Every finding on record at Rawlins Rehabilitation and Wellness

Based on observation, medical record review, staff interview, and policy procedure review, the facility failed to ensure infection prevention practices were implemented for 3 of 6 sample residents (#3, #5, #11) observed during resident care. The findings were: 1. Observation on 8/6/25 at 9:46 AM showed CNA #2 applied a gown, gloves, and face mask then entered the room of resident #11 and resident #3. The CNA removed soiled linen from the bed then placed the soiled linen in a plastic bag. Without removing her gloves, the CNA removed her facemask by placing her fingers around the facemask's elastic ear loops, contacting her bare skin, and pulled the mask off. 2. Observation on 8/6/25 9:50 AM showed CNA #2 applied a gait belt to resident #11 and removed the resident's foot cradle from the wheelchair. The CNA applied gloves, removed the resident's catheter drainage bag from the wheelchair, and placed the catheter drainage bag on the floor near a recliner by the front entrance. Without removing her gloves, the CNA touched the residents clothing, assisted the resident to transfer with a gait belt, removed the gait belt, rolled it up, and placed in a pocket of her pants, then removed her gloves. Continued observation showed the CNA applied clean gloves, removed the contaminated gait belt and applied it resident #3. The CNA removed the resident's catheter drainage bag and placed it on the floor by a recliner near the front entrance. Without removing the gloves, the CNA transferred the resident to the recliner, removed the gait belt, rolled it up, and placed it in a pocket of her pants.3. Observation on 8/6/25 at 10:56 AM showed CNA #1 and CNA #2 entered resident #5's room to assist him/her out of bed. After applying personal protective equipment which included gloves, gowns, face masks, and goggles, CNA #2 performed perineal care on the resident by wiping the resident's catheter tubing, urinary meatus, and rectum. While cleaning the resident's rectum, feces was visible of the wipes. When perineal care was complete, the CNA applied cream to an open area on the resident's buttocks then touched items which included the mechanical lift sling, the resident's pants, the resident's catheter tubing, the resident's wheelchair foot pedal, the resident's leg, items on the bedside table, the resident's shoe, the mechanical lift handle, the mechanical lift controller, and the bed linen used to make the resident's bed. 4. Interview with the administrator/infection preventionist on 8/7/25 at 10:29 AM revealed catheter drainage bags should not be stored on the floor and gloves should be removed after the catheter drainage bag was secured. She revealed staff should remove their gloves and perform hand hygiene after performing perineal care, prior to touching other items, to prevent cross-contamination. Further interview revealed staff should not touch their face with contaminated gloves when removing face masks. 5. Review of the policy titled Work Practices dated May 2015 showed .1. Employees wash their hands as soon as possible after removing gloves or other personal protective equipment and after contact with blood or other potentially infectious material .6. Review of the policy titled Performing Perineal Care on a [Gender] provided by the facility administrator on 8/7/25 showed after performing perineal care the staff member should .9. Remove and dispose of gloves in a receptacle and perform hand hygiene . prior to assisting the resident with additional cares.

Based on medical record review and staff interview, the facility failed to ensure a gradual dose reduction (GDR) or risk versus benefit statement was performed on psychotropic medications for 1 of 5 sample residents (#27) reviewed for unnecessary medications. The findings were: 1. Review of the 3/25/25 quarterly MDS assessment showed resident #27 had BIMS score of 8 out of 15, which indicated moderate cognitive impairment, and diagnoses which included non-Alzheimer's dementia, anxiety disorder, and depression. Further review showed the resident received antipsychotic medication, antianxiety medication, and antidepressant medication and a gradual dose reduction had not been attempted for the antipsychotic medication. Review of the physician orders showed the resident received alprazolam 0.5 milligrams (mg) by mouth at bedtime with a start date of 8/3/25 and duloxetine 30 mg by mouth daily with a start date of 5/25/25. The following concerns were identified: a. Review of the medical record showed the facility had identified target behaviors which included physical behaviors directed toward others, verbal behaviors directed toward others, socially inappropriate behaviors, and other behaviors not directed toward others; however, they did not identify which target behaviors or target symptoms were being treated by the individual psychotropic medications. b. Review of a physician note dated 11/6/24 and timed 8:45 PM showed .Continue Zyprexa 2.5 mg PO [by mouth] daily -Continue alprazolam 0.5 mg PO QHS [every hours of sleep] No GDR are recommended due to multiple psychiatric diagnoses and due to ongoing status . c. Review of a Consultant Pharmacist Report to Physician dated 2/3/25 showed Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder. This resident has been taking diphenhydramine 25 mg hs and alprazolam 0.5 mg hs without a GDR. Could we attempt a dose reduction at this time to verify resident is on the lowest possible dose? If not, please indicate response below . Further review showed the physician discontinued diphenhydramine; however, the alprazolam was not addressed. d. Interview with the administrator on 8/7/25 at 10:26 AM confirmed no GDR or risk vs benefit, with physician rationale for continued use, was performed for the alprazolam in the last year. Further she confirmed there were no medication specific target symptoms identified.

Based on staff and resident representative interview and medical record review, the facility failed to ensure residents or resident's representative participation in care plan decisions for 1 of 13 sample residents (#3). The findings were: 1. Interview with the resident representative for resident #3 on 8/4/25 at 2:49 PM revealed she had not participated in a care plan meeting for quite a while. She revealed the facility use to have care plan meetings to discuss the resident's care every 2 to 3 months. 2. Review of the medical record for resident #3 showed no evidence the resident or representative had participated in care plan development or a care plan meeting had been performed in 2025.3. Interview with the social services director on 8/7/25 at 8:47 AM revealed she had worked at the facility previously an then left for 6 months. She revealed during the time she was not employed at the facility, there was nobody in the social services position full-time and care plan meetings were not performed during that time. She revealed since she returned, she was attempting to catch up on the care plan meetings and confirmed a care plan meeting had not been performed for the resident.

Based on observation, staff interview, medical record review, and manufacturer's instruction review, the facility failed to ensure appropriate use of mechanical lifts for 1 of 5 sample residents (#5) reviewed for lift/transfer safety. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #5 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included multiple sclerosis. Further review showed the resident had lower extremity impairment on one side and was dependent on staff for chair/bed-to-chair transfer. Review of the resident's care plan last revised on 7/13/25 showed the resident had a left lower extremity amputation and required a mechanical lift for transfers. The following concerns were identified:a. Observation on 8/6/25 at 10:56 AM showed CNA #1 and CNA #2 entered the resident's room to assist him/her out of bed. After performing care, the CNAs assisted the resident to roll toward the wall and placed a full body lift sling under the resident, positioned the Invacare Reliant 450 full body mechanical lift over the resident, and attached the sling to the mechanical lift. CNA #1 locked the caster brakes on the mechanical lift and lifted the resident out of bed, then unlocked the caster brakes and the CNAs positioned the resident over the wheelchair. The CNAs switched places and CNA #2 locked the caster brakes then lowed the resident into the wheelchair. b. Review of the manufacturer's recommendations for the Invacare Reliant 450 battery powered patient lift provided by the facility on 8/6/25 showed .Lifting the Patient .Warning .Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed, or any stationary object .c. Interview with the administrator on 8/6/25 at 6:28 PM revealed she thought it was ok to lock the casters during the transfer. At that time, she confirmed the manufacturer's recommendation showed it was not recommended to lock the casters when operating the mechanical lift.

