 AM, Nurses Note Note Text: Resident sent to hospital for low 02 saturation. e. On 5/12/24 at 3:56 AM, Incident Note Note Text: At 0250 [2:50 AM], resident was yelling for help, while outside. Staff found the resident away from her walker and lying on the ground. I just fell she told the staff. She also stated, I have too much oxygen. Staff checked and resident's O2 level was 35%. A fewminutes [sic] passed and it jumped to 40%. The resident was helped up to her walker, then walked to her room. Assessment and first set of Neuros were to be started. Resident was placed on 4L of oxygen and only came up to 67%. She was able to answer simple Yes or No questions clearly. However, if she began to explain something, her words became slurred. Staff reported that she had become agitated and raised her fist to staff when told she couldn't go out to smoke. No wounds were visible and resident denied pain. DON [director of nursing] and Administrator were notified at 0257 [2:57 AM]. Because of her low oxygen level and resident's orientation continuing to change when asked questions, 911 was called and she was taken to the [name of hospital] hospital. f. On 6/26/24 at 8:08 AM, Nurses Note Note Text: Resident was sent to the hospital. Resident was lathargic [sic], weak and dizzy, she couldn't stand with out assistance. Residents vitals were b/p- 74/43 T-101.2 HR- 104 O2- 66% Resident was sent to the [name of hospital] g. On 7/7/24 4:10 PM, Nurses Note Note Text: CNA notified me that [resident 8] fell on her face outside on the pavement. When this nurse went outside [resident 8] was laying in supine position. She had blood on the R [right] side of her face and inside her mouth. Noted abrasions to her face, blood in hair and in her mouth and throat. Head to toe assessment done. No hip fx [fracture] upon assessment. Head to toe assessment. Neuro check WNL [within normal limits] , VS:B/P 155/85, Resp, 20, Pulse 88, SPO2 88%. 911 called. Notified DON and guardian [name redacted]. MD [medical doctor] notified. Ambulance took [resident 8] to [name of hospital] hospital. h. On 7/15/24 11:11 PM, Nurses Note Note Text: Resident was struggling to oxygenate, causing ALOC [altered level of consciousness] and confusion, she was cyanotic, very lethargic and weak, unable to sit up long enough to take meds. She agreed to be transported to [name of hospital] for evaluation. Guardian and husband were notified. I called for anupdate [sic], and she has been admitted to [name of hospital] Shock/Trauma unit. Personnel on the unit were unavailable to answer the phone for a status update. Will follow up. i. On 9/28/24 at 9:27 AM Nurses Note Note Text: Resident was sent to the hospital. This morning her oxygen was 60% on 5L. She was not being compliant with keeping her Nasal cannula on. When I ask, she said I am breathing and keep walking. On call NP [nurse practitioner] [name redacted] Notified about patient conditions at 7:39 Am and agree to send her to the hospital. Resident guardian was notified. A hospital history and physical report dated 1/10/24 documented, .Patient comes with no documentation from her care facility, attempted to call with no answer/continuous ringing .unable to obtain further information Review of resident 8's electronic medical record revealed no documentation of a transfer/discharge assessment or paperwork that might have accompanied the resident to the hospital. 4. Resident 19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, Alzheimer's Disease, dementia, type 2 diabetes mellitus, bipolar disorder, anxiety disorder, hyperkalemia, peripheral vascular disease, and gastro-esophageal reflux disease without esophagitis. Resident 19's medical record was reviewed on 9/22/24. A review of the progress notes documented the following: a. On 9/4/at 3:21 AM, Orders - General Note from eRecord Note Text: Resident returned from the [name of hospital] ER [emergency room ] department at 0245 [2:45 AM]. She had requested to go to the hospital because she was feeling sick. not feeling well. ER department performed the following tests CT [computed tomography] of her brain/head CT maxillofacial w/o [with out] contrast CT spine cervical w/o contrast CBC [complete blood count] w/ auto Diff CMP [comprehensive metabolic panel] Lipase level Urinalysis w/ microscope Everything was found to be unremarkable, except the urinalysis. A urinary tract infection was found, and resident was given a Rocephin shot. The ER sent a script for Keflex 500 mg three times a day for 7 days. Resident was placed in her bed and is sleeping. b. On 9/7/24 at 8:30 AM, Nurses Note Note Text: Patient was transported by EMS [emergency medical services] to [name of hospital] ER. She was drooling while she was waiting which is her primary complaint that her throat is sore enough that she can't swallow. was unable to take her pills due to this. Family, on call provider and DON alerted. Review of resident 19's electronic medical record revealed no documentation of a transfer/discharge assessment or paperwork that might have accompanied the resident to the hospital. On 10/01/24 at 12:57 PM, an interview was conducted with Registered Nurse [RN] 1. RN 1 stated that a face sheet, medication list, and POLST [Physician Orders for Life Sustaining Treatment] form should accompany a resident to the hospital. RN 1 stated that this information was given to the EMTs [emergency medical technicians]. RN 1 stated that the documents needed to be printed and sent with EMS. RN 1 stated that a progress note should be made and the DON should be notified. On 10/02/24 at 11:32 AM, an interview was conducted with the DON. The DON stated that it should be documented in the progress noted that a resident went to the hospital. The DON stated there was something called e-interact that wasn't done as much as he would like the nurses to do to document that the resident had been transferred to the hospital. The DON stated that the progress notes should document the situation as to why the resident needed to go to the hospital, that the provider, DON, and responsible party should have been notified. The DON stated that the resident's medication list and POLST form should accompany the resident to the hospital.

Based on observation and interview, it was determined that for 3 of 28 sampled residents, that the facility did not treat each resident with respect and dignity. Specifically, staff at the facility were observed standing next to residents while assisting them with eating, staff were observed using labels instead of resident names when addressing residents, residents were not served meals at the same time, and residents did not receive necessary assistance during dining. Resident identifiers: 11, 18, and 19. Findings included: 1. On 9/22/24 at 12:32 PM, an observation was made of the lunch time dining service. Nursing Assistant (NA) 2 was observed to assist Resident 19 with eating her meal. NA 2 was standing next to Resident 19 while assisting her with eating. 2. On 9/23/24 at 8:09 AM, an observation was made of the breakfast time dining service. The facility had already started to serve meals by the time the observation had started. At 8:17 AM, all residents had been served their meals except for Resident 11. At 8:23 AM, Resident 11 finally received his meal after staff tracked it down from the cart used to deliver meals to residents who eat in their rooms. On 9/25/24 at 10:02 AM, an interview was conducted with NA 1. NA 1 stated that when assisting residents with feedings, staff should sit next to residents to promote dignity. NA 1 stated that the assistance each resident requires varies. NA 1 stated that some residents just need to be coached while others may need to be fed manually. 38031 3. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed. Resident 18's diet order was for a no added salt diet, regular texture, regular consistency. On 8/27/24, the Minimum Data Set (MDS) Assessment documented that resident 18 required supervision or touching assistance for eating. On 8/29/24, resident 18's nutritional assessment documented that resident 18 required setup help and supervision for dining. On 9/22/24 at 12:41 PM, an observation was made of resident 18 during the lunch meal service. Resident 18 was observed lifting her fork to her mouth two times without any food on the utensil. Nurse Assistant (NA) 1 was observed to load resident 18's fork with mashed potatoes and beef and attempted to feed the resident while standing at the resident's side. The aide offered the resident a bite of food but did not take the utensil fully to resident 18's mouth. Flies were observed to be hovering and then landing on resident 18's head during the meal. On 10/01/24 at 12:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the aides should be seated with the resident when assisting with dining. The DON stated that the aides should load the utensil for the resident, cue the resident to eat, or provide total assistance with feeding the resident.

Based on interview and record review, it was determined that for 1 out of 28 sampled residents, the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized and the facility kept confidential all information contained in the resident's records. Specifically, resident's information was left open on a computer screen unsecured on two different occasions while residents were in the vicinity and no documentation of a resident's hospital visit was found in the medical record. Resident identifier: 14. Findings included: On 9/22/24 at 09:40 AM, an observation was made of Registered Nurse [RN] 4 walk away from the medication cart. The computer on top of the medication cart was left open with resident information available to view. An observation was made of residents 10 and 18 around the medication cart. On 9/22/24 at 12:40 PM, an interview was conducted with RN 4. RN 4 stated that any time the medication cart was left unattended the computer and medication cart should be locked. RN 4 stated that she usually locked the computer screen when she left the cart. On 9/24/24 at 07:50 AM, an observation was made of RN 1 leaving the medication cart unattended with the computer open with resident information visible. Residents 10 and 31 were in the hallway next to the medication cart. On 9/25/24 at 1: 22 PM, an interview was conducted with RN 1. RN 1 stated when she left the medication cart she made sure she locked the cart and the computer so that no information was visible to residents. RN 1 stated she tried to always have her computer screen locked when she was not in the area. On 10/1/24 at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the expectation of staff was to keep all identifiable resident information confidential. The DON stated that if a medication cart was left unattended the nurse should lock the computer screen to avoid residents from seeing Health Insurance Portability and Accountability Act (HIPAA) protected information. 38031 2. Resident 14 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. On 3/7/24 at 2:27 PM, resident 14's nurse note documented, Resident is at hospital for trying to hurt himself. No documentation could be found in resident 14's electronic medical records (eMR) of the hospital history and physical or discharge paperwork following his hospitalization on [DATE]. On 10/2/24 at 1:14 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 14 was blue sheeted a couple of months back. The DON stated that something upset resident 14 and he believed it had to do with the resident being out of cigarettes. The DON stated that resident 14 walked away and said might as well get a body bag. The DON stated that he went and talked to resident 14 and he was holding a butter knife. He looked like he was about to cut himself, one arm extended like he was going to cut himself. The DON asked resident 14 to give him the knife and he did. The DON stated that he asked resident 14 if he was actively suicidal and he responded yes. The DON stated that he asked if he had a plan and resident 14 replied what do you think?. The DON stated that resident 14 did not want to go to the hospital so the provider blue sheeted him. The DON stated that they should have resident 14's discharge paperwork, and that the hospital did not admit him. On 10/03/24 at 9:28 AM, a follow-up interview was conducted with the DON. The DON stated that he requested the hospital records for resident 14 and the hospital had replied that he was not seen there. The DON stated that he then called the ambulance service and they had a record of the transport. The DON stated that he would follow-up with the hospital again. On 10/8/24 at 4:18 PM, the facility provided the hospital history and physical (H & P) for resident 14's hospitalization on [DATE]. The DON stated, Here's the H&P for that hospitalization . On review of old messages, I realized a blue sheet wasn't initiated on this resident for this incident. When he made these expressions, the ambulance was contacted without a blue sheet and he agreed to go to the hospital.

Based on interview and record review it was determined that the facility did not ensure that the resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine, and that the resident's medical record included documentation that indicated that the resident was provided education regarding the benefits and potential risks associated with the vaccine; documentation of each dose administered; and documentation of declinations or contraindications to the vaccine. Specifically, for 4 out of 5 sampled residents, the facility did not have evidence that each resident was provided education about the COVID-19 vaccine, was provided the COVID-19 vaccine, or declined the COVID-19 vaccine. Resident identifiers: 7, 18, 28, and 30. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of presence of right and left artificial shoulder joint, chronic obstructive pulmonary disease, hypertensive heart disease, pulmonary hypertension, chronic pain syndrome, ventricular premature depolarization, insomnia, nonrheumatic mitral valve insufficiency, history of myocardial infarction, dysphagia, overactive bladder, lesion of ulnar nerve, hypertension, lymphedema, osteoporosis, and hyperlipidemia. Resident 7's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination. 2. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination. 3. Resident 28 was admitted to the facility on [DATE] with diagnoses which included aphasia, frontotemporal neurocognitive disorder, insomnia, and dementia. Resident 28's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination. 4. Resident 30 was admitted to the facility on [DATE] with diagnoses which included unspecified focal traumatic brain injury, chronic obstructive pulmonary disease, Alzheimer's disease, dementia, hypertension, hyperlipidemia, cognitive communication deficit, chronic pain, and osteoarthritis. Resident 30's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination for the current vaccine season. The facility Coronavirus Disease (COVID-19) - Vaccination of Residents policy documented that the resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine and before the vaccine was offered the resident was provided education regarding the benefits, risks, and potential side effects associated with the vaccine. The policy further stated that residents must sign a consent to vaccinate form prior to receiving the vaccine and a vaccine administration record was filed in the resident record. The policy also stated that if a resident did not receive the COVID-19 vaccine due to medical contraindications or refusal the documentation was made in the resident record. The policy was last revised in August 2024. On 10/3/24 at 10:58 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that he was not sure where the documentation was located for the resident COVID-19 immunization records.

Based on record review and interview, it was determined that for 2 of 28 sample residents, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, there were at least two instances where the facility did not obtain International Normalized Ratio (INR) labs for a resident despite there being physician orders for the labs to be obtained every 4 weeks and one instance where the facility did not obtain a Basic Metabolic Panel (BMP) for another resident despite there being physician orders for the BMP to be drawn. Resident identifiers: 31 and 9. Findings Included: Resident 31 was admitted [DATE] with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, other asthma, venous insufficiency, generalized anxiety disorder, post-traumatic stress disorder, unspecified combined systolic and diastolic heart failure, peripheral vascular disease, unspecified cirrhosis of liver, obsessive-compulsive disorder, and chronic embolism and thrombosis of unspecified deep veins of right lower extremity. Resident 31's medical record was reviewed. The following Physician's orders were reviewed: Draw INR once every 4 weeks on Thursdays. INR results for the dates of 4/12/24, 7/12/24, 8/27/24, 9/12/24, and 9/19/24 were uploaded into Resident 31's medical record. INR results for the months of May and June were not found in Resident 31's medical record. On 6/10/24, a pharmacy consultant review for the month of May 2024 documented, Nursing-I did not find routine monthly monitoring of PT[prothrombin]/INR values to follow warfarin treatment. He has fluctuating weight and medications which may alter warfarin effectiveness. Recommendation: Check and record PT/INR value at least monthly. On 8/9/24, a pharmacy consultant review for the month of July 2024 documented, .[Resident 31's] PT/INR has been subtherapeutic the last two labs found (April and July). Goal INR is 2-2.5 to provide protection against clotting. Recommendations: 1. Monitor PT/INR at least once a month . On 10/03/24 at 10:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that he had reviewed the orders for Resident 31's INR to be checked in May and June of 2024. The DON stated that it was likely that the phlebotomist contracted to work for the facility never obtained the labs for the months of May and June 2024. 38031 2. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. On 8/13/24, resident 9's physician ordered a Basic Metabolic Panel (BMP). No documentation could be found in resident 9's electronic medical records of the BMP results. On 9/23/24 at 1:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the BMP that was ordered on 8/13/24 was missed and not obtained. On 9/25/24 at 9:20 AM, a follow-up interview was conducted with the DON. The DON stated that lab orders were placed by him and he followed-up with the providers. The DON stated that the laboratory process was that the order requisition was placed in the computer system and a resident face sheet was placed in a binder for the phlebotomist. The DON stated that the order requisition did not have a carbon copy for the facility records. The DON stated that the lab placed the results in the portal and it notified him automatically when the results were ready. The DON stated that the lab would call him directly if the labs had critical high or low values. The DON stated that once the provider reviewed the report they would sign the report and then it was scanned into the resident's medical records. The DON stated that he was the only staff that had access to the portal with the laboratory results. The DON stated that the results were also faxed to the facility at the same time they were uploaded into the portal. The DON stated that part of the process was making sure that the nurses were documenting in a progress note that the labs were being done. The DON stated that all labs should have the date and signature of the provider once they have been reviewed.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or included the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, in the medication refrigerator, one multi-dose vial was not labeled with an opened date, insulin pens did not have names or dates, one insulin pen was expired with an open date of [DATE], and a Prevnar 13 dose was expired and available to use. Findings included: On [DATE] at 7:35 AM, the medication refrigerator was inspected. A multi-dose vial of Tuberculin was observed open and available for use and an open date was not marked on the vial. A Prevnar 13 vaccine with an expiration date of [DATE] was available for use. A Tresiba insulin pen was observed to have been used with no opened date. A Lantus insulin pen was observed to be available for use with an open date of [DATE]. A Lantus insulin pen was observed to be opened and used with no open date. An aspart insulin flex pen was observed to have been opened and used with no name or open date on it. An insulin glargine pen was observed to be opened and used with no name on it. On [DATE] at 07:36 AM, an interview was conducted with RN 1. RN 1 stated she thought insulin pens were good for 30 days once they were used or at least by the expiration date listed on the pen. RN 1 stated that if she could not read the name or the date on the insulin pen then the pen should be discarded in the sharps container. RN 1 stated that she was unable to see names listed on some of the insulin pens or any opened dates. On [DATE] at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON was informed of the expired medication, the medications that were not labeled with expiration dates/opened dates, and the medication not labeled with the resident identifiable information. The DON stated that all medications should be labeled with the resident's name. The DON stated that insulin stored in the refrigerator should be labeled with an open date and the resident's name. The DON stated that once insulin was opened it was good for 30 days. The DON stated that there should not be anything else stored in the refrigerator but medications.

Based on interview and record review it was determined, for 3 of 28 sampled residents, that the facility in response to allegations of abuse did not prevent further potential abuse while the investigation was in progress. Specifically, the facility did not put effective measures in place to ensure that abuse did not occur and corrective measure that were identified were not implemented. Resident identifier, 14, 85, and 86. Findings included: 1. a. Resident 86 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of atrial fibrillation, type I diabetes mellitus, acute respiratory failure, bipolar disorder, hepatic failure, hypertensive heart disease, anxiety disorder, post-traumatic stress disorder, dementia, hepatic encephalopathy, hyperlipidemia, essential tremor, pain, insomnia, major depressive disorder, benign prostatic hyperplasia, osteoarthritis, and age-related cognitive decline. Resident 14 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. The facility notification to the SSA, form 358, documented an allegation of physical abuse between resident 14 and resident 86. On 9/5/23 at 7:15 PM, the form documented that facility staff became aware of the incident. It is alleged that [resident 86] and [resident 14] were arguing over [resident 14's] radio and both residents were found on the floor. The form documented that the residents were separated and resident 86 was removed to another room. The form documented that resident 14 had a small cut on the top of his left hand and resident 86 had a small cut on his right elbow and his lip. The form 359 documented the corrective actions taken were a room change for resident 86, alert charting, skin assessments, and 15-minute checks on both residents for 24 hours. Med review was requested. It should be noted that no documentation could be found that 15-minute safety checks were completed for resident 86 or resident 14 after the incident occurred. 1. b. Resident 85 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included Alzheimer's disease, pseudobulbar affect, anxiety disorder, anemia, dementia with anxiety and mood disorder, and major depressive disorder. The facility notification to the SSA, form 358, documented an allegation of sexual abuse by resident 86 towards resident 85. The form documented that Licensed Practical Nurse (LPN) 1 witnessed resident 86 seated on the couch next to resident 85. Its reported that [resident 86] was seen with his hand down the front of his pants and his other hand moving up the female residents leg and briefly making contact with her genital area. The residents were quickly separated, and [resident 86] was taken to his apartment. [Resident 85] was assessed and was unable to give any verbal feedback due to significant cognitive deficits, but was not showing signs of distress, pain or discomfort outside of her baseline. The corrective actions documented on form 359 were that resident 86 was placed on 15-minute checks to reduce the risk of continued incidents. [Resident 86's] provider ordered Depo-Provera, in order to reduce continued behaviors of a sexual nature Resident 86's medical records were reviewed. Resident 86's progress notes documented the following: a. On 9/14/23 at 5:07 PM, the Order Note documented, On 9/14, resident's POA [Power of Attorney][name omitted] was contacted following event with a female resident of the community. The provider ordered Depo-Provera in response to the event, and this order was discussed in detail with POA. POA had no concerns with this medication, and provided consent to DON to administer the medication. b. On 9/16/23 at 10:55 AM, the Orders - Administration Note documented that the Depo-Provera Intramuscular injection was unavailable from the pharmacy. Review of resident 86's 15-minute check logs revealed that the visual checks were initiated on 9/15/24 at 12:15 AM and entries continued until 10:00 AM. No documentation was entered on the log from 10:15 AM to 9:45 PM on 9/15/24. On 9/16/24, the 15 minute check log had missing entries from 6:15 AM to 1:45 PM. On 9/17/24, the 15 minute check log had missing entries from 4:00 PM to midnight. It should be noted that no other documentation of 15-minute checks was found. On 10/02/24 at 11:11 AM, an interview was conducted with the DON. The DON stated that to his knowledge resident 86 did not have a history of sexually inappropriate behaviors. The DON stated that resident 86's family member reported a past incident of sexual behavior with the onset of dementia, but nothing at the facility that he was aware of. The DON stated that the provider ordered Depo Provera in response to the incident. The DON stated that they tried to keep the residents separated, and ensure they were not in the common area at the same time. The DON stated 15-minute checks were not typically used as an intervention. The DON stated that with the facility demographic it was difficult to maintain 15-minute checks when you had another 10+ behavioral residents. The DON stated that the staff should have been consistent with the 15-minute checks and filling out the form completely. On 10/03/24 at 9:55 AM, an interview was conducted with the ADM. The ADM stated that 15-minute checks were a poor intervention in the facility. The ADM stated that 15-minute checks were basically a 1:1 staffing situation. The ADM stated that the immediate intervention was to identify what they could do to keep resident 86 and resident 85 separated. The ADM stated that he would expect to see the interventions documented in the facility investigation under corrective measures. The ADM stated that if they could not take measure to keep residents safe then he had to take drastic measures and transfer residents out. [Cross-refer F600] 47432

Based on interview and record review it was determined, for 2 out of 28 sampled resident, that the facility did not ensure that all alleged violations involving abuse or injuries of unknown source 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, a resident had a newly identified bruise that was not reported to the SSA and an incident of verbal abuse by a Certified Nurse Assistant (CNA) towards a resident was not reported to APS. Resident identifiers 18 and 22. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed. On 8/27/24, resident 18's Admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 1/15, which would indicate a severe cognitive impairment. On 9/2/24, resident 18's Montreal Cognitive Assessment (MOCA) score was a 2/30, which would indicate a severe cognitive impairment. On 9/4/24 at 7:06 AM, resident 18's nurse note documented, CNAs [Certified Nurse Assistant(s)] found a bruise on the resident's upper thigh area. This appears to be a new bruise. Resident doesn't know how it happened. On 9/9/24, a skin assessment documented no new skin integrity problems. It should be noted that no documentation could be found of an assessment of the identified bruise. Resident 18's care plan for at risk for skin breakdown was initiated on 8/21/24. The care plan goal was that resident 18 would not develop a pressure injury. Interventions identified were do not massage bony prominence and implement weekly skin checks. It should be noted that the care plan did not have interventions related to monitoring, reporting or treating altered skin conditions. On 10/01/24 at 11:39 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if she identified a newly developed bruise on a resident she would notify the provider, notify the Director of Nursing (DON), document in a progress note and monitor the skin. RN 1 stated that she would document an event note to alert other staff and would pass off the information in shift report. RN 1 stated that areas of the body that were suspicious for bruising would be private areas, inner thighs, breast, butt, vagina, back of arm, or face. RN 1 stated that if she identified a new bruise she would document characteristics of the bruise such shape like finger prints, and coloring to date the bruise. RN 1 stated she would also document the exact location on the thigh to indicate if it was the outer or inner thigh. RN 1 stated that she felt like the exact location made a difference in investigating the bruise, especially if the resident was not cognitively aware to describe how it happened, the more details the better. On 10/01/24 at 11:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that CNAs should notify the nurse of any new skin conditions such as a bruise. The DON stated that the licensed nurse needed to assess the skin to see if it was suspicious before reporting it as abuse. The DON stated that the nurse should notify the provider as a non-urgent symptom to review and there was a list in the provider communication book for issues that needed attention by the provider. The DON stated that the licensed nurse sometimes documented in a progress note, but they were not consistently doing that. The DON stated that the licensed nurse should document a progress note that stated the provider was notified of the condition. The DON stated that a bruise would be considered suspicious if the size was large, was located in areas of the genitals or anus, and if it appeared like fingerprints or if the resident reported an allegation of abuse. The DON stated that if the resident was not able to report what caused the injury the staff should also consider observations and resident behaviors that may be at cause. The DON was informed of the nurse note identifying a new bruise on resident 18. The DON asked if the bruise was located on the lateral or medial aspect of the thigh. The DON stated that for the lateral aspect of the thigh he would still expect the nursing staff to assess for suspicious circumstances. The DON stated that if the bruise was located on the medial aspect of the thigh it would be considered suspicious and the Administrator (ADM), DON and provider should be notified. The DON stated that if the bruise was located on the inner thigh it could be a possible indicator of abuse. The DON stated that if it was an indicator of abuse, or an injury of unknown origin it should have been notified to the SSA. The DON stated that the note did not contain the precise location or characteristics of the bruise and the licensed nurse should have done a better note. The facility policy on Identifying Types of Abuse documented Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual, or because of the number of injuries either at the single point in time or over time. The policy further documented possible examples of injuries that could indicate physical abuse were bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms, or posterior torso and trunk, or bruises in shapes (e.g., finger imprints); The policy was last revised in September 2024. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder, unspecified mood disorder, impulse disorder, insomnia, disinhibited attachment disorder, asthma, anxiety disorder, chronic respiratory failure, and hepatic encephalopathy. The facility notification to the SSA, form 358, documented an allegation of verbal abuse by CNA 4 towards resident 22. The form documented the details of the incident as, [RA] observed the CNA [name omitted] yelling 'Goodbye' repeatedly in an aggravating and mocking tone to the resident while [name omitted] was passing breakfast trays. Review of the facility abuse investigation revealed no documentation that demonstrated that APS was notified of the incident. On 10/01/24 at 10:07 AM, an interview was conducted with the ADM. The ADM stated that when he was first informed of any allegation of abuse he would immediately check for resident safety. The ADM stated that as soon as the resident was deemed safe he would gather information regarding the incident. The ADM stated that he would gather the details and interview any person who could corroborate the story. The ADM stated that once he obtained a rough timeline of events then he would determine if a staff member needed to be suspended. The ADM stated that the nurse would assess the resident for any injuries. The ADM stated that he would then report the incident to the SSA, Adult Protective Services, and the ombudsman within 2 hours. The facility policy for Resident Abuse Procedural Summary documented that the supervisor will be responsible for taking immediate actions to report the abuse to the appropriate individuals. The Administrator and Director of Nursing will be responsible for reporting the concerns, as required by law, and conducting the investigation. The policy further stated that all employees would be given specific example and measurable limits as to when reporting was required and they could be found contained within the Abuse Policy. The facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program documented that allegations of abuse would be reported within timeframes required by federal requirements. The policy was last revised in April 2024. [Cross-refer F600] 47432

Based on interview and record review it was determined, for 9 out of 28 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Specifically, the facility did not protect residents from abuse following an incident of sexual abuse by a Certified Nurse Assistant (CNA), an incident of verbal abuse by a CNA, multiple incidents of physical abuse following residents to resident altercations, and two incidents of sexual abuse from other residents. Resident identifiers: 2, 7, 9, 14, 22, 85, 86, 91, and 92. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of presence of right and left artificial shoulder joint, chronic obstructive pulmonary disease, hypertensive heart disease, pulmonary hypertension, chronic pain syndrome, ventricular premature depolarization, insomnia, nonrheumatic mitral valve insufficiency, history of myocardial infarction, dysphagia, overactive bladder, lesion of ulnar nerve, hypertension, lymphedema, osteoporosis, and hyperlipidemia. On 9/22/24 at 10:15 AM, an interview was conducted with resident 7. Resident 7 stated that CNA 3 was a wonderful aide, he was jovial, he was lovely. Resident 7 stated that one day while talking to CNA 3 he had mentioned that he was going to Kauai, and he told her that he would take her with him. Resident 7 stated that she was not sure how it happened, but CNA 3 said that it would be better if she went as his wife. Resident 7 stated that CNA 3 had told her that he really cared for her. Resident 7 stated that it then felt like manipulation when CNA 3 had asked her to take a photo of her bare breast. Resident 7 stated that she told CNA 3 no and that it was not appropriate. Resident 7 stated that CNA 3 then told her that he must have an obedient wife. Resident 7 stated that she thought it was a ridiculous request and she felt uncomfortable. Resident 7 stated that after CNA 3 was terminated he sent threatening texts to her. Resident 7 stated that the texts said that he could not get a job, that she had ruined his life, and that he was so good to her. Resident 7 stated that she later learned from another aide that CNA 3 was married and had children. Resident 7 stated that she confronted CNA 3 via text, and he replied something nasty and that was the last of it. Resident 7 stated that she showed the text to one of the important people here and then he got fired. Resident 7 stated that CNA 3 was inappropriate, and that was the reason he lost his job and not her. Resident 7 stated She did nothing inappropriate. When you're a married man you don't ask another woman to be your wife. Obviously he has some mental issues and I don't know where he is now. Resident 7 stated that she texted CNA 3 and asked him if he asked her to be his wife so he could get American citizenship and he replied no. Resident 7 stated that she wished he had continued to be a good CNA and that he was a lot of fun. Resident 7 stated that this occurred approximately 6-8 months ago, and she no longer had contact with CNA 3. Resident 7 stated that CNA 3 had called her a silly woman with delusions and denied that it had occurred. Resident 7 stated that was when she handed the text over to the facility staff. Resident 7 stated that she did not have the text messages any longer and that she may have gotten a new phone since this occurred. Resident 7's medical records were reviewed. On 2/14/24, resident 7's Quarterly Minimum Data Set (MDS) Assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that resident 7 was cognitively intact. On 3/18/24 at 6:11 PM, resident 7's Social Service Note documented, LCSW [Licensed Clinical Social Worker] met with [resident 7] to assess potential indicators of psychosocial distress. [Resident 7] appears friendly, attentive, communicative, well groomed, and happy. She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. Associations are intact. There were no signs of psychotic symptoms. She denies having suicidal ideas. Homicidal ideas or intentions are denied. Cognitive functioning and fund of knowledge are intact and age appropriate. Short- and long- term memory are intact. This patient is fully oriented. Vocabulary and fund of knowledge indicate cognitive functioning in the normal range. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. [Resident 7's] behavior was cooperative and attentive with no gross behavioral abnormalities. When asked about the situation regarding the texts between her and an employee [resident 7] stated 'we were supposed to get married. I don't know why he would ask for pictures. That's not right' and 'he told me he wanted an obedient wife, and I told him children are obedient'. [Resident 7] expressed that 'now he is going to lose his CNA license and I didn't want that to happen.' When LCSW asked her how she was feeling she stated, 'I wish it could go back to how it was before, he was fun and we're not going to talk anymore, he said goodbye'. [Resident 7] was offered mental health services and declined stating 'I'm tired of talking about it.' Screening for s/sxs [signs and symptoms] abuse was negative. Based on review of resident's medical chart, assessments. staff observations, and clinical interview, resident does not appear to be experiencing psychosocial distress. The facility notification to the State Survey Agency (SSA), form 358, documented an allegation of sexual abuse by CNA 3 towards resident 7. The form documented that the Resident Advocate (RA) became aware of the incident on 3/18/24 at 9:22 AM. The details of the incident documented inappropriate phone correspondence between staff and a resident of a sexual nature. The form documented that the incident occurred on 3/14/24. Review of the facility investigation, form 359, revealed an interview that was conducted with resident 7. The interview summary documented, 'He was always very playful and fun with me. He never made any inappropriate comments until he asked to communicate with me through email. I told him that I don't use email well, and we exchanged phone numbers instead. Very early in the conversation, he suddenly said that he wanted me to be his wife. I enjoyed the conversation. Then he started asking me to send him nude photos of my breasts. I was surprised and a little annoyed by that. I told him that he can take them himself the next time he's at work (3/21).' DON [Director of Nursing] offered to assist her with blocking the perpetrator's number and she declined. The next day, upon learning of the investigation, perpetrator sent several frustrated messages to the resident, as divulged by her when DON met with her for the day. Resident expressed that she is not upset by the content of the messages, and when DON again offered to assist her to block the number, she again declined. Resident was not observed displaying any symptoms of distress, physical or psychological harm. She indicated that the two of them had never had any sort of inappropriate physical contact, and a complete skin check revealed no abnormalities. The summary of interviews also documented, No witnesses present with this incident, though the staff member that the resident divulged to read the text messages. The information obtained is quotations from the perpetrator's text messages to the victim: 'Good morning, [resident 7]! I need to get some sleep after my night shift. After that, I will start sending you messages on your cell phone and your email about our future trip to the islands with the aim of your recovery. Have a wonderful day!' '[Resident 7], I just sent a test message to your email. (Kissing emoji)' (The email simply said 'Hello [name omitted], this is a test email' 'Hey [name omitted]! I am so sorry, but I am very busy with my extra work. Don't worry, I am continuing to communicate with you and would like to hug you in a private place. I didn't use a car because public transport in Salt Lake City is perfect. But I understand your desire to make with me always. Would you like to be my wife?' 'Thanks for your amazing messages! But I would like to ask you a simple question: Would you like to be my wife? (Heart emoji)' 'If you are ready to be my wife, then send me a photo fo (sic) your bare breasts. I love you and much!! (Face and heart emoji)' 'Sorry, but you can't see your photo (Heart-eyes emoji)' 'I need an obedient wife, so try to send me your special photo' 'My spoken English is imperfect, so let's correspond .' '[name omitted], do you really love me?' The conclusion of the facility investigation verified the allegation of sexual abuse. The corrective action implemented by the facility was termination of CNA 3. The entry gate code was changed to ensure that CNA 3 had no ability to enter the facility grounds. On 9/30/24 at 2:59 PM, an interview was conducted with the RA. The RA stated that she became aware that resident 7 and CNA 3 had a relationship. The RA stated that it was texting, and she had viewed those text messages. The RA stated that she had taken photos of the text communication between CNA 3 and resident 7 but did not know if she still had those copies. The RA read the text messages that were documented in the facility abuse investigation, form 359, and stated that it was accurate. The RA stated that when she first spoke to resident 7 regarding this incident resident 7 was hinting about it to her. The RA stated that resident 7 seemed happy about the relationship because she thought she had found love. The RA stated that she persuaded resident 7 to show her the text communication with CNA 3. The RA stated that after reading the text messages she explained to resident 7 why it was wrong. The RA stated that she told resident 7 that CNA 3 had professional obligations and could not have relations with any resident, and that it was inappropriate and against the law. The RA stated that resident 7 had reported that nothing physical had happened. The RA stated that resident 7 did not seem upset about the request for nude photos but did state that it was inappropriate. The RA stated that resident 7 had replied that was not who she was, when CNA 3 stated he needed an obedient wife. The RA stated that she reported the incident to the DON immediately. On 10/01/24 at 3:00 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he and the previous ADM conducted the investigation. The ADM stated that CNA 3 had begun texting resident 7. The ADM stated that resident 7 had the right to a romantic relationship but the staff could not have a romantic relationship with residents. The ADM stated that the RA had informed the ADM of the incident. The ADM stated that the RA had informed them of the text messages between resident 7 and CNA 3. The ADM stated that the messages were making resident 7 uncomfortable. The ADM stated it seemed like it was romantic and it went wrong. The ADM stated that he informed CNA 3 by the phone communication app that he was suspended. The ADM stated that they did not speak to CNA 3 and he seemed to avoid all conversation with the facility. The ADM stated that they attempted several times to call CNA 3 but was never able to communicate with him. The ADM stated that they changed the security code to the gate, they communicated with the staff through whats app that CNA 3 was not allowed back in the facility. The ADM stated that when he spoke to resident 7 she was embarrassed about the whole situation. The ADM stated that resident 7 had a good conversation with the RA and DON. The ADM stated We wanted to protect her but wanted to respect her rights. The ADM stated that they asked resident 7 if she wanted to continue talking to CNA 3 after he was terminated or if she wanted them to block his number. The ADM stated that resident 7 did not want to talk to CNA 3 anymore, did not want to respond to his texts, but did not want to block him. The ADM stated that he had viewed the photos of the text messages that the RA had taken. The ADM stated that the text messages included CNA 3 requesting photos of resident 7's bare breasts. The ADM stated that any sort of communication like that was an instant termination. The ADM stated that afterwards they tried to determine if there were any other residents that were involved with CNA 3. The ADM stated that they interviewed 5 other cognitively intact women and asked them if they had ever had any text communication with staff or any request for inappropriate photos from staff. The ADM stated that determined that there were no other incidents of sexual abuse. The ADM stated that they provided staff education after the incident that included professional relationships and what was considered inappropriate. On 10/01/24 at 3:16 PM, an interview was conducted with the DON. The DON stated that they discovered through the RA a relationship between resident 7 and CNA 3. The DON stated that resident 7 had some text messages in which CNA 3 had requested a photo of resident 7's breasts. The DON stated that CNA 3 had texted that he wanted resident 7 to be an obedient wife and it chapped her. The DON stated that resident 7 was a strong willed individual. The DON stated She did not feel victimized, she felt annoyed, and she would not be obedient. The DON stated that resident 7's response to the photo request was come take it yourself. The DON stated that resident 7 did not send a picture, and did not want to be caught up in a photograph. The DON stated that resident 7 was more annoyed by the request. The DON stated that they informed resident 7 of the seriousness and extent of violation that was in healthcare. The DON stated that resident 7 understood and she expressed some sadness because she wanted to be loved. It made her sad. Not because it happened but because it wasn't going to continue. The DON stated that CNA 3 was terminated the same day. The DON stated that he performed a full body skin check on resident 7, and there was no new skin issues. The DON stated that resident 7 adamantly denied anything physical had happened. The DON stated that the incident had occurred the night before. The DON stated resident 7 stated He was playful, flirty and fun and she like it. The DON stated that CNA 3 had tried to initiate email communication, but that resident 7 did not know how to do that. The DON stated that he talked to resident 7 about her emotional status and offered behavioral health services. The DON stated that the LCSW visited resident 7 and assessed her. The DON stated that resident 7 refused to block CNA 3's phone number. She thought it was resolved and he wouldn't continue. The DON stated that resident 7 continued to engage her normal way, but was sad that she did not have that relationship. The DON stated that after CNA 3 was terminated he sent some nasty messages to resident 7, something along the lines of your actions cost me my job. The DON stated that afterwards they initiated an ability to consent by the provider and resident 7 was deemed capable of consenting. The DON stated that even if resident 7 was capable it was not appropriate with a CNA. The DON stated that he called CNA 3 and left a voicemail stating that he was suspended. The DON stated that CNA 3 never called back or texted. The DON stated that corporate human resources called about the termination. The DON stated that they changed the gate code and notified the police department of the incident. The DON stated that they conducted a facility wide sweep to see if any other female residents had any contact with a staff member in an uncomfortable or sexual manner. The DON stated that all responses were negative. The DON stated that they did abuse training and appropriate communication forms afterwards. 2. a. Resident 22 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder, unspecified mood disorder, impulse disorder, insomnia, disinhibited attachment disorder, asthma, anxiety disorder, chronic respiratory failure, and hepatic encephalopathy. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 22's medical records were reviewed. On 4/25/24, resident 22's MDS Assessment documented that a BIMS could not be conducted because resident 22 was rarely or never understood. The assessment documented that resident 22 Mood Interview was not conducted because resident 22 was rarely or never understood. The Assessment documented that resident 22 did not have hallucinations or delusions, and did not have any physical or verbal behavioral symptoms directed toward others. On 6/21/24 at 11:29 PM, resident 22's Social Service Note documented, LCSW met with resident to assess for potential indicators of psychosocial distress. [Resident 22] appears anxious, distracted, minimally communicative, and casually groomed, which is consistent with her typical daily baseline. She exhibits speech that is fast in rate, normal in volume, is coherent at times and is repetitive. There were no signs of psychotic symptoms. Vocabulary and fund of knowledge indicate cognitive functioning in the below normal range. Insight and judgement into problems appears low. [Resident 22] behavior was uncooperative, and she repeated 'I'm good', and 'goodbye. goodbye'. [Resident 22] also 'fist-bumped' LCSW for the second time as she walked away. Based on a review of resident's medical chart, assessments. staff observations, and clinical interview, her behaviors appear to be within her baseline, and it does not appear that she is experiencing psychosocial harm. On 6/27/24, resident 22's skin assessment documented no new skin problems. It should be noted that no documentation could be found that resident 22's skin was assessed after the incident with resident 9 on 6/21/24. On 6/21/24 at 4:47 PM, resident 9's Nurses Note documented, Resident reported to one of the aides that she jabbed another resident with a pen last night 'hard enough to leave a mark' because she is 'fucking psychotic and manic' (referring to herself). Skin check revealed no significant injury on the other resident. On 6/21/24 at 9:50 PM, resident 9's hospital behavioral health intake notes documented that another resident with dementia came into her room, touched her things and resident 9 stabbed her with a pencil. Per pt [patient], she was trying to write 'stop it' on the resident's arm. Pt told staff, 'I'm fucking psychotic and manic.'. The facility notification to the SSA, form 358, documented an allegation of physical abuse by resident 9 towards resident 22. On 6/21/24 At 1530 [3:30 PM] [CNA 2] was toileting [resident 9]. While washing her hands, [resident 9] stated that she is manic bipolar and that today she 'got so psycho' that she stabbed [resident 22] with a pen for toughing (sic) her things. At 1535 [3:35 PM] [CNA 2] informed [name omitted] (Operations Manager) of what she was told. [ADM] told [CNA 2] to tell the DON [name omitted] and to have [resident 22] get a skin check. They found a pen mark with a skin abrasion at 1538 [3:38 PM]. The form documented that resident 22 sustained a skin abrasion to her left forearm. Review of the facility investigation, form 359, revealed, There were no witnesses to the altercation, but our CNA [name omitted] was providing cares when [resident 9] stated that she was experiencing a manic episode and that she had stabbed [resident 22] with a pen which she attributed to her manic episode. Skin assessment was done with [resident 22] to confirm the story and an abrasion was found and the abrasion did match a scratch with a pen due to the ink line still on the skin. The conclusion of the facility investigation verified the allegation of physical abuse. The corrective action implemented by the facility was a Stop sign installed on resident 9's door to prevent resident 22 from wandering into the room. The systemic changes identified were to in-service the staff to re-direct resident 22 when wandering and resident 9 was referred to physical therapy to help channel excess energy of mania. On 9/24/24 at 1:49 PM, an interview was conducted with the DON. The DON stated that he had read the note that resident 9 had not received her Latuda. The DON stated that he called the pharmacy and balled them out. The DON stated that when he identified that the medication was out of stock, he called the pharmacy and they did not provide a good explanation, and that the general explanation was due to a dose change. The DON stated that if a resident was not provided their ordered psychotropic medications, it could cause an exacerbation of their psychiatric illness. The DON stated that resident 9 had an episode of aggression towards resident 22. The DON stated that resident 22 had wandered into resident 9's room and reached for something. The DON stated that resident 9 shouted and jabbed at resident 22. The DON stated that this resulted in a drawing mark on resident 22 but no broken skin. It should be noted that this contradicted form 358 and form 359 that documented an abrasion to resident 9's left forearm. The DON stated that resident 9 was blue sheeted and sent to the hospital for evaluation. The DON stated that resident 9 returned with a diagnosis of a urinary tract infection. The DON stated that interventions after the incident were to place a stop sign so that resident 22 would not wander into resident 9's room. The DON stated that resident 22 was fixated on food and would wander during mealtimes in search of food. The DON stated that staff were instructed to redirect resident 22 during meals. On 9/25/24 at 1:52 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 9 had reported an incident between her and resident 22. CNA 2 stated that resident 9 had been coloring and writing letters. CNA 2 stated that resident 22 frequently takes other residents belongings. CNA 2 stated that resident 9 reported that resident 22 attempted to take her belongings and she stabbed her with a pen. CNA 2 stated that resident 9 was upset that resident 22 took her stuff, and knew she should not have done what she did. CNA 2 stated she asked resident 9 if she had hurt resident 22 and she replied, I don't think so. CNA 2 stated that she finished resident 9's care and reported the incident to the ADM. CNA 2 stated that she checked resident 22's hand and it had an ink mark but no broken skin. CNA 2 stated that resident 22 did not appear in any distress and was lying in bed when she observed the skin. [Cross-refer to F755] 2. b. On 5/3/24 at 10:28 am, the facility reported to the SSA that on 5/3/24 at 8:05 am, a CNA was observed repeatedly yelling Goodbye in an aggressive and mocking tone towards the resident 22 while passing out breakfast trays in the dining room. The facility notification to the SSA, form 358, documented an allegation of verbal abuse by CNA 4 towards resident 22. The form documented the details of the incident as, [RA] observed the CNA [name omitted] yelling 'Goodbye' repeatedly in an aggravating and mocking tone to the resident while [name omitted] was passing breakfast trays. Another CNA, [name omitted] walked the resident away from the dining room. The RA reported the incident to the DON who informed the ADM. The form documented that the immediate steps taken were suspension of the CNA 4. The RA then spoke to resident 22 who was given a fist bump, a hug, and told [RA] 'I'm good, I'm fine.'. Review of the facility investigation, form 359, documented a summary of the interview with resident 22. Per resident's cognitive and communicative baseline, she does not elaborate deeply into the event or how she's feeling. Her responses are curt, largely consisting of 'I'm good, see you later'. Then a fist bump to the RA, which is a baseline pleasantry exchanged with staff. On 5/3/24, a facility interview with CNA 5 documented, I heard someone shouting 'Goodbye, goodbye' repeatedly and responded to the area to find the perpetrator shouting at the victim because she was looking for food. On her [CNA 4] way out I heard her [CNA 4] threating (sic) that 'They better pay me my money or I am going to come back and shoot this place up' in front of [ADM] office. On 5/3/24, a facility interview with Registered Nurse (RN) 3 documented, I heard [CNA 4] shouting and found her saying 'Goodbye' loudly at the resident because she was out looking for the breakfast tray. On her way out I heard her talking back to us but couldn't hear what she said because I was helping another resident. On 5/3/24, a facility interview with the RA documented, I was sitting in my office and heard what sounded like a staff member shouting 'Goodbye' very loudly and seemingly in a mocking way. I responded to find her shouting it toward a resident's face as the resident was searching for snacks on the breakfast tray, which is a behavior of hers. [CNA 4] has a tendency to be abrupt when redirecting resident behaviors, but has never shown a tendency towards mocking or shouting at residents in the past. I went to [resident 22's] room after to see how she was doing and she told me that she was ok and that she was good. She even gave me a hug and a fist bump. The form 359 documented that resident 22 had a medical history of frontotemporal neurocognitive disorder, impulse control disorder, disinhibited attachment disorder, and behaviors related to binge eating from other resident trays while trays are being passed, resulting in a necessity of redirection. Resident 22 had a BIMS of 0. When staff attempt redirection, she will often say 'I'm good, goodbye', which is assumed by the investigators to be where the repeatedly shouted 'Goodbye' stems from. Resident responds well to calm verbal redirection the majority of the time. The conclusion of the facility investigation was verified the allegation of verbal abuse and documented, Incident of abuse verified in this circumstance due to the incident being witnessed by other staff, though resident observes no signs of mental or physical harm and continues to function at her physical and psychosocial baseline. On 9/30/24 at 3:20 PM, a telephone interview was conducted with CNA 5. CNA 5 stated that resident 22 had a behavior of seeking food, and that staff were to get her something to eat and then redirect her. CNA 5 stated that she observed CNA 4 scream at resident 22 in her face and then dragged her back to her room. CNA 5 was read her original statement from the facility investigation and CNA 5 confirmed the accuracy of that statement. CNA 5 stated that CNA 4 had said goodbye to resident 22 and then told her that she did not need to eat. CNA 5 stated that the RA was in her office at the desk and heard what was said by CNA 4. CNA 5 stated that the incident occurred in the TV room. CNA 5 stated that the facility sent CNA 4 home after the incident. CNA 5 stated that she heard CNA 4 state that she was going to blow up the place when she was on her way out the door. CNA 5 stated that CNA 4 made this comment next to the ADM office and that the ADM had also heard the threat. On 9/30/24 at 2:45 PM, an interview was conducted with the RA. The RA stated that she heard from her office the altercation between CNA 4 and resident 22. The RA stated that resident 22 had come out looking for food and CNA 4 was shouting goodbye repeatedly at her. The RA stated that this was during a meal pass in the dining room area. The RA stated that this was said in a raised voice. The RA stated that when she came out of her office, she observed resident 22 walking back to her room. The RA stated that form 359 had a discrepancy in the summary, not sure why it was worded that way. The RA stated that the ADM interviewed her for the investigation. The RA stated that she could not verify the accuracy of the interview summary that was documented by the ADM. The RA stated that she did not recall stating that CNA 4 had a tendency to be abrupt when redirecting resident behaviors. The RA stated that she could have said that CNA 4 has never shown a tendency towards mocking or shouting at residents in the past. The RA stated that she did not witness CNA 4 in resident 22's face shouting, but instead heard the altercation from her office that was located next to where the incident occurred. The RA stated that if you told resident 22 to go back to her room, she would respond by saying goodbye. The RA stated that was why she described CNA 4's comments as mocking towards resident 22. The RA stated that CNA 4 was her sister but she was not her immediate supervisor. The RA stated that she was not present when CNA 4 made the statement when exiting the building. The RA stated that she was aware of the statement though. On 10/1/24 at 10:07 AM, an interview was conducted with the ADM. The ADM stated that when he was first informed of any allegation of abuse he would immediately check for resident safety. The ADM stated that as soon as the resident was deemed safe, he would gather information regarding the incident. The ADM stated that he would gather the details and interview any person who could to corroborate the story. The ADM stated that once he obtained a rough timeline of events then he would determine if a staff member needed to be suspended. The ADM stated that the nurse would assess the resident for any injuries. The ADM stated that he would then report the incident to the SSA, Adult Protective Services, and the ombudsman within 2 hours. The ADM stated that during the investigation he would try to determine if this was a systemic problem verses a one time occurrence. The ADM stated that he gathered information by asking the person reporting to tell him all the details, and then he would follow-up with any other witnesses. The ADM stated that he took notes on the interviews and then summarized in the form 359. The ADM stated that he shredded his notes after he summarized the interviews. The ADM stated that he would also have the interviewee write a statement in their own words and sign it. The ADM stated that he was new at the time of the incident between CNA 4 and resident 22. The ADM stated that he was on the way to the facility when the DON called him and notified him. The ADM stated that the RA had overheard CNA 4 yell at resident 22 in a mocking tone. The ADM stated that CNA 5 stepped in to help separate resident 22 and CNA 4. The ADM stated that they immediately suspended CNA 4. The ADM stated that he told CNA 4 that she was suspended immediately because there was an abuse allegation. The ADM stated that he explained to CNA 4 that if the allegation was not substantiated then she would be paid for the days she was suspended, but if it was substantiated then there was no pay. The ADM stated that CNA 4 responded like a teenager would with disrespect and said, fine I guess. The ADM stated that he asked CNA 4 to grab her things and clock out and they would do the process and keep her informed. The ADM stated that CNA 4 made some negative comments on her way out the door, they better pay me my money or I'm going to come back and shoot this place up. The ADM stated that this was said directly in front of his office window. The ADM stated that he was so shocked by the comment that he had to confirm with CNA 5 and RN 3 what w [TRUNCATED]

Based on interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not immediately consult with the resident's physician and notify when there was an accident involving the resident which resulted in injury; a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment, or a decision to transfer or discharge the resident from the facility. Specifically, a resident had an injury of unknown origin identified and the physician was not notified. Additionally, the physician was not notified when a resident refused blood draws for laboratory orders. Resident identifiers: 14 and 18. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed. On 9/4/24 at 7:06 AM, resident 18's nurse note documented, CNAs [Certified Nurse Assistant(s)] found a bruise on the resident's upper thigh area. This appears to be a new bruise. Resident doesn't know how it happened. On 9/9/24, a skin assessment documented no new skin integrity problems. It should be noted that no documentation could be found of an assessment of the identified bruise. Resident 18's care plan for at risk for skin breakdown was initiated on 8/21/24. The care plan goal was that resident 18 would not develop a pressure injury. Interventions identified were do not massage bony prominence and implement weekly skin checks. It should be noted that the care plan did not have interventions related to monitoring, reporting or treating altered skin conditions. On 10/01/24 at 11:39 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if she identified a newly developed bruise on a resident she would notify the provider, notify the Director of Nursing (DON), document in a progress note and monitor the skin. On 10/01/24 at 11:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that CNAs should notify the nurse of any new skin conditions such as a bruise. The DON stated that the licensed nurse needed to assess the skin to see if it was suspicious before reporting it as abuse. The DON stated that the nurse should notify the provider as a non-urgent symptom to review and there was a list in the provider communication book for issues that needed attention by the provider. The DON stated that the licensed nurse sometimes documented in a progress note, but they were not consistently doing that. The DON stated that the licensed nurse should document a progress note that stated the provider was notified of the condition. 2. Resident 14 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. Resident 14's physician orders revealed the following: a. On 1/18/24, an order for a B-type natriuretic peptide (BNP) and and basic metabolic panel (BMP) was ordered. The order was documented as completed in resident 14's electronic medical records (eMR). b. On 2/22/24, an order for a complete blood count (CBC), a comprehensive metabolic panel (CMP), a thyroid-stimulating hormone (TSH) with reflex thyroxine (T4), a BNP, and a magnesium level (Mg) was ordered. The order was documented as completed in resident 14's eMR. It should be noted that no results could be found for either laboratory order. Review of resident 14's progress notes revealed no documentation of the laboratory results or physician notification. On 10/01/24 at 11:01 AM, an interview was conducted with the DON. The DON stated that on 1/18/24 and 2/22/24 resident 14 refused the lab draw but they did not have documentation of that. The DON stated that the refusal for the blood draws should have been documented in a progress note. The DON stated that the licensed nurse should have notified the physician of resident 14's refusal for the blood draws, and that the refusal and physician notification should have been documented in a progress note.

Based on observation, interview, and record review it was determined for 3 of 27 sampled residents that the facility did not promote the resident right of self-determination through support of the resident's choice. Specifically, the facility prevented cognitively intact residents from exiting the facility premises independently per their choice. Additionally, the physician's evaluation of the residents' ability to exit facility premises independently did not take into consideration the residents' cognitive abilities. The findings for resident 14 were cited at a harm level. Resident identifiers; 14, 25, and 31. Findings include: HARM 1. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/30/19 at 8:53 AM, resident 14 was interviewed. Resident 14 stated that she felt she did not have freedom at the facility. Resident 14 stated that she felt like she was incarcerated and a prisoner because she was not allowed to leave the facility unsupervised. Resident 14 was observed crying while she stated that she needed to take her service dog to the veterinarian because he was sick, and was not allowed to leave the facility. Resident 14 stated that she must have signed away all her rights, but that she did not recall doing this. Resident 14 stated that the facility was misrepresented to her prior to admission as a place where she could come and go. Resident 14 stated that she did not understand the whole suicide thing and that everyone has thoughts of dying at one point in their life. Resident 14 denied having any current suicidal thoughts or plans, and stated she had too much to live for. On 7/1/19 at 10:30 AM, a follow-up interview was conducted with resident 14. Resident 14 stated that she had a hard time getting use to not being able to come and go when she wanted to. Resident 14 stated that a Certified Nurse Assistant (CNA) must go with her when she goes out of the facility but there was not enough staff available to take her where she wanted to go. Review of the hospital History and Physical (H & P) on 4/19/19 for resident 14 documented the present illness as, Patient is a 72 y.o. (year old) female who presented with a chief complaint of foot swelling. Patient came to the ER (emergency room ) because of swelling in her feet. She reports the swelling going on for only a few days. She is homeless, living out of her truck with her animals. In the ER, she admitted , started (sic) she did not care if she lived. She was initially evaluated in the ER, underwent crisis evaluation and was being planned to go to (name of hospital) for further evaluation and stabilization. Patient has a dog with her, dog has a service vest and patient says that he is a service animal. Because she is unwilling to part with her dog, she is not willing to go momentarily to (name of hospital). Social work last night trying to obtain placement for the dog but that was not possible. Again, patient is quite emphatic that she is not able to be separated from her dog. The patient was reportedly seen by (name of physician) but I do not see a note from him. Per the crisis counselor, he felt that she did not require psychiatric inpatient hospitalization . Patient wants to get into a care facility and was brought into the hospital in observation status for placement The assessment and plan for the suicidal comment stated, patient seen by ER, report that another ER doctor did not feel that she was having suicidal ideation. Reevaluated by crisis and patient does not appear to be suicidal. I think patient is trying to be manipulative. A note by the hospital Licensed Clinical Social Worker (LCSW) documented, Advised the whole reason the patient came to the ED last night was because she needs an MD note stating that she needs skilled nursing services due to [MEDICAL CONDITION], swelling in her legs and feet, for assistance with her ADLs (activities of daily living), dressing, showering, and eating. Review of resident 14's progress notes revealed the following: a. On 4/23/19 at 12:57 PM, .admitted to (facility name) on 4/22/19 from (name of hospital). Prior to that she was living out of her suburban with her service dog. She has serval (sic) [DIAGNOSES REDACTED]. She is able to communicate her needs and wants to the staff. Level I PASRR (Pre-Admission Screening Resident Review) indicates there is no need for a level II. Will continue to monitor. b. On 4/24/19 at 7:22 PM, the physician admission note stated, Chief Complaint: post-acute care following hospitalization for [MEDICAL CONDITION] and bilateral leg swelling. HPI (History of Present Illness): Patient was admitted to (name of hospital} on 4/19/2019 with suicidal thoughts and bilateral LE (lower extremity) weakness, complaining of bilateral foot swelling increasing over the previous few days Patient reports a significant medical history of [REDACTED]. She has also had DDD ([MEDICAL CONDITION] Disc Disease) in her L (lumbar) spine which led to spinal stenosis and 3 spine surgeries. With this, she has [MEDICAL CONDITION] affecting sensorimotor to her bilateral lower extremities. She requires the use of AFOs (ankle-foot orthotics). The history documented the resident's living arrangement was homeless and lived out of trailer. The psychosocial assessment documented, Affect is a bit anxious and seemingly defensive. On 4/19/19 the toxicology laboratory results for resident 14 documented, Urine [MEDICATION NAME] Screen Negative, Urine Barbiturate Screen Negative, Urine Benzo Screen Negative, Urine Cannabinoid Screen Negative, Urine Opiate Screen Negative, Urine [MEDICATION NAME] Screen Negative, Urine PCP Screen Negative. The assessment for [MEDICAL CONDITION] documented, Patient was admitted to (name of hospital), partly due to concerns of being potentially suicidal if she was discharged back to her truck. However, she does not come to us on any antidepressants. And she indicates that she does not feel depressed. She refused antidepressants while at (name of hospital) Patient currently does not endorse being suicidal Patient does indicate a history of significant anxiety and panic at times. But she does not come in on any medications for these. c. On 5/8/19 at 3:23 PM, the physician progress notes [REDACTED]. d. On 5/22/19 at 4:31 PM, the physician progress notes [REDACTED].General: Sitting upright in bedside chair, visibly irritable and upset today about numerous issues, including the chaos of the dining room, the PRN (as needed) administration of her [MEDICATION NAME], insisting that she must be allowed to leave the facility unaccompanied. She looks downright angry about a host of issues. The physician's assessment documented, I'm very concerned about her behaviors. Very confrontational and manipulative today and prior visits. Insists that she must be allowed to leave without being accompanied. States that this facility was misrepresented to her as a place that she could freely come and go. Patient became threatening to me stating that my refusal to allow her to leave unaccompanied is tantamount to medical malpractice. She is not interested in recreational therapy excursions. My rationale for not allowing unaccompanied excursions is that she has expressed feeling suicidal here, is an elopement risk, was living in a truck with has no good place to go, and we can find other safer ways to get her some time away. The physician's plan of care was documented as, Change [MEDICATION NAME] to 1 mg (milligram) PO (by mouth) qid (four times a day). Referral to (name of behavioral health services) for depression, anxiety, panic, behaviors and to help guide treatment to eventually allow her to leave unaccompanied as she wishes. e. On 5/29/19 at 8:07 PM, the physician progress notes [REDACTED]. Did not want to increase the [MEDICATION NAME], as it could be construed as a higher dose being needed to treat depression. The physician assessment documented, [MEDICAL CONDITION]: Denies ongoing feelings of depression. Doing OK with the [MEDICATION NAME]: Denies feeling suicidal. The physicians plan was to increase resident 14's [MEDICATION NAME]. On 4/22/19, a wander assessment was completed for resident 14 and identified that the resident was a low risk for wandering. On 5/5/19, the admission Minimum Data Set (MDS) documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated that resident 14 was cognitively intact. Review of resident 14's physical therapy (PT) evaluation and plan of treatment on 5/2/19 documented that therapy services were required to improve walking tolerance. The evaluation documented that resident 14's functional ability for transfers was a stand by assist with a minimum assist for a manual wheelchair. Resident 14 was discharged from PT services on 5/21/19. The Discharge Summary stated resident 14 met the goal of increased bilateral lower extremity strength and was able to perform gait with set up assistance. The summary further stated that resident 14 was able to ambulate with a 4 wheeled walker for 200 feet with set up assistance. Review of the facility Leave of Absence policy stated, Nursing will obtain a physician's orders [REDACTED]. The decision of appropriateness of a leave is made by the physician in conjunction with the interdisciplinary team. On 7/1/19 at 1:16 PM, with the Resident Advocate (RA) was interviewed. The RA stated that only two residents were cleared by the Medical Director (MD) as being able to leave the facility unsupervised, and resident 14 was not one of them. The RA stated that the process for residents to go on leave unsupervised was that the facility MD would assess the resident and determined who could go out independently. The RA stated that the other residents can only leave the facility with supervision by the facility staff or with family members. The RA stated that they find a way to take the residents outside of the facility, usually within 2 days, to accompany them to appointments. On 7/2/19 at 7:06 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that he had worked at the facility for just over a year. RN 1 stated that the Director of Nursing (DON) and MD would assess the residents to determine if they could leave the facility by themselves. RN 1 stated that if the resident was approved for unsupervised Leave of Absence (LOA) then they would sign out in a book when they left the facility. RN 1 stated that those resident's who were allowed to leave the facility unsupervised were located in the LOA book. RN 1 stated that he was not involved in the determination process of who could leave the building unsupervised. RN 1 stated that resident 14 was not able to leave the facility on her own and was only allowed with a responsible party. RN 1 stated resident 14 was alert and oriented to person, place, time and situation. RN 1 stated that resident 14 used a walker for ambulation due to nerve damage in the bilateral lower extremities. RN 1 stated that resident 14 would know how to return to the facility if resident 14 left the facility unsupervised. RN 1 stated that resident 14 was homeless prior to admission to the facility. RN 1 stated that resident 14 had mentioned that she wanted to go back to her truck to get her belongings. RN 1 stated that resident 14 could choose to go out on her own, and had the ability to make that choice, but was not approved for unsupervised LOA. RN 1 stated that resident 14 had a sweet temperament, and he was not aware of any behaviors that resident 14 had. RN 1 stated that he worked the night shift and that resident 14 usually slept most of the time. RN 1 stated that during his shift he would speak to resident 14 when he administered medications at 11:00 PM and 5:00 AM. RN 1 stated that resident 14 had never made any suicidal comments, comments of self harm, or harming others. RN 1 stated that resident 14 got along well with the majority of the residents in the facility. On 7/2/19 at 10:58 AM, an interview was conducted with the facility Administrator. The Administrator stated that resident 14 wanted to take her service dog to a veterinarian (vet) because she had stated that the dog was not eating and was sick. The Administrator stated that the facility had a volunteer who would come to the facility and take the animals to the vet if they were sick. The Administrator stated that the volunteer would take the sick animal to any vet who had an opening. The Administrator stated that the volunteer came to the facility on [DATE] and determined that resident 14's service dog was not sick. The Administrator stated that the volunteer was not a veterinarian but determined the dog was not sick because it was playful. The Administrator stated that the volunteer had made an appointment for the dog to be seen by a vet on 6/28/19. The Administrator had the facility kitchen prepare chicken and rice for the dog and the dog ate all of it. On 6/28/19 the volunteer called the facility and the Administrator stated she informed the volunteer that the dog seemed to be better because it ate all of the food. The Administrator stated she asked resident 14 if she felt that the dog still needed to go out to the vet. Resident 14 stated she did not want the dog to go with a stranger to someplace that she did not know. Resident 14 told the Administrator that the dog would be nervous to go without resident 14. Resident 14 told the Administrator that she wanted the dog to be seen by her vet. Resident 14 provided information of the dog's vet in Idaho. The Administrator explained that they could not take the dog to Idaho. The Administrator stated that resident 14 told her she was a prisoner at the facility because she wanted to go to Idaho. The Administrator stated that she was not sure how to assess the difference between the resident not comprehending and just disagreeing with her decision. The Administrator stated that resident 14 was capable of making a decision to go to Idaho. The Administrator stated she would need to call the corporate office to find out what resident 14 needed to do to go to Idaho. The Administrator stated that she did not assess the situation of transporting the resident and animal to Idaho or call the corporate office to identify options for the resident. The Administrator stated that typically the volunteer would be the person to transport the animal to a local vet and that resident 14 would be allowed to accompany the dog with staff supervision. Resident 14 told the Administrator that she did not want a facility aide to assist her. The Administrator stated that resident 14 wanted to go by herself to the vet and wanted to call a cab. The Administrator stated that resident 14 would be going Against Medical Advice (AMA) if she was to leave without a staff member. The Administrator stated that she did not have resident 14 sign AMA paperwork but explained that this would be the process if resident 14 chose to take her dog to a vet unsupervised. The Administrator again stated that resident 14 was capable of making her own decisions. The Administrator stated that the process for determining which residents could go on LOA without supervision was that the MD would assess if the resident was capable of going out on their own. The Administrator stated that the MD would communicate that to the DON. If residents wanted to go out on leave then the DON would explain to them if she felt there was a medical or physical reason why that resident could not go. The Administrator stated she did not know the LOA policy in detail and that the MD had a few days after admission to determine if the resident had LOA privileges. On 7/2/19 at 7:31 AM, a follow-up interview was conducted the RA. The RA stated that it was the MD who decided when a resident could leave the building unsupervised. The RA stated that she and the DON provided the MD information on the resident to assist in the MD's determination of who had LOA privileges. The RA stated that the MD asked if we thought the resident was safe to leave on their own because we see them all the time and he did not. The RA stated that the MD would obtain input on resident safety and ability to leave the facility. The RA stated that she did not document any recommendations, opinions, or feedback that she provided to the MD. The RA stated that the recommendations included the resident's safety awareness, ability to ambulate and ability to interact with other people out in the community. The RA also stated she assessed if the resident was okay to be out on their own, and if they were cognitively able to care for themselves. The RA stated that she was the individual who conducted the BIMS interview and clicked on the boxes in the assessment. The RA stated that according to the MDS assessment resident 14 was cognitively intact. The RA stated that resident 14 was able to express her needs. The RA was able to identify three current residents in the facility who had LOA privileges. The RA stated that they were safe to go on LOA unsupervised because, they won't exert themselves, they'll return to the facility, and can stand up for themselves. The RA stated that resident 14 was not safe out in the community because she carried all her money with her and people could take advantage of her. The RA stated that she spoke to the MD regarding resident 14's LOA privileges and the RA stated that she believed resident 14 was not safe with ambulation. The RA stated she did not evaluate resident 14 for safe ambulation, I'm just a CNA. The RA stated that resident 14 did have a motorized wheelchair but that the facility did not allow them inside the building as it was too small. The RA stated that the facility had the ability to store resident 14's motorized wheelchair. The RA stated that resident 14 would not be safe in a motorized wheelchair. The RA stated she had not evaluated resident 14 in her motorized wheelchair for safety nor had she seen resident 14 operate it. The RA was unable to state if resident 14 had been evaluated for safety operating her motorized wheelchair. The RA was unable to state the location of resident 14's motorized wheelchair. The RA stated that resident 14 was alert and oriented, capable of making her own decisions, and was her own responsible party. The RA stated that resident 14 was quick to be upset if she felt like she was not being heard, tended to overreact, and extended the truth. The RA stated that resident 14 was irritable at least once a day. The RA stated that resident 14 was not a Christian and held Wiccan beliefs. The RA stated that resident 14 believed that the moon impacted her mood and emotions. The RA stated that resident 14 had not made any statements of self harm, harming others, and that there were no reports from staff of resident 14 doing this. The RA stated that the facility LCSW met with resident 14 on 6/27/19 for the first time. The RA stated that resident 14 had a referral to a behavior health service three weeks ago and that she was the staff responsible for contacting the behavioral health agency. The RA stated that there was no documentation of when the referral was made, and that she did not keep a copy of the faxed referral form. The RA stated that the process was to document a progress note of the referral but that she did not complete a note for resident 14's referral. The RA stated that resident 14 had not been seen by the behavioral health agency yet, they are slow with responding. The RA stated that she had spoken to the nurse from the behavioral health agency yesterday when she was in the facility and was told that they were still working on the referral process. The RA stated that she was assisting resident 14 with a waiver process for obtaining placement in an assisted living facility (ALF). The RA stated that resident 14 had applied for the waiver last week and that she had approximately 3 more weeks at the facility before she was transferred to an ALF. On 7/2/19 at 8:29 AM, the DON was interviewed. The DON stated that the LOA determination process for new admits was that the MD held off on privileges until they got to know the resident. The DON stated that residents could always leave with supervision if not cleared to go out independently. The DON stated that they needed to determine if the resident was safe before they were cleared to leave independently. The DON stated that they were cautious with residents going outside of the facility if they were recent drug users. The DON was unable to state if resident 14 was a recent drug user, but had a history of [REDACTED]. We don't want them to get stuck in the community and can't get back safely. The DON stated that cognitive issues would have to be cleared as well. The DON stated that the wander assessment was used as part of the determination with LOA. The DON stated that the process was to evaluate the nursing assessment, wander risk assessment, and discuss them with MD when a resident requested LOA. The DON stated that she had not discussed LOA for resident 14 with the MD. The DON stated that if the MD had a discussion with resident 14 about LOA it should have been communicated to her. The DON stated she was not aware if resident 14 had requested LOA, I haven't discussed her going LOA at all with her. The DON stated that resident 14 was alert and oriented and cognitively intact. The DON stated that resident 14 had physical limitations with mobility. The DON stated that she was just recently informed last week that resident 14 had a motorized wheelchair. The DON stated that the motorized wheelchair was not at the facility, but that it could be stored at the facility. The DON further stated that resident 14 could use the motorized wheelchair when going outside of the facility, and the facility could make accommodations to have it available for use outside of the facility. The DON stated that if resident 14 needed a motorized wheelchair for ambulation the facility could arrange for a transfer to another facility that would allow the use of one. The DON stated that a transfer would not affect resident 14's waiver for placement in an ALF. The DON stated she had not discussed these options with resident 14. The DON stated that resident 14 was capable of making her own choices, and she had no reason to believe that resident 14 was not safe to go out on LOA. The DON stated that resident 14 had been assessed as safe to live in an ALF. The DON stated that resident 14 had outbursts demonstrated by impatience, excessive tearfulness, and crying. The DON stated that if resident 14 did not like what was being said she would demonstrate impatience and frustration by tearfulness. The DON stated that resident 14 had never made any suicidal statements to her or to other staff. The DON stated that the MD had ordered a referral to a behavioral health agency, but that resident 14 had not been seen by them yet. Again, the DON stated that she was not aware of resident 14's request for LOA, and that the MD had not spoke to her about the resident's request. On 7/2/19 at 12:35 PM, the facility MD was interviewed. The MD stated that resident 14 was previously living in a truck, was hospitalized and then sent to the facility. The MD stated that the first meeting with resident 14, she was a troubled individual with an unhealthy perspective about a variety of things is a control person, and a borderline personality disorder. Pretty sure she has that, she's pretty manipulative about things. The MD was informed that resident 14 did not have a [DIAGNOSES REDACTED]. The MD stated some of the friction points with her was that she hadn't been at the facility long before she wanted to leave the facility. She's one of the ones not allowed to go out on her own. The MD stated that this was not a permanent arrangement but that he wanted to think about it for a little bit. The MD stated that in the hospital resident 14 had suicidal ideation. The MD stated that during the first visit with resident 14 the resident never stated she was suicidal. The MD stated that resident 14 was upset about life in general, did not trust anyone, and had some self defeating behaviors. The MD stated that resident 14 refused treatment with an antidepressant, but wanted anti-anxiety medication. The MD stated, she wanted to get herself drugged up, and has a history of [MEDICAL CONDITION]. It's not wise to give her Benzos and pass to leave and then give her a pass to go out and find alcohol. The MD stated that resident 14 was alert and oriented. The MD stated that he was not sure if resident 14 could make her own decision, I don't know, nothing ever been judged that she can't. She lied to me such as contradicting the history and physical notes. She wasn't really honest with herself. We just make a judgement with what we see in front of us. The MD stated that resident 14 wanted to leave the facility to go to her truck and thought it was still located at the hospital. The MD stated that resident 14 wanted to obtain some personal items from her truck. The MD stated that he was not aware of the location of resident 14's truck. The MD stated that it did not seem like a safe plan for her to leave the facility. The MD stated that resident 14 was angered by this and he brought the meeting to a close. The MD told resident 14 that he would come back and talk to her later. The MD stated that this conversation occurred about a month ago. The MD stated that he had not re-evaluated resident 14 for safety to go on LOA without supervision. The MD stated, maybe we could have done better for her. The MD stated he was not aware if resident 14's alcohol use was a past history or a current use of alcohol. The MD stated that he recalled the hospital records stated resident 14 would drink 3 beers a day. The MD stated that resident 14 denied current use of alcohol but admitted to past use. The MD stated that resident 14 had made a statement that if someone found her dead in her truck it was okay, but that she did not have a plan or make any statements of self harm. The MD stated that resident 14 would get belligerent and would already know what she wanted and if you questioned her she would become impatient. I suspect that we erred on the side of caution. She became confrontational immediately like we flipped a switch . If someone takes my choice away it might be an appropriate response . She just wanted to go and have no one with her. She just needed to go outside the fence. Maybe we kind of . part of it for me was listening to what the nursing staff was telling me. Nurses reported that she was demanding and not reasonable. We probably messed up with her. The MD stated that resident 14 did not want any mental health services. I never felt like I was closing the door with her, I told her it's not a jail and was free to go, but didn't go into detail that she had the option to return to the facility if she went out. I think we messed up on things. I never feel like she was honest. She never wanted to do anything to make us feel better about letting her go. On 7/2/19 at 2:35 PM, a follow-up interview was conducted with resident 14. Resident 14 stated she had talked to the DON, RA, and Licensed Practical Nurse (LPN) 1, and no one would let me go open the gate and go out. Resident 14 stated she was informed that she could not go on LOA after she was admitted to the facility. I found out I couldn't go out as soon as I got here. I wanted to go to (grocery store) and to (name of community center) to speak to my case worker to help with the waiver. Resident 14 stated that she had asked why could she not leave, am I a danger to myself or others? I was told it was for my own safety. Resident 14 stated that now she felt totally crazy because I can't leave. I get no answers why. I don't remember signing away my rights. Resident 14 stated she asked for copies of her paperwork from the RA and has not received it. Resident 14 stated that she had asked the RA many times to leave the facility unsupervised. Resident 14 stated that with her motorized wheelchair she would be safe. Resident 14 stated that she had traveled all over town in her motorized wheelchair with her service dog. I never got hurt, no one ever hurt me and I never hurt anyone. Resident 14 stated that she was not allowed to leave and go out by herself. Resident 14 stated that the facility had not given her a reason why she could not leave, but just stated it was for her own safety and they would be liable. Resident 14 stated that the DON told her it was not allowed for her own safety. Resident 14 stated that she felt like she was not worthy, not responsible for her own well being, and not reliable because she cant go out on her own. Resident 14 stated wanted to go outside to the store and could catch a cab to go there. Resident 14 stated that she did not have a local vet and her previous vet was in Idaho. Resident 14 stated that she needed to find a local vet for her dog. Resident 14 stated that the facility Administrator had contacted a volunteer to take her dog to the vet when he was sick. Resident 14 stated that the Administrator told her that that there was not enough room for her to accompany the volunteer and dog to the vet. Resident 14 stated that the MD told her that because of her background and previous living arrangements in the truck that he did not think she was stable and well enough to go out on her own. Resident 14 stated she was safe, well, and clean even though she was homeless. Resident 14 stated that her housing rotated frequently from family, friends, motels, and the truck. Resident 14 stated that she always had food, showered at a local truck stop, and spent a lot of time at the library. Resident 14 stated that some friends had obtained her possessions from her truck and then it was sold to a junk yard. Resident 14 stated she would return to the facility if she was allowed to leave until she was transferred to an ALF. 2. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/30/19 at 10:13 AM, resident 25 was interviewed. Resident 25 stated that she was unable to leave the facility. Resident 25 stated that she was unable to sign out and had not seen her physician about signing out and go anywhere. Resident 25's medical record was reviewed on 7/2/19. A quarterly MDS dated [DATE] revealed resident 25 had a BIMS conducted. Resident 25 scored a 15 which indicated she was cognitively intact. A care plan dated 5/26/19 and updated on 6/12/19 revealed, resident 25 is a potential elopement risk/wanderer r/t (related to) Disoriented to place, Impaired safety awareness s/t (sic) wandering has not been designated as aimless. (On) 6/11/19 (Resident 25) climbed the fence and eloped from facility, returned later today and has decided to stay. The goals developed were, resident 25's safety will be maintained through the review date. (Resident 25) will demonstrate happiness with daily routine through the review date. (Resident 25) will not leave facility unattended or without signing self out through the review date. The interventions developed were, Assess for fall risk. (Resident 25) will notify facility staff prior to leaving facility and will sign herself out in LOA (Leave of Absence) book, Distract (resident 25) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Identif (TRUNCATED)

Based on observation, interview, and record review, it was determined for 15 of 28 sample residents, that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the facility had not had a SSW (Social Service Worker) or RA (Resident Advocate) since September 2016 and the facility Administrator had been told by the Corporate Administration that he would have to take on the SSW role without any proper training. Additionally, multiple residents were engaged in physical, verbal and sexual abuse, one resident had multiple incidents of placing the call light around her neck, and one resident was improperly discharged to a homeless shelter. In all of the instances, no SSW interventions, behavior contracts, behavior interventions or appropriate discharge planning had been implemented for the involved residents. Resident identifiers: 9, 10, 12, 15, 17, 18, 20, 22, 24, 25, 26, 27, 32, 33 and 34. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 2/21/17 at 3:30 PM. At that time the Administrator was informed that there was a great potential for something catastrophic to happen and was asked to develop an immediate plan to ensure that the residents of the facility were free from the verbal, physical and sexual abuse; that an appropriate discharge plan was in place for each resident; and that the residents had access to medically related social services for behaviors and aggression. On 2/23/17, the facility Administrator provided the following written allegation of removal of the immediate jeopardy: Please see the attached plan of correction to show a credible allegation of removal of the Immediate Jeopardy for Pine Creek. We are alleging the removal of Immediate Jeopardy as of 9:20 PM on 2/22/17. Pine Creek Rehab (Rehabilitation) and Nursing will do the following: -Resident 34 no longer resides at the facility. -Resident 22 no longer resides at the facility. -Resident 27 was evaluated by the Social Services Director to ensure residents safety and needs were met, a social history completed as well as behavior training. LCSW (licensed clinical social worker) interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated her plan of care as needed. -Resident 25 has 15 minute checks in place including what the resident is doing during that 15 minute check. A stop sign was placed across the doorway of his room to keep residents from wandering into his room. He was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated his plan of care as needed. -Resident 26 was ordered one piece jumpsuits that are very comfortable to help ensure the safety of her. She was evaluated by the Social Services Director to ensure resident's safety and needs were met. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated her plan of care as needed. -Resident 9 wears one piece jumpsuits to discourage inappropriate sexual touching. Resident receives Estradiol to decrease sexually inappropriate behavior. He was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated his plan of care as needed. -Resident 12 was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated his plan of care as needed. -Resident 17 was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated her plan of care as needed. -Resident 10 was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated her plan of care as needed. -Resident 15 was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated her plan of care as needed. -Resident 18 was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated his plan of care as needed. -Resident 13 was evaluated by the Social Services Director, a social history complete (sic) as well as behavior training. LCSW interviewed and evaluated resident, completed a Psychosocial Evaluation, evaluate (sic) for proper placement and updated his plan of care as needed. -A new Administrator and Social Services Director have been hired and started immediately. -The Social Services Director completed social history's (sic) on each of the residents in the facility and behavior training on current residents to the facility staff. (See attachment 6). -The LCSW reevaluated (sic) resident's (sic) plan of care and ensured all are appropriate, up to date and current for all residents. -The Administrator and Social Services Director held an Adhoc (sic) resident council meeting to reeducated (sic) current residents on the resident's (sic) rights to be free from harm or abuse. This education included inappropriate and unacceptable behavior i.e. (that is): hitting, slapping, yelling, inappropriate touching, spitting etc. (etcetera) (See attachment 7). -The Administrator completed staff education on the abuse prohibiting (sic) policy and procedure, abuse allegation and reporting, and reporting abuse focused rounds. (See attachment 8). -The Administrator consulted with LCSW regarding behavioral training's (sic) with staff and completed staff education on De-escalating a Resident Behavior Crisis, De-escalating Aggressive Behaviors, A Positive Physical Approach, Having a Conversation, and Communication Tips with the Alert Elderly. (See Attachment 9). -The Administrator and LCSW educated the Social Services Director on the policy for Medical Related Social Services. (See Attachment 10). -The Administrator met with the LCSW and went over his expectation as to her monthly visits, consultant reports, follow up and follow through, completing (sic) of her assessments and care plans on time, and communication to the staff of her implementations of her care plans and interventions. (See attachment 11). -The Social Services Director contacted State Ombudsman, (name of ombudsman) to help with ongoing and future training's (sic). State Ombudsman will be in to conduct follow up training and education on March 23, 2017 at 2:00 PM. -All incident reports will be brought to standup meeting and reviewed ensuring that if; any abuse allegations were made, inappropriate behavior was conducted, or any injury of unknown origin were noted, that proper procedures were taken. -The Administrator/Designee will conduct Abuse Prevention Focus Rounds to ensure staffs (sic) continued understanding and training of abuse prevention. (See Attachment 12). -The Administrator/Designee will conduct Focus Rounds 3 times per week to ensure resident specific interventions continue to be implemented and followed. (See Attachment 13). -The Administrator/Designee will complete Abuse Focus Rounds weekly to ensure all residents to (sic)continue to be free from abuse and all staff remains educated. (See Attachment 14). -Identified trends will be addressed immediately as well as reviewed and reported monthly and as needed to the Quality Assurance Committee until a lesser frequency is deemed appropriate. On 2/23/17, The State Agency reviewed Pine Creek Rehab and Nursing immediate plan of correction for removal of the immediate jeopardy for abuse and confirmed the abatement of the Immediate Jeopardy situation as of 2/22/17. Findings include: 1. Resident 27 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17 resident 27's medical record was reviewed. A nurse's note dated 1/29/17 at 12:00 PM revealed that resident 27 had swelling increased to right eye, dark purple area to lateral/inferior right eye, red abrasion to upper right cheek at zygomatic area. MD (medical director) notified, send (sic) to ER (emergency room ) to eval (evaluate) injury to right eye. An incident report dated 1/29/17 at 10:15 AM for resident 27 revealed Pt (patient) reported that another resident (resident 34) hit her, pt stated that other resident was putting something in railing outside in back porch ramp area, she stated she told him to stop. He got mad and smacked me as hard as he could. Asked if (resident 34) hit with open or closed hand, pt stated open . According to the incident report resident 27 had swelling, dark purple/red bruising to lateral inferior R (right) eye, abrasion to R cheek. A hospital report dated 1/29/17 for resident 27 revealed that there is a fracture of the nasal bone noted with depression of the nasal bone on the right side. A nurse's note dated and an incident report dated 9/7/16 at 16:38 (4:38 PM), for resident 27, revealed that resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. A nurse's note dated 10/30/16 revealed Pt reported that another resident (Resident 22) 'hit' her, she stated she did not know why but that 'he just came up and hit me, I wasn't doin (sic) nothin (sic).' CNA (Certified Nursing Assistant) was present and witness (sic) pt slapped (Resident 22) and called him 'asshole', (Resident 22) slapped back and the two pts slapped at each other until separated by CNA, no redness to face or cheek where she stated she was hit. No injury noted. Pt denies any pain. Pt stated she will avoid being near (Resident 22) to prevent further incidence. An incident report dated 10/30/16 revealed (Resident 27) reported that pt had 'hit' her, CNA witnessed (Resident 27) 'slap' pt first then pt (Resident 22) slapped (Resident 27) back. The two pt's slapped at each other until separated by CNA. No injury noted. Pt (Resident 22) stated 'she attacked me and called me names, what was I supposed to do'? A nurse's note dated 2/9/17 at 1900 and an incident report dated 2/9/17 at (7:00 PM) revealed This nurse saw (Resident 27) outside of room 108 and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room 108 and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD (Medical Doctor) ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON about it tomorrow (NOTE: The report was filed by the police department and was case number 17- .) The MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 27 had a BIMS (Brief Interview for Mental Status) score of 10 which indicated that resident 27 had moderate cognitive impairment. Resident 27's care plan was reviewed. A behavior care plan dated 3/10/15 revealed that resident 27 had a problem of History of suicide attempts by jumping off a balcony, attempting to go into traffic, cutting self and overdose. History of violence toward staff. The goal for resident 27 was (Resident 27) will be safe from self harm and will not harm others or cause resident to resident incidents. The interventions on the care plan for resident 27 included the following: 1. When she is anxious, frustrated or upset, offer supportive listening and encourage her to go for a walk or talk to staff. 2. When she is calm, encourage her to do the things she enjoys such as TV (television), listen to music, walk and/or read books. 3. Ask her if she is in pain. If she complains of leg pain, encourage her to tell nursing and elevate her leg and walk less. 4. If he agrees to receiving her calls, remind her she can call her ex-husband if she wants to. 5. Be sure she swallows her pills and does not cheek them. 6. Remind her that it is safest for her to stay in the yard and not go out the gate or into the community alone. 7. If she says that she wants to hurt herself or kill herself, call the doctor and call '911'. 8. Keep in line of sight supervision until situation is resolved. 9. Coordinate/follow up with mental health services for medication management and other supportive services as needed. 10. Each day ensure her room is free of items she could potentially use to harm herself: call light cords, belts, plastic bags, unswallowed medications, glass items and anything labeled keep out of the reach of children. 2. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/16/17 resident 26's medical record was reviewed. A nurse's note dated 1/21/16 and an incident report dated 1/21/16 for resident 26, revealed (Resident 26) was standing at the door looking outside when (Resident 25) came up in back of her and began to grope her on her buttocks to her vaginal area and up to her breasts. He was immediately sent to another area in the facility. (resident 26) stated 'thank you'. (NOTE: No report was filed with the State Survey Agency. No police report was filed regarding the incident. No report was filed with the Adult Protective Services Agency.) The MDS assessment dated [DATE] revealed that resident 26's BIMS score was 6 which indicated that resident 26 had severe cognitive impairment. A care plan for resident 26 dated 4/28/15 revealed the problem Resident 26 has impaired cognitive function/dementia or impaired thought processes r/t (related to) dementia. The goal for resident 26 was (Resident 26) will be able to communicate basic needs on a daily basis through the review date. (Resident 26) was sexually groped by a male resident while she was standing in front of the front glass door. As a result, she will be closely monitored when she is roaming the hallways by herself to make sure that she is safe at all times. The interventions for resident 26 on the care plan included the following: 1. Ask yes/no questions in order to determine the resident's needs. 2. Communication: use the resident (sic) preferred name. Identify yourself at each interaction. 3. Face (Resident 26) when speaking and make eye contact. 4. Reduce any distractions-turn off TV, radio, close door etc. (etcetera). The resident understands consistent simple directive sentences. 5. Provide the resident with necessary cues-stop and return if agitated. Cue, reorient and supervise as needed. Present just one thought, idea, question or command at a time. 6. Use task segmentation to support short term memory deficits. Break tasks into one step at a time. A care plan for resident 26 dated 4/28/15 revealed that (Resident 26) goes into male residents' rooms and male residents will fondle her. Since she is seeking male attention and affection, this does not appear to be abusive in nature. The goal for resident 26 was (Resident 26) will not receive any unwanted or unsolicited touching or groping by others Q (every) day. The interventions for resident 26 included the following: 1. Monitor (Resident 26's) whereabouts closely to ensure she is not seeking affection from other residents who are too confused to consent and to ensure that she is not receiving unwanted advances. 2. Put stop sign across other resident's doorways as needed. 3. Talk to guardian about obtaining some one piece jumpsuits for (Resident 26). 4. Remind male residents she interacts with that touching is off limits (NOTE: No observations were made throughout the facility on 2/14/17 and 2/15/17 of a stop sign placed across any resident room nor was resident 26 wearing any one piece jumpsuit until 2/23/17. The stop sign was observed on 2/16/17 and 2/17/17 on multiple instances to be hanging from one side of the door for resident 25's room and lying on the floor.) An incident report dated 9/7/16 revealed that (Resident 9) was sitting in a chair next to (Resident 26). (Resident 9) had his hand up the shirt of (Resident 26) where he was inappropriately touching her breast. When Housekeeper (HK) 1 came in room and saw, she told him to stop and separated immediately. The investigation conducted by the facility LCSW revealed that resident 9 was talked with immediately after this incident was reported. (Resident 9) did admit to sexually touching (Resident 26) but stated that '(resident 26) asked him to.' (Resident 9) was immediately taken to his personal bedroom. He was talked with very seriously about this incident by the facility SSW (Social Service Worker), LCSW and facility DON. The interview by the LCSW with HK1 revealed that She (HK 1) reported the incident as she saw it when she walked into the main TV/Living room area. (Resident 9) was sitting in a chair next to (Resident 26) where he was inappropriately touching her breast. When (HK1) saw what was happening, she told (Resident 9) to 'stop' and then reported this incident immediately to management. She (HK1) stated more specifically that (Resident 26) had one of her breasts completely out of her shirt and (Resident 9) was touching resident 26's nipple with his fingers. A Nurse's note dated 1/16/17 revealed that It was reported by another resident, that he saw (Resident 26) get touched inappropriately by another resident. (Resident 22) said he saw this resident (Resident 26) wander into their room and (Resident 25) 'felt her up.' When asked what he saw, he stated he saw (Resident 25) put his hands in her brief and move his hands towards the front of her brief. (Resident 26) showed no signs of injury. She was taken to her room and monitored so she does not make her way down the hall and into that room again (NOTE: Resident 26 was sexually molested by resident 25 in January 2016 and again by resident 25 in January 2017. Resident 25 remained in the facility. Resident 26 continuously roamed the hallways by herself.) An incident report dated 1/16/17 for resident 26 revealed that It was reported by another resident, that he saw (Resident 26) get touched inappropriately by another resident. (Resident 22) said he saw this resident (Resident 26) wander into their room and (Resident 25) 'felt her up.' When asked what he saw, he stated he saw (Resident 25) put his hands in her brief and move his hands towards the front of her brief. The MDS assessment dated [DATE] revealed that resident 26 BIMS score was 0 which indicated that resident 26 had severe cognitive impairment (Note: the BIMS was down 6 points from the BIMS score on 3/4/16). On 2/15/17 at 2:00 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they try to redirect resident 26 to keep resident 26 out of other resident rooms and that they put a stop sign across the door to prevent resident 26 from entering resident 25's room. The facility DON stated that I can't tie her up. On 2/16/17 at 3:18 PM, an interview was again conducted with the facility DON. The facility DON stated that she had instructed her staff on nursing interventions for aggressive and violent behaviors, which was primarily redirection. The facility DON stated that she had informed resident 25 after he sexually assaulted resident 26 on 1/21/16, that if he assaulted resident 26 again, that the police would be notified and that resident 25 had verbalized understanding. The facility DON stated that the surveyors needed to read a note authored by the Social Work Consultant (SWC). The facility DON stated that the SWC had written that resident 26 was How do I put this? Wants the attention and affection from men. When the State Surveyors asked if resident 26 was seeking sexual attention or sexual favors from the residents of the facility, the DON stated I don't know about sexual favors but yes, she seeks the sexual attention from the male residents in the facility and I cannot keep (Resident 26) out of (resident 25's) room. The facility DON stated that the police had not been notified after the first or second incident. The facility DON stated that the police had not been notified after the second incident in which resident 25 sexually assaulted resident 26 on 1/16/17 because it had occurred, on the night shift or the weekend. I was at home. The DON stated that the police should have been notified the next day, but were not. The DON stated that resident 26 was non-verbal but would answer yes or no questions and that resident 26 had dementia. The DON further stated that she had in-serviced her staff regarding abuse prevention. On 2/17/17 at 2:00 PM, an interview was conducted with CNA (Certified Nursing Assistant) 5. CNA 5 stated that resident 26 was not allowed in resident 25's room. CNA 5 stated that facility staff, including herself, had been informed yesterday that the stop sign needed to hang across the doorway to resident 25's room to prevent resident 26 from entering. 3. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 22 sitting in his wheelchair outside of his room. Resident 22 was observed to be waiting to enter his room as the floor was wet from housekeeping mopping the floor and a caution sign was observed in the doorway. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 26 as she wandered up and down the hallway. Resident 26 was observed to enter resident 22's room. Resident 22 was observed to yell at resident 26, Get out of there! The floor is wet. Resident 26 was observed to stay in resident 22's room and not respond to resident 22. Resident 22 was observed to get up from his wheelchair to confront resident 26 and yelled at her, Dumb [***] . CNA 1 was then observed to intervene by removing resident 26 from resident 22's room and led resident 22 down the hallway toward the nurse's station. On 2/14/17 at 8:05 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 had a history of [REDACTED]. On 2/14/17 the facility Administrator was asked for all of the incident reports for resident 22's altercations with other residents. A review of the facility's abuse investigations revealed that resident 22 had multiple incidents of physical and verbal abuse toward other residents. The documentation of the incidents revealed that the residents were always separated. On 2/14/17 at 2:15 PM, after the state surveyors returned from lunch, resident 22 could not be located in the facility. Resident 22's medical record could not be located on the facility online medical record. On 2/14/17 at 2:30 PM, an interview was conducted with the DON. The DON stated that resident 22's records could be found in the online medical record, under the discharged residents. The state surveyor asked the DON if they had discharged resident 22. The DON stated that they had discharged resident 22 to the homeless shelter. The DON stated that the reason for the discharge was that resident 22 was volatile and that the facility could not meet his needs. On 2/14/17 at 2:35 PM, an interview was conducted with the DON and Administrator (ADM) 1. The DON and ADM 1 stated that they had been told by the Corporate Nurse (CN) that they needed to discharge resident 22 immediately. The DON stated that resident 22 had been taken to the homeless shelter in the facility van. The DON stated that resident 22's medications had not been sent with him as he was not capable of medicating himself. The DON stated that resident 22's medications were taken by ADM 2 to the homeless shelter later on and dropped off at the front desk of the reception area of the homeless shelter. A review of resident 22's care plans dated 8/2/16 revealed that no care plan had been created for resident 22 for a safe, orderly discharge from the facility. On 2/14/17 at 3:15 PM, an interview was conducted with the Corporate Nurse (CN). The CN stated that she did not know if resident 22 was admitted to a medical bed at the homeless shelter and would find out. The CN stated that they had been in contact with resident 22's POA (Power of Attorney) yesterday when she was in the facility and that they had discussed resident 22's discharge. The CN stated that the POA had told the facility to just discharge him to the homeless shelter. On 2/14/17 at 4:04 PM, an interview was conducted with resident 22's POA. Resident 22's POA stated that she had visited with resident 22 yesterday and had brought resident 22 some cigarettes. The POA stated that the facility DON had mentioned that resident 22's behaviors had been escalating and thanked the POA for her cooperation in addressing the behaviors, but denied that they had ever talked about any plans to discharge resident 22. The POA stated that she had been informed by the ADM 1 on 2/14/17 at approximately 1:00 PM via a telephone call that resident 22 was going to be discharged immediately to the homeless shelter due to the ongoing behaviors and altercations with other residents and that the facility was no longer able to provide care for resident 22. The POA stated that she had asked if she could make some phone calls to try to make alternative arrangements for resident 22 and was denied the time to do that by ADM 1 because the discharge was to be effective immediately. The POA further stated that she felt that this plan was not safe and was pretty crappy. The POA stated that the facility was very aware of (resident 22's) anger management issues, dementia and long term abuse of alcohol. The POA stated that she was worried about resident 22's well being and that he was not with it enough to make decisions, often confused and unable to recall the city he is residing in. The POA stated that she was afraid that (resident 22) will end up dead. On 2/14/17 at 4:35 PM, an interview was again conducted with the CN. The CN stated that resident 22 had not been admitted to a medical bed at the homeless shelter, as they were full. The CN stated that resident 22 was not a candidate for that area of the shelter and that because of that, his medications could not be administered to him. The CN stated that because of this, we are going to go pick him up tonight from the homeless shelter and not discharge him because this cannot come back on us. On 2/14/17 resident 22's medical record was reviewed. A patient history dated 6/30/16 from a behavioral hospital that resident 22 had been admitted to prior to the facility revealed that resident 22 had dementia aggression and alcohol dependence. [AGE] year old male medically cleared at (Name of Hospital). Family called police on patient for being intoxicated and belligerent. Hard of hearing. Per sister in law of patient he has been declining for months. Family unable to care for him at home Was kicked out of (Name of Assisted Living Facility) for being belligerent with staff. Patient has made suicidal comments and threats to harm others. Has hidden knifes (sic) to lash out at staff. Cheeking meds (medications) Needs locked facility. Has passive suicidal ideation and passive homicidal ideation. Patient refuses counseling. Suspected substance use but no verification. Very treatment resistant and aggressive. A facility Psychosocial assessment dated [DATE] revealed Prior living arrangement: (Resident 22) came to this facility from (Name of Behavioral Hospital). He was removed from a prior facility for aggressive physical actions towards staff and other residents. He has also been homeless, living in (another state) 'with a group of other people who lived in tents and wrapped in blankets at night to sleep (Resident 22) appears alert and oriented to person, place and situation with some forgetfulness at times. His short term memory and long term memory appears intact. (Resident 22) can make his own daily decisions as to what he wants to do (Resident 22) gets upset over not being able to smoke whenever he wants to. Assessment of behavioral concerns: (Resident 22) has been physically and verbally aggressive since his admission to this facility There is not a plan to have (Resident 22) return to living in the community outside of a residential placement. A nurse's note dated 9/7/16 at 16:38 (4:38 PM) and an incident report dated 9/7/16 revealed that resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. A nurse's note dated 10/30/16 revealed Pt reported that another resident (Resident 22) 'hit' her, she stated she did not know why but that 'he just came up and hit me, I wasn't doin (sic) nothin (sic).' CNA was present and witness (sic) pt slapped (Resident 22) and called him 'asshole', (Resident 22) slapped back and the two pts slapped at each other until separated by CNA, no redness to face or cheek where she stated she w

Based on observation, interview and record review, it was determined for 14 of 28 sample residents, that the facility failed to ensure that residents were free from abuse, including verbal, physical and sexual abuse. Specifically, one resident had her nose broken after she was hit in the face by another resident, one resident had multiple incidents of fondling and molestation and multiple residents were engaged in physical hitting, kicking, and verbal attacks. No documentation could be found to show that facility staff implemented interventions specific to perpetrators to stop the abuse nor the victims to prevent futher abuse, including sexual assault, from occurring. The facility's failure to implement the policies and procedures for abuse was determined to constitute immediate jeopardy to resident safety. Resident identifiers: 9, 10, 12, 15, 17, 18, 20, 22, 24, 25, 26, 27, 33, and 34. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 2/21/17 at 3:30 PM. At that time the Administrator was informed that there was a great potential for something catastrophic to happen and was asked to develop an immediate plan to ensure that the residents of the facility were free from the verbal, physical, and sexual abuse. On 2/23/17, the facility Administrator provided the following written allegation of removal of the immediate jeopardy: Please see the attached plan of correction to show a credible allegation of removal of the Immediate Jeopardy for Pine Creek. We are alleging the removal of Immediate Jeopardy as of 9:20 PM on 2/22/17. -A new Administrator and Social Services Director have been hired and started immediately. -The facility Social Services Director completed social history's on each of the residents in the facility and behavior training on current residents to the facility staff. (See attachment 6). -The facility LCSW (Licensed Clinical Social Worker) reevaluated resident's plan of care and ensured all are appropriate, up to date and current for all residents. -The Administrator and Social Services Director held an Adhoc resident council meeting to reeducated (sic) current residents on the resident's rights to be free from harm or abuse. This education included inappropriate and unacceptable behavior i.e.: hitting, slapping, yelling, inappropriate touching, spitting etc. (See attachment 7). -The Administrator completed staff education on the abuse prohibiting policy and procedure, abuse allegation and reporting, and reporting abuse focused rounds. (See attachment 8). -The Administrator consulted with LCSW regarding behavioral training's with staff and completed staff education on De-escalating a Resident Behavior Crisis, De-escalating Aggressive Behaviors, A Positive Physical Approach, Having a Conversation, and Communication Tips with the Alert Elderly. (See Attachment 9). -The Administrator and LCSW educated the Social Services Director on the policy for Medical Related Social Services. (See Attachment 10). -The Administrator met with the LCSW and went over his expectation as to her monthly visits, consultant reports, follow up and follow through, completing of her assessments and care plans on time, and communication to the staff of her implementations of her care plans and interventions. (See attachment 11). -The Social Services Director contacted State Ombudsman, (name of State Ombudsman) to help with ongoing and future training's. State Ombudsman will be in to conduct follow up training and education on March 23, 2017 at 2:00 PM. -All incident reports will be brought to standup meeting and reviewed ensuring that if; any abuse allegations were made, inappropriate behavior was conducted, or any injury of unknown origin were noted, that proper procedures were taken. -The Administrator/Designee will conduct Abuse Prevention Focus Rounds to ensure staffs continued understanding and training of abuse prevention. (See Attachment 12). -The Administrator/Designee will conduct Focus Rounds 3 times per week to ensure resident specific interventions continue to be implemented and followed. (See Attachment 13). -The Administrator/Designee will complete Abuse Focus Rounds weekly to ensure all residents to continue to be free from abuse and all staff remains educated. (See Attachment 14). -Identified trends will be addressed immediately as well as reviewed and reported monthly and as needed to the Quality Assurance Committee until a lesser frequency is deemed appropriate. On 2/23/17, The State Agency reviewed the immediate plan of correction for removal of the immediate jeopardy for abuse and confirmed the abatement of the Immediate Jeopardy situation as of 2/22/17. Findings include: 1. Resident 27 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17, resident 27's medical record was reviewed. An incident report dated 1/29/17 at 10:15 AM, for resident 27 revealed Pt (patient) reported that another resident (resident 34) hit her, pt stated that other resident was putting something in railing outside in back porch ramp area, she stated she told him to stop. He got mad and smacked me as hard as he could. Asked if (resident 34) hit with open or closed hand, pt stated open . According to the incident report resident 27 had swelling, dark purple/red bruising to lateral inferior R (right) eye, abrasion to R cheek. A nurse's note dated 1/29/17 at 12:00 PM, revealed that resident 27 had swelling increased to right eye, dark purple area to lateral/inferior right eye, red abrasion to upper right cheek at zygomatic area. MD (Medical Doctor) notified, send to ER (emergency room ) to eval (evaluate) injury to right eye. A hospital report dated 1/29/17, for resident 27 revealed that there is a [MEDICAL CONDITION] bone noted with depression of the nasal bone on the right side. A nurse's note dated 9/7/16 at 4:38 PM, for resident 27, revealed that resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. An incident report dated 9/7/16, for resident 27 revealed resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. A nurse's note dated 10/30/16, revealed Pt reported that another resident (Resident 22) 'hit' her, she stated she did not know why but that 'he just came up and hit me, I wasn't doin (sic) nothin (sic).' CNA (Certified Nursing Assistant) was present and witness (sic) pt slapped (Resident 22) and called him 'asshole', (Resident 22) slapped back and the two pts slapped at each other until separated by CNA, no redness to face or cheek where she stated she was hit. No injury noted. Pt denies any pain. Pt stated she will avoid being near (Resident 22) to prevent further incidence. An incident report dated 10/30/16, revealed (Resident 27) reported that pt had 'hit' her, CNA witnessed (Resident 27) 'slap' pt first then pt (Resident 22) slapped (Resident 27) back. The two pt's slapped at each other until separated by CNA. No injury noted. Pt (Resident 22) stated 'she attacked me and called me names, what was I supposed to do'? A nurse's note dated 2/9/17 at 7:00 PM, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON (Director of Nursing) about it tomorrow (Note: The report was filed by the police department and was case number 17- .) An incident report dated 2/9/17, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON about it tomorrow The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 27 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated that resident 27 had moderate cognitive impairment. Resident 27's care plan was reviewed. A behavior care plan dated 3/10/15, revealed that resident 27 had a problem of History of suicide attempts by jumping off a balcony, attempting to go into traffic, cutting self and overdose. History of violence toward staff. The goal for resident 27 was (Resident 27) will be safe from self harm and will not harm others or cause resident to resident incidents. The interventions on the care plan for resident 27 included the following: 1. When she is anxious, frustrated or upset, offer supportive listening and encourage her to go for a walk or talk to staff. 2. When she is calm, encourage her to do the things she enjoys such as TV (television), listen to music, walk and/or read books. 3. Ask her if she is in pain. If she complains of leg pain, encourage her to tell nursing and elevate her leg and walk less. 4. If he agrees to receiving her calls, remind her she can call her ex-husband if she wants to. 5. Be sure she swallows her pills and does not cheek them. 6. Remind her that it is safest for her to stay in the yard and not go out the gate or into the community alone. 7. If she says that she wants to hurt herself or kill herself, call the doctor and call '911'. 8. Keep in line of sight supervision until situation is resolved. 9. Coordinate/follow up with mental health services for medication management and other supportive services as needed. 10. Each day ensure her room is free of items she could potentially use to harm herself: call light cords, belts, plastic bags, unswallowed medications, glass items and anything labeled keep out of the reach of children. 2. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/16/17, resident 26's medical record was reviewed. A nurse's note dated 1/21/16, revealed that resident 26 was standing at the doorway looking out when a male resident (Resident 25) came up behind her and began to touch her buttocks area around to her vaginal area and up to her breast. He was immediately taken to another area of the facility An incident report dated 1/21/16, for resident 26 revealed (Resident 26) was standing at the door looking outside when (Resident 25) came up in back of her and began to grope her on her buttocks to her vaginal area and up to her breasts. He was immediately sent to another area in the facility. (Resident 26) stated 'thank you'. (Note: No report was filed with the State Agency. No police report was filed regarding the incident. No report was filed with the Adult Protective Services Agency.) The MDS assessment dated [DATE], revealed that resident 26's BIMS score was 6 which indicated that resident 26 had severe cognitive impairment. A care plan for resident 26 dated 4/28/15, revealed the problem Resident 26 has impaired cognitive function/dementia or impaired thought processes r/t (related to) dementia. The goal for resident 26 was (Resident 26) will be able to communicate basic needs on a daily basis through the review date. (Resident 26) was sexually groped by a male resident while she was standing in front of the front glass door. As a result, she will be closely monitored when she is roaming the hallways by herself to make sure that she is safe at all times. The interventions for resident 26 on the care plan included the following: 1. Ask yes/no questions in order to determine the resident's needs. 2. Communication: use the resident preferred name. Identify yourself at each interaction. 3. Face (Resident 26) when speaking and make eye contact. 4. Reduce any distractions-turn off TV, radio, close door etc. The resident understands consistent simple directive sentences. 5. Provide the resident with necessary cues-stop and return if agitated. Cue, reorient and supervise as needed. Present just one thought, idea, question or command at a time. 6. Use task segmentation to support short term memory deficits. Break tasks into one step at a time. A care plan for resident 26 dated 4/28/15, revealed that (Resident 26) goes into male residents' rooms and male residents will fondle her. Since she is seeking male attention and affection, this does not appear to be abusive in nature. The goal for resident 26 was (Resident 26) will not receive any unwanted or unsolicited touching or groping by others Q (every) day. The interventions for resident 26 included the following: 1. Monitor (Resident 26's) whereabouts closely to ensure she is not seeking affection from other residents who are too confused to consent and to ensure that she is not receiving unwanted advances. 2. Put stop sign across other resident's doorways as needed. 3. Talk to guardian about obtaining some one piece jumpsuits for (Resident 26). 4. Remind male residents she interacts with that touching is off limits (Note: No observations were made throughout the facility on 2/14/17 and 2/15/17 of a stop sign placed across any resident room nor was resident 26 wearing any one piece jumpsuit until 2/23/17. The stop sign was observed on 2/16/17 and 2/17/17 on multiple instances to be hanging from one side of the door for resident 25 and lying on the floor.) An incident report dated 9/7/16, revealed that (Resident 9) was sitting in a chair next to (Resident 26). (Resident 9) had his hand up the shirt of (Resident 26) where he was inappropriately touching her breast. When Housekeeper (HK) 1 came in room and saw, she told him to stop and separated immediately. The investigation conducted by the facility LCSW revealed that resident 9 was talked with immediately after this incident was reported. (Resident 9) did admit to sexually touching (Resident 26) but stated that 'resident 26 asked him to.' (Resident 9) was immediately taken to his personal bedroom. He was talked with very seriously about this incident by the facility SSW (Social Service Worker), LCSW and facility DON. The interview by the LCSW with HK1 revealed that She (HK 1) reported the incident as she saw it when she walked into the main TV/Living room area. (Resident 9) was sitting in a chair next to (Resident 26) where he was inappropriately touching her breast. When (HK1) saw what was happening, she told (Resident 9) to 'stop' and then reported this incident immediately to management. She (HK1) stated more specifically that (Resident 26) had one of her breasts completely out of her shirt and (Resident 9) was touching resident 26's nipple with his fingers. A Nurse's note dated 1/16/17, revealed that It was reported by another resident, that he saw (Resident 26) get touched inappropriately by another resident. (Resident 22) said he saw this resident (Resident 26) wander into their room and (Resident 25) 'felt her up.' When asked what he saw, he stated he saw (Resident 25) put his hands in her brief and move his hands towards the front of her brief. (Resident 26) showed no signs of injury. She was taken to her room and monitored so she does not make her way down the hall and into that room again (Note: Resident 26 was sexually molested by resident 25 in January 2016 and again by resident 25 in January 2017. Resident 25 remains in the facility. Resident 26 continuously roams the hallways by herself.) An incident report dated 1/16/17, for resident 26 revealed that It was reported by another resident, that he saw (Resident 26) get touched inappropriately by another resident. (Resident 22) said he saw this resident (Resident 26) wander into their room and (Resident 25) 'felt her up.' When asked what he saw, he stated he saw (Resident 25) put his hands in her brief and move his hands towards the front of her brief. The MDS assessment dated [DATE], revealed that resident 26's BIMS score was 0 which indicated that resident 26 had severe cognitive impairment. On 2/15/17 at 2:00 PM, an interview was conducted with the facility DON. The facility DON stated that they try to redirect resident 26 to keep resident 26 out of other resident rooms and that they put a stop sign across the door to prevent resident 26 from entering resident 25's room. The facility DON stated that I can't tie her up. On 2/16/17 at 3:18 PM, an interview was again conducted with the facility DON. The facility DON stated that she had instructed her staff on nursing interventions for aggressive and violent behaviors, which was primarily redirection. The facility DON stated that she had informed resident 25 after he sexually assaulted resident 26 on 1/21/16, that if he assaulted resident 26 again, that the police would be notified and that resident 25 had verbalized understanding. The facility DON stated that the surveyors needed to read a note authored by the Social Work Consultant (SWC). The facility DON stated that the SWC had written that resident 26 was how do I put this, wants the attention and affection from men. When the State Surveyors asked if resident 26 was seeking sexual attention from the residents of the facility or sexual favors from the residents of the facility, the facility DON stated I don't know about sexual favors but yes, she seeks the sexual attention from the male residents in the facility and I cannot keep (Resident 26) out of (resident 25's) room. The facility DON stated that the police had not been notified after the first or second incident. The facility DON stated that the police had not been notified after the second incident in which resident 25 sexually assaulted resident 26 on 1/16/17 because it had occurred, on the night shift or the weekend. I was at home. The facility DON stated that the police should have been notified the next day, but were not. The facility DON stated that resident 26 was nonverbal but would answer yes or no questions and that resident 26 had dementia. The facility DON further stated that she had in-serviced her staff regarding abuse prevention and that she had instructed her staff on nursing interventions for aggressive and violent behaviors which were primarily redirection. On 2/17/17 at 2:00 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 26 was not allowed in resident 25's room. CNA 5 stated that facility staff including herself had been informed yesterday that the stop sign needed to hang across the doorway to resident 25's room to prevent resident 26 from entering. 3. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 22 sitting in his wheelchair outside of his room. Resident 22 was observed to be waiting to enter his room as the floor was wet from housekeeping mopping the floor and a caution sign was observed in the doorway. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 26 as she wandered up and down the hallway. Resident 26 was observed to enter resident 22's room. Resident 22 was observed to yell at resident 26 get out of there! The floor is wet. Resident 26 was observed to stay in resident 22's room and not respond to resident 22. Resident 22 was observed to get up from his wheelchair to confront resident 26 and yelled at her dumb [***] . CNA 1 was then observed to intervene by removing resident 26 from resident 22's room and led resident 26 down the hallway toward the nurse's station. On 2/14/17 at 8:05 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 had a history of [REDACTED]. On 2/16/17 resident 22's medical record was reviewed. A patient history dated 6/30/16 from the behavioral hospital revealed that resident 22 had dementia aggression and alcohol dependence. [AGE] year old male medically cleared at (Name of Hospital). Family called police on patient for being intoxicated and belligerent. Hard of hearing. Per sister in law of patient he has been declining for months. Family unable to care for him at home Was kicked out of (Name of Assisted Living Facility) for being belligerent with staff. Patient has made suicidal comments and threats to harm others. Has hidden knifes (sic) to lash out at staff. Cheeking meds (medications) Needs locked facility. Has passive suicidal ideation and passive homicidal ideation. Patient refuses counseling. Suspected substance use but no verification. Very treatment resistant and aggressive. A facility Psychosocial assessment dated [DATE], revealed Prior living arrangement: (Resident 22) came to this facility from (Name of Behavioral Hospital). He was removed from a prior facility for aggressive physical actions towards staff and other residents. He has also been homeless, living in (another state) 'with a group of other people who lived in tents and wrapped in blankets at night to sleep (Resident 22) appears alert and oriented to person, place and situation with some forgetfulness at times. His short term memory and long term memory appears intact. (Resident 22) can make his own daily decisions as to what he wants to do (Resident 22) gets upset over not being able to smoke whenever he wants to. Assessment of behavioral concerns: (Resident 22) has been physically and verbally aggressive since his admission to this facility There is not a plan to have (Resident 22) return to living in the community outside of a residential placement. A nurse's note dated 9/7/16 at 4:38 PM, for resident 27, revealed that resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. An incident report dated 9/7/16, for resident 27 revealed resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. A nurse's note dated 10/30/16, revealed Pt reported that another resident (Resident 22) 'hit' her, she stated she did not know why but that 'he just came up and hit me, I wasn't doin (sic) nothin (sic).' CNA was present and witness (sic) pt slapped (Resident 22) and called him 'asshole', (Resident 22) slapped back and the two pts slapped at each other until separated by CNA, no redness to face or cheek where she stated she was hit. No injury noted. Pt denies any pain. Pt stated she will avoid being near (Resident 22) to prevent further incidence. An incident report dated 10/30/16, revealed (Resident 27) reported that pt had 'hit' her, CNA witnessed (Resident 27) 'slap' pt first then pt (Resident 22) slapped (Resident 27) back. The two pt's slapped at each other until separated by CNA. No injury noted. Pt (Resident 22) stated 'she attacked me and called me names, what was I supposed to do'? A nurse's note dated 2/9/17 at 7:00 PM, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON about it tomorrow (Note: The report was filed by the police department and was case number 17- .) An incident report dated 2/9/17, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON about it tomorrow On 2/16/17 resident 22's MDS assessment dated [DATE] revealed that resident 22 had a BIMS score of 4, indicating that resident 22 had severe cognitive impairment. A care plan for resident 22 dated 8/23/16 revealed that The resident is/has potential to be physically aggressive (sic) r/t anger, dementia, history of harm to others, poor impulse control. The goal for resident 22 was The resident will not harm self or others through the review date. (11/4/16) The interventions for resident 22 included the following: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. The update on the care plan dated 9/7/16 revealed that resident 22 hit another resident (Resident 27) because she wanted to sit in a seat he did not want her to sit in. The new interventions on the care plan for 9/7/16 included the following: 1. Observe resident (Resident 22) while in motorized wheelchair and move him away from others when he becomes argumentative with other residents in the facility. The update on the care plan dated 10/30/16 revealed Resident had anothe

Based on observation, interview and record review, it was determined for 14 of 28 sample residents, that the facility failed to ensure that residents were free from abuse, including verbal, physical and sexual abuse. Specifically, one resident had her nose broken after she was hit in the face by another resident, one resident had multiple incidents of fondling and molestation and multiple residents were engaged in physical hitting, kicking, and verbal attacks. No documentation could be found to show that facility staff implemented interventions specific to perpetrators to stop the abuse nor the victims to prevent futher abuse, including sexual assault, from occurring. The facility's failure to implement the policies and procedures for abuse was determined to constitute immediate jeopardy to resident safety. Resident identifiers: 9, 10, 12, 15, 17, 18, 20, 22, 24, 25, 26, 27, 33, and 34. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 2/21/17 at 3:30 PM. At that time the Administrator was informed that there was a great potential for something catastrophic to happen and was asked to develop an immediate plan to ensure that the residents of the facility were free from the verbal, physical, and sexual abuse. On 2/23/17, the facility Administrator provided the following written allegation of removal of the immediate jeopardy: Please see the attached plan of correction to show a credible allegation of removal of the Immediate Jeopardy for Pine Creek. We are alleging the removal of Immediate Jeopardy as of 9:20 PM on 2/22/17. -A new Administrator and Social Services Director have been hired and started immediately. -The facility Social Services Director completed social history's on each of the residents in the facility and behavior training on current residents to the facility staff. (See attachment 6). -The facility LCSW (Licensed Clinical Social Worker) reevaluated resident's plan of care and ensured all are appropriate, up to date and current for all residents. -The Administrator and Social Services Director held an Adhoc resident council meeting to reeducated (sic) current residents on the resident's rights to be free from harm or abuse. This education included inappropriate and unacceptable behavior i.e.: hitting, slapping, yelling, inappropriate touching, spitting etc. (See attachment 7). -The Administrator completed staff education on the abuse prohibiting policy and procedure, abuse allegation and reporting, and reporting abuse focused rounds. (See attachment 8). -The Administrator consulted with LCSW regarding behavioral training's with staff and completed staff education on De-escalating a Resident Behavior Crisis, De-escalating Aggressive Behaviors, A Positive Physical Approach, Having a Conversation, and Communication Tips with the Alert Elderly. (See Attachment 9). -The Administrator and LCSW educated the Social Services Director on the policy for Medical Related Social Services. (See Attachment 10). -The Administrator met with the LCSW and went over his expectation as to her monthly visits, consultant reports, follow up and follow through, completing of her assessments and care plans on time, and communication to the staff of her implementations of her care plans and interventions. (See attachment 11). -The Social Services Director contacted State Ombudsman, (name of State Ombudsman) to help with ongoing and future training's. State Ombudsman will be in to conduct follow up training and education on March 23, 2017 at 2:00 PM. -All incident reports will be brought to standup meeting and reviewed ensuring that if; any abuse allegations were made, inappropriate behavior was conducted, or any injury of unknown origin were noted, that proper procedures were taken. -The Administrator/Designee will conduct Abuse Prevention Focus Rounds to ensure staffs continued understanding and training of abuse prevention. (See Attachment 12). -The Administrator/Designee will conduct Focus Rounds 3 times per week to ensure resident specific interventions continue to be implemented and followed. (See Attachment 13). -The Administrator/Designee will complete Abuse Focus Rounds weekly to ensure all residents to continue to be free from abuse and all staff remains educated. (See Attachment 14). -Identified trends will be addressed immediately as well as reviewed and reported monthly and as needed to the Quality Assurance Committee until a lesser frequency is deemed appropriate. On 2/23/17, The State Agency reviewed the immediate plan of correction for removal of the immediate jeopardy for abuse and confirmed the abatement of the Immediate Jeopardy situation as of 2/22/17. Findings include: 1. Resident 27 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17, resident 27's medical record was reviewed. An incident report dated 1/29/17 at 10:15 AM, for resident 27 revealed Pt (patient) reported that another resident (resident 34) hit her, pt stated that other resident was putting something in railing outside in back porch ramp area, she stated she told him to stop. He got mad and smacked me as hard as he could. Asked if (resident 34) hit with open or closed hand, pt stated open . According to the incident report resident 27 had swelling, dark purple/red bruising to lateral inferior R (right) eye, abrasion to R cheek. A nurse's note dated 1/29/17 at 12:00 PM, revealed that resident 27 had swelling increased to right eye, dark purple area to lateral/inferior right eye, red abrasion to upper right cheek at zygomatic area. MD (Medical Doctor) notified, send to ER (emergency room ) to eval (evaluate) injury to right eye. A hospital report dated 1/29/17, for resident 27 revealed that there is a [MEDICAL CONDITION] bone noted with depression of the nasal bone on the right side. A nurse's note dated 9/7/16 at 4:38 PM, for resident 27, revealed that resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. An incident report dated 9/7/16, for resident 27 revealed resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. A nurse's note dated 10/30/16, revealed Pt reported that another resident (Resident 22) 'hit' her, she stated she did not know why but that 'he just came up and hit me, I wasn't doin (sic) nothin (sic).' CNA (Certified Nursing Assistant) was present and witness (sic) pt slapped (Resident 22) and called him 'asshole', (Resident 22) slapped back and the two pts slapped at each other until separated by CNA, no redness to face or cheek where she stated she was hit. No injury noted. Pt denies any pain. Pt stated she will avoid being near (Resident 22) to prevent further incidence. An incident report dated 10/30/16, revealed (Resident 27) reported that pt had 'hit' her, CNA witnessed (Resident 27) 'slap' pt first then pt (Resident 22) slapped (Resident 27) back. The two pt's slapped at each other until separated by CNA. No injury noted. Pt (Resident 22) stated 'she attacked me and called me names, what was I supposed to do'? A nurse's note dated 2/9/17 at 7:00 PM, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON (Director of Nursing) about it tomorrow (Note: The report was filed by the police department and was case number 17- .) An incident report dated 2/9/17, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON about it tomorrow The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 27 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated that resident 27 had moderate cognitive impairment. Resident 27's care plan was reviewed. A behavior care plan dated 3/10/15, revealed that resident 27 had a problem of History of suicide attempts by jumping off a balcony, attempting to go into traffic, cutting self and overdose. History of violence toward staff. The goal for resident 27 was (Resident 27) will be safe from self harm and will not harm others or cause resident to resident incidents. The interventions on the care plan for resident 27 included the following: 1. When she is anxious, frustrated or upset, offer supportive listening and encourage her to go for a walk or talk to staff. 2. When she is calm, encourage her to do the things she enjoys such as TV (television), listen to music, walk and/or read books. 3. Ask her if she is in pain. If she complains of leg pain, encourage her to tell nursing and elevate her leg and walk less. 4. If he agrees to receiving her calls, remind her she can call her ex-husband if she wants to. 5. Be sure she swallows her pills and does not cheek them. 6. Remind her that it is safest for her to stay in the yard and not go out the gate or into the community alone. 7. If she says that she wants to hurt herself or kill herself, call the doctor and call '911'. 8. Keep in line of sight supervision until situation is resolved. 9. Coordinate/follow up with mental health services for medication management and other supportive services as needed. 10. Each day ensure her room is free of items she could potentially use to harm herself: call light cords, belts, plastic bags, unswallowed medications, glass items and anything labeled keep out of the reach of children. 2. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/16/17, resident 26's medical record was reviewed. A nurse's note dated 1/21/16, revealed that resident 26 was standing at the doorway looking out when a male resident (Resident 25) came up behind her and began to touch her buttocks area around to her vaginal area and up to her breast. He was immediately taken to another area of the facility An incident report dated 1/21/16, for resident 26 revealed (Resident 26) was standing at the door looking outside when (Resident 25) came up in back of her and began to grope her on her buttocks to her vaginal area and up to her breasts. He was immediately sent to another area in the facility. (Resident 26) stated 'thank you'. (Note: No report was filed with the State Agency. No police report was filed regarding the incident. No report was filed with the Adult Protective Services Agency.) The MDS assessment dated [DATE], revealed that resident 26's BIMS score was 6 which indicated that resident 26 had severe cognitive impairment. A care plan for resident 26 dated 4/28/15, revealed the problem Resident 26 has impaired cognitive function/dementia or impaired thought processes r/t (related to) dementia. The goal for resident 26 was (Resident 26) will be able to communicate basic needs on a daily basis through the review date. (Resident 26) was sexually groped by a male resident while she was standing in front of the front glass door. As a result, she will be closely monitored when she is roaming the hallways by herself to make sure that she is safe at all times. The interventions for resident 26 on the care plan included the following: 1. Ask yes/no questions in order to determine the resident's needs. 2. Communication: use the resident preferred name. Identify yourself at each interaction. 3. Face (Resident 26) when speaking and make eye contact. 4. Reduce any distractions-turn off TV, radio, close door etc. The resident understands consistent simple directive sentences. 5. Provide the resident with necessary cues-stop and return if agitated. Cue, reorient and supervise as needed. Present just one thought, idea, question or command at a time. 6. Use task segmentation to support short term memory deficits. Break tasks into one step at a time. A care plan for resident 26 dated 4/28/15, revealed that (Resident 26) goes into male residents' rooms and male residents will fondle her. Since she is seeking male attention and affection, this does not appear to be abusive in nature. The goal for resident 26 was (Resident 26) will not receive any unwanted or unsolicited touching or groping by others Q (every) day. The interventions for resident 26 included the following: 1. Monitor (Resident 26's) whereabouts closely to ensure she is not seeking affection from other residents who are too confused to consent and to ensure that she is not receiving unwanted advances. 2. Put stop sign across other resident's doorways as needed. 3. Talk to guardian about obtaining some one piece jumpsuits for (Resident 26). 4. Remind male residents she interacts with that touching is off limits (Note: No observations were made throughout the facility on 2/14/17 and 2/15/17 of a stop sign placed across any resident room nor was resident 26 wearing any one piece jumpsuit until 2/23/17. The stop sign was observed on 2/16/17 and 2/17/17 on multiple instances to be hanging from one side of the door for resident 25 and lying on the floor.) An incident report dated 9/7/16, revealed that (Resident 9) was sitting in a chair next to (Resident 26). (Resident 9) had his hand up the shirt of (Resident 26) where he was inappropriately touching her breast. When Housekeeper (HK) 1 came in room and saw, she told him to stop and separated immediately. The investigation conducted by the facility LCSW revealed that resident 9 was talked with immediately after this incident was reported. (Resident 9) did admit to sexually touching (Resident 26) but stated that 'resident 26 asked him to.' (Resident 9) was immediately taken to his personal bedroom. He was talked with very seriously about this incident by the facility SSW (Social Service Worker), LCSW and facility DON. The interview by the LCSW with HK1 revealed that She (HK 1) reported the incident as she saw it when she walked into the main TV/Living room area. (Resident 9) was sitting in a chair next to (Resident 26) where he was inappropriately touching her breast. When (HK1) saw what was happening, she told (Resident 9) to 'stop' and then reported this incident immediately to management. She (HK1) stated more specifically that (Resident 26) had one of her breasts completely out of her shirt and (Resident 9) was touching resident 26's nipple with his fingers. A Nurse's note dated 1/16/17, revealed that It was reported by another resident, that he saw (Resident 26) get touched inappropriately by another resident. (Resident 22) said he saw this resident (Resident 26) wander into their room and (Resident 25) 'felt her up.' When asked what he saw, he stated he saw (Resident 25) put his hands in her brief and move his hands towards the front of her brief. (Resident 26) showed no signs of injury. She was taken to her room and monitored so she does not make her way down the hall and into that room again (Note: Resident 26 was sexually molested by resident 25 in January 2016 and again by resident 25 in January 2017. Resident 25 remains in the facility. Resident 26 continuously roams the hallways by herself.) An incident report dated 1/16/17, for resident 26 revealed that It was reported by another resident, that he saw (Resident 26) get touched inappropriately by another resident. (Resident 22) said he saw this resident (Resident 26) wander into their room and (Resident 25) 'felt her up.' When asked what he saw, he stated he saw (Resident 25) put his hands in her brief and move his hands towards the front of her brief. The MDS assessment dated [DATE], revealed that resident 26's BIMS score was 0 which indicated that resident 26 had severe cognitive impairment. On 2/15/17 at 2:00 PM, an interview was conducted with the facility DON. The facility DON stated that they try to redirect resident 26 to keep resident 26 out of other resident rooms and that they put a stop sign across the door to prevent resident 26 from entering resident 25's room. The facility DON stated that I can't tie her up. On 2/16/17 at 3:18 PM, an interview was again conducted with the facility DON. The facility DON stated that she had instructed her staff on nursing interventions for aggressive and violent behaviors, which was primarily redirection. The facility DON stated that she had informed resident 25 after he sexually assaulted resident 26 on 1/21/16, that if he assaulted resident 26 again, that the police would be notified and that resident 25 had verbalized understanding. The facility DON stated that the surveyors needed to read a note authored by the Social Work Consultant (SWC). The facility DON stated that the SWC had written that resident 26 was how do I put this, wants the attention and affection from men. When the State Surveyors asked if resident 26 was seeking sexual attention from the residents of the facility or sexual favors from the residents of the facility, the facility DON stated I don't know about sexual favors but yes, she seeks the sexual attention from the male residents in the facility and I cannot keep (Resident 26) out of (resident 25's) room. The facility DON stated that the police had not been notified after the first or second incident. The facility DON stated that the police had not been notified after the second incident in which resident 25 sexually assaulted resident 26 on 1/16/17 because it had occurred, on the night shift or the weekend. I was at home. The facility DON stated that the police should have been notified the next day, but were not. The facility DON stated that resident 26 was nonverbal but would answer yes or no questions and that resident 26 had dementia. The facility DON further stated that she had in-serviced her staff regarding abuse prevention and that she had instructed her staff on nursing interventions for aggressive and violent behaviors which were primarily redirection. On 2/17/17 at 2:00 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 26 was not allowed in resident 25's room. CNA 5 stated that facility staff including herself had been informed yesterday that the stop sign needed to hang across the doorway to resident 25's room to prevent resident 26 from entering. 3. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 22 sitting in his wheelchair outside of his room. Resident 22 was observed to be waiting to enter his room as the floor was wet from housekeeping mopping the floor and a caution sign was observed in the doorway. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 26 as she wandered up and down the hallway. Resident 26 was observed to enter resident 22's room. Resident 22 was observed to yell at resident 26 get out of there! The floor is wet. Resident 26 was observed to stay in resident 22's room and not respond to resident 22. Resident 22 was observed to get up from his wheelchair to confront resident 26 and yelled at her dumb [***] . CNA 1 was then observed to intervene by removing resident 26 from resident 22's room and led resident 26 down the hallway toward the nurse's station. On 2/14/17 at 8:05 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 had a history of [REDACTED]. On 2/16/17 resident 22's medical record was reviewed. A patient history dated 6/30/16 from the behavioral hospital revealed that resident 22 had dementia aggression and alcohol dependence. [AGE] year old male medically cleared at (Name of Hospital). Family called police on patient for being intoxicated and belligerent. Hard of hearing. Per sister in law of patient he has been declining for months. Family unable to care for him at home Was kicked out of (Name of Assisted Living Facility) for being belligerent with staff. Patient has made suicidal comments and threats to harm others. Has hidden knifes (sic) to lash out at staff. Cheeking meds (medications) Needs locked facility. Has passive suicidal ideation and passive homicidal ideation. Patient refuses counseling. Suspected substance use but no verification. Very treatment resistant and aggressive. A facility Psychosocial assessment dated [DATE], revealed Prior living arrangement: (Resident 22) came to this facility from (Name of Behavioral Hospital). He was removed from a prior facility for aggressive physical actions towards staff and other residents. He has also been homeless, living in (another state) 'with a group of other people who lived in tents and wrapped in blankets at night to sleep (Resident 22) appears alert and oriented to person, place and situation with some forgetfulness at times. His short term memory and long term memory appears intact. (Resident 22) can make his own daily decisions as to what he wants to do (Resident 22) gets upset over not being able to smoke whenever he wants to. Assessment of behavioral concerns: (Resident 22) has been physically and verbally aggressive since his admission to this facility There is not a plan to have (Resident 22) return to living in the community outside of a residential placement. A nurse's note dated 9/7/16 at 4:38 PM, for resident 27, revealed that resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. An incident report dated 9/7/16, for resident 27 revealed resident was involved in an incident with another resident. Resident (27) was sitting outside in a recliner at the top of the cement ramp when (Resident 22) was backing up his motorized wheelchair and asked her to move out of the way. (Resident 22) became angry and slapped this resident (27) on the head. A nurse's note dated 10/30/16, revealed Pt reported that another resident (Resident 22) 'hit' her, she stated she did not know why but that 'he just came up and hit me, I wasn't doin (sic) nothin (sic).' CNA was present and witness (sic) pt slapped (Resident 22) and called him 'asshole', (Resident 22) slapped back and the two pts slapped at each other until separated by CNA, no redness to face or cheek where she stated she was hit. No injury noted. Pt denies any pain. Pt stated she will avoid being near (Resident 22) to prevent further incidence. An incident report dated 10/30/16, revealed (Resident 27) reported that pt had 'hit' her, CNA witnessed (Resident 27) 'slap' pt first then pt (Resident 22) slapped (Resident 27) back. The two pt's slapped at each other until separated by CNA. No injury noted. Pt (Resident 22) stated 'she attacked me and called me names, what was I supposed to do'? A nurse's note dated 2/9/17 at 7:00 PM, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON about it tomorrow (Note: The report was filed by the police department and was case number 17- .) An incident report dated 2/9/17, revealed This nurse saw (Resident 27) outside of room [ROOM NUMBER] and another resident (Resident 22) standing up out of his wheelchair trying to hit (Resident 27). There were two aides present who were trying to separate the two residents and keep (Resident 22) from hitting her. The CNA said she saw (Resident 27) come out of room [ROOM NUMBER] and (Resident 22) was waiting outside the door. When (Resident 27) walked out (Resident 22) stood up and slapped (Resident 27) across the face with an open hand on the right side of her cheek. Resident was asked why he slapped her and he said, 'well she hit me first.' (Resident 27) denied this and said she never hit him. There were no witnesses to (Resident 27) hitting (Resident 22) during this evening shift. Earlier in the evening at about 17:45 (5:45 PM) (Resident 27) called out to this nurse saying (Resident 22) had stolen her radio. This nurse went into (Resident 22's) room and he had hidden the radio under his bed. (Resident 22) stated that they were both outside and (Resident 27) sat down in her chair which got in the way of him spitting so he took her radio away from her in anger. He stated 'I just grabbed what I could.' This nurse took the radio from under his bed and gave it back to (Resident 27). (Resident 22) wanted the radio taken away for good but he was told there was no good reason for it to be taken away and it was given back to (Resident 27) MD ordered to call the police and file a police report. Two police officers arrived at about 19:30 (7:30 PM) and interviewed both residents. (Resident 27) expressed to them that she wanted to press charges and the police told her that she could pursue that if she wanted to and they would file a report tonight. (Resident 27) said she would talk to the DON about it tomorrow On 2/16/17 resident 22's MDS assessment dated [DATE] revealed that resident 22 had a BIMS score of 4, indicating that resident 22 had severe cognitive impairment. A care plan for resident 22 dated 8/23/16 revealed that The resident is/has potential to be physically aggressive (sic) r/t anger, dementia, history of harm to others, poor impulse control. The goal for resident 22 was The resident will not harm self or others through the review date. (11/4/16) The interventions for resident 22 included the following: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. The update on the care plan dated 9/7/16 revealed that resident 22 hit another resident (Resident 27) because she wanted to sit in a seat he did not want her to sit in. The new interventions on the care plan for 9/7/16 included the following: 1. Observe resident (Resident 22) while in motorized wheelchair and move him away from others when he becomes argumentative with other residents in the facility. The update on the care plan dated 10/30/16 revealed Resident had anothe

Based on observation, interview and record review, it was determined for 1 of 28 sample residents, that the facility failed to permit a resident to remain in the facility and not transfer or discharge the resident from the facility unless the discharge or transfer were necessary for the resident's welfare and the resident's need could not be met in the facility. Specifically, a resident with dementia was abruptly discharged to a homeless shelter due to his resident to resident altercations. Resident identifier: 22. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 2/21/17 at 3:30 PM. On 2/23/17, the facility Administrator provided the following written allegation of removal of the immediate jeopardy: Please see the attached plan of correction to show a credible allegation of removal of the Immediate Jeopardy for (facility name). We are alleging the removal of Immediate Jeopardy as of 9:20 PM on 2/22/17. -A new Administrator and Social Services Director have been hired and started immediately. -The Social Services Director has reevaluated all residents in the facility ensuring discharge planning has been established and put in place for all residents. (See Attachment 1). -The Social Services Director will initiate the discharge plan of all residents on admission and reevaluate them quarterly and as necessary. -The Licensed Nurse will complete a Discharge Summary Plan of Care on all residents prior to discharge. (See Attachment 2). -The Social Services Director will ensure Notice of Proposed Discharge/Transfer is complete for all residents prior to discharge. (See Attachment 3). -The Licensed Nurses were educated on the Discharge Summary Plan of Care and how to complete. -The Social Services Director was educated on the Notice of Proposed Discharge/Transfer and how to complete. -New policies have been developed and implemented; Making an Emergency Transfer/Discharge, Preparing a Resident for a Transfer/Discharge, and Documentation of Transfer/Discharge. (See Attachment 4). -Staff was educated by the Administrator, Social Services Director, and Director of Nursing on all new policies and systems. (See Attachment 5). -All upcoming discharged will be reviewed each Monday in stand up to ensure that the discharge put in place for that resident has been followed and accommodated as appropriate and that the Notice of Proposed Discharge/Transfer has been complete. -All transfer/discharges will be reviewed the following day during stand up to ensure the Discharge Summary Plan of Care was complete and a copy sent with the resident, that the resident was properly prepared for the discharge, and that all documentation was complete. -The Administrator/Designee will complete a transfer/discharge check off to ensure proper discharge procedure was followed. (See Attachment 15). -Identified trends will be addressed immediately as well as reviewed and reported monthly and as needed to the Quality Assurance Committee until a lesser frequency is deemed appropriate. On 2/23/17, The State Agency reviewed the immediate plan of correction for removal of the immediate jeopardy for abuse and confirmed the abatement of the Immediate Jeopardy situation as of 2/22/17. Findings include: Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 22 sitting in his wheelchair outside of his room. Resident 22 was observed to be waiting to enter his room as the floor was wet from housekeeping mopping the floor and a caution sign was observed in the doorway. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 26 as she wandered up and down the hallway. Resident 26 was observed to enter resident 22's room. Resident 22 was observed to yell at resident 26 get out of there! The floor is wet. Resident 26 was observed to stay in resident 22's room and not respond to resident 22. Resident 22 was observed to get up from his wheelchair to confront resident 26 and yelled at her dumb [***] . CNA (Certified Nursing Assistant) 1 was then observed to intervene by removing resident 26 from resident 22's room and led resident 26 down the hallway toward the nurse's station. On 2/14/17 at 8:05 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 had a history of [REDACTED]. On 2/14/17 the facility Administrator was asked for all of the incident reports for resident 22's altercations with other residents. A review of the facility's abuse investigations revealed that resident 22 had multiple incidents of physical and verbal abuse toward other residents. The only documented intervention was to separate the residents involved in the incident. No documentation could be found to show that facility staff implemented interventions to minimize the altercations or incidents. On 2/14/17 at 2:15 PM, after the state surveyors returned from lunch, resident 22 could not be located in the facility. Resident 22's medical record could not be located on the facility online medical record. On 2/14/17 at 2:30 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the surveyor could find the online medical record under the discharged residents. The state surveyor asked the facility DON if they had discharged resident 22. The facility DON stated that they had discharged resident 22 to the homeless shelter. The facility DON stated that the reason for the discharge was that resident 22 was volatile and that the facility could not meet his needs. On 2/14/17 at 2:35 PM, an interview was conducted with the facility DON and the facility Administrator. The facility DON and facility Administrator stated that they had been told by the Corporate DON that they needed to discharge resident 22 immediately. The facility DON stated that resident 22 had been taken to the homeless shelter in the facility van. The facility DON stated that resident 22's medications had not been sent with him as he was not capable of medicating himself. The facility DON stated that resident 22's medications were taken by the Corporate Administrator to the homeless shelter later on and dropped off at the front desk of the reception area of the homeless shelter. On 2/14/17 resident 22's medical record was reviewed. A patient history and physical (H&P) from the behavioral hospital, where resident 22 had been admitted to prior to admission to the facility, revealed that resident 22 had been kicked out of assisted living facility for being belligerent with staff. Patient has made suicidal comments and threats to harm others. Has hidden knifes (sic), to lash out at staff. The H&P revealed that resident 22 needs a locked facility and that his risk assessment was passive suicidal ideation and passive homicidal ideation. A facility physician note dated 8/2/16, revealed that resident 22 had a volatile hx (history) previous to (facility). Resident's situation prior to admission/precipitation events to becoming a nursing home resident: came to this facility from (Behavioral Hospital). He was removed from a prior assisted living facility for aggressive physical behaviors against staff and other resident. The physician note also revealed that resident 22 had dementia. No note could be located in the medical record by the physician that resident 22's needs could not be met in the facility. A Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 22 had a Brief Interview for Mental Status (BIMS) score of 7. According to the key on the MDS Assessment a 7 meant that resident 22 was considered to have severe cognitive impairment. A review of resident 22's care plans dated 8/2/16, revealed that no care plan had been created for resident 22 for a safe, orderly discharge from the facility. On 2/14/17 at 3:15 PM, an interview was conducted with the facility Corporate Nurse. The facility Corporate Nurse stated that she did not know if resident 22 was admitted to the medical side of the homeless shelter and would find out. The facility Corporate Nurse stated that they had been in contact with resident 22's Power of Attorney (POA) yesterday when she was in the facility and that they had discussed resident 22's discharge. The facility Corporate Nurse stated that the POA had told the facility to just discharge him to the homeless shelter. On 2/14/17 at 4:04 PM, an interview was conducted with resident 22's POA. Resident 22's POA stated that she had visited with resident 22 yesterday and had brought resident 22 some cigarettes. The POA stated that the facility DON had mentioned that resident 22's behaviors had been escalating and thanked the POA for her cooperation in addressing the behaviors but denied that they had ever talked about any plans to discharge resident 22. The POA stated that she had been informed by the facility Administrator on 2/14/17 at approximately 1:00 PM, via a telephone call, that resident 22 was going to be discharged immediately to the homeless shelter due to the ongoing behaviors and altercations with other residents and that the facility was no longer able to provide care for resident 22. The POA stated that she had asked if she could make some phone calls to try to make alternative arrangements for resident 22 and was denied the time to do that by the facility Administrator because the discharge was to be effective immediately. The POA further stated that she felt that the plan was not safe and was pretty crappy. The POA stated that the facility was very aware of (resident 22's) anger management issues, dementia and long term abuse of alcohol. The POA stated that she was worried about resident 22's wellbeing, that he was not with it enough to make decisions, often confused and unable to recall the city he is residing in. The POA stated that she was afraid that (resident 22) will end up dead. On 2/14/17 at 4:35 PM, an interview was again conducted with the facility Corporate Nurse. The facility Corporate Nurse stated that resident 22 had not been admitted to the medical side of the homeless shelter as the medical side of the homeless shelter was full. The facility Corporate Nurse stated that resident 22 was not a candidate for that side of the shelter and that because of that, his medications could not be administered to him. The facility Corporate Nurse stated that because of this, we are going to go pick him up tonight from the homeless shelter and not discharge him because this cannot come back on us. On 2/14/17 the facility Policy and Procedure, Notice of a Transfer and/or Discharge was reviewed and revealed the following: Policies and Procedures Notice of a Transfer and/or Discharge Policy The facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice in a language and manner the resident understands and, if known, to a family member or legal representative of the resident of an impending transfer or discharge. Procedure 1. Except as specified below, a resident, and/or his or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or medicaid) a stay at the facility; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident is transferred for other than medical reasons; h. The resident has not resided in the facility for thirty (30)-days; and/or i. The facility ceases to operate. 2. The resident, and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. The name, address, and telephone number of the state long-term care ombudsman; e. The name, address and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies); and f. The name, address, and telephone number of the State Health Department Agency that has been designated to handle appeals of transfers or discharge notices.

Based on observation, interview and record review, it was determined for 1 of 28 sample residents, that the facility failed to provide and document sufficient preparation and orientation to a resident or resident's Power of Attorney (POA) to ensure a safe and orderly transfer or discharge from the facility. Specifically, a resident with dementia was abruptly discharged without a 30 day notice, to a homeless shelter without preparation for a safe orderly discharge. The resident's POA was not involved in selecting a facility nor allowed to find a facility that could accommodate the resident's needs. Resident identifier: 22. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 2/21/17 at 3:30 PM. On 2/23/17, the facility Administrator provided the following written allegation of removal of the immediate jeopardy: Please see the attached plan of correction to show a credible allegation of removal of the Immediate Jeopardy for (facility name). We are alleging the removal of Immediate Jeopardy as of 9:20 PM on 2/22/17. -A new Administrator and Social Services Director have been hired and started immediately. -The Social Services Director has reevaluated all residents in the facility ensuring discharge planning has been established and put in place for all residents. (See Attachment 1). -The Social Services Director will initiate the discharge plan of all residents on admission and reevaluate them quarterly and as necessary. -The Licensed Nurse will complete a Discharge Summary Plan of Care on all residents prior to discharge. (See Attachment 2). -The Social Services Director will ensure Notice of Proposed Discharge/Transfer is complete for all residents prior to discharge. (See Attachment 3). -The Licensed Nurses were educated on the Discharge Summary Plan of Care and how to complete. -The Social Services Director was educated on the Notice of Proposed Discharge/Transfer and how to complete. -New policies have been developed and implemented; Making an Emergency Transfer/Discharge, Preparing a Resident for a Transfer/Discharge, and Documentation of Transfer/Discharge. (See Attachment 4). -Staff was educated by the Administrator, Social Services Director, and Director of Nursing on all new policies and systems. (See Attachment 5). -All upcoming discharged will be reviewed each Monday in stand up to ensure that the discharge put in place for that resident has been followed and accommodated as appropriate and that the Notice of Proposed Discharge/Transfer has been complete. -All transfer/discharges will be reviewed the following day during stand up to ensure the Discharge Summary Plan of Care was complete and a copy sent with the resident, that the resident was properly prepared for the discharge, and that all documentation was complete. -The Administrator/Designee will complete a transfer/discharge check off to ensure proper discharge procedure was followed. (See Attachment 15). -Identified trends will be addressed immediately as well as reviewed and reported monthly and as needed to the Quality Assurance Committee until a lesser frequency is deemed appropriate. On 2/23/17, The State Agency reviewed the immediate plan of correction for removal of the immediate jeopardy for abuse and confirmed the abatement of the Immediate Jeopardy situation as of 2/22/17. Findings include: Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 22 sitting in his wheelchair outside of his room. Resident 22 was observed to be waiting to enter his room as the floor was wet from housekeeping mopping the floor and a caution sign was observed in the doorway. On 2/14/17 at 7:50 AM, an observation was made by a state surveyor of resident 26 as she wandered up and down the hallway. Resident 26 was observed to enter resident 22's room. Resident 22 was observed to yell at resident 26 get out of there! The floor is wet. Resident 26 was observed to stay in resident 22's room and not respond to resident 22. Resident 22 was observed to get up from his wheelchair to confront resident 26 and yelled at her dumb [***] . CNA (Certified Nursing Assistant) 1 was then observed to intervene by removing resident 26 from resident 22's room and led resident 26 down the hallway toward the nurse's station. On 2/14/17 at 8:05 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 had a history of [REDACTED]. On 2/14/17 the facility Administrator was asked for all of the incident reports for resident 22's altercations with other residents. A review of the facility's abuse investigations revealed that resident 22 had multiple incidents of physical and verbal abuse toward other residents. The only documented intervention was to separate the residents involved in the incident. No documentation could be found to show that facility staff implemented interventions to minimize the altercations or incidents. On 2/14/17 at 2:15 PM, after the state surveyors returned from lunch, resident 22 could not be located in the facility. Resident 22's medical record could not be located on the facility online medical record. On 2/14/17 at 2:30 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that I could find the online medical record under the discharged residents. The state surveyor asked the facility DON if they had discharged resident 22. The facility DON stated that they had discharged resident 22 to the homeless shelter. The facility DON stated that the reason for the discharge was that resident 22 was volatile and that the facility could not meet his needs. On 2/14/17 at 2:35 PM, an interview was conducted with the facility DON and the facility Administrator. The facility DON and facility Administrator stated that they had been told that they needed to discharge resident 22 immediately. The facility DON stated that resident 22 had been taken to the homeless shelter in the facility van. The facility DON stated that they had been told by the facility Corporate Nurse to discharge resident 22 immediately to the homeless shelter. The facility DON stated that resident 22's medications had not been sent with him as he was not capable of medicating himself. The facility DON stated that resident 22's medications were taken by the Corporate Administrator to the homeless shelter later on and dropped off at the front desk of the reception area of the homeless shelter. On 2/14/17 resident 22's medical record was reviewed. A facility physician note dated 8/2/16, revealed that resident 22 was volatile hx (history) previous to (facility). Resident's situation prior to admission/precipitation events to becoming a nursing home resident: came to this facility from (Behavioral Hospital). He was removed from a prior assisted living facility for aggressive physical behaviors against staff and other resident. The physician note also revealed that resident 22 had dementia. No note could be located in the medical record by the physician that resident 22's needs could not be met in the facility. A Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 22 had a Brief Interview for Mental Status (BIMS) score of 7. According to the key on the MDS Assessment a 7 meant that resident 22 was considered to have severe cognitive impairment. A review of resident 22's care plans dated 8/2/16, revealed that no care plan had been created for resident 22 for a safe, orderly discharge from the facility. On 2/14/17 at 3:15 PM, an interview was conducted with the facility Corporate Nurse. The facility Corporate Nurse stated that she did not know if resident 22 was admitted to the medical side of the homeless shelter and would find out. The facility Corporate Nurse stated that they had been in contact with resident 22's POA yesterday when she was in the facility and that they had discussed resident 22's discharge. The facility Corporate Nurse stated that the POA had told the facility to just discharge him to the homeless shelter. On 2/14/17 at 4:04 PM, an interview was conducted with resident 22's POA. Resident 22's POA stated that she had visited with resident 22 yesterday and had brought resident 22 some cigarettes. The POA stated that the facility DON had mentioned that resident 22's behaviors had been escalating and thanked the POA for her cooperation in addressing the behaviors but denied that they had ever talked about any plans to discharge resident 22. The POA stated that she had been informed by the facility Administrator on 2/14/17 at approximately 1:00 PM, via a telephone call that resident 22 was going to be discharged immediately to the homeless shelter due to the ongoing behaviors and altercations with other residents and that the facility was no longer able to provide care for resident 22. The POA stated that she had asked if she could make some phone calls to try to make alternative arrangements for resident 22 and was denied the time to do that by the facility Administrator because the discharge was to be effective immediately. The POA further stated that she felt that this plan was not safe and was pretty crappy. The POA stated that the facility was very aware of (resident 22's) anger management issues, dementia and long term abuse of alcohol. The POA stated that she was worried about resident 22's wellbeing, that he was not with it enough to make decisions, often confused and unable to recall the city he is residing in. The POA stated that she was afraid that (resident 22) will end up dead. On 2/14/17 at 4:35 PM, an interview was again conducted with the facility Corporate Nurse. The facility Corporate Nurse stated that resident 22 had not been admitted to the medical side of the homeless shelter as the medical side of the homeless shelter was full. The facility Corporate Nurse stated that resident 22 was not a candidate for that side of the shelter and that because of that, his medications could be administered to him. The facility Corporate Nurse stated that because of this, we are going to go pick him up tonight from the homeless shelter and not discharge him because this cannot come back on us. On 2/14/17 the facility Policy and Procedure, Notice of a Transfer and/or Discharge was reviewed and revealed the following: Policies and Procedures Notice of a Transfer and/or Discharge Policy The facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice in a language and manner the resident understands and, if known, to a family member or legal representative of the resident of an impending transfer or discharge. Procedure 1. Except as specified below, a resident, and/or his or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or medicaid) a stay at the facility; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident is transferred for other than medical reasons; h. The resident has not resided in the facility for thirty (30)-days; and/or i. The facility ceases to operate. 2. The resident, and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. The name, address, and telephone number of the state long-term care ombudsman; e. The name, address and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies); and f. The name, address, and telephone number of the State Health Department Agency that has been designated to handle appeals of transfers or discharge notices.

Based on observation, interview and record review it was determined that the facility failed to be administered in a manner that enabled 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, areas of deficient practice were identified to have occurred at an Immediate Jeopardy level in abuse, inappropriate discharge and medically related social services. Resident identifiers: 9, 10, 12, 13, 15, 17, 18, 20, 22, 24, 25, 26, 27, 32, 33 and 34. Substandard Quality of Care Level with Harm and deficient practice which resulted in Harm was identified in three areas. The deficient practice identified for residents was found to have occurred at a Harm Level. Findings include: 1. The facility administration failed to ensure that residents were free from abuse, including verbal, physical and sexual abuse. This failure resulted in a finding of Harm for 2 residents. Resident identifiers: 26, 27. (Cross refer to F-223 and F-226) 2. The facility administration failed to ensure a safe and orderly discharge for one resident. As a result one resident with dementia was discharged to a homeless shelter, being brought back into the facility and resulting in the resident not receiving medication timely and causing the resident to have a potentially unfavorable outcome. Additionally, residents identified in the immediate jeopardy did not have any discharge planning assessments or care plans in place. Resident identifier: 22. (Cross refer to F-201 and F-204) 3. The facility administration failed to ensure that residents with violent behaviors/aggression and suicidal ideation and attempts, had access to medically related social services on a daily basis. The deficient practice identified included the lack of assessing and providing safe and orderly discharges, identifying physical, verbal and sexual abuse and updating care plans specific to behaviors, notifying mental health providers of resident behaviors and needs and assessing residents who verbalize suicidal ideation and/or act out on the suicidal ideation. This failure resulted in a finding of Harm for 2 residents. Resident identifiers: 26 and 27. (Cross refer to F-250) 4. The facility administration failed to maintain a Quality Assessment and Assurance Committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F-520) On 2/15/17 at approximately 2:00 PM, an interview was conducted with the facility Administrator and the facility DON (Director of Nursing). The facility Administrator stated that they had been without an SSW (Social Service Worker) or RA (Resident Advocate) since September 2016. The facility Administrator stated that he had been notified by their Corporate Administration that he was to take on the tasks of the SSW or RA. The facility Administrator stated that he had received a little training by the SWC (Social Work Consultant) a couple of times a month to complete the quarterly assessments but that he had not had any formal training for providing Social Services to the facility residents. The facility DON verified that the facility had been without a SSW and that the facility Administrator had taken on those duties per the Corporate Administration. The facility DON stated that she and the facility Administrator worked closely regarding any incident involving the facility residents. On 2/16/17 at 3:18 PM, an interview was conducted with the facility DON. The facility DON stated that they had been without a SSW or RA for several months and that she could not address the behaviors in the medical record because of her lack of training to do Social Services. The facility DON stated that she was not qualified to devise behavior contracts with residents or to devise specific interventions for behaviors, and that requires a social work degree to do such. The facility DON stated that the Administrator had been completing the Social Services tasks within the facility. The facility DON further stated that the Administrator did not have any formal training for taking on the Social Services tasks but had been getting a little training at times from the facility Social Work Consultant.

Based on on observation, interview and record review, it was determined that the facility failed to maintain a Quality Assessment and Assurance Committee that developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, five areas of deficient practice were identified to have occurred at an Immediate Jeopardy level. Resident identifiers: 9, 10, 12, 13, 15, 17, 18, 20, 22, 24, 25, 26, 27, 32, 33 and 34. Three areas of deficient practice were identified to have occurred at a Substandard Quality of Care Level with harm identified for residents 26 and 27. Findings include: 1. The facility administration failed to ensure that residents were free from abuse, including verbal, physical and sexual abuse. This failure resulted in a finding of Harm for 2 residents. Resident identifiers: 26, 27. (Cross refer to F-223 and F-226) 2. The facility administration failed to ensure a safe and orderly discharge for one resident. As a result one resident with dementia was discharged to a homeless shelter, being brought back into the facility and resulting in the resident not receiving medication timely and causing the resident to have a potential unfavorable outcome. Additionally, residents identified in the immediate jeopardy did not have any discharge planning assessments or care plans in place. Resident identifier: 22. (Cross refer to F-201 and F-204) 3. The facility administration failed to ensure that residents with violent behaviors/aggression and suicidal ideation and attempts, had access to medically related social services on a daily basis. The deficient practice identified included the lack of assessing and providing safe and orderly discharges, identifying physical, verbal and sexual abuse and updating care plans specific to behaviors, notifying mental health providers of resident behaviors and needs and assessing residents who verbalize suicidal ideation and/or act out on the suicidal ideation. This failure resulted in a finding of Harm for 2 residents. Resident identifiers: 26 and 27. (Cross refer to F-250) 4. The facility Administration failed to maintain a Quality Assessment and Assurance Committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F-490) On 2/15/17 at approximately 2:00 PM, an interview was conducted with the facility Administrator and the facility DON. The facility Administrator stated that they had been without an SSW (Social Service Worker) or RA (Resident Advocate) since September 2016. The facility Administrator stated that he had been notified by their Corporate Administration that he was to take on the tasks of the SSW or RA. The facility Administrator stated that he had received a little training by the SWC (Social Work Consultant) a couple of times a month to complete the quarterly assessments but that he had not had any formal training for providing Social Services to the facility residents. The facility DON (Director of Nursing) verified that the facility had been without a SSW and that the facility Administrator had taken on those duties per the Corporate Administration. The facility DON stated that she and the facility Administrator worked closely regarding any incident involving the facility residents. On 2/16/17 at 3:18 PM, an interview was conducted with the facility DON. The facility DON stated that they had been without a SSW or RA for several months and that she could not address the behaviors in the medical record because of her lack of training to do Social Services. The facility DON stated that she was not qualified to devise behavior contracts with residents or to devise specific interventions for behaviors, and that requires a social work degree to do such. The facility DON stated that the Administrator had been completing the Social Services tasks within the facility. The facility DON further stated that the Administrator did not have any formal training for taking on the Social Services tasks but had been getting a little training at times from the facility Social Work Consultant.

Based on observation, interview, and medical record review it was determined for 2 of 28 sample residents that the facility did not ensure that the resident environment remained as free of accident hazards as was possible. Specifically, one resident sustained [REDACTED]. Resident identifiers: 15 and 32. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15's medical record was reviewed on 2/22/17. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 15 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated that resident 15 had severe cognitive impairment. The facility staff assessed resident 15 as requiring extensive two person physical assistance for transfers. A review of the Incident Reports and Progress Notes documented the following entries: a. 2/21/17 at 7:45 PM, a Progress Note documented At 1800 (6:00 PM) the CNA (Certified Nursing Assistant) reported that while she was transferring this resident from her bed to her wheelchair, she fell forward and hit her face on the night stand next to her bed. The CNA stated she hit her face pretty hard. When I arrived there was visible swelling on this resident's nose and when asked if she was in pain, resident at first said no then stated yes when asked a second time. DON (Director of Nursing) and MD (Medical Doctor) notified. MD ordered to put ice pack on nose, give Tylenol if endorsing pain and send resident to (name of local hospital) ER (emergency room ). Ice pack was applied by the aide and Tylenol was given by this nurse. Resident was transported via (name of ambulance company) ambulance to (name of local hospital) ER at 1900 (7:00 PM). Her emergency contact was notified by (name of facility staff) (medical records). b. 2/21/17, an Incident Report documented that injury occurred during transfer from chair to bed. A review of the local hospital discharge summary dated 2/21/17, documented that resident 15 had small bilateral nondisplaced fractures of the nasal bones. On 2/23/17 at 12:07 PM, an interview was conducted with the DON. The DON stated that resident 15 was one on one with staff but she was not sure when that was implemented. The DON stated that a bed wedge had been implemented for resident 15 but she was not sure when that was implemented. The DON stated that resident 15 was pretty light and was only a one person assistance with transfers. On 2/23/17 at 12:46 PM, an interview was conducted with CNA 5. CNA 5 stated that sometimes resident 15 would need two CNA's to assist with transfers in the bathroom. CNA 5 stated that it was easier to change resident 15's brief in the bathroom. On 2/23/17 at 12:52 PM, and interview was conducted with CNA 3. CNA 3 stated that resident 15 was total dependence with all activities of daily living (ADL). CNA 3 stated that resident 15 was a two person assist with ADLs but on a good day resident 15 only required a one person assist with ADLs. CNA 3 stated that when resident 15 was sleeping the staff were required to check on her every 15 minutes. On 2/23/17 at 1:33 PM, an interview was conducted with CNA 7. CNA 7 stated that she was getting resident 15 up to use the restroom and the resident had taken her socks off and threw them on the floor earlier. CNA 7 stated that she turned her back to pick up the socks and heard a crash. CNA 7 stated that resident 15 had fallen forward off the bed. CNA 7 stated that she wasn't sure if the resident had hit anything but her face started to bruise instantly. CNA 7 stated that there were no other residents or staff in the room to witness what happened. CNA 7 stated that she was transferring resident 15 without assistance. 2. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 32's medical record was reviewed on 2/23/17. A review of the Incident Reports and Progress Notes documented the following entries: a. 1/12/17 at 8:43 PM, a Progress Note documented CNA on shift reported at about 2000 (8:00 PM), that this resident had the call light around her neck. When I arrived resident was laying on her back in bed, with the call light loosely draped around her neck. Resident showed no signs of physical or emotional distress, she was calmly laying in bed. Cord was then removed from her neck. Resident was asked why she was doing that and she did not respond. Resident was then told not to do that anymore and she replied OK. Moments later she fell asleep. MD and emergency contact notified of this behavior. An Incident Report dated 1/12/17, documented that the MD and emergency contact were not notified until 1/16/17 at 8:00 PM. b. 1/13/17 at 9:16 PM, a Progress Note documented Pt (patient) found in bed with call light wrapped around neck. laying on back, cord wrapped loosely, able to easily fit a finger between cord and neck, pt breathing with even unlabored breaths. pt not responding, eyes closed but noted to be voluntarily moving, continued to call out pt's name until she finally responded. when asked about why she wrapped a cord around her neck she stated she is upset because she took a shower today and her hair is not growing out fast enough. this nurse asked pt if she planned to hurt herself, pt stated that she feels fine and did not want to hurt herself, offered activity, movie, pt accepted. pt went into day room and watched a movie, has been calm with no further behavior episodes. An Incident Report dated 1/13/17, documented that the MD and emergency contact were not notified. c. 1/17/17 at 2:48 PM, documented that resident 32 was sent to the local hospital for a psychiatric evaluation for placing call light cord around her neck. Resident 32 returned to the facility because she did not meet criteria to be admitted into the hospital. Resident 32's discharge papers showed that she had a urinary tract infection and was prescribed Macrobid. d. 1/22/17 at 9:08 PM, a Progress Note documented Pt approached this nurse at the nurses cart where I was already engaged in care with another resident, pt was asked to wait until medication and care was finished with other resident, pt began crying and walked away rapidly back to bedroom, cna followed pt to find pt wrapping call light cord around neck. Pt stated I don't care about anything anymore. pt brought out into day room with CNA to be supervised at all times, MD notified; notify family, do incident report. pt remained tearful x (for) 20 min (minutes), became calm, cheerful, remains in day room for observation. An Incident Report dated 1/22/17, documented that the MD and emergency contact were notified on 1/22/17 at 9:00 PM. Resident 32 had slight redness to the anterior left side of her neck approximately 2 cm (centimeters) x (by) 1 cm. e. 1/29/17 at 7:43 PM, a Progress Note documented cna responded to call light to find pt in room with 3 scratches on left wrist approx (approximately) 3 cm long, pt stated it was done with finger nails. pt removed from room, brought out into day room to be monitored. finger nails clipped. f. 1/30/17 at 11:18 AM, a Progress Note documented pt (resident 32) was brought into the resident advocate's office to talk. We do our little talks each morning to make sure she's doing okay here. Today, we talked about how she was scratching herself due to what was going on around her. (Note: the Administrator was acting Resident Advocated during this time.) g. 1/31/17 at 6:52 PM, a Progress Note documented Resident was pink sheeted to the (local hospital) for stating she felt suicidal. Resident had called the police and told them she felt suicidal. She left via ambulance at 1850 (6:50 PM). DON, MD and her mother were notified. h. 1/31/17 at 10:05 PM, a Progress Note documented call from (local hospital) stating this resident stated she was not suicidal and they would be sending this resident back to the facility. i. 2/14/16 at 11:45 AM, a Progress Note documented LCSW (licensed clinical social worker) received phone call from administrator asking about procedures for her suicidal gestures. Due to changes at facility, psychosocial assessment will be done today and care plan revised to address her mood and behavior issues more completely. LCSW also reviewed POA (power of attorney) paperwork and discovered that, in fact, her mother has guardianship. Her mother has stated that she does not want (resident 32) leaving the facility without family or staff and that she does not want her to have access to the telephone. See full psychosocial. j. 2/14/16 12:34 PM, a Psychosocial Evaluation documented . (resident 32) has a dx (diagnosis) of bipolar disorder which manifests as multiple suicidal gestures and verbal outbursts & (and) screaming along with threats to harm others. Her mood swings are dramatic. At least twice (resident 32) has tried to escape from the facility by climbing over the fence. Her guardian/mother does not want her in the community on her own. (Resident 32) has wrapped the call light around her neck a few times as a suicidal gesture. (Resident 32) has threatened to harm others including when she threatened to kill the nurse when she did not get her own way. Her room needs to be free from anything she could use to harm herself (call lights, plastic bags, belts, any products considered dangerous and/or labeled 'keep out of the reach of children' . (Resident 32) needs to be closely monitored to prevent any harm to self or others. When she makes a suicidal gesture, she should be evaluated by a mental health professional . This can be done in the E.R. and it is recommended that knowledgeable staff accompany her to the hospital to explain what has been going on. She should be referred to (behavior clinic) for medication management and counseling as needed. (Note: resident 32 had no Psychosocial Evaluation on admission and no evaluation after each incident.) k. 2/20/17 at 10:01 PM, a Progress Note documented LCSW received message around 9:20 that (resident 32) was again found with the call light cord around her neck . LCSW conferred with DON and MD and she is being sent to the E.R. at (local hospital). Dr. (doctor) agreed to phone the hospital and try to speak to the E.R. doctor and explain that she needs to be admitted due to her multiple suicidal gestures. LCSW called and spoke to the charge nurse at (facility) and requested that she call her mother/guardian again and request that her mother go to the E.R. right now and stress the importance of her being admitted as well. l. 2/20/17 at 10:25 PM, a Progress Note documented At approximately 2100 (9:00 PM), this nurse was notified by the CNA that this resident was laying in bed with the call light wrapped around her neck. This nurse was in the room at the time, helping another resident (name removed) when I was alerted that this resident had pulled the call light and had the call light cord around her neck. The call light was quickly removed. Resident was awake and alert. She was asked why she did that she stated I hate this place. She was assessed for injuries. None apparent. This nurse went back to the nurse's station to make a call to the DON and MD. When I got off the phone with them I was notified that she had wrapped the call light cord around her neck again. She was then taken to the living room where she had an aide watching her to make sure she would not harm herself. MD ordered neuro (neurological) checks and to send resident to the (local hospital) ER. Resident's mother was also notified. She stated she would call the ER and speak to them as well. Resident left via (local ambulance company) at about 2150 (9:50 PM). Shortly after she left, I received a call from the social worker who requested I speak to the mother and ask her to be with the resident at the hospital as it would be helpful in getting her admitted . Her mother, (name removed) was called and she stated she had work in the morning and is unable to be at the hospital with her. She stated she spoke to someone at the ER and expressed to them that she wanted her admitted . She also stated she would be there if she could but she has to be at work at 7am. m. 2/20/17 at 10:32 PM, a Progress Note documented Also, the second time this resident wrapped the call light cord around her neck, she had also placed a pillow case over her head. A care plan dated 1/11/17, documented The resident has a mood problem r/t (related to) her disease process and [DIAGNOSES REDACTED]. The goal for resident 32 included, The resident will have improved mood state happier, calmer appearance, no s/sx (signs or symptoms) of depression, anxiety or sadness through the review date. The interventions on the care plan were as follows: -Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. -Educate the resident/family /caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. A care plan dated 2/14/17, documented (Resident 32) has made AWOL (absent without official leave) attempts. The goal for resident 32 included, (Resident 32) will only leave the facility to go into the community when she is accompanied by facility staff or family. The interventions on the care plan were as follows: -Be sure that (resident 32) has personal identification (such as identification card, dog tags or facility business card) with her at all times. -Remind her that she is safer going out only when with another responsible person. A care plan dated 2/14/17, documented (Resident 32) has attempted to harm herself by putting the call light around her neck multiple times. The goal for resident 32 included, (Resident 32) will have no attempt to harm herself q (every) day. The interventions on the care plan were as follows: -Monitor whereabouts closely. After she has an explosive outburst or has not gotten what she requested, increase monitoring as such event may trigger suicidal gestures. -Treat every attempt, gesture or comment seriously and notify M.D. -If she has a plan for killing herself, go with her to the E.R. for a mental health evaluation or contact the Mobile Crisis Outreach Team . -Ensure her room is always free of anything she could use to kill herself. -After an attempt, ensure she is 1:1 (one on one) until she is evaluated in person by M.D. or mental health professional. -Ensure she has regular visits with (name of mental health clinic) for counseling and medication mgt (management). -Encourage positive outlook and help her focus on her strengths especially during weekly visits with RA (Resident Advocate). Refer to LCSW as needed. 2/23/17 at 1:24 PM, an interview was conducted with the DON. The DON stated that she would expect the social worker to be involved with the residents on admission to the facility. The DON stated that the facility staff would try to keep an eye on resident 32 but the incidents were on the graveyard shift when the staff ratio was decreased. The DON stated that the staff would try to bring resident 32 out to the dayroom to keep an eye on her. No additional information was provided.