Every finding on record at Rocky Mountain Care - Cottage on Vine

Based on interview and record review, the facility failed to ensure a resident was free from neglect. Specifically, for 1 out of 7 sampled residents, staff failed to provide timely assistance to transfer a resident with quadriplegia and Stage 3 pressure ulcers from a power wheelchair to bed, leaving the resident in the wheelchair for nearly 12 hours. This resulted in the resident experiencing increased buttock pain.The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by July 11, 2026, including the following measures; Resident 4's care plan and assessments were re-evaluated to ensure interventions continue to meet his needs; Resident 4 was provided with contact information for the administrator that was taped to his wall; all residents care plans, who required hoyer lift assistance, were screened for accuracy; an auditing and monitoring tool was developed and implemented to ensure timely assistance was provided to residents who required Hoyer transfer assistance; counseling was provided to the RN regarding her oversight of care; CNA 1 was no longer providing care and services at the facility; all CNAs and nurses were interviewed regarding effectiveness in prioritizing care, and in-service training was conducted for all CNA and nursing staff. The facility incorporated the corrections into the Quality Assessment and Assurance Activities. Resident Identifier: 4Resident 4 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included quadriplegia and Type 2 diabetes mellitus. On August 18, 2026, the licensor reviewed Resident 4's electronic medical record.Review of Resident 4's care plan, revealed Resident 4 required the assistance of two people and a hoyer lift for all transfers. Resident 4 also required assistance with frequent repositioning and offloading to manage Stage 3 pressure ulcers on the coccyx and right rear thigh.On August 18, 2026, the licensor reviewed a facility-reported incident report, dated May 31, 2026. The report documented that on May 31, 2026, Resident 4 was placed in a wheelchair at 7:30 AM. According to the facility's incident report and witness corroboration from Resident 4's relative, Resident 4 requested assistance from Certified Nursing Aide (CNA) 1 to lie down in bed 15 minutes before lunch. CNA 1 denied this request and Resident 4 remained in his wheelchair.During an internal interview on June 2, 2026, CNA 1 stated to facility Administration that Resident 4 had requested assistance to get into bed again after lunch, but was denied due to alleged staffing issues. However, when interviewed by the licensor on August 20, 2026, CNA 1 altered the timeline, claiming the first request occurred before dinner. The incident documentation also noted that CNA 1 did not seek assistance from CNA 2 to facilitate the transfer.The incident report also indicated that Resident 4 requested assistance from a Registered Nurse (RN). The RN informed Resident 4 the CNA staff would assist him as soon as possible, but provided no further aid. At 6:45 PM, Resident 4 contacted a relative to report that he was still in the wheelchair. Following communication from Resident 4's relative, Resident 4 was finally assisted to bed at 7:14 PM, after remaining in the wheelchair for nearly 12 hours.On June 1, 2026, a Nurse Practitioner and a Physician documented that Resident 4 presented with buttock pain, which resulted from remaining in the wheelchair for over 10 hours the previous day. The medical team ordered bed rest to facilitate recovery and directed staff to monitor the resident's pain and skin integrity.On August 18, 2026, the licensor interviewed the acting Director of Nursing (DON), who confirmed Resident 4 has severe skin breakdown and pressure ulcers requiring bed rest and pressure offloading. The DON stated that on May 31, 2026, CNA 1 should have been proactive in asking other staff members to help assist Resident 4 from his wheelchair to his bed, and noted that there was sufficient staffing available in the building at the time. The DON confirmed that CNA 1 was no longer permitted to work at the facility, and the RN involved had received counseling regarding her oversight. The surveyor reviewed the corrective action plan, which was implemented onJuly 11, 2026, and included the following;Resident 4's care plan and assessments were re-evaluated to ensure interventions continued to meet his needs.Resident 4 was provided with contact information for the administrator and DON that was taped to his wall. All residents care plans, who required hoyer lift assistance, were screened for accuracy.An auditing/monitoring tool was developed and used to ensure timely assistance was provided to residents with hoyer needs.Counseling was provided to the RN regarding her oversight of care.CNA 1 was no longer providing care and services at the facility.All CNAs and nurses were interviewed regarding effectiveness in prioritizing care and in-service training was conducted for all CNA and nursing staff.The facility incorporated the corrections into the Quality Assessment and Assurance Activities.

Based on interview and record review it was determined that the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, a resident had left the facility and was unaccounted for approximately 18 hours before management was alerted. Resident identifier: 3Findings included:Resident 3 was admitted to the facility on [DATE] and discharged on 5/28/25 with diagnoses which included sequelae of cerebral infection, injury of left kidney, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.Resident 3's medical record was reviewed on 11/5/25. An admission Minimum Data Set (MDS) dated [DATE] revealed that resident 3 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated resident 3 was cognition was intactOn 5/24/25 at 3:29 PM, the facility reported to the State Survey Agency that on 5/24/25 at 11:00 AM, resident 3 left the building without checking out or letting staff know where he was going. The facility was unsure of the exact time he left but it was believed it was the evening before. Resident 3 spoke to a family member around 6:00 PM on 5/23/25 and told them he was still in the facility. The facility's investigation dated 5/24/25 revealed the following:During the evening shift Certified Nursing Assistant (CNA) went to check on resident 3 several times and noticed that his television was on during the shift and his dinner was untouched. The CNA asked about resident 3 due to her being an agency CNA and wasn't familiar with resident 3, but did not get any concrete answers on where he could be. During shift change the CNA told the Night CNA about resident 3's absence and documented it in the medical record. The night shift CNA reported that resident 3 had been gone the whole day; the previous aide said it was like it was normal and did not know that resident 3 was missing. The 5/24/25 day shift CNA reported during the shift change report they were informed that resident 3 was not there and under the impression that resident 3 was with family. The day shift CNA did not know the resident was missing.The administrator interviewed resident 3, he stated that he had left to go to the convenience store, while he was there he saw a bus and decided to get on it for no reason. Resident 3 traveled up to Salt Lake City and did not feel like coming back at the time and went to a friend's house. Resident 3 said he had forgotten that he needed to sign out or let someone know he was leaving.On 11/5/25 a review of the resident 3's medical records revealed the following:On 5/24/25 at 3:23 PM, a Nurses Note revealed that the patient was not here all day long, meds not given today. Police called, the Director of Nursing (DON) notified and came into the facility. On 5/24/25 at 4:51 PM, a late entry nursing note revealed the following. Administrator and DON notified this morning that the patient had been gone on a leave of absence (LOA) since yesterday. The patient was alert and oriented at times four and able to communicate effectively, however he did not sign out or tell anyone where he was going. Although the patient was not considered an elopement risk, elopement procedure was activated and facility and surrounding grounds were searched and the patient was not found. All the patient belongings were still in his room. The sister and provider were notified by the floor nurse. A family member was called and stated that she talked to the patient on Friday afternoon. She had told him that his brother was being discharged from the hospital and being admitted to a skilled nursing facility (SNF) today. She thinks that he may be going there as he and his brother are very close and usually were not apart. She also stated that we may want to check the jail. The SNF was notified that if they have seen the patient to call DON. The jail roster was checked and the patient was not booked yesterday or today. Police called and a missing person was reported. The patient was set to discharge on 5/28 to an assisted living facility (ALF). On 5/25/25 at 8:17 PM, a late entry nursing note revealed the following: The patient was picked up at a pharmacy by facility DON and unit manager. The patient was found in the lobby waiting to get his belongings that had been left there after his stay prior to coming to the facility. He was in good condition with no visible injuries at this time. When asked why he left, he stated that he went to the store to get a soda and then could not find his way back. So he stated that he went to a friend's house who lived nearby and today he got on the bus to go up to the pharmacy to get his medications. He agreed to come back to the facility and finish his antibiotic treatment then be properly discharged to the ALF. He stated that he would not leave until then. The patient was brought back to the facility and he was fed. Floor nurse to do a head to toe assessment and skin check. The sister and provider were notified at this time. The police were called to let them know that a patient had been found. The patient again verbalized that he would not leave again without telling anyone. On 11/5/25 at 1:20 PM, an interview was conducted with certified nurse assistants (CNA) 2 and 3. Both CNA 2 and 3 stated that they were agency staff and were not permanent employees of the facility. Both CNA 2 and 3 stated that they rounded on residents at least every two hours, more frequently whenever possible. The CNA's both stated if they have not seen a resident they would go look for the resident by walking around the facility and look at outside areas. CNAs 2 and 3 stated that if they have not been able to see or locate a resident they would notify the nurse. On 11/5/25 at 1:48 PM, an interview was conducted with registered nurse (RN) 1. RN 1 stated that residents should be rounded on at least every two hours. RN 1 stated that residents who were leaving the facility needed to sign the LOA book, located at the nurses' station. RN 1 stated the residents should list a time they were leaving and a time they expected to be back. RN 1 stated that if a resident had not returned at the time they had listed, the nurse would try to contact the resident and their family to get their location. RN 1 stated that if a resident cannot be located and especially when the resident had not signed the LOA book, the nurse would contact management for further instruction. On 11/5/25 at 12:52 PM, an interview was conducted with the DON. The DON stated that she was notified that resident 3 was not in the building on the morning of Saturday, 5/24/25. The DON stated they believed that resident 3 had left the facility Friday evening and was gone all night. The DON stated that video footage showed resident 3 at the facility at approximately 4:30 PM on 5/23/25. The DON stated that resident 3 had gone on LOA at other times and returned with no issues prior to this event. The DON stated that resident 3 was finally located on 5/25/25, when they received a call from a pharmacy requesting a medication list. The DON stated resident 3 was brought back to the facility and was discharged to an assisted living facility on 5/28/25.The DON stated that the night shift nurse on duty the evening of 5/23/25 was found to have falsified documentation and was terminated. The DON stated the facility learned that the nurse never checked on resident 3 that evening, but medical records indicated that the nurse marked that they had. The DON also stated the nurse that was assigned that morning was an agency nurse and she was not familiar with residents. The DON stated that the CNA should be rounding on the residents a minimum of every two hours. If a resident had not been rounded on after a couple of attempts then they were to notify the nurse. The DON stated at the time of resident 3's incident they had a lot of agency staff in the facility. The DON stated that residents were educated when they want to leave the facility, they were to sign the LOA book with the time they were leaving, where they were going, and a time they expected to return. The DON stated the LOA book was located at the nurses' station. The DON stated the residents that were alert and oriented were usually granted LOA privileges.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was undated food in the refrigerator and freezer, the dietary manager was not wearing a hair net, and the dish machine and sanitizer buckets were not testing at the required levels. Findings included: On 3/3/25 at 8:04 AM, an initial tour of the kitchen was conducted. The following observations were made: a. There was a jar of mayonnaise opened in the refrigerator but without an opened date. b. There was a box of green peppers in the refrigerator that were not labeled or dated. c. There was an opened whipped topping in the refrigerator without an opened date. d. There was a box of opened sausage links in the refrigerator without an opened date. e. There was a box of lettuce in the refrigerator without an opened date. f. There was an opened container of filled churros in the freezer without an opened date. g. There was a box of donuts, open to air, in the freezer without an opened date. h. There was a box of opened pork egg rolls in the freezer without an opened date. i. There was a container of opened ice cream that was undated. j. The Dietary Manager (DM) was inside the kitchen without a hairnet. On 3/3/25 at 8:19 AM, during the initial tour the chemical dish machine was observed. The DM stated that the dish machine was tested this morning. The DM was observed to run a dish cycle and used a chemical strip to check the amount of sanitizer. The strip was observed to not change color. On 3/3/25 at 8:25 AM, an observation was made of the DM running another cycle in the chemical dish machine. The DM was observed to use the sanitizer strips to check the amount of sanitizer. The strip was observed to not change color. The DM stated that the chemicals were not sanitizing and she would have to get the dish machine serviced. The DM stated that the kitchen would not wash dishes until the dish machine was serviced. On 3/3/25 at 8:33 AM, during the initial tour the sanitizer buckets were observed. The DM stated that the sanitizer was changed three times a day-before breakfast, lunch, and dinner. The DM was observed to use the sanitizer strips to check the amount of sanitizer. The strip was observed to not change color. The DM stated that there was not enough sanitizer in the bucket and she should let the chemicals run more into the bucket. The DM stated that there needed to be over 200 parts per million (PPM) to effectively sanitize. On 3/5/25 at 8:40 AM, a follow up tour was conducted. The following was observed: a. There was an opened box of frozen filled churros without an opened date. b. There was an opened box of frozen rolls without an opened date. On 3/5/25 at 8:44 AM, the facility dish machine was observed. The DM was observed to run the dish machine and the sanitizer solution was tested with test strips. The sanitizer test strip changed to a deep purple and read at 100 PPM. The DM stated that the dish machine was serviced on 3/3/25 and 3/4/25. On 3/5/25 at 8:47 AM, the facility sanitizer buckets were observed. The DM was observed to dip a sanitizer strip into the bucket. The DM stated that the sanitizer strip read 300 PPM and this was too high. The DM stated there were too many chemicals in the sanitizer bucket and she would have to consult with the Registered Dietitian (RD) on how to remedy this. The DM stated if the sanitizer chemicals were too high, the chemicals would stay on the dishes and come off in the resident's mouth. The DM stated that this was dangerous to the residents. On 3/5/25 at 8:48 AM, a follow-up interview was conducted with the DM. The DM stated that all items should be labeled and dated in the refrigerator and in the freezer. The DM stated that fresh produce should be used within three days. The DM stated that she had thrown out all the undated and opened food. On 3/5/25 at 9:05 AM, an additional interview was conducted with the DM. The DM stated that for the sanitizer buckets that have too much sanitizer, she would need to add water and then keep testing the sanitizer until it reached the correct chemical amount. On 3/6/25 at 9:35 AM, an interview was conducted with the RD. The RD stated that a service company serviced the dishwasher on 3/3/25 and 3/4/25, and the sanitizing issue should now be resolved. The RD stated that if the sanitizer buckets showed a sanitizer level that was too high, staff should add water to dilute the chemicals and continue testing until the correct PPM was reached. The RD stated that if residents were served dishes with excessive sanitizer residue, there was a risk that it could contaminate the food and potentially cause gastrointestinal issues. The RD stated that all staff should wear hairnets while in the kitchen and that all food stored in the refrigerator and freezer should be properly labeled and dated. On 3/6/25 at 10:32 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that all kitchen staff were required to wear proper head coverings and follow the facility's kitchen policy. The DON stated that the DM was responsible for ensuring all food items were properly labeled and dated.