Based on medical record review, resident representative, hospital staff and staff interview the facility failed to ensure a resident was allowed to return following a transfer to an acute care setting for 1 of 3 sample residents (#1) reviewed for discharge. The findings were: 1. Review of the medical record for resident #1 showed the resident was admitted to the facility on [DATE]. Review of the admission MDS assessment dated [DATE] showed resident #1 was unable to complete a BIMS assessment, had severely impaired cognitive skills for daily decision making, and diagnoses which included non-Alzheimer's dementia, Pick's disease, other frontotemporal neurocognitive disorder, and aphasia. Further review of the medical record showed resident #1 had behavioral issues, which included wandering through the hallways and other resident rooms, defecating and urinating in the hallway, and physical aggression toward other residents and staff. The following concerns were identified: a. Review of a progress note dated 4/1/25 and timed 1:35 PM showed Late entry: While RN was completing resident's admission with [his/her] sister/POA, [name], she stated that resident has regressed quite a bit since [his/her] last stay here. She reported [s/he] was voiding and defecating in inappropriate places, often hypersexual, aggressive, and has not been bathed in 4 months due to her not wanting to fight with [him/her] to take a shower. RN reported this to [name], SSD, and [name], ED, as I felt as if these things were concerning with accepting this admission. This RN witnessed [SSD] enter the resident's room and tell [sister] that we will take resident on a trial basis, however if resident proves too much for our staff to handle or it doesn't work out we will send out referrals to get [him/her] to a more secure locked unit, however she would need to come pick [him/her] up. b. Review of a progress note dated 4/7/25 and timed 7:11 PM showed Spoke with sister [name] at length regarding placement to a locked unit. We have not been successful at this time. She is distraught and afraid [s/he] will be placed far away. She is teary and concerned. We assured her that we will do everything we can for [him/her] and her. She gave some insight into some activities [s/he] does enjoy . c. Review of a progress note dated 5/28/25 and timed 2:36 PM showed referrals were sent to 10 care centers by the SSD. d. Review of a progress note dated 5/28/25 and timed 3 PM showed DNS [name] informed RN that we are to send resident to [hospital] ER for aggression via ambulance at this time. She completed the ER transport form. 911 called to request EMS. Report called to [name] in the ER. Dr. [name] notified via phone of transport by this RN at 3:37 PM. Resident admitted to Med Surg 3rd floor per RN from [hospital name] who called with a medication question. e. Review of a progress note dated 5/28/25 and timed 5:35 PM showed SSD called [name] and let her know resident was sent to the ER @ [hospital name] again today. The connection was bad and SSD made sure [name] could hear me when speaking. SSD informed [name] resident was sent out and [facility] would not be accepting [him/her] back. [name] told SSDit [sic] is my responsibility to find [him/her] placement. SSD let [name] know I have a list of places that may accept him/her and s/he is on the waiting list for [facility]. The call was dropped at this time [sic] [name] called back and SSD answered the phone. [Name] asked if I meant to hang up on her and I explained I did not. SSD asked if she had heard the last information on the places that may be willing to take resident. [Name] had not heard me? (she was driving in a rain storm near [name of town] where the service is spotty)[sic] [name] said she did not and began to repeat herself about it being [facility's] responsibility to find [him/her] placement. SSD let [name] know this decision came from cooperate [sic] and gave her [name of corporate staff] name to follow up with. SSD apologized and told her it was not a choice we here made and the safety of the other residents and staff had to be considered. [Name] said she did not disagree with [facility] not keeping resident. SSD then told her again I have a list of places that may accepthim [sic] and spoke to her directly about [ list of 3 facilities]. [Name] thanked SSD and asked if there were any places in [2 cities]. SSD let her know I was not able to locate any. SSD offered to provide [name] with a list of places I have sent referrals to . SSD told [name] we will get residents belongings packed up and if she wants to let us know when she is in town we will make sure they are all ready for her along with th4 [sic] list of places ho [sic] may be willing to accept resident. SSD explained the hope was to find a place to transfer [him/her]. [Name] thanked SSD and said she will let us know when she is able to come pick up [his/her] things. f. Review of a Resident Notice of Transfer or Discharge dated 5/28/25 showed the reason for transfer/discharge was The resident's clinical or behavioral status (or condition) otherwise endangers the health of individuals in the facility. Further review showed You have the right to appeal this decision and the resident's representative was notified by phone. g. Review of a letter written by the ED, dated 5/28/25 and addressed to the resident's sister showed This letter will serve as formal notification that it is the intention of [NAME] Rehabilitation and Wellness to discharge [name] on 6/29/25 due to [his/her] clinical or behavioral status endangers the safety of self and individuals in the facility and the physician also supports this discharge. As discussed upon admission, [facility name] would admit [name] on a trial to see if [his/her]needs and behavioral status could be met at the center. This has been an ongoing situation that the facility has attempted to reconcile on numerous occasions. You are encouraged to contact Social Services to give appropriate instructions of the location where you desire [name] to be discharged . In the absence of alternative instructions, [name] will be discharged to the custody of you h. Interview with the ED on 6/12/25 at 8:40 AM revealed resident #1 had been at the facility prior to the 4/1/25 admission, and when the resident's sister had asked if the facility would take him/her back, she neglected to tell them s/he had increased behaviors. She reported the facility staff asked his/her sister if she would be able to take him/her back home if the facility could not provide the care s/he needed and she said yes, however that changed when the behaviors got worse. She stated the doctor had reported the resident had more going on than Pick's disease and his/her behaviors could change hourly, which was why a medication might work one day and not the next. i. Interview with the resident's sister on 6/12/25 at 8:54 AM revealed the facility did not secure a different facility for the resident and dumped the resident at the hospital on 5/28/25 where s/he was put on a Title 25 hold in a metal cell before the hospital secured placement out of state at a short-term psychiatric facility. She reported the current out of state facility was trying to find in-state placement, and that was difficult because no facilities in the state were accepting the resident. j. Interview with the hospital social worker on 6/12/25 at 2:48 PM revealed she received an email from the SSD on 5/28/25 at 6:10 PM with a list of 3 places that were willing to accept the resident, and 2 of them were out of state. She contacted the resident's sister who did not want to move the resident to the assisted living facility out of state because it was private pay, and stated when she contacted the in-state facility, they informed her the resident was not appropriate for the facility and was not on the waiting list. The third facility was an out of state psychiatric facility but did not have any openings at first, and told the social worker that she should call frequently to check if they had an opening. Further interview revealed she did not receive any further communication from the facility, she called the third facility frequently as they had suggested, and she was able to place the resident at that facility for short term psychiatric rehabilitation. k. Interview with the SSD on 6/12/25 at 4:00 PM revealed when she learned of the resident's increased behaviors and aggression toward others, she let the resident's sister know they would do a 30-day trial and if they could not manage the resident's behaviors, she would need to agree to take him/her back home, which the SSD reported she did. She reported she sent many referrals and was either told the resident would not be accepted by the facility or did not receive a response. Further interview revealed on 5/28/25 the resident choked a CNA and hit a nurse, and was sent to the hospital for adjustments to his/her medications. She confirmed she called the resident's sister to inform her of the assaults and that the facility would not be able to take the resident back. She reported she found 3 places that would possibly accept the resident, and that she had emailed the social worker at the hospital the list of facilities. Further interview confirmed she was not in contact with the hospital and did not know where the resident had been discharged . She reported the hospital social worker had picked up the resident's belongings. l. Interview with the ED on 6/12/25 at 4:50 PM revealed while s/he was in the facility, the resident had injured CNAs and 1 had been sent to the ER. She reported the facility staff had tried multiple interventions and the behaviors had continued. She reported the rooms at the hospital were open window psych rooms where the nurse could get in to assist and the resident could not get out. m. During an interview on 6/27/25 at 10:03 AM the hospital social worker stated when the patient was sent to the hospital the nurse from the facility called and stated the resident had been aggressive and hit staff. The nurse told the hospital they were not taking the resident back. The social worker further stated the facility never called to arrange a time to evaluate the patient to see if s/he was appropriate to return to the nursing home. The patient was discharged from the hospital on 6/3/25.

Based on medical record review, staff and physician interview, and policy review, the facility failed to provide CPR in accordance with a resident's advance directive for 1 of 1 sample resident (#36) who expired. The emergency happened shortly after admission. The facility had not identified the issue, which left all new admits at risk and a determination of immediate jeopardy. The census was 35 and there were two new admits in the last 30 days. The findings were: 1. Medical record review for resident #36 showed an admission and discharge date of [DATE]. Further review showed the resident signed the admission paperwork, including a POLST [physician orders for life-sustaining treatment] dated [DATE] that indicated the resident chose to be a full code. The POLST was signed by the physician on [DATE]. The nurse admission evaluation was completed by LPN #1 on [DATE] at 2:43 PM and the resident was alert and oriented. The following concerns were identified: a. Review of a progress note on [DATE] at 6:15 PM showed two RN's (RN #1 and RN #2) were providing care to the resident when s/he became unresponsive and lost signs of life. The note did not show that CPR was done on the resident. b. Interview with the administrator (RN #1) on [DATE] at 5:03 PM revealed she had heard the resident was a DNR/DNI in the hospital and did not start CPR on the resident. She was unaware that in the event of a cardiopulmonary arrest the resident and physician had signed a POLST that requested CPR. An additional interview on [DATE] at 11 AM revealed the resident showed signs of mottling to the extremities just prior to the resident becoming unresponsive and the physician was notified. However, further review of progress notes showed no documentation of mottling or notification of the physician prior to notification of the death. c. Interview with LPN #1 on [DATE] at 9:05 AM revealed he admitted the resident and did not recall the resident stating a code status. d. Interview with social worker #1 on [DATE] at 9:12 AM revealed when a new resident arrived at the facility, medical records personnel met with the resident to process the admission paperwork, including the POLST. e. Interview with CNA #1 on [DATE] at 9:20 AM verified the residents' POLST and code status documents were kept in the disaster recovery binder at the nurses station. A random check of two residents verified the information in the binder was correct and there was a tab with resident #36's name on it but the POLST was no longer in the binder. f. Interview with the DON (RN #2) on [DATE] at 9:30 AM revealed she was providing care to the resident when s/he lost consciousness and did not have a pulse. She had heard that while hospitalized the resident chose a DNR/DNI status and she was not aware the resident had signed a POLST earlier in the day requesting CPR in the event of a cardiopulmonary arrest. g. Interview with physician #1 on [DATE] at 12:50 AM revealed he had signed the resident's POLST and was aware of the resident's pending admission to the facility but had not yet seen the resident. He further revealed he had not been notified of any concerns the facility had regarding the resident until the notification of the resident's death. 2. Review of the personnel files for the DON and the administrator showed both were currently certified in CPR. 3. Review of the admission packet, last revised [DATE], showed .The center will abide by any instructions provided in your Advance Directive, Living Will, Health Care Power of Attorney, other Directive, or any POLST/POST issued by your physician. If you have not provided an Advance Directive or if a POLST/POST has not been issued, the Center will take all appropriate actions during an emergency, including administering CPR, calling 911 and sending you to a hospital. 4. Review of the facility's Code Blue (Resident found without vital signs) policy, published [DATE], showed .The resident's code status is established immediately by the nearest Licensed Nurse (LN) using the POLST/POST/Advance Directives .CPR is initiated by the LN for those residents who: a. Have requested, through advance directive or POLST/POST, to have CPR initiated when cardiac or respiratory arrest occurs. b. Have not formulated an advanced directive nor have a POLST in their medical record. c. Do not have a valid DNR order. 5. Review of the facility's Advance Directive policy, updated [DATE], showed .The Center follows each advance directive that has been provided to it in accordance with State and Federal Law .In the absence of an Advanced Directive, the Center provides full treatment to the resident in the event of an emergency of health change. 6. On [DATE] at 8:30 AM the administrator was informed of the immediate jeopardy related to lack of CPR in accordance with advance directives. 7. The facility submitted a removal plan which included: a. Education to all staff regarding POLST forms and code blue. b. 100% audit of all POLST forms for all current residents. c. Audit of all licensed nurses for verification of up to date CPR. e. A mock Code Blue drill was conducted on [DATE], and would occur on every shift for the next 24 hours. 8. The removal plan was accepted on [DATE] at 11:50 AM. 9. The implementation of the removal plan was verified and immediacy was removed on [DATE] at 12:34 PM; however, deficient practice remained at a scope and severity of G.

Based on observation, staff interview, and review of the 2022 Food Code, the facility failed to store and prepare food in accordance with professional standards related to expired food and cleanliness during 2 of 2 observations in the kitchen. The findings were: 1. Observation of the walk-in refrigerator on [DATE] at 2:54 PM showed two 5 pound containers of sour cream with an expiration date of [DATE] and another with an expiration date of [DATE]. In addition there was a 5 pound container of cottage cheese with an expiration date of [DATE] and another with an expiration date of [DATE]. Observation again on [DATE] at 1:31 PM with the dietary manager showed the expired food items were still there. Interview at that time with the dietary manager revealed staff usually looked through the refrigerator weekly for expired items. Review of the 2022 Food Code, US Food and Drug Administration, showed .Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer ' s use-by date if the manufacturer determined the use-by date based on FOOD safety. 2. Observation on [DATE] at 5 PM in the kitchen showed the hanging pot/utensil rack had dust and dirt visible on the surface. At the time, there were 3 pots and 10 utensils hanging from the rack. In addition, the fan in the window above the spice rack and the fire extinguisher near the spice rack were both visibly dusty/dirty. During an interview on [DATE] at 1:31 PM the dietary manager stated the hanging pot holder was on the weekly cleaning schedule and the fan in the window was going to be removed. Review of the 2022 Food Code, US Food and Drug Administration, showed XXX,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, medical record review, and staff and physician interview, the facility failed to ensure the medication error rate was 5% or less. There were 2 errors out of 25 medications administered, for an error rate of 8%. The findings were: 1. Observation of RN #1 on 5/1/23 at 9 AM showed administration of folic acid 2 tablets of 400 mcg and 20 ml of liquid potassium to resident #24. Interview with the nurse at that time revealed the MAR showed the resident's order for folic acid was 2-400 MG tablets and the folic acid was dispensed in micrograms (not milligrams) so she corrected the MAR from mg to mcg to prevent the error and gave a total of 800 mcg of folic acid to the resident. In addition, the potassium chloride bottle showed the concentration as 20 mEq/15 ml give 20 ml's and the nurse confirmed there was 20 ml in the resident's medication cup. 2. Review of the medication orders in resident #1's medical record showed an order for folic acid 400 mg tablets, 2 tablets, twice a day and for liquid potassium chloride 15 mEq with a concentration of 20 mEq/15 mls. 3. Interview with the ordering physician (physician #1) on 5/2/24 at 12:55 PM confirmed the order should have been written in mEq not mls; the pharmacy should have calculated the dose based on the concentration of the liquid (mEq/ml) and 20 ml was not equal to 15 mEq as ordered.

Based on medical record review, staff interview, facility-reported incident review, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 5 sample residents (#23) reviewed for allegations of abuse. This failure resulted in a determination of immediate jeopardy due to inadequate protections from sexual abuse for vulnerable residents. The findings were: 1. Review of the 1/20/23 quarterly MDS assessment for resident #23 showed the resident had a BIMS score of 4 out of 15, indicating the resident had significantly impaired cognition. The review showed the resident had diagnoses that included epilepsy, dementia, cognitive communication deficit, depression, irritability and anger. Further review showed the resident used a wheelchair for mobility, had disorganized thinking, and needed extensive assistance from staff for toileting, personal hygiene, and locomotion. 2. Review of the 12/19/22 quarterly MDS assessment showed resident #8 was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety disorder, depression, and bipolar disease. The resident's brief interview for mental status score was 15 out of 15, which indicated the resident was cognitively intact. Review of the assessment at section G for transfer, walk in room, walk in corridor, locomotion on unit, and locomotion off unit showed the resident required only supervision, oversight, encouragement or cueing, and set up only. The area at section G showed the resident was not steady, but was able to stabilize without human assistance, and the resident utilized a walker. 3. Review of CNA behavior documentation for resident #8 from 2/28/23 to 3/29/23 showed the facility was monitoring the resident for behaviors that included the following: unsolicited sexual comments, gestures, touching staff or residents, masturbating and ringing call light (forced observation), and sexual gestures toward residents. The documentation noted the resident had one or more of these behaviors on 3/13/23 and 3/18/23, but did not specify what the behaviors were. The interventions noted on 3/13/23 and 3/18/23 were 1 to 1 supervision by staff. 4. Review of facility incident reports showed a 12/31/20 incident where it was reported resident #23's hands were down resident #8's pants. Further review showed a 3/18/23 incident where it was reported resident #8 was heard asking resident #23 Do you want to suck it, while holding his/her genitals. The CNA #1 separated both residents, asking resident #8 to return to his/her room, explaining this was inappropriate behavior. The facility's interview with the CNA who witnessed the interaction revealed resident #8 did not have his/her genitals exposed, but was holding his/her genitals in his pants. The incident further noted that resident #8 was independently ambulatory with a front-wheeled walker, had a history of sexually inappropriate behavior, gestures, and vocalizations toward staff and others. The follow concerns were identified: a. Interview with CNA #1 on 3/30/23 at 9:43 AM revealed while she was working on 3/18/23, both residents were in the hallway when she heard resident #8 say to resident #23, Do you want to suck it. When the CNA approached the residents she saw that resident #8 had his/her pants halfway between his/her waist and hips, with his/her hands in the pants, grabbing his/her own genitals and standing with his/her genitals close to the face of resident #23, who was sitting in a wheelchair. The CNA stated resident #23 was leaning forward like [s/he] was going to suck it if I had not intervened. The CNA then separated both residents. The CNA stated management provided verbal education after the incident. The education consisted of keeping those two residents separated. b. Further review of the 12/19/22 quarterly MDS assessment showed resident #8 ambulated independently with the use of a walker. Review of the assessment at section G for transfer, walk in room, walk in corridor, locomotion on unit, and locomotion off unit showed the resident required only supervision, oversight, encouragement or cueing, and set up only. The area at section G also showed the resident was not steady, but was able to stabilize without human assistance, and the resident utilized a walker. c. Review of the 3/15/23 Psychotropic Drug and Behavior Monthly form for resident #8 showed the resident came out of his/her room for meals and activities, had been doing well with his/her depressive-like behaviors, and had been doing well overall. The resident received mental health therapy about every other week and appeared to be reaching his/her highest functional level. Further review showed the resident had no new behaviors since the last review and the resident's overall behaviors continued to decrease with the current medication regimen. The interdisciplinary team recommended that the resident continue to be monitored regarding behaviors. However, the facility failed to address or investigate the sexually inappropriate behavior documented by CNAs on 3/13/23. d. Interview with CNA #4 on 3/30/23 at 1:30 PM revealed her concern that other residents were not safe around resident #8, noting the resident continued to make inappropriate comments. e. Interview with CNA #5 on 3/30/23 at 3:10 PM, revealed the CNA had witnessed two separate occasions last year (2022) when resident #23 had his/her hand in resident #8's pajama pants, and the police were called after the second incident. After the second incident CNA #5 said she asked resident #23 if s/he knew what was going on, and resident #23 replied to CNA #5 s/he did not know and that resident #8 had told him/her it was a game. CNA #5 also stated s/he felt the facility failed to prevent the behavior because it kept happening. S/he also stated that resident #23 did not provoke these behaviors and did not have the capacity to do so, that s/he was a follower and didn't think of the ideas first. She also stated her opinion resident #8 had targeted resident #23 because s/he could get away with it. f. An additional interview with CNA #1 on 3/30/23, at 5:30 PM confirmed her original written statement and further added that resident #8 did not reveal his/her genitals at that time, his/her pants were at his/her hips and the CNA was glad she caught them and stopped it from happening because she did not want that for anyone. g. Interview with CNA #3 on 3/30/23 at 1:45 PM revealed resident #8 often made sexual comments about others. She also stated the resident could be redirected; however s/he just does it again, and the CNA felt that the resident would continue to manipulate vulnerable residents. The CNA also confirmed that resident #23 did not solicit sexual comments or behaviors from others. h. Review of resident #8's room change notice dated and signed on 3/20/23 showed the room change was due to safety issues and repeated occurrences with fell ow residents. Review of the progress notes for resident #8 showed on 3/18/23 at 10:24 AM, It was reported to the nurse this resident was in the hall, approached another resident, pulled down [his/her] own pants, and asked the other resident to suck it. The CNA then confronted and redirected both residents, and notifications were made. Further review showed resident #8 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] due to an incident with another resident. However, the facility failed to change the resident's room until 2 days after the incident. i. Review of resident #8's care plan, last revised on 8/1/22, failed to show any new revisions or interventions since 6/8/22. j. Review of the facility staff education dated 3/30/23 titled Staff Education on Monitoring Resident while in common areas throughout the building, showed Due to recent incidents with [resident #8], we must monitor [his/her] whereabouts throughout the facility at all times, especially during times when other vulnerable residents are around. Please read and sign. Further review showed 19 signatures on the document. k. Interview with the ED on 3/30/23 at 9:15 AM revealed the facility was unable to do a root cause analysis because resident #8 chronically denied any and all allegations of sexual misconduct, and the resident had cycles of misbehaving. The ED stated they moved the resident closer to the manager's offices to help monitor but did not have a staff member continuously observing the resident for prevention and safety. 5. Review of the facility policy titled Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation. last updated September 2017, definitions showed: -Sexual Abuse: Non-consensual sexual contact of any type with a resident. It includes but is not limited to: Unwanted intimate touching of any kind, especially of breast or perineal areas; Forced observation of masturbation and/or pornography; and . Generally, sexual contact is non-consensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent. -Mistreatment: Inappropriate treatment or exploitation of a resident. -Exploitation: Taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. 6. Review of the facility policy titled Prevention of all Types of Abuse, Neglect, Mistreatment, Involuntary Seclusion, Exploitation, and Misappropriation of Resident Property'' last updated October 2022, showed the following: 7 Correct and intervene in reported identified situations in which abuse, neglect, exploitation, or misappropriation is more likely to occur by analyzing the following .b confirm that the staff assigned has knowledge of the individual residents' care needs and behaviors; e. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as: i. Verbally aggressive behavior; ii. Physically aggressive behavior; iii. Sexually aggressive behaviors such as saying sexual things, inappropriate touching, grabbing; .vii. Residents with communication disorder or language barrier; .9. Residents identified by staff as being self-injurious or exhibiting abusive behavior .are reviewed .Referrals are made and treatment plans modified as appropriate. 7. Review of the facility policy titled Abuse Protection last updated October 2022, showed .1. The Center responds immediately to suspicion and/or allegations of abuse in order to protect the victim and the integrity of the investigation .5. The Center suspends and/or removes the alleged perpetrator from the patient care area immediately .6. The Center changes the resident's room and/or assigned staff as necessary to protect the resident .7. The Center increases supervision of the alleged victim and other residents as determined by the Executive Director/designee. 8. Review of the facility policy titled Abuse Identification last updated October 2022 showed .4 .The Quality Assurance and Performance Improvement (QAPI) program, investigates occurrences, patterns, and trends that may indicate the presence of abuse .to determine the direction of investigation/interventions, through analysis of systems, audits, and reports. On 3/30/23 at 2:45 PM the ED was informed of an immediate jeopardy situation in the regulatory area of freedom from abuse, neglect, and exploitation. The facility submitted an action plan which included the following immediate changes: .Corrective Action: Identified Resident was put on one to one observation on 3/30/23 at 2:50 PM related to an incident occurring on 3/18/23. Identification of others: Initial audit completed of 25% random residents to assess for others who may have been affected. Re-interview of the only eye witness and other staff completed by Executive Director and Divisional Director of Clinical Operations. Systemic Change: Re-education provided to all staff related to one on one status of identified Resident. Executive Director/Designee will audit one on one assignment sheet daily times three months for one on one compliance. Monitoring: Ad hoc QAPI meeting held with Medical Director at approximately 6:15 PM on 3/30/23 to discuss immediate jeopardy specifics as described by surveyors. Results of initial as well as ongoing audits will be monitored via the QAPI process monthly times three months for further recommendations . The action plan was accepted on 3/31/23 at 11:42 AM. The implementation of the plan was verified and immediacy was removed on 3/31/23 at 11:42 AM; however, deficient practice remained at a scope of G, as a reasonable person would feel intimidated, humiliated or demeaned by the behavior.

Based on medical record review, staff interview, incident review, and facility policy review, the facility failed to ensure adequate protective measures were in place to prevent abuse for 1 of 5 sample residents (#8) reviewed. The findings were: 1. Review of the 12/19/22 quarterly MDS assessment for resident #8 showed the resident has a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of the assessment at section G for transfer, walk in room, walk in corridor, locomotion on unit, and locomotion off unit showed the resident required only supervision, oversight, encouragement or cueing, and set up only. The area at section G showed the resident was not steady, but was able to stabilize without human assistance, and the resident utilized a walker. Review of facility-reported incidents showed a 3/18/23 incident where it was reported resident #8 was heard asking resident #23 Do you want to suck it, while holding his/her genitals. CNA #1 separated both residents, asking resident #8 to return to his/her room, explaining this was inappropriate behavior. The facility's interview with the CNA who witnessed the interaction revealed resident #8 did not have his/her genitals exposed, but was holding his/her genitals in his/her pants. The incident further noted that resident #8 was independently ambulatory with a front-wheeled walker, had a history of sexually inappropriate behavior, gestures, and vocalizations toward staff and others. The follow concerns were identified: a. Interview with CNA #1 on 3/30/23 at 9:43 AM revealed while she was working on 3/18/23, both residents were in the hallway when she heard resident #8 say to resident #23, Do you want to suck it. When the CNA approached the residents she saw that resident #8 had his/her pants halfway between his/her waist and hips, with his/her hands in the pants, grabbing his/her own genitals and standing with his/her genitals close to the face of resident #23, who was sitting in a wheelchair. The CNA stated resident #23 was leaning forward like [s/he] was going to suck it if I had not intervened. The CNA separated the residents. The CNA stated management provided verbal education after the incident. The education consisted of keeping those two residents separated. b. Interview with CNA #4 on 3/30/23 at 1:30 PM revealed her concern that other residents were not safe around resident #8, noting the resident continued to make inappropriate comments. c. Interview with CNA #5 on 3/30/23 at 3:10 PM, revealed the CNA had witnessed two separate occasions last year (2022) when resident #23 had his/her hand in the fly of resident #8's pajama pants, and the police were called after the second incident. After the second incident CNA #5 said she asked resident #23 if s/he knew what was going on, and resident #23 replied to CNA #5 s/he did not know and that resident #8 had told him/her it was a game. CNA #5 also stated s/he did not feel the facility kept resident #23 safe because it kept happening. S/he also stated that resident #23 did not provoke these behaviors and did not have the capacity to do so, that s/he was a follower and didn't think of the ideas first. She also stated her opinion resident #8 had targeted resident #23 because s/he could get away with it. d. An additional interview with CNA #1 on 3/30/23, at 5:30 PM confirmed her original written statement and further added that resident #8 did not reveal his/her genitals at that time, his/her pants were at his/her hips and the CNA was glad she caught them and stopped it from happening because she did not want that for anyone. e. Interview with CNA #3 on 3/30/23 at 1:45 PM revealed resident #8 often made sexual comments about others. She also stated the resident could be redirected; however s/he just does it again, and the CNA felt that the resident would continue to manipulate vulnerable residents. The CNA also confirmed that resident #23 did not solicit sexual comments or behaviors from others. f. Review of resident #8's room change notice dated and signed on 3/20/23 showed the room change was due to safety issues and repeated occurrences with fell ow residents. Review of the progress notes for resident #8 showed on 3/18/23 at 10:24 AM, It was reported to the nurse this resident was in the hall, approached another resident, pulled down [his/her] own pants, and asked the other resident to suck it. The CNA then confronted and redirected both residents, and notifications were made. Further review showed resident #8 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] due to an incident with another resident. However, the facility failed to change the resident's room until 2 days after the incident. g. Review of the facility staff education dated 3/30/23 titled staff education on monitoring resident while in common areas throughout the building, showed Due to recent incidents with [resident #8], we must monitor [resident #23's] whereabouts throughout the facility at all times, especially during times when other vulnerable residents are around. h. Interview with the ED on 3/30/23 at 9:15 AM revealed the facility was unable to do a root cause analysis because resident #8 chronically denied any and all allegations of sexual misconduct, and the resident had cycles of misbehaving. The ED stated they moved the resident closer to the manager's offices to help monitor but did not have a staff member continuously observing the resident for prevention and safety. 2. Review of the facility policy titled Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation. last updated September 2017, definitions showed: -Sexual Abuse: Non-consensual sexual contact of any type with a resident. It includes but is not limited to: Unwanted intimate touching of any kind, especially of breast or perineal areas; Forced observation of masturbation and/or pornography; and . Generally, sexual contact is non-consensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent. -Mistreatment: Inappropriate treatment or exploitation of a resident. -Exploitation: Taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. 3. Review of the facility policy titled Abuse Protection last updated October 2022, showed .1. The Center responds immediately to suspicion and/or allegations of abuse in order to protect the victim and the integrity of the investigation .5. The Center suspends and/or removes the alleged perpetrator from the patient care area immediately .6. The Center changes the resident's room and/or assigned staff as necessary to protect the resident .7. The Center increases supervision of the alleged victim and other residents as determined by the Executive Director/designee. 4. Review of the facility policy titled Abuse Identification last updated October 2022 showed .4 .program, investigates occurrences, patterns, and trends that may indicate the presence of abuse .to determine the direction of investigation/interventions, through analysis of systems, audits, and reports.

Based on observation, and staff interview, the facility failed to ensure the proper use of PPE during blood glucose testing and failed to ensure adequate disinfection of glucometers during 1 random observation. Observation on 3/29/23 at 10:47 AM showed LPN #2 gathered the glucometer, lancet, alcohol pad, and test strip while at the nurse's station medication cart at the front of the facility. The LPN performed hand hygiene, prepared the supplies, and inserted the test strip into the glucometer. The LPN then walked to the resident's room and placed the glucometer on top of the blanket which covered the resident's abdomen. The LPN picked up the glucometer for the test, then placed the glucometer back on the blanket. The glucometer was not disinfected at this time. The LPN failed to don gloves when performing the glucose test. No barrier was used between the glucometer and supplies, and the resident's blanket. The LPN left the resident's room after completing the test and placed the contaminated glucometer on the medication cart. The LPN also took the used test strip out of the glucometer and threw it in the biohazard container without donning gloves. Interview with the LPN at that time revealed s/he should have utilized appropriate personal protective equipment at that time to include gloves. Interview with the DON on 3/29/23 at 11:40 AM revealed the staff were expected to wear gloves during glucose testing related to contamination risk for blood borne pathogens. Also, a barrier should be placed between the glucometer and the environment, and bleach wipes should be utilized to disinfect glucometers between each resident use. 47344

Based on staff interview and class enrollment documentation review, the facility failed to ensure a full-time staff member with the required competencies managed the dietary department. The findings were: Interview on 3/27/23 at 12:51 PM with the dietary manager revealed she was not certified as a dietary manager. She further confirmed the facility had a contracted registered dietitian who was not present for the day to day operation of the dietary department, but could take calls from the facility as needed. Review of the class enrollment receipt showed the dietary manager had enrolled in an acceptable on-line class on 3/29/23 at 1:53 PM to become a certified dietary manager.

Based on medical record review, staff interview, facility policy review, and review of the CMS Resident Assessment Instrument (RAI) manual version 3.0, the facility failed to ensure comprehensive assessments were completed within 14 days after admission for 2 of 2 sample residents (#19, #28) reviewed for timely comprehensive MDS completion. The findings were: 1. Review of the medical record for resident #19 showed the resident was admitted to the facility on [DATE]. Review of the admission MDS assessment showed an ARD of 2/23/23 and section Z0500 showed the RN assessment coordinator had signed the assessment as completed on 3/1/23 (5 days late). 2. Review of the medical record for resident #28 showed the resident was admitted to the facility on [DATE]. Review of the admission MDS assessment showed an ARD of 1/3/23 and section Z0500 showed the RN assessment coordinator signed the assessment as completed on 1/18/23 (12 days late). Further review of the MDS summary report showed the MDS assessment, the care plan decisions, and associated care area assessments (CAAs) were completed on 1/5/23. The following concerns were identified: 3. Interview with the MDS Coordinator on 3/30/23 at 9:50 AM confirmed the completion dates were late. 4. Review of the facility policy titled Resident Assessment Instrument Process- MDS Scheduling) last updated March 2019 showed, The Center completes Minimum Data Set (MDS) assessments to satisfy the Omnibus Budget Reconciliation Act (OBRA) requirements for admission, quarterly . 5. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual showed .The MDS completion date (item Z0500B) must be no later than day 14 .

Based on medical record review, beneficiary notice review, staff interview, and policy review, the facility failed to ensure the appropriate Notice of Medicare Provider Non-Coverage (NOMNC) form was issued for 2 out of 4 (#7, #14) sample residents. The findings were: 1. Review of the Notice of Medicare Provider Non-Coverage (NOMNC) form completed by the facility showed resident #14 had a Medicare Part A stay that used fewer than maximum 100 days covered by Medicare Part A. Further review of the medical record showed Medicare A coverage ended on 3/3/23. The following concerns were identified: a. Review of the NOMNC form showed the facility failed to enter the correct Quality Improvement Organization (QIO) information for questions and/or appeals. b. Further review of the medical record failed to show evidence a copy of the signed NOMNC form was provided to the resident. 2. Review of the NOMNC form completed by the facility showed resident #7 had a Medicare Part A stay that used fewer than the maximum 100 days covered by Medicare Part A. Further review of the medical record showed Medicare A coverage ended on 8/5/22. The following concerns were identified: a. Review of the NOMNC form showed the facility failed to enter the correct Quality Improvement Organization (QIO) information for questions and/or appeals. b. Further review of the medical record failed to show evidence a copy of the signed NOMNC form was provided to the resident. 3. Interview on 3/29/23 at 2:09 PM with the #Social Service Director (SSD) revealed the facility did not send any NOMNC forms per the requirements and did not know the correct QIO contact for appeals. 4. Review of the facility policy titled Medicare Part A Denial of Coverage last updated March 2019, showed .The address and phone number of the state's QIO also included on the form . a copy is given to the resident/responsible party. 5. Review of the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 retrieved on 4/3/23 https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Instructions-for-Notice-of-Medicare-Non-Coverage-NOMNC.pdf showed: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure physician visits were performed at least every 60 days for 1 of 3 sample residents (#2). The findings were: 1. Review of the physician visits for resident #2 showed the resident was seen by a physician on 3/23/22, 84 days later on 6/15/22, 107 days later on 9/30/22, 12 days later on 10/12/22, and 104 days later on 1/24/23. 2. Interview with the MDS coordinator on 3/2/23 at 9:25 AM revealed she tracked all the physician visits and made sure they were performed on time; however, she thought physician's visits were to be performed every 90 days not every 60 days. 3. Review of the policy titled Physician Visits last updated October 2022 showed .After the first 90 days, visits must be conducted at least every 60 days thereafter .

Based on medical record review, staff interview, and review of policy and procedure, the facility failed to ensure appropriate behavior monitoring and interventions were in place for 2 of 4 sample residents (#2, #7) who received psychotropic medications. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #7 had a brief interview for mental status (BIMS) score of 1 out 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and depression. Further review showed the resident had hallucinations and delusions, physical behavioral symptoms directed toward others on 1 to 3 days during the look back period, and verbal behavioral symptoms directed toward others on 4 to 6 days during the look-back period. Review of the physician orders showed at the time of discharge, the resident received Ativan (antianxiety) 1 milligram (mg) by mouth twice daily for anxiety/agitation, sertraline hydrochloride (antidepressant) 100 mg by mouth daily for depression, and olanzapine (anti-psychotic) 5 mg by mouth twice daily for dementia in other disease classified elsewhere with behavioral disturbance. The following concerns were identified: a. Review of the psychotropic medication care plan initiated on 8/24/22 showed interventions which included .Monitor/record occurrence of for [sic] target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol . Further review showed no evidence specific target symptoms were identified for the use of each individual psychotropic medication. a. Review of the medication administration record (MAR) and treatment administration record (TAR) for August 2022, September 2022, and October 2022 showed the facility had monitoring in place for withdrawal symptoms related to the use of psychotropic medication; however, there was no evidence the facility was monitoring the resident for identified target symptoms specific to the use of each psychotropic medication. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 0 out of 15, which indicated the resident was severely cognitively impaired, and diagnoses which included non-Alzheimer's dementia and adjustment disorder with mixed anxiety and depressed mood. Review of the physician orders on 11/3/2022 showed the resident received aripiprazole (anti-psychotic) 7.5 mg by mouth one time daily for adjustment disorder with mixed anxiety and depressed mood and citalopram hydrobromide (antidepressant) 30 mg by mouth daily for unspecified dementia without behavioral disturbance. The following concerns were identified: a. Review of the psychotropic medication care plan dated 2/11/2022 showed no evidence the facility identified target symptoms specific to the use of each individual psychotropic medication. b Review of the MAR and TAR for August 2022, September 2022, October 2022 and November 2022 showed the facility had monitoring in place for side effects related to the use of psychotropic medication; however, there was no evidence the facility was monitoring the resident for identified target symptoms or effectiveness specific to the use of each psychotropic medication. 3. Interview with the DON, SSD, MDS coordinator, and BOM on 11/4/22 at 9:34 AM revealed residents on psychotropic medications were to have identified target symptoms for each psychotropic medication used and staff were expected to document the frequency of the target symptoms on the MAR. Further interview confirmed the residents did not have specific target symptoms identified for the use of the psychotropic medications and no monitoring was on the residents' MARs. 4. Review of the policy titled Psychotropic Drugs last updated October 2022 showed .2. Psychotropic drugs can be therapeutic and enhancing quality of life for residents suffering from mental illness (schizophrenia, depression, etc.), the Interdisciplinary Team (IDT) validates there are appropriate diagnoses of behavioral symptoms, so the underlying cause of the symptoms is recognized, and the condition is treated appropriately .5. Prior to initiating any psychotropic drug, the IDT: .c. Investigates the causal factors triggering the behavior symptoms for residents exhibiting behaviors .

Based on medical record review and resident representative and staff interview, the facility failed to ensure residents or resident representatives received a written notice of bed-hold for 1 of 3 sample residents (#7) reviewed for hospitalization . The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #7 had a brief interview for mental status (BIMS) score of 1 out 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and depression. Further review showed the resident had hallucinations and delusions, physical behavioral symptoms directed toward others on 1 to 3 days during the look back period, and verbal behavioral symptoms directed toward others on 4 to 6 days during the look-back period. The following concerns were identified: a. Review of a progress note dated 10/6/22 and timed 12:29 PM showed SSD attempted to reach [resident representative's name] to let her know that the Salt Lake City Regional Hospital has accepted [resident's name] and that [s/ he] is on [his/her] way at this time. b. Review of the medical record showed no evidence written information about the bed-hold policy was provided to the resident, or resident's representative at the time of transfer. c. Interview with the resident's representative on 11/3/22 at 4:14 PM revealed the family was aware the resident was having behavioral problems while at the facility; however, they did not receive bed-hold information at the time of the resident's transfer. Further interview revealed she believed the resident would be allowed to return to the facility following the hospital stay. 2. Interview with the DON, SSD, MDS coordinator, and BOM on 11/4/22 at 9:34 AM confirmed written bed-hold information was not provided to the resident or the resident's representative at the time of transfer.

Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to ensure residents or residents' representatives received a written transfer notice for 1 of 3 sample residents (#7) reviewed for hospitalization . The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #7 had a brief interview for mental status (BIMS) score of 1 out 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and depression. Further review showed the resident had hallucinations and delusions, physical behavioral symptoms directed toward others on 1 to 3 days during the look back period, and verbal behavioral symptoms directed toward others on 4 to 6 days during the look-back period. The following concerns were identified: a. Review of a progress note dated 10/6/22 and timed 12:29 PM showed SSD attempted to reach [resident representative's name] to let her know that the Salt Lake City Regional Hospital has accepted [resident's name] and that [s/ he] is on [his/her] way at this time. b. Review of the medical record showed no evidence a written transfer notice was provided to the resident, or resident's representative at the time of transfer. c. Interview with the resident's representative on 11/3/22 at 4:14 PM revealed the family was aware the resident was having behavioral problems while at the facility; however, they did not receive a written discharge/transfer notice at the time of the resident's transfer. 2. Interview with the DON, SSD, MDS coordinator, and BOM on 11/4/22 at 9:34 AM confirmed a written transfer notice was not provided to the resident's representative representatives at the time of transfer. 3. Review of the policy titled Transfer and Discharge last updated October 2022 showed .5. When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge which includes the includes the [sic] following items: a. Date notice is given. b. Effective date of the transfer/discharge. c. Reason for the transfer/discharge. d. Where the resident is to be moved. e. Contact information for the State Long-Term Care Ombudsman. f. Contact Information for protection and advocacy agency for residents with a mental disorder, intellectual disability, developmental disability, or other related disability. g. Explanations of right to appeal the transfer or discharge. h. Additional information required by applicable state law. i. If the discharge location and or date changes a new Resident Notice of Transfer or Discharge is to be given .

Based on medical record review, staff interview, and review of the facility's neurological evaluation form, the facility failed to follow physician orders, and failed to assess or monitor changes in condition for 2 of 4 sample residents (#1, #2,) reviewed for changes in condition requiring transport to the hospital. This failure resulted in harm to resident #1, whose need for assessment, treatment, and monitoring of his/her diabetes mellitus went unaddressed, and whose change in condition on 7/8/22 was not evaluated in a timely manner. Resident #1 required emergency transport to the hospital, where his/her prognosis was determined to be [NAME]. The findings were: 1. Review of the physician orders showed resident #1 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, morbid obesity due to excess calories, thrombocytopenia, obstructive sleep apnea, hypertension, and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. His/her admission vitals were a blood pressure of 122/60, temperature of 97.5 degrees Fahrenheit, a pulse of 86 beats per minute, and an oxygen saturation of 94% while receiving supplemental oxygen via nasal cannula. Review of a physician's telehealth visit progress note from 7/5/22 at 3:38 PM showed the physician stated the resident was feeling ok, and noted . No change in appetite . no abdominal pains, no bowel habit changes, no emesis . Review of physician orders showed 7/5/22 orders for orthostatic vital signs to be performed: lying, sitting, standing, and standing repeated after three minutes. Each order was to be administered .one time a day for 3 days. Further review showed a 7/5/22 order stating blood sugars [in the morning] and [at bedtime] two times a day related to diabetes mellitus . Review of the July 2022 medication administration record/treatment administration (MAR/TAR) record showed a 7/5/22 insulin order for Humalog Solution 100 unit/mL Inject as per sliding scale: if [blood glucose level] 70-150 = 0; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-501 = 12 units call [doctor] for [blood sugar] over 400, subcutaneously every 12 hours as need for prophylaxis . The following concerns were identified: a. Review of the documented blood pressures showed only sitting and lying blood pressures were documented on 7/5/22, only sitting on 7/6/22, no evidence blood pressure readings were taken on 7/7/22, and only a sitting blood pressure was documented on 7/8/22. It was noted that pressures taken on 7/6/22 and 7/8/22 triggered as being low, and no follow-up actions were documented. b. Review of the medical record on 7/25/22 showed no evidence the resident's blood glucose levels were measured on the mornings of 7/6/22, 7/7/22, or 7/8/22. However, review of the resident's July 2022 MAR/TAR documentation provided by the facility on 8/16/22 showed registered nurse (RN) #2 documented a blood glucose of 227 for the morning of 7/8/22, with no corresponding administration of insulin. Interview with RN #2 on 8/18/22 at 11:34 AM revealed he did not complete or document the blood glucose check of 227 the morning of 7/8/22. He stated he did not work that morning, and took over caring for the resident at approximately 1:00 PM that afternoon, after licensed practical nurse (LPN) #1 cared for the resident that morning beginning at 6 AM. c. Interview with LPN #1 on 8/17/22 at 3:06 PM revealed she cared for the resident on 7/8/22 from approximately 6 AM to 12 PM, then performed rounds with the physician that afternoon. She stated the resident refused his/her medications that morning, and she did not notify the physician of the refusal since he would be in later that day. However, review of the July 2022 MAR/TAR documentation showed all of the morning medications for 7/8/22 were documented as administered. d. Interview with LPN #1 on 8/18/22 at 11:34 AM revealed she did administer the medications after re-approach, including insulin administration, and did not report to the provider the resident had refused. e. Review of a nursing progress note from 7/8/22 at 1:25 PM showed Resident did not want [his/her] AM meds, refusal honored . However, this was a late entry note, and was not created until 7/12/22. Review of the medical record showed no documentation the physician was notified of the medication refusal. f. Review of a nursing progress note from 7/10/22 at 2:30 PM showed . resident refused to take medications earlier this shift . Resident refused to eat lunch . However, this note was not created until 7/11/22. Review of a progress note showed Note dated 7/10/22 is late entry report for 7/8/22 day shift; however, this correction to correct the late entry note was not created until 7/25/22 at 4:56 PM. g. Review of the the MAR/TAR for July 2022 showed bedtime blood glucose levels of 227 on 7/7//22, and 155 on 7/8/22. According to the physician order for insulin dated 7/5/22, each of these bedtime blood glucose readings was in range for administration of insulin, however, further review of the MAR/TAR showed no evidence insulin was administered to the resident subsequent to these readings, and no documentation to show why no insulin was administered. h. Further review of the medical record showed insulin was administered to the resident only once during his/her stay at the facility. i. Review of Fluid and Meal intake documentation showed no dinner intake documented on 7/6/22, refusal of breakfast documented with no lunch or dinner intake documented on 7/7/22, and refusing all three meals on 7/8/22. Further medical record review showed no evidence the physician was notified the resident was not eating. j. Review of a 7/6/22 nursing progress note timed 4:26 AM showed Resident appears to display confusion/anxiety with [shortness of breath] this night . k. Review of a physician's telehealth visit progress note from 7/7/22 at 3:11 PM showed the resident was struggling with anxiety and frequently requesting staff assistance because s/he was .never comfortable. In addition, the physician noted the resident was agitated and angry with staff. l. Review of a nursing progress note from 7/7/22 at 4:24 PM showed Resident has obvious anxiety, related to shortness of breath . Further medical record review showed no documentation the physician was notified of the change. m. Review of an untimed physician nursing home visit progress note from 7/8/22 showed the resident .has been more somnolent today . n. Review of a Nutrition/Dietary progress note from 7/8/22 at 1:46 PM showed [Certified Dietary Manager] in to do food preferences eval [evaluation] resident sleeping not easily rousable . o. Interview with the certified dietary manager on 8/19/22 at 3:19 PM revealed she first attempted verbal stimulation to try and rouse the resident for the evaluation on 7/8/22 at 1:46 PM. After unsuccessful attempts, she tried gently shaking the resident, which resulted in no response. She stated after she was unable to wake the resident, she reported the information to LPN #1, who directed her to document a progress note and attempt the assessment later. She further stated she did not report the resident status to the physician, assuming LPN #1 would communicate the information to the physician since LPN #1 was caring for the resident that day and performing rounds with the physician. Further interview revealed when she reviewed the intake documentation for the resident, it showed the resident had very minimal intake, which was worrisome since the resident was . a bigger [person]. p. Further review of nursing progress notes showed no evidence the resident was assessed by nursing staff after the report from the certified dietary manager the resident could not be awakened. q. Review of a nursing progress note from 7/8/22 at 9:16 PM showed the resident . has been 'unresponsive all day.' Night staff confirm that resident is still unresponsive. Further review showed a temperature of 99.4 degrees Fahrenheit, a blood pressure of 80/46, a pulse of 88 beats per minute, and an oxygen saturation of only 35%. The physician was notified, and orders were given to send the resident to the hospital. Further, .Ambulance arrives and notes either emesis or food coming from resident's mouth and black loose stools, EMTs suspect GI bleed and/or sepsis . r. Interview with RN #2 on 8/17/22 at 2:35 PM confirmed the missing blood glucose checks, as well as the lack of recorded insulin administrations with correlating blood glucose checks. s. Interview with the physician on 8/19/22 at 2:49 PM revealed the resident was somnolent during the visit on 7/8/22. He also stated he did not recall being notified the resident was not eating, or that the resident had refused any medications. He stated staff communicated with him through calls, texts, emails, and in person. Further, he would expect staff to notify him of abnormalities, as well as changes in condition, including lack of intake and medication refusals. t. Review of a nursing progress note from 7/9/22 at 4:47 AM showed the resident was admitted to the intensive care unit at the hospital and required blood transfusions. Further review showed the resident continued to have very low blood pressure and oxygen levels, and his/her .prognosis is [NAME] . Review of a nursing progress note from 7/9/22 at 10:22 AM showed . resident is to be put on comfort measures after family arrives. 2. Review of the physician orders showed resident #2 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, congenital renal failure, Type II diabetes mellitus with diabetic polyneuropathy, hypertension, chronic embolism and thrombosis of other specified veins, unsteadiness on feet, and other abnormalities of gait and mobility. Review of the care plan, last revised 5/9/22, showed the resident required assistance with ambulation because s/he .wanders and is confused. Further review showed the resident's cognitive function as confused and forgetful; communication was clear. The resident required a wander guard, and was at risk for falls. Review of a 5/6/22 Morse Fall Scale assessment showed any score above 45 was at high risk for falls, and the resident was assessed as having a score of 55. Review of the medical record showed the resident sustained falls on 3/1/22, 5/4/22, 5/5/22, and 5/6/22. The following concerns were identified: a. Review of the 5/6/22 incident report showed the resident suffered an unwitnessed fall at 12:30 AM. Review of a nursing progress note from 5/6/22 at 12:50 AM showed the resident was found on the floor with .a moderate amount of blood everywhere. Further review showed the resident sustained a skin tear to the back of his/her left hand and an injury to his/her suprapubic catheter site. Continued review showed . Fall mat placed beside bed. Review of neurological evaluation documentation showed on 5/6/22 neurological assessments were performed at 12:30 AM, 12:45 AM, and 1:00 AM. Further review showed no evidence neurological assessments were performed after 1:15 AM. b. Review of the facility neurological evaluation form showed guidelines for post-fall assessments as A = Every 15 [minutes] (x8) for first 2 hours, THEN B = Every 30 [minutes] (x4) for 2 hours, THEN C = Every 1 hour (x4) for 4 hours, THEN D = Every 8 hours (x8) for the remaining 64 hours after a fall. c. Review of a nursing progress note from 5/6/22 at 8:00 AM showed the resident had suffered a seizure, and family had requested the resident return to the hospital for evaluation. Review of a nursing progress note from 5/7/22 at 1:00 PM showed the resident had passed away while at the hospital. d. Interview with RN #1 on 8/23/22 at 8:33 AM confirmed after the resident suffered the unwitnessed fall on 5/6/22 at 12:30 AM, she did not complete orthostatic vital signs, or complete neurological assessments per protocol. 3. Interview with the administrator and DON on 7/25/22 at 7:07 PM revealed the facility did not have a policy for monitoring changes in condition. However, their expectation was for staff to document and monitor all changes in condition, including labs, vitals, and behaviors. Further, they expect staff to notify the physician and family if the changes worsened and/or a resident needed additional evaluation at the hospital. They stated with any variance from baseline residents are put on alert charting that lasts for at least three days and requires at least one assessment to be performed per shift. They confirmed assessments after falls should be completed and documented, including neurological assessments. 4. Interview with the staff development coordinator on 8/18/22 at 3:04 PM revealed the expectation was for orthostatic vital signs and neurological assessments to be performed with every fall, witnessed or unwitnessed, immediately after the fall. She stated if there were no abnormal findings with orthostatic vital signs, complete once per shift; if abnormal, notify the physician for further orders. Further, if the fall was witnessed and there are no abnormal findings with neurological assessments, complete assessments once per shift. If the fall was witnessed with head impact, or the fall was unwitnessed, neurological assessments were to be completed per guidelines for 72 hours.

Based on observation, staff interview, review of the Food Code, and maintenance record review, the facility failed to ensure food storage areas (the walk-in cooler, ice machine) were kept sanitary. The census was 40. The findings were: 1. Observation on 3/21/22 at 1:05 PM showed the condenser unit in the walk-in-cooler was leaking. The condenser unit was located above the slatted food storage shelves and there was a bucket on the top shelf collecting the water. Next to the collection bucket were bags of bread and buns. There were also boxes of food stored on the shelves below. Interview with cook #1 on 3/21/22 at 1:05 PM revealed she was unsure how long the leak had been there. 2. Observation of the ice machine on 3/22/22 at 2:54 PM showed there was a speckled blackish discoloration on the interior plastic located above the ice in the bin. There was also what appeared to be mineral deposits built up on the interior edges. 3. Interview with the consultant RD and the administrator on 3/22/22 at 2:54 PM confirmed the ice machine was in need of cleaning/sanitizing. Further, they confirmed the drip in the walk-in cooler needed to be contained in a way that ensured food stored in the area was not at risk of becoming contaminated. 4. Interview with the maintenance manager on 3/22/22 at 3:48 PM revealed the ice machine was last cleaned and the filter was changed on 2/22/22. Review of the maintenance record confirmed this information. He stated there must have been an issue since the last cleaning. Additionally, regarding the condenser unit on the interior of the walk-in cooler, the maintenance manager stated he was not aware of the leak until that day. 5. According to Food Code 2017, U.S. Public Health Service: 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, medical record review, staff interviews and review of policies and procedures, the facility failed to implement measures in a timely manner to prevent the develop of pressure ulcers, and failed to provide consistent monitoring, assessments and treatments for 1 of 1 sample resident (#40) who developed a facility acquired avoidable stage III pressure ulcer. This failure resulted in actual harm for the resident. The findings were: Review of the 11/7/11 admission MDS assessment for resident #40 showed s/he did not have pressure ulcers and was not at risk for developing them. This assessment also showed s/he required extensive assistance of one with transfers, dressing and toileting, was unsteady due to [MEDICAL CONDITION], had the ability to eat independently, and self propelled his/her wheelchair. Review of the corresponding care plan, updated 12/19/11, revealed staff interventions that included: assist with ADLs, record the amount of supplement the resident consumed, and complete skin checks according to the facility's policy for weekly skin checks. Review of the 11/9/11 nurse's notes showed there was an area of redness on the resident's anus and coccyx. Review of the December 2011 weekly pressure ulcer condition report showed staff noted a stage II pressure ulcer on the sacrum and coccyx on 12/1/11. The report also showed the length times the width of the pressure ulcer was less than four square centimeters, the undermining was less than two centimeters and there was no visible necrotic tissue or drainage. Review of the medical record showed the physician ordered the following treatment on 12/1/11: "Cleanse open areas on the coccyx with Sea Cleans, then apply [MEDICATION NAME], cover with foam pad with paper tape. Change every day." Further review showed the physician ordered IV fluids and antibiotics on 12/15/11 because the resident had problems with his/her teeth. Review of the 12/19/11 weekly pressure ulcer condition report showed the length times the width of the pressure ulcer increased to four to sixteen centimeters, the area was draining thin watery pale red/pink drainage, and 25% to 50% of the area had visible necrotic tissue. Review of the medical record showed periodic RD assessments and recommendations for supplemental nutrition to address the resident's weight loss. During an interview on 12/19/11 at 2:48 PM, CNA #3 stated the resident's functional ability and health began to decline "about a month ago" and now s/he was totally dependent on staff for all ADLs. On 12/19/11 at 3:50 PM, RN #1 and the wound care nurse were observed providing care for the resident. At that time a stage III pressure ulcer on the resident's coccyx was observed, and the ulcer had areas of necrotic tissue and pink/red drainage. The following concerns were identified regarding the facility's failure to provide the skin care this resident needed: a. Review of the December 2011 weekly pressure ulcer condition report showed the assessments were completed on 12/1/11 and 12/19/11, but not on 12/8/11 and 12/15/11. During an interview on 12/21/11 at 10:15 AM the administrator stated he had no explanation for why the weekly assessments had not been done. b. Review of the December 2011 TAR documentation and interview on 12/20/11 at 8:02 AM with the wound care nurse revealed the daily treatments were not done on 12/1, 12/2, 12/8, 12/10, 12/14 and 12/15. c. Review of the weekly pressure ulcer condition report documentation showed the continued deterioration in the pressure ulcer, however, review of the December 2011 TAR and interview on 12/20/11 at 8:02 AM with the wound care nurse revealed the same treatment was continued from 12/1/11 to 12/20/11 (twenty days) without an assessment of the effectiveness of the treatment. d. On 12/20/11 at 8:55 AM, the wound care nurse stated staff provided nutritional supplements for the resident, but it was difficult to assess the effectiveness because staff failed to document the amount, if any, the resident consumed. e. During an interview on 12/20/11 at 4 PM, the administrator stated the resident's pressure relieving mattress was replaced with a special pressure relieving air flow mattress earlier that day (nineteen days after the stage II pressure ulcer was first identified). He stated this mattress would be more effective in reducing pressure for the resident. He further stated there was a delay in implementing the change in the pressure relieving mattress because staff had not reported the resident needed it until last week. f. Interview on 12/20/11 at 3:45 PM with the MDS coordinator revealed she had not received information regarding the changes in the resident's condition until 12/19/11, therefore, the significant change MDS assessment that was needed had not been done. g. Review of the care plan revealed interventions that addressed pressure ulcer prevention, however interventions for the care of the existing pressure ulcer were not included. In an interview on 12/20/11 at 8:55 AM, the wound care nurse verified the care plan did not include interventions for pressure ulcer care. The nurse stated the pressure ulcer was identified on 12/1/11 and the care plan interventions should have been developed at that time. The nurse also stated he was in the process of revising the facility's pressure ulcer care program because currently the facility did not have a systematic approach for determining effective measures, identifying contributing factors, and ensuring treatments were done as ordered. Review of the policy entitled "Pressure Ulcer Prevention", POL 614, 4/28/09, revealed the policy included the following compliance guidelines: "1. Identify residents at risk for pressure ulcer development upon admission within six hours, then weekly for an additional four weeks...and... with significant change in condition or functional status. 2. Identify clinical conditions that are the primary risk factors for developing pressure ulcers... 10. Monitor the impact of the interventions, and modify the interventions as appropriate... 12. Evaluate and individualize use of various devices to reduce or relieve pressure and/or reduce skin injuries that may result in pressure ulcers... 17. Assess resident from head to toe for skin and effectiveness of care plan interventions and document in the resident's medical record."