Based on observation, interview, and record review, the facility did not follow menus that met the nutritional needs of residents in accordance with established national guidelines. Specifically, correct portion sizes were not provided to residents. Findings included: On 3/5/25 at 12:28 PM, an observation was made of lunch being plated. The cook in training was observed to pick up two pieces of meat, potatoes, Brussels sprouts, and pour gravy over the meat and potatoes with a ladle. It should be noted that the meat, Brussels sprouts, and potatoes were being picked up with tongs and placed on plates. No measurement scoops were observed to be used. On 3/5/25 at 12:42 PM, an interview was conducted with the cook in training. The cook in training stated that she tried to give all the residents an even amount of food in order to fill the plate. On 3/5/25 at 1:50 PM, a review of the menu daily spreadsheet revealed the portion sizes for the lunch meal were: a. [NAME] Pot Roast: 3 ounces for regular portion and 4 ounces for large portion. b. Roasted Yukon Potatoes: #8 scoop (4 ounces) regular potion and #6 scoop (5.3 ounces) large portion. c. Fresh Brussels Sprouts with Bacon: #8 scoop (4 ounces) regular portion and #6 scoop (5.3 ounces) large portion. d. Yukon Gold Mashed Potatoes: #8 scoop (4 ounces) and Gravy 1 ounce. It should be noted that the Yukon Gold mashed potatoes were served with an ice cream scoop that was 2.3 ounces, the gravy was served with a ladle that was 2 ounces, the Brussels sprouts, potatoes, and pot roast were not measured. On 3/6/25 at 9:10 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the cook in training became flustered during lunch service yesterday and used the wrong serving scoops. The DM stated the cook in training was new to the role. The DM stated that the lunch meal should have been served using correct scoops to ensure residents received the appropriate portion sizes according to the menu. The DM stated that the pot roast had not been measured before serving because it was a crumbly texture and it made it difficult to portion accurately. On 3/6/25 at 9:35 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated that the resident menus included specific portion sizes and should be followed using standardized spoons and ladles. The RD stated that the menus were designed to ensure residents received their daily nutritional requirements. The RD stated that failing to follow the menus could negatively impact residents' health. On 3/6/25 at 10:32 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected the kitchen staff to follow the menus correctly.

Based on interview and record review, the facility did not ensure that residents were free from significant medication errors. Specifically, for 3 out of 27 sampled residents, a dialysis resident did not receive his phosphate binding medication with meals as ordered, a resident with a chronic wound and osteomyelitis did not receive his scheduled intravenous (IV) antibiotic medication as ordered, and a resident's seizure medication was not held when ordered by the provider. Resident identifiers: 11, 21, and 41. Findings included: 1. Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of end stage renal disease, dependence on renal dialysis, edema, renal osteodystrophy, and posthemorrhagic anemia. On 3/3/25 at 12:05 PM, an interview was conducted with resident 21. Resident 21 stated that he was having a problem getting his medication on time. Resident 21 stated that his phosphorus binder medication needed to be taken with meals or at the latest 30 minutes after meals. Resident 21 stated that he was receiving the medication an hour to an hour and a half late or sometimes not at all. Resident 21 stated that he would ask the Certified Nursing Assistants to tell the nurse that he needed his medication and the nurse would not come to administer it. Resident 21 stated that this happened frequently. Resident 21 stated that he reported the problem to the Director of Nursing (DON). Resident 21 stated that the DON stated that she had put in the computer that his medication was a priority and should be administered first. Resident 21 stated that it flagged in the electronic medical records as red to draw attention to the nurses. Resident 21 stated that this change was done two weeks ago and there had been no real change since then. Resident 21 stated that he had the dialysis center and the dietician talk to the facility about the timing of his medication. Resident 21 stated that the problem was having so many agency nurses who did not know what needed to be done. Resident 21 stated sometimes he had a nurse that was on top of it but a lot of times it did not happen. Resident 21's medical record was reviewed. On 2/3/25, an order was initiated for Auryxia Oral Tablet 1 GM [gram] 210 MG [milligram] (Iron) (Ferric Citrate), give 2 tablet by mouth before meals for end stage renal disease (ESRD) with meals. On 2/3/25, an order was initiated to administer all medications before dialysis on Monday, Wednesday, and Friday. The Medication Administration Record (MAR) documented the Auryxia medication administration times were scheduled at 7:30 AM, 11:30 AM, and 4:30 PM. Resident 21's February and March 2025 MAR documented the following administration times for the Auryxia: a. On 2/20/25 at 10:03 AM, b. On 2/22/25 at 4:06 PM, c. On 2/25/25 at 3:32 PM, d. On 2/26/25 at 4:15 PM, e. On 2/27/25 at 9:38 AM, f. On 2/28/25 at 5:44 AM, g. On 2/28/25 at 4:30 PM, h. On 3/1/25 at 5:21 AM, i. On 3/1/25 at 3:48 PM, j. On 3/2/25 at 9:59 AM, k. On 3/2/25 at 3:46 PM, l. On 3/3/25 at 6:25 AM, and m. On 3/4/25 at 10:03 AM. It should be noted that the medication administration times were not done in conjunction with scheduled meal times. Meal schedule times posted in the dining room documented the following for meal service: Breakfast dining room [ROOM NUMBER]:00 AM - 8:45 AM Breakfast hall carts 8:15 AM - 9:00 AM Lunch dining room [ROOM NUMBER]:00 PM - 12:45 PM Lunch hall carts 12:15 PM - 1:00 PM Dinner dining room [ROOM NUMBER]:00 PM - 5:45 PM Dinner hall carts 5:15 PM - 6:00 PM Resident 21's progress notes documented: a. On 2/15/25 at 11:17 AM, the Orders - Administration Note documented that the Auryxia was not administered due to too close to next dose. b. On 2/18/25 at 3:23 PM, the Orders - Administration Note documented that the Auryxia was not administered due to missed dose. c. On 2/19/25 at 10:18 AM, the Orders - Administration Note documented that the Auryxia was not administered due to pt [patient] at dialysis. d. On 2/19/25 at 12:20 PM, the Orders - Administration Note documented that the Auryxia was not administered due to pt at dialysis. e. On 2/20/25 at 1:38 PM, the Orders - Administration Note documented that the Auryxia was not administered due to Pt off site at an appt. [appointment] f. On 2/21/25 at 8:11 PM, the Orders - Administration Note documented that the Auryxia was not administered due to pt at dialysis. g. On 2/21/25 at 12:22 PM, the Orders - Administration Note documented that the Auryxia was not administered due to pt at dialysis. h. On 2/23/25 at 5:35 PM, the Orders - Administration Note documented that the Auryxia was not administered due to medication was not found in medication cart. It should be noted that the MAR documented a check mark indicating administered at 4:30 PM, and also documented a code 11 which meant medication was not available at the same time. i. On 2/26/25 at 6:53 AM, the Orders - Administration Note documented that the Auryxia was not administered due to pt at dialysis. j. On 2/26/25 at 10:16 AM, the Orders - Administration Note documented that the Auryxia was not administered due to pt at dialysis. k. On 3/4/25 at 5:56 AM, the Orders - Administration Note documented that the Auryxia was not administered due to not available will administer when available. On 3/4/25 at 2:02 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated she located two Auryxia medication bottles in the medication cart. One bottle had nine tablets remaining and the other bottle was full. RN 3 stated that one bottle had a fill date of 12/20/24, and the second bottle had a fill date of 10/31/25. RN 3 stated that the medication was highlighted in green in the electronic MAR and that meant something had been charted on that medication such as given or refused. RN 3 stated that the medication was scheduled to be administered 30 minutes before meals at 6:00 AM, 10:00 AM, and 4:00 PM. On 3/4/25 at 3:32 PM, an interview was conducted with the DON. The DON stated that she was aware of resident 21's concern with his Auryxia administration. The DON stated that on 2/22/25, she updated the nurse report sheet to indicate that the resident should get his medication first before meals. His medications were moved from the general medication room into the medication cart and was labeled on top of the bottle. The DON stated that they updated the narcotic book to speed up the count time at shift change to minimize delays for the oncoming nurse. The DON stated that resident 21's medication administration time was moved to 5:00 AM, to administer first before he went to breakfast. On 3/5/25 at 12:24 PM, a follow-up interview was conducted with resident 21. Resident 21 was on his way to the dining room for lunch. Resident 21 stated that he had not yet received his Auryxia medication. At 1:19 PM, resident 21 was observed taking his Auryxia medication. Resident 21 stated that the nurse did not know he was back from dialysis and he had to go ask her for the medication. Resident 21 stated that he finished lunch at about 1:00 PM. On 3/6/25 at 9:04 AM, a follow-up interview was conducted with the DON. The DON stated that resident 21's dashboard in the electronic medical record documented the Auryxia administration times. The DON stated that she educated the agency nurse yesterday on resident 21's medication needs. The DON stated that the agency nurses should see the medication instructions on the resident dashboard. 2. Resident 41 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, type 2 diabetes mellitus, osteomyelitis, non-pressure chronic ulcer, gas gangrene, cutaneous abscess of left foot, and cellulitis. On 3/3/25 at 10:22 AM, an interview was conducted with resident 41. Resident 41 stated that the facility did not have enough staff and that he did not receive his IV antibiotics on time. Resident 41's medical record was reviewed. Resident 41's physician orders revealed the following: a. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50 milliliters (ml), give 750 mg intravenously every 24 hours for Infection. The medication order documented an administration time of 1:00 PM daily. b. Micafungin Sodium Chloride Intravenous Solution 100-0.9 MG/100 ML, give 100 mg intravenously every 24 hours for infection. The medication order documented an administration time of 10:00 PM. The Medication Administration Record documented that the Daptomycin was administered late on the following days: on 2/13/25 at 3:29 PM, on 2/18/25 at 4:01 PM, on 2/22/25 at 2:52 PM, and on 2/25/25 at 2:55 PM. The Medication Administration Record documented that the Micafungin was administered late on the following days: on 2/14/25 at 2:38 PM, on 2/16/25 at 2:55 PM, on 2/18/25 at 6:08 PM, on 2/23/25 at 11:48 PM, and on 2/25/25 at 11:43 PM. On 2/10/25, resident 41 had a care plan initiated for .an actual skin impairment/wound tarsometatarsal amputation site to left foot with an intervention to provide treatments as prescribed. On 3/4/25 at 9:08 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 41's Daptomycin was scheduled to be administered every 24 hours at 1:00 PM, and the Micafungin was scheduled every 24 hours at 10:00 PM. RN 3 stated that the medication could be administered 30 minutes before or after the scheduled time and still be considered on time. RN 3 stated that if the antibiotic was not given on time, she would notify the physician. On 3/6/25 at 8:39 AM, an interview was conducted withe the DON. The DON stated that the antibiotic could be administered 30 minutes before or 30 minutes after the scheduled time. The DON stated that the physician needed to be notified if the medication was not administered per the ordered schedule. The DON stated that staff should have notified the physician of the delay in treatment. The Corporate Nurse stated that the delayed antibiotic administration should have been entered as a medication error. 33215 3. Resident 11 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, localization-related symptomatic epilepsy and epileptic syndromes and convulsions. Resident 11's medical record was reviewed on 3/4/25 through 3/6/25. On 2/21/25 at 4:00 PM, a Nurses Note documented Note Text: Lacosamide level done yesterday WNL [within normal limits] 11.6, provider reviewed with no new orders at this time. On 2/21/25 at 8:38 PM, a Labs Results Report documented a lacosamide serum level result of 11.6. The reference range on the report was 1.0-10.0. The report flagged the result as High. On 2/23/25 at 9:55 AM, an Orders - Administration Note documented Note Text: LACOSAMIDE 200MG TABLET Give 1 tablet by mouth two times a day for EPILEPSY MEDICATION IS LOCATED IN THE NARCOTIC DRAWER Per Oncall NP [Nurse Practitioner] Hold Lacosamide x [for] 2 doses. The February 2025 MAR was reviewed. It should be noted that the lacosamide was held for one dose on 2/23/25 at 6:00 AM. On 2/24/25 at 12:30 PM, a NP - Senior Health Services note documented . Over the weekend, the patient had a lab draw, and her lacosamide level was elevated. The on-call provider [name redacted was contacted, who ordered for the patient's lacosamide to be held for 2 doses. On review of the patient's level, it was 11, slightly elevated. The patient will resume her lacosamide, as the 2 doses have been held. The patient is stable with no signs or symptoms of toxicity at this time and will restart taking her lacosamide as ordered. On 3/6/25 at 8:06 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the high lacosamide lab was reported to the facility Medical Director (MD) and the MD did not give orders. LPN 1 stated the night nurse reported the high lacosamide lab to the on call MD and they gave orders to hold the medication for two days. LPN 1 stated when she reported to work the next morning she reported to the MD and he said not to hold the medication and resident 11 was fine. LPN 1 stated they were drawing another lacosamide level today and then a month from now. LPN 1 stated a phlebotomist came to the facility twice a week. LPN 1 stated if the lab was ordered immediately the facility staff would draw the lab. On 3/6/25 at 9:11 AM, a follow up interview was conducted with LPN 1. LPN 1 stated that she would usually call the MD to get a faster response than texting. LPN 1 stated on that day she had called the MD.

Based on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 4 out of 27 sampled residents, the residents did not have laboratory results filed in their medical record. Resident identifiers: 3, 12, 15, and 25. Findings included: 1. Resident 12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included paraplegia, generalized muscle weakness, neurogenic bladder, and other cystostomy status. On 5/8/24 at 2:45 PM, a nursing note documented, New order to start Levofloxacin 750mg [milligrams] PO [by mouth] Q24h [every 24 hours] x [times] 5 days for UTI [ urinary tract infection]. It should be noted that a review of resident 12's medical record revealed that the urinalysis results and urine culture and sensitivity from 5/8/24, were not documented in the medical record. On 3/6/24 at 8:48 AM, an interview was conducted with Assistant Director of Nursing (ADON). The ADON stated that she would ensure a urinalysis was conducted if a resident had a history of UTI's, exhibited symptoms, and had a catheter. The ADON stated she needed to be more vigilant in monitoring such situations and planned to print the lab results, have the nurse practitioner sign them, and submit them to medical records for uploading so they would be properly documented in the resident's chart. On 3/06/25 at 10:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was not able to locate the urinalysis results from 5/8/24 and the results should have been uploaded into the medical record. 38031 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included quadriplegia Cervical (C) 1-C4 incomplete, neuromuscular dysfunction of the bladder, flaccid neuropathic bladder, and autonomic neuropathy. On 3/5/25, the facility infection control tracking and trending log was reviewed. The December 2024 tracking documented that resident 3 had a urinary tract infection and the organism was Leukocyte esterase. The log documented that the infection was treated with Bactrim double strength (DS) 800-160 mg two times a day. Resident 3's Medication Administration Record documented that Bactrim DS tablet, 800-160 mg by mouth two times a day was administered on 11/26/24 through 11/30/24, and 12/1/24 through 12/4/24, for a total of 18 doses administered. No documentation could be found of a urinalysis with a culture and sensitivity report in resident 3's medical record. On 3/6/25 at 8:21 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that she obtained a copy of the laboratory result on the lab's website. The IP confirmed that the lab report was not located in resident 3's medical record and that it was missed in the process of uploading the document to the medical record. The IP stated that prior to the new electronic medical records she would obtain the laboratory reports, give them to the provider to sign, and then give them to the medical records to upload into the resident's electronic medical record. 3. Resident 15 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, acute kidney failure, and hypertension. On 3/5/25, the facility infection control tracking and trending log was reviewed. The January 2025 tracking documented that resident 15 had a urinary tract infection and the organism was Klebsiella pneumonia. Resident 15's Medication Administration Record documented that Nitrofurantoin macrocrystal capsule 100 mg by mouth two times a day for a urinary tract infection was administered on 1/9/25 through 1/18/25, for a total of 20 doses administered. No documentation could be found of a urinalysis with a culture and sensitivity report in resident 15's medical record. On 3/5/25 at 3:58 PM, an interview was conducted with the IP. The IP stated that she had just received a faxed copy of the laboratory results for resident 15's urinalysis with a culture and sensitivity report. The IP confirmed that the laboratory report was not located in resident 15's medical record. 47431 4. Resident 25 was admitted to the facility on [DATE] with diagnoses which included Osteomyelitis of vertebra, methicillin resistant staphylococcus aureus infection, paraplegia, and encephalopathy. Resident 25's medical record was reviewed on 3/3/25 through 3/6/25. On 1/20/25 at 6:52 PM, a nursing progress note revealed the following. New order received to collect routine stool sample and send it to be tested for Clostridioides difficile. It should be noted that no laboratory results could be located in the medical record. On 1/27/25 at 1:37 PM, a nursing progress note revealed the following. Face sheet and prerequisite lab work filled out to be drawn on 1/28/25. Lab work to be completed included a comprehensive metabolic panel, Complete Blood Count with differential (CBC w/diff), Creatine Kinase, and C-Reactive Protein. It should be noted that no laboratory results could be located in the medical record. On 1/28/25 at 6:27 PM, a nursing progress note revealed the following. On call provider notified of labs, new order for urgent (STAT) CBC w/diff. It should be noted that no STAT laboratory results could be located in the medical record. On 3/6/25 at 12:37 PM, an interview with the ADON was conducted. The ADON stated that she needed to call the central lab to get the lab results for 1/20/25 and 1/28/25. The ADON stated that she was unable to find the labs on the medical record. The ADON stated the lab results were not in the medical record.

Based on interview and record review, the facility did not notify and consult with the physician when there was a need to alter the resident's treatment. Specifically, for 2 out of 27 sampled residents, a resident's suprapubic catheter order was changed and the physician was not notified. Additionally, a resident's intravenous antibiotic was not administered per the physician ordered times and the physician was not notified. Resident identifiers: 3 and 41. Findings included: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included quadriplegia Cervical (C)1-C4 incomplete, neuromuscular dysfunction of the bladder, flaccid neuropathic bladder, and autonomic neuropathy. On 3/3/25 at 8:55 AM, an interview was conducted with resident 3. Resident 3 stated that he needed the catheter changed due to it being plugged and the facility did not have the correct size in stock and he had to wait for a replacement. Resident 3's medical record was reviewed. On 2/3/25, resident 3 had a physician order that documented, Change PRN [as needed] - Suprapubic Catheter: 24 French Size [SPECIFY] 10ML [milliliter] Balloon as needed for Occlusion or Leakage As Needed. On 2/24/25 at 10:29 PM, resident 3's Treatment Administration Record documented that resident 3's suprapubic catheter was changed with a 24 French Size, 10 ml balloon per the physician order. Resident 3's progress notes revealed the following: a. On 12/17/24 at 3:45 PM, the note documented, 20 g [gauge] suprapubic catheter placed and bag replaced, due to pt [patient] leaking. Pt tolerated it well and has had no new complaints. b. On 12/30/24 at 5:25 PM, the note documented, Catheter and bag replaced today. Catheter size 20/10. No issues. Pt reports no pain or discomfort. c. On 1/4/25 at 2:12 PM, the note documented, Patient catheter change, 22 French, 30mL, skin intact, dressing in place. d. On 2/22/25 at 3:54 PM, the note documented, pt scheduled for cath [catheter] change today. pt it [sic] 22 gauge. we are out of 22 gauge. offered to go one size smaller. pt declined and stated he will wait. On 3/4/25 at 11:49 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 3's catheter size was a 24 French per the physician order. RN 1 checked the supply room for the 24 French catheter and stated that they did not have any 24 French suprapubic catheters in stock. RN 1 stated that she would not be able to change the catheter if it needed to be done because they did not have any in stock. RN 1 stated that the Certified Nursing Assistant Coordinator (CNAC) was in charge of reordering supplies. On 3/4/25 at approximately 11:55 AM, an interview was conducted with the CNAC. The CNAC stated that earlier this week RN 2 told her that they were out of stock of the 24 French suprapubic catheter. The CNAC stated that she informed RN 2 that they had a 22 French catheter with a 30 ml balloon available and asked if they could use that one instead until they got the other one in stock. The CNAC stated that she did not know what catheter size RN 2 used for resident 3's treatment. On 3/4/25 at 12:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if staff placed a 22 French catheter instead of the 24 French they should have contacted the physician and put an order in for the change. The DON stated that she would have to reach out to the nurse to see if the treatment was completed. On 3/4/25 at 2:30 PM, a follow-up interview was conducted with the DON. The DON confirmed that resident 3 had a 22 French suprapubic catheter inserted. The DON stated that the physician was not notified of the 22 French insertion and she did not have an order for it. [Cross-refer F690] 2. Resident 41 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, type 2 diabetes mellitus, osteomyelitis, non-pressure chronic ulcer, gas gangrene, cutaneous abscess of left foot, and cellulitis. On 3/3/25 at 10:22 AM, an interview was conducted with resident 41. Resident 41 stated that the facility did not have enough staff and that he did not receive his intravenous (IV) antibiotics on time. Resident 41's medical record was reviewed. Resident 41's physician orders revealed the following: a. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 milligram (mg)/50ML, give 750 mg intravenously every 24 hours for Infection. The medication order documented an administration time of 1:00 PM daily. b. Micafungin Sodium Chloride Intravenous Solution 100-0.9 MG/100ML, give 100 mg intravenously every 24 hours for infection. The medication order documented an administration time of 10:00 PM. The Medication Treatment Record documented that the Daptomycin was administered late on the following days: on 2/13/25 at 3:29 PM, on 2/18/25 at 4:01 PM, on 2/22/25 at 2:52 PM, and on 2/25/25 at 2:55 PM. It should be noted that no documentation could be found to indicate that the physician was notified of the late administrations of the antibiotic. The Medication Treatment Record documented that the Micafungin was administered late on the following days: on 2/14/25 at 2:38 PM, on 2/16/25 at 2:55 PM, on 2/18/25 at 6:08 PM, on 2/23/25 at 11:48 PM, and on 2/25/25 at 11:43 PM. It should be noted that no documentation could be found to indicate that the physician was notified of the late administrations of the antibiotic. On 3/4/25 at 9:08 AM, an interview was conducted with RN 3. RN 3 stated that resident 41's Daptomycin was scheduled to be administered every 24 hours at 1:00 PM, and the Micafungin was scheduled every 24 hours at 10:00 PM. RN 3 stated that the medication could be administered 30 minutes before or after the scheduled time and still be considered on time. RN 3 stated that if the antibiotic was not given on time she would notify the physician. On 3/6/25 at 8:39 AM, an interview was conducted withe the DON. The DON stated that the antibiotic could be administered 30 minutes before or 30 minutes after the scheduled time. The DON stated that the physician needed to be notified if the medication was not administered per the ordered schedule. The DON stated that staff should have notified the physician of the delay in treatment. [Cross-refer F760]

Based on interview and record review, the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 1 out of 3 sampled residents, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated. Resident identifier: 100. Findings included: Resident 100 was admitted to the facility on [DATE] with diagnoses that included pneumonia, septicemia, renal insufficiency, and diabetes mellitus. Resident 100 was discharged to home on 10/3/24. Resident 100's medical record was reviewed on 3/6/25. A NOMNC was not found in resident 100's medical record. On 3/6/25, a request was made with the Administrator (ADM) to provide a copy of resident 100's signed NOMNC form. On 3/6/25 at 11:12 AM, an interview was conducted with the ADM who stated he was unable to find a NOMNC for resident 100.

Based on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 1 out of 27 sampled residents, it was observed that the resident's shower had a bad odor, black substance along the grout lines, white buildup on tile surfaces, and circular red rings along the shower floor. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, atherosclerosis, unspecified protein-calorie malnutrition, rhabdomyolysis and osteoarthritis. On 3/3/25 at 10:31 AM, it was observed that the resident's shower had a bad odor, black substance along the grout lines, white buildup on tile surfaces, and circular red rings along the shower floor. On 3/5/25 at 9:07 AM, it was observed that the black substance along the grout lines, white buildup on tile surfaces, and circular red rings along the shower floor remained as the previous observation. The bad odor had decreased in intensity. On 3/5/25 at 9:33 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that residents typically showered in their room bathrooms, not a shower room. On 3/5/25 at 11:40 AM, an interview was conducted with the Housekeeping Supervisor (HS). The HS stated that residents' rooms and bathrooms were cleaned daily and as needed. The HS stated that when cleaning rooms and bathrooms focus was put on locations the patients frequently touch. On 3/5/25 at 12:49 PM, an observation of resident 23's shower was made with the HS present. The HS stated that housekeeping had not completed daily cleaning in resident 23's room and bathroom yet. The HS stated that Housekeeping used Contender Cleaner and Destainer with bleach on the shower in resident 23's shower during the next daily cleaning. On 3/5/25 at 12:59 PM, an interview was conducted with the Housekeeper (HK). The HK stated that residents' bathrooms were cleaned daily. The HK stated that cleaning the bathroom included spraying the shower floor and walls with bathroom cleaner and scrubbing with a scrub brush. Resident 23's bathroom was observed with the HK. The HK stated that resident 23's bathroom's daily cleaning had not been completed. The HK stated that the tile and grout in resident 23's bathroom were possibly stained. On 3/5/25 at 1:50 PM, an observation was made of resident 23's shower after daily cleaning had been completed by the HK. The HK was present in the bathroom. There was an odor of bleach, the floors and walls were wet. A damp scrub brush was observed. The black substance along the grout lines, white buildup on the tile surfaces, and the circular red rings along the shower floor remained the same as previous observations. On 3/5/25 at 1:57 PM, an interview was conducted with the Maintenance Director while observing resident 23's shower. The Maintenance Director stated that the circular red rings along the shower floor are rust marks from shower chair feet. The Maintenance Director stated that the black substance in the grout could be dirt. The Maintenance Director stated that he completed visual inspections in the resident rooms and bathrooms once a week. The Maintenance Director stated that housekeeping and staff report maintenance needs in the Maintenance Binder kept at the nursing station. The Maintenance Binder recorded who reported the maintenance need, when the maintenance need was reported, a description of the maintenance need, who addressed the maintenance need and when the maintenance need was addressed. On 3/5/25 at 2:28 PM, an interview was conducted with the Corporate Nurse (CN) while observing resident 23's shower. The CN acknowledged the black substance along the grout lines, white buildup on tile surfaces, and circular red rings along the shower floor.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made to the Administrator (ADM) of the facility, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, for 1 out of 27 sampled residents, a resident reported an allegation of verbal abuse to a staff member and that information was not reported to the facility ADM, the SSA, or APS. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of chronic kidney disease, morbid obesity, type 2 diabetes mellitus, borderline personality disorder, Post Traumatic Stress Disorder, bipolar disorder, anxiety disorder, and hypertension. On 3/3/25 at 9:35 AM, an interview was conducted with resident 10. Resident 10 stated that last night she requested the male nurse check her blood sugar early so she could go to bed. Resident 10 stated that the nurse told her where to go and replied fuck you to her request. Resident 10 stated that the Certified Nursing Assistant Coordinator (CNAC) provided her with incontinence care at 4:00 AM, and she reported the incident to her. Resident 10's medical record was reviewed. On 11/20/24, resident 10's Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15/15, which would indicate that the resident was cognitively intact. Review of the facility abuse investigations revealed no documentation for the investigation of the allegation of verbal abuse as alleged by resident 10 on 3/3/25. On 3/5/25 at 10:11 AM, an interview was conducted with the CNAC. The CNAC stated that resident 10 reported to her on Monday morning that the night nurse was rude to her. The CNAC stated that resident 10 had stated that the way the nurse spoke to her when providing her medication was rude. The CNAC stated that she told resident 10 that she would let nursing management know about the incident. The CNAC stated that she did not report the incident to anyone. The CNAC stated that the facility abuse coordinator was the ADM, and any allegation of abuse needed to be reported immediately to the ADM. The CNAC stated that she should have reported the incident on Monday immediately, but she was not sure if it was an allegation of abuse. On 3/5/25 at 10:46 AM, an interview was conducted with the ADM. The ADM stated that he was just informed of an incident with resident 10 and a staff member. The ADM stated that he interviewed resident 10 and the resident had reported that the nurse told her fuck you. The ADM stated that he would initiate an abuse investigation and that he was aware that he was late in reporting the allegation to the SSA.

Based on interview and record review, the facility in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, for 2 out of 27 sampled residents, two allegations of abuse/neglect by staff members were not thoroughly investigated. Resident identifiers: 200 and 201. Findings included: 1. Resident 200 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, chronic kidney disease, bipolar disorder, type 2 diabetes mellitus, and morbid obesity. On 6/14/24 at 2:24 PM, an entity 358 report was received by the SSA. The report stated that on 6/13/24, during the evening shift, resident 200 alleged that a Certified Nursing Assistant (CNA) told her to go to the bathroom in your pants and that she did not have time to help the resident. The report also stated that the resident alleged that the CNA pulled up her shirt without the resident's permission. The report stated the CNA had been placed on administrative leave and Adult Protective Services (APS) had been notified. The report stated resident 200 was at baseline with no signs of injury or distress. The entity 359 investigation report could not be found in the abuse binder provided by the facility. On 3/6/25 at 11:51 AM, an email was provided by the Administrator (ADM). The email contained the following information, [CNA 3] denies lifting up the resident's shirt in an abusive manner. [CNA 3] denies refusing to assist the resident. A summary of interviews with other residents who may have had contact with the alleged perpetrator included, I conducted interviews with multiple residents regarding [CNA 3] and her performance and demeanor. [Resident 3] reports that [CNA 3] is a good CNA. [Resident name redacted] report no concerns with [CNA 3]. [Resident name redacted] reports [CNA 3] is a good employee and caring. A summary of interviews with staff responsible for oversight and supervision of the location where the alleged victim resides included, [Registered Nurse (RN) 1] was interviewed, [RN 1] reports that [resident 200] is at her baseline mood and behavior and does not present with any signs or symptoms of psychosocial trauma or abuse. A summary of interviews with staff responsible for oversight and supervision of the alleged perpetrator revealed, [RN 1] has not had any concerns related to [CNA 3]'s performance behavior. The allegation appears to be inconclusive although no information was provided as to how it was determined. Actions taken as a result of the investigation included, resident's plan of care was updated to reflect new intervention and approaches to reduce behaviors and falls. No plan for oversight was provided, No actions were identified to address policies or training to prevent potential abuse. It should be noted the above information was provided from the previous administrator's email, and could not be verified to have been submitted to the SSA. 2. Resident 201 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included atrial fibrillation, heart failure, and depression. On 5/22/24 at 3:58 PM, the facility received an anonymous report, via the facility compliance hotline, that resident 201 had been left soiled due to lack of care or neglect. APS the SSA were notified. An entity 358 Facility Reported Incident form revealed the alleged perpetrator of neglect was unknown and the facility became aware of the incident on 5/22/24 at 3:30 PM. The time when the incident occurred was unknown and no injury was noted. The report stated the Resident is at baseline and not displaying signs of psychosocial trauma. The resident was assessed by nursing and no injuries were noted. The report states, Resident interviewed by facility administrator. Denies abuse/neglect at this time. Witnesses were unknown and APS was notified. The entity 359 investigation report could not be found in the abuse binder provided by the facility. No other documentation was provided. On 3/6/25 at 11:42 AM, an interview was conducted with the Director of Nursing (DON) who stated the administration takes complaints and allegations very seriously. The DON stated, depending on who the resident comes to first the investigation would be given to the appropriate team member. The DON stated if the allegation was regarding abuse or neglect, it would be given to the ADM who was the abuse coordinator. The DON stated information was shared in the morning stand up meeting regarding the resident and the complaints or allegations. The DON stated if necessary, social work would get involved. The DON stated a corporate meeting was held every morning to discuss concerns also. The DON stated that the ADM would take the lead on investigations and delegate tasks as needed. The DON stated the ADM liked to do the interviews himself and make decisions accordingly. The DON stated instructions were on the wall by the nurse's station as to the requirements for notification and reporting. The DON stated the facility used text messaging to report information immediately.

2. Resident 41 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, type 2 diabetes mellitus, osteomyelitis, non-pressure chronic ulcer, gas gangrene, cutaneous abscess of left foot, and cellulitis. On 3/3/25 at 10:25 AM, an interview was conducted with resident 41. Resident 41 stated he had a reaction to the last antibiotic he was taking and had to go to the hospital. Resident 41 stated that he went to the hospital twice, once in January and once in February. Resident 41's medical record was reviewed. Resident 41's progress notes documented the following: a. On 1/2/25 at 3:36 PM, the note documented, Pt [patient] continued to have elevated temperature 103 Provider notified of results of lab work, per provider order patient sent out to hospital. b. On 2/5/25 at 12:57 PM, the note documented, pt received 400mg [milligrams]/200mL [milliliters] of their STAT [immediate] IV [intravenous] Fluconazole. pt asked LN [licensed nurse] to hold the next dose for an hour before administering the 2nd 400mg dose. in that time frame, pt asked for something for nausea. LN communicated with provider about pt concerns. pt then c/o [complained of] to aide [Certified Nursing Assistant] and said they wanted to be sent out. LN went in and spoke with pt again. ADON spoke with pt as well. pt concerns were communicated to provider. LN received instruction to go ahead and send pt out. LN called [ambulance service omitted] to pick pt up nonemergent. pt wants to go to [name of hospital omitted]. No documentation could be found of the transfer forms/assessments or the documentation that was sent to the receiving provider. Review of the Emergent Discharge/Transfer to the Hospital Checklist located in the agency binder documented the following: a. Make 2 copies of the discharge order, generate and print clinical chart from the medical records, copy of POLST, the emergent discharge assessment, and a copy of the signed bed hold policy. b. Call the hospital and give a nurse to nurse report. Obtain the nurse name and document it in the discharge progress note. c. Document a progress note that the above items were sent with the resident. d. Document a discharge nurse's note in the electronic medical records with details of the change in condition; the assessment and treatment provided; the notification of physician/family; the date and time of discharge; where they were discharged to; document who you gave report to and that the POLST, assessments, signed bed hold policy, physician orders, and order to discharge were sent with the resident or faxed. e. Notify the Director of Nursing (DON) or Unit Manager of the discharge/transfer. On 3/4/25 at 2:54 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that the process for discharging the resident to the hospital was to get orders for the transfer; notify the family; print the resident face sheet, medication list, and POLST form; document a note of everything in the progress notes. RN 3 stated that the progress note should have who was notified, reason for transfer, times they left, what documents were sent with the resident and who took the patient. On 3/4/25 at 2:58 PM, an interview was conducted with the DON. The DON stated that for any resident change in condition the provider was notified. The DON stated that staff should follow the emergent discharge process when transferring a resident to the hospital. Based on interview and record review, when the facility transfers a resident, the facility must ensure that the transfer is documented in the resident's medical record and the appropriate information was communicated to the receiving health care institution or provider. Specifically, for 2 out of 27 sample residents, residents that were transferred to the hospital were not sent with necessary documentation to ensure a safe and effective transition of care. Resident identifiers: 28 and 41. Findings included: 1. Resident 28 was admitted to the facility on [DATE] with diagnoses which included, but were not limited, to neuropathy, osteomyelitis, type 2 diabetes mellitus, left leg below knee amputation, right toe amputation, and epilepsy. Resident 28's medical record was reviewed on 3/3/2025 through 3/6/2025. On 2/15/2025, Resident 28 was transferred via Emergency Medical Services from the facility to the emergency room at the local hospital, where the resident was admitted . The resident returned to the facility on 2/23/25. A progress note dated 2/16/25 at 2:33 AM, documented Resident stated that she has not received her pain medication for a week and is in intense pain. ADON [Assistant Director of Nursing] called pharmacy and confirmed that her Lyrica will be delivered with the next delivery. She then stated that she wants to go to the hospital and if I don't arrange transport, she will call 911 herself. I called the on-call MD [Medical Director], and he agreed to let her go to the hospital. Transport was called and resident was picked up. Family was notified . ADON was notified. No documentation could be located regarding the transfer forms, assessments, or the documentation that was sent to the receiving provider. On 3/6/25 at 10:39 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1 regarding transfers to a hospital. LPN 1 stated that the process was to obtain the order from the doctor. LPN 1 stated that the hospital needed to be called and given a report. LPN 1 stated that the family should be notified of transfer. LPN 1 stated that the following forms were printed out and given to transportation: Physicians Orders for Life-Sustaining Treatment (POLST) form, face sheet, orders, and the bed hold policy. LPN 1 stated that the phone call to the hospital and family, along with the forms given to transportation should be documented in a progress note.

Based on observation, interview, and record the review, the facility did not ensure that residents who were continent of bladder received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain. In addition, the facility did not ensure that residents with urinary catheters received services based on the resident's comprehensive assessment. Specifically, for 2 out of 27 sampled residents, a resident that was assessed as a candidate for scheduled toileting was not on a toileting program and a resident with a suprapubic catheter did not have the correct size inserted per physician orders. Resident identifiers: 3 and 99. Findings included: 1. Resident 99 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, metabolic encephalon, acute kidney failure, low back pain, generalized anxiety disorder, macular degeneration, chronic pain, and urinary tract infection (UTI). On 3/3/25 at 11:46 AM, an interview was conducted with resident 99. Resident 99 stated that she currently had a UTI. Resident 99 stated the staff did not come quick enough when she needed to use the toilet and staff told her that she was better off wearing diapers. Resident 99 stated that she could use the restroom if staff assisted her. Resident 99 stated that she thought she got UTIs because she had to urinate in the diaper. Resident 99 stated that she could not get up without assistance. Resident 99's medical record was reviewed on 3/3/25 through 3/6/25. A care plan Focus initiated on 2/12/25, documented [Resident 99] is incontinent secondary to anxiety, history of UTIs, pain, anxiety, depression, HTN [hypertension], macular degeneration. The Goal documented that resident 99 would not experience any adverse effects of incontinence through the next review. The Interventions included, but were not limited to, provide assistance for toileting. A care plan Focus initiated on 2/21/25 and revised on 2/24/25, documented [Resident 99] has bladder incontinence r/t [related to] Active infections with symptoms of UTI. The Interventions included, bur were not limited to, encourage fluids during the day to promote prompted voiding responses. On 2/28/25, the facility completed a Bowel and Bladder Program Screener for resident 99. The screener documented that resident 99 did not always, but at least daily voided appropriately without incontinence. Resident 99 was immobile or required a two person assist, forgets but follows commands, and was sometimes aware of the need to toilet. Resident 99 was categorized as a Candidate for Schedule toileting (timed voiding). On 3/6/25 at 8:52 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated the facility had a toileting program. CNA 2 stated any resident that was able to move the staff would try to encourage the resident to use the toilet. CNA 2 stated the CNAs were to round on the residents every two hours. CNA 2 stated that some CNAs would tell the residents if they had a brief on they were fine and go in the brief but if the resident was able to move the staff should be encouraging the resident to use the toilet if they were capable. CNA 2 stated it was hard with agency staff to get them trained. CNA 2 stated agency staff would tell the residents to use the brief if the resident had one on. CNA 2 stated that some residents would let staff know they need to use the toilet. CNA 2 stated if it was time for rounds and the resident was wet the staff should still be encouraging the resident to use the toilet. CNA 2 stated that resident 99 should be on a toileting program. CNA 2 stated she had heard that some of the CNAs have said that resident 99 did not want to use the toilet. CNA 2 stated that resident 99 would use her call light if she needed to use the toilet. CNA 2 stated in the resident medical record toileting times could be scheduled as a task. On 3/6/25 at 9:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a toileting program. The DON stated the toileting program would be waking, at bedtime, and after meals. The DON stated the documentation of the toileting program would be part of the task. The DON stated that it looked like resident 99 was not on a toileting program but we do have an order for increased hydration. 38031 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included quadriplegia cervical (C)1-C4 incomplete, neuromuscular dysfunction of the bladder, flaccid neuropathic bladder, and autonomic neuropathy. On 3/3/25 at 8:55 AM, an interview was conducted with resident 3. Resident 3 stated that he needed the suprapubic catheter changed due to it being plugged and the facility did not have the correct size in stock and he had to wait for a replacement. Resident 3 stated the last time the catheter was changed the nurse who performed the treatment was dirty and did not change his gloves or use antispetic to clean the insertion site. Resident 3's medical record was reviewed. Resident 3's physician orders revealed the following: a. Flush catheter with 60 milliliters (ml) of acetic acid twice a week and as needed (PRN) every night shift on Tuesday and Friday. b. Ensure privacy/dignity bag was in place for catheter down drain bag every shift. c. Catheter - Monitor urine for abnormal color, clarity, odor - if abnormal notify the Medical Director every shift. d. Change PRN - Suprapubic catheter: 24 French size 10 ML balloon for occlusion or leakage as needed. e. Urinary catheter: irrigate with normal saline at bedtime. f. Urinary catheter care every shift. On 2/24/25 at 10:29 PM, resident 3's Treatment Administration Record documented that resident 3's suprapubic catheter was changed with a 24 French size, 10 ml balloon per the physician order. Resident 3's progress notes revealed the following: a. On 12/17/24 at 3:45 PM, the note documented, 20 g [gauge] suprapubic catheter placed and bag replaced, due to pt leaking. Pt [patient] tolerated it well and has had no new complaints. b. On 12/30/24 at 5:25 PM, the note documented, Catheter and bag replaced today. Catheter size 20/10. No issues. Pt reports no pain or discomfort. c. On 1/4/25 at 2:12 PM, the note documented, Patient catheter change, 22 French, 30mL, skin intact, dressing in place. d. On 2/22/25 at 3:54 PM, the note documented, pt scheduled for cath [catheter] change today. pt it [sic] 22 gauge. we are out of 22 gauge. offered to go one size smaller. pt declined and stated he will wait. On 12/18/24, resident 3's risk versus benefit form documented, .has a suprapubic catheter, which needs to be flushed each shift. He has been refusing, stating he only wants it done when it is not flushing or draining. It was explained that was why it was getting clogged was because it needs to be flushed regularly. He then stated he would be ok with it done at night and then as needed for other times. On 8/31/2020, resident 3 had a care plan initiated for .requires a suprapubic catheter at this time secondary to Urinary retention/neurogenic bladder. Interventions identified on the care plan were to flush the catheter as ordered; provide suprapubic site care as ordered; catheter care every shift; and change the suprapubic 20 French 30 ml balloon per providers orders. It should be noted that the care plan did not accurately reflect the current physician orders for the suprapubic catheter size. On 3/4/25 11:49 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 3's catheter size was a 24 French per the physician order. RN 1 checked the supply room for the 24 French catheter and stated that they did not have any 24 French suprapubic catheters in stock. RN 1 stated that she would not be able to change the catheter if it needed to be done because they did not have any in stock. RN 1 stated that the CNA Coordinator (CNAC) was in charge of reordering supplies. On 3/4/25 at approximately 11:55 AM, an interview was conducted with the CNAC. The CNAC stated that she was in charge of ordering supplies for the facility. The CNAC stated that a reorder form was placed on the front of her door, in the medication room, and at the nurse's station for staff to add requested supplies to. The CNAC stated that she ordered supplies every week by Wednesday and then received the order on Thursday. The CNAC stated that she ordered resident 3's suprapubic catheter by the case and he was the only resident that used them. The CNAC stated that when they were close to running out the nurse would inform her and she would place a new order. The CNAC stated that earlier this week RN 2 told her that they were out of stock of the 24 French suprapubic catheter. The CNAC stated that she informed RN 2 that they had a 22 French catheter with a 30 ml balloon available and asked if they could use that one instead until they got the other one in stock. The CNAC stated that she did not know what catheter size RN 2 used for resident 3's treatment. The CNAC stated that they should have the correct size suprapubic catheter in stock for resident 3 at all times. The CNAC stated that the item was not reordered in this week's shipment because she had already placed the order when she became aware that it was out of stock. On 3/4/25 at 12:17 PM, an interview was conducted with the DON. The DON stated that the CNAC was responsible for reordering all stock supplies for the facility. The DON stated that resident 3 should have a 24 French suprapubic catheter available in the supplies. The DON stated that if staff placed a 22 French catheter instead of the 24 French they should have contacted the physician and put an order in for the change. The DON stated that she would have to reach out to the nurse to see if the treatment was completed. On 3/4/25 at 2:30 PM, a follow-up interview was conducted with the DON. The DON confirmed that resident 3 had a 22 French suprapubic catheter inserted. The DON stated that the physician was not notified of the 22 French catheter insertion and she did not have an order for it. The DON stated that she notified the provider and he was currently speaking to the resident.

Based on interview and record review, the facility did not provide routine and emergency drugs to its residents. Specifically, for 1 out of 27 sampled residents, a resident that was prescribed a medication to manage neuropathic pain did not have the medication available for administration due to pending delivery. Resident identifier: 28. Findings Included: Resident 28 was admitted to the facility on [DATE] with diagnoses which included, but were not limited, to neuropathy, osteomyelitis, type 2 diabetes mellitus, left leg below knee amputation, right toe amputation, and epilepsy. Resident 28's medical record was reviewed on 3/3/2025 through 3/6/2025. On 3/3/25 at 9:44 AM, an interview was conducted with resident 28. Resident 28 stated that she was concerned that the facility did not always have medications in stock. Resident 28 stated that she had missed scheduled medications in the past due to the facility not having the medications in stock. A review of the Medication Administration Record (MAR) for February 2025 was completed. It was noted that five consecutive doses of pregabalin capsule 100 milligrams (mg) were not administered between 2/14/25 and 2/15/25. On 2/14/25, pregabalin was not given at the scheduled 6:00 AM, 10:00 AM, and 06:00 PM, administration windows. On 2/15/25, pregabalin was not given at the scheduled 6:00 AM and 10:00 AM, administration windows. The chart code documented in the MAR for all five missed administrations was code 11, indicating Med [medication] not available. On 2/14/2025 at 9:29 PM, an Orders - Administration Note documented Note Text: Pregabalin Capsule 100MG Give 1 capsule by mouth three times a day for nerve pain Unable to locate. On 2/15/2025 at 8:31 AM, an Orders - Administration Note documented Note Text: Pregabalin Capsule 100MG Give 1 capsule by mouth three times a day for nerve pain pending delivery. On 2/15/2025 at 12:42 PM, an Orders - Administration Note documented Note Text: Pregabalin Capsule 100MG Give 1 capsule by mouth three times a day for nerve pain pending delivery. On 3/4/25 at 10:27 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 Stated that when there was an out of stock medication in the medication cart she would confirm if the medication had been ordered. RN 3 stated that she would call the pharmacy to verify the delivery date if the order for the medication had been made more than two days previously. RN 3 stated that there was a back up supply of over the counter medications in the room behind the nurses station. RN 3 stated that there was not a back up supply of prescription medications available in the facility. RN 3 stated that she would order more medications from the pharmacy if there were less than a 7 day supply available in the medication cart. On 3/4/25 at 11:53, an interview was conducted with RN 1. RN 1 stated that if a medication in the medication cart that has less then a 5 day supply new medication would be ordered for delivery from the pharmacy. RN 1 stated that the pharmacy routinely delivered medications once a day. RN 1 stated that if there was an urgent order a separate delivery from the pharmacy would be made. RN 1 stated urgent orders usually were delivered within the shift that they were ordered. RN 1 stated that back up medications, including prescription medications like narcotics or antibiotics, were stocked in the emergency medication system located in the room behind the nurses station. RN 1 stated that if an ordered medication could not be located in the medication cart or the emergency medication system the nurse should chart that the medication was unavailable; notify the provider for new orders; notify nursing management; and attempt to obtain the out of stock medication by requesting an urgent delivery from the pharmacy. A review was made of the Agency Nurse Binder located at the nurses station. The steps for unavailable medications during normal business hours were listed as follows: Call pharmacy for delivery, if late get from ekit [emergency kit], if not in ekit call pharmacy for emergency delivery, if not obtained timely notify MD [Medical Director] and ask for orders/instructions. If a medication was not available in normal business hours the following steps should be taken: Get med from ekit, if not in ekit call on call pharmacist. If emergency delivery is not available contact MD to obtain orders/instructions. Further guidelines provided were: Do not just document that the medication is unavailable - document the steps you are taking to get it.

Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. In addition, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days. Specifically, for 1 out of 27 sampled residents, a resident taking medications for Post-Traumatic Stress Disorder (PTSD), insomnia, night terrors, and anxiety did not have behavior tracking or adverse side effect (ASE) tracking for those medications. In addition, the resident was prescribed a PRN psychotropic that was extended beyond 14 days without a practitioner justification. Resident identifier: 45. Findings included: Resident 45 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, PTSD, major depressive disorder, borderline personality disorder, and generalized anxiety disorder. Resident 45's medical record was reviewed on 3/4/25 through 3/6/25. 1. A care plan Problem started on 1/17/25, documented Category: Psychotropic Drug Use [resident 45] is at risk for adverse side effects secondary to Psychotropic medication use. The Interventions included, but were not limited to, monitor for adverse side effects to medications every shift and notify Medical Director (MD) if present. Monitor for behaviors and document as needed. On 1/31/25, a physician's order documented zolpidem 10 milligrams (mg) at bedtime for insomnia. On 1/31/25, a physician's order documented clonidine 0.1 mg at bedtime for night terrors. The medication was started on 2/3/25. On 2/3/25 at 4:00 PM, a Nurse Practitioner (NP) progress note documented . Insomnia, unspecified: On 01/29 [25], patient endorsed sleeping better. Continuing to monitor sleep patterns. No changes in management mentioned in current dictation. On 2/26/25, a physician's order documented doxazosin 4 mg at bedtime for PTSD. On 2/26/25 at 11:30 AM, Psych- NP - Senior Health Support Services progress note documented . Insomnia, unspecified: Patient endorses sleeping better. Will continue to monitor sleep patterns. 2. PTSD/Nightmares: Start doxazosin 4 mg QHS [at bedtime] for nightmares. Monitor effectiveness and any side effects. 5. Hallucinations: Monitor auditory hallucinations and their impact on pt's [patients] anxiety and mood. There were no physician's orders to monitor hours of sleep, night terrors, PTSD, or medication ASE. There was no documentation that staff were monitoring hours of sleep, night terrors, PTSD, or medication ASE. 2. On 2/18/25, a physician's order documented clonazepam 0.5 mg PRN three times a day (TID) for anxiety for 14 days. The physician's order was discontinued on 2/24/25. On 2/24/25, a physician's order documented clonazepam 0.5 mg PRN four times a day (QID) for anxiety for 14 days. There was no documented rationale by the prescribing practitioner in resident 45's medical record to extend the clonazepam beyond 14 days. There was no physician's orders to monitor for anxiety and there was no documentation that staff were monitoring for anxiety. On 3/6/25 at 8:18 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that behaviors were monitored on the Medication Administration Record (MAR) in the monitors section. LPN 1 stated that under monitors it would indicate to track hours of sleep. LPN 1 stated that resident 45 had monitors for behaviors of crying, emotional distress, self harm, shortness of breath, and pain. LPN 1 stated that she would track hours of sleep for zolpidem. LPN 1 stated there would be separate monitoring for night terrors and PTSD. LPN 1 stated for resident 45's PTSD she had night terrors, anxiety, and depression. LPN 1 stated that resident 45 was homeless prior and was afraid of being homeless again. LPN 1 stated that medication side effects should be monitored. LPN 1 confirmed that monitors for hours of sleep, night terrors, PTSD, or medication ASE were not on the MAR and staff were not monitoring for those behaviors. LPN 1 stated a physician's order would be required for the monitors but the floor staff could put the monitors on the MAR. LPN 1 stated that she was not sure that every nurse knew to put the monitors in. LPN 1 stated that resident 45 took the clonazepam as ordered. LPN 1 stated the clonazepam was TID and the MD increased the clonazepam to QID. LPN 1 stated the MD would do the order for 14 days and the MD would reevaluate the medication. On 3/6/25 at 9:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was on a sleep medication the staff should be tracking sleep. The DON stated if a resident was on a PRN psychotropic medication the MD would look at the frequency of use of the medication at the end of the 14 days. The DON stated the MD should be reevaluating the PRN medication.

Based on interview and record review, the facility did not have an infection prevention and control program that included a system to monitor antibiotic use for the antibiotic stewardship program. Specifically, for 1 out of 27 sampled residents, a resident's urinalysis and urine culture and sensitivity was not completed. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, paraplegia, neurogenic bladder, and neuromuscular dysfunction of bladder. Resident 12's medical record was reviewed on 3/3/25 through 3/6/25. A review of resident 12's progress notes revealed the following: a. On 11/4/24 at 6:43 AM, a physician progress note documented, . [resident 12] presents with a suspected urinary tract infection (UTI). She reports experiencing backache, stomachache, and headache, which she believes are typical symptoms of a UTI for her, patient is a quadriplegic and cannot feel dysuria. [Resident 12] also mentions feeling cold and unwell. She reports having fever and chills, but states she has been taking Tylenol, which may be masking the fevers. [Resident 12] has a cough but denies any congestion. She is concerned about the possibility of having the flu or another viral infection in addition to the UTI. The patient has previously been treated with Levaquin for UTIs and has responded well to it. She expresses a preference for receiving Levaquin without a urinalysis .-Plan: Prescribe Levaquin as the patient has had a positive response to this medication in the past. No need for a urinalysis at this time as the patient prefers to proceed with the antibiotic treatment. b. On 11/4/24 at 2:33 PM, a nursing note documented, [resident 12] c/o [complaining of] UTI like symptoms. Fever, chills, body aches. Reported to NP [Nurse Practitioner]. New order received to give Levaquin 250 mg [milligrams] PO [by mouth] q [every] 24 hours x [times] 5 days for UTI symptoms. RP [responsible party] aware of new order. It should be noted that a urinalysis culture and sensitivity dated 9/18/24 showed resident 12 grew bacteria that was resistant to Levaquin. On 3/4/25 at 1:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility had an infection preventionist responsible for overseeing all aspects of antibiotic stewardship. The DON stated that nurses were required to notify the medical doctor if a resident began showing signs of a suspected UTI. On 3/4/25 at 2:09 PM, an interview was conducted with the NP. The NP stated that resident 12 had a history of frequent UTIs and had a suprapubic catheter. The NP stated that he used McGreer's criteria to determine the appropriate treatment for infections. The NP stated he did not recall specific details from November but remembered possibly prescribing an antibiotic once without obtaining a urinalysis or urine culture. The NP stated that he typically ordered a urinalysis and culture for resident 12 to identify the specific bacteria and ensure the correct antibiotic was prescribed. On 3/6/24 at 8:48 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that resident 12 had gentamycin flushes but inconsistently accepted them. Sometimes, she allowed certain nurses to administer the flushes, while other times, she refused. The IP stated that if a resident showed symptoms of a urinary tract infection, staff needed to notify the doctor, who typically ordered a urinalysis and sometimes prescribed a broad-spectrum antibiotic. The IP stated if residents exhibited minimal symptoms, the doctor usually waited for urine culture results before prescribing antibiotics. The IP stated that she would always get a urinalysis done for residents with a history of UTIs, had urinary symptoms, or had a urinary catheter. The IP stated that she needed to be more vigilant about monitoring these cases. The IP stated she had some ongoing challenges with lab reports being faxed to the facility, causing confusion for both her and the NP. The IP stated that to address this issue, she planned to send a text to the NP to ensure lab results were reviewed while also documenting a note in the resident's chart about the labs and their results. The IP stated that prescribing antibiotics without a urinalysis or culture testing contributed to the development of antibiotic-resistant superbugs. The IP stated if a resident was given an antibiotic they were resistant to, it would not be effective, which posed a serious concern to the resident's health.

Based on interview and record review, the facility did not ensure that each resident was offered the influenza and pneumococcal immunizations, had the opportunity to refuse the immunizations, and that the documentation indicated that the resident was offered education about the benefits and potential side effects of the immunizations and either received or declined the immunization. Specifically, for 2 out of 5 sampled residents, a resident had a signed consent form for the pneumococcal vaccine but the form did not contain any other documentation, and a resident had a signed consent form for the pneumococcal vaccine that indicated he wished to receive the vaccine but no other documentation was contained on the form. Resident identifiers: 19 and 28. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which consisted of quadriplegia, type 2 diabetes mellitus, dysphagia, anemia, antiphospholipid syndrome, pressure ulcer of right buttocks, and hypertension. On 3/5/25, resident 19's medical record was reviewed. On 8/29/24, resident 19 signed the Pneumococcal vaccine form and gave consent to receive the vaccine. The form did not document if the vaccine was administered, the location of administration, the lot number of the vial of the vaccine, or the date of administration. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, polyneuropathy, anemia, hypothyroidism, and pain. On 3/5/25, resident 28's medical record was reviewed. On 2/7/25, resident 28's Pneumococcal vaccine consent form contained the residents signature. The form did not document if the resident gave consent or declined the vaccination. No other information was documented on the form. On 3/6/25 at 9:10 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that for immunization administration the nurse should document the date, medication, time, manufacturer, lot number, and location of administration. On 3/6/25 at 11:38 AM, an interview was conducted with the Corporate Nurse (CN). The CN stated that resident 19 consented to the pneumococcal vaccine but they did not have any documentation of it being administered. Review of the facility policy and procedures for Infection Prevention and Control Program documented under Influenza and Pneumococcal Immunizations that residents would be offered the vaccines each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time. The policy stated that residents would be provided education on the benefits and potential side effects of the immunizations, have the opportunity to refuse the immunization, and the documentation would reflect that the education was provided and whether or not the resident received the immunization. The policy was last revised on 1/12/24.

Based on observation, interview, and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically, for 1 out of 27 sampled residents, a resident was observed to have medications in her closet and was not evaluated to determine if they were safe to self-administer medications. Resident identifier: 25. Findings included: Resident 25 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis of vertebra, methicillin resistant staphylococcus aureus infection, paraplegia, and encephalopathy. On 3/3/25 at 10:09 AM, an observation was conducted of resident 25's room. A large bottle of store-brand B-complex medication supplement was observed inside resident 25's closet. An interview was immediately conducted with resident 25. Resident 25 stated that the doctor said it was okay for her to take supplements to help her heal. Resident 25 stated that if the facility provided supplements for her, it would cost a lot more money. Resident 25 stated, due to this her daughter brought them to her and she was just taking them herself to save money. Resident 25's medical record was reviewed on 3/3/25 through 3/6/25. On 1/7/25, resident 25's Self-Administration Of Medication assessment documented no that the resident did not wish to self administer medications. Resident 25's care plan was reviewed and no care areas were identified for self administration of medication. An admission Minimum Data Set assessment dated [DATE], revealed that resident 25 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated an intact cognition. A nurse's note dated 3/2/25 at 5:54 PM, revealed that resident 25's daughter brought in a pill case of vitamins approved by the Medical Director over the phone. The pill case was now missing Saturday's slot. On 3/4/25 at 1:38 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that if she saw medications or supplements at a resident's bedside or in their room, she would inform the nurse. On 3/5/25 at 1:56 PM, an interview was conducted with CNA 2. CNA 2 stated if medications or supplements were in a resident's room, she would have a nurse come and/or talk to the nurse. CNA 2 stated that the residents were not allowed to have medications in their room or left at the bedside. 38031 On 3/6/25 at 11:03 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 25's cognitive status was alert and oriented times two to self and location. RN 1 stated that resident 25 had episodes of frequent confusion, needed reminders about her care, and had short term memory deficits. RN 1 stated that resident 25 was not able to self administer medications. RN 1 stated that resident 25 did not have a self administration evaluation that concluded the resident was safe to self administer medication. RN 1 stated that resident 25's family member had brought medication to the facility and had left it at the bedside. RN 1 stated that they collected the medication and gave it to nurse management. RN 1 stated that she would administer resident 25's medication in the morning and then she would forget that she had taken it. RN 1 stated that resident 25 was not safe to self administer medication because she often forgot that she had taken medication previously and she would be at risk for administering too much medication. On 3/6/25 at 11:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 25 had a BIMS score of 15/15, which would indicate that the resident was cognitively intact. The DON stated that she did not see that resident 25 had any diagnoses of memory deficits. The DON stated that she should not have medications at the bedside for self administration based on the completed self administration of medication assessment.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, for 1 out of 11 sampled residents, a resident who had psychological needs and multiple falls did not have a care plan for mental health or falls developed. Resident identifiers: 10. Findings include: Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included suicide attempt, fall on same level, morbid obesity, obstructive sleep apnea, suicidal ideations, difficulty walking, dissociative identity disorder, need for assistance with personal care, hypothyroidism, type II diabetes mellitus, hypertension, atrial fibrillation, bipolar disorder, post traumatic stress disorder, chronic kidney disease stage 3 and panic disorder. Resident 10's medical record was reviewed on 5/14/24. Psychological needs: A complaint form was submitted to the State Agency on 5/3/24 regarding resident 10. The complaint indicated that resident 10 had a history of self-injurious behaviors and inflicted another wound with an unknown implement. No protocol for self-harm or suicidal ideation was put into place; the only new order was for bactracin to the wound. Review of resident 10's progress notes revealed that on 5/4/24, At approximately 1630 [4:30 PM], [resident 10] took this RN [registered nurse] to the side and stated that another personality of hers had initiated self-harm behaviors, inflicting an incision of approximately half an inch on the front of her right thigh. The incision was very clean and straight, as if made by a razor blade. The other RN on duty made a search, with [resident 10's] consent, of her room and purse. No implements capable of inflicting such a wound were found. On-call provider and administrator notified; close monitoring ordered as well as bacitracin ointment to prevent infection of wound. Staff will monitor closely. Resident 10's care plan was reviewed. The focus adjustment to placement was dated 3/12/24 and indicated that the resident was at risk for adjustment/psychological well-being issues secondary to recent need for skilled nursing . With an approach which indicated 1:1 with social services to discuss any psychosocial concerns; LCSW (licensed clinical social worker) consult, PRN (as needed) N/A - Not Applicable. Review of the care plan revealed that it had not been updated since it's initial entry of 3/12/24. A review of the New Admission Checklist dated 3/5/24 revealed that the section for Psychotropic care plan was marked as completed but no care plan was found in the medical record. Falls: Progress notes documented resident 10 had a fall on the following dates: a. 3/21/24 b. 3/27/24 c. 3/28/24 d. 4/2/24 e. 4/3/24 f. 4/10/24 g. 5/6/24 h. 5/7/24 No fall care plan was located in resident 10's medical record. On 5/14/24 at 1:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 10 did not have a care plan for her specific behaviors or falls, ideally those should have been care planned. The DON stated the staff have a checklist of what they are supposed to follow after a resident falls but stated there was not one specific place where the staff could find the information of what had been done previously to help the resident avoid falls. The DON stated she was aware of resident 10's behaviors and psychological issues and that her medications were being managed but her behaviors were not being managed, especially for someone who was self harming. The DON stated in order for the staff to know their residents the CNA's are expected to use their report sheet and look at the CNA brain book to find the information about resident cares and behaviors. And the nurses can get the information from report and through the progress notes.

Based on record review and interview, the facility did not ensure that 1 of 11 sample residents had a care plan that was revised by the interdisciplinary team. Specifically, a resident had repeated behaviors that were not care planned, including interventions that should be taken by staff to prevent behaviors. Resident identifiers: 1 and 3. Findings include: Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included substance use disorder, schizoaffective disorder, anxiety, and a traumatic brain injury. Resident 3 was admitted on [DATE] with diagnoses that included dementia and encephalopathy. Resident 1's and resident 3's medical records were reviewed on 5/14/24. Resident 1's quarterly Minimum Data Set (MDS) assessment documented that resident 1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Resident 3's quarterly MDS assessment documented that resident 3 had a BIMS score of 4, which indicated severe cognitive impairment. Review of resident 1's progress notes revealed that on 1/9/24 Nurse witnessed [resident 1], going into [resident 3's] room. Upon entering the nurse saw that the curtain was closed. Upon opening the curtain the nurse witnessed residents participating in sexual activity with [resident 3]. [Resident 1] was giving oral sex to [resident 3]. Residents were separated immediately. DON (Director of Nursing), abuse coordinator, social worker and provider were notified. Resident placed on Q15 (every 15 minute) checks, and charting for emotional distress [for] 7 days. A form 359 was submitted to the State Agency regarding the incident on 1/9/24. The form 359 indicated that resident 1 had been very friendly towards other male residents. [Other residents] also indicated that she has been asking others for money and cigarettes. Staff documented that both residents denied anything happened. The form 359 indicated staff had verified that sexual abuse had occurred, and that both residents are cognitively impaired and unable to give consent to sexual acts. Review of resident 1's progress notes revealed that on 1/12/24, a Certified Nursing Assistant (CNA) was walking down the hallway to pick up food trays and noticed [resident 1] in a male residents room, she went to grab another CNA to remove [resident 1], when the second CNA went in to get [resident 1], [resident 1] was pulling down her shirt, the CNA asked '[resident 1] why were you doing that', in which [resident 1] replied 'I didn't do anything', but as she was being wheeled out she stated 'I didn't mean to show my breasts.' Review of resident 1's progress notes revealed that on 4/17/24, Resident was present in another residents room when alleged drug abuse occurred. Resident was separated immediately and placed in a safe location. Resident denies using any drug abuse. Residents vitals are stable, resident has been educated about drug use and the danger of behaviors. Provider has been notified . Resident will be monitored for emotional distress, . and vitals will be monitored for the next 24 hours. On 5/6/24, a form 358 was submitted to the State Agency. The form 358 indicated that resident 3 reported to a staff member that resident 3 had touched his penis. Resident 1's behavior care plan was reviewed. The behavior care plan was dated 12/20/23, and indicated that the resident has physical behavioral symptoms toward others (e.g., hitting, kicking, pushing, scratching, abusing others sexually). Review of the care plan revealed that it had not been updated after 12/20/23, including after resident 1's sexual behaviors as listed above. On 5/14/24 at 11:10 AM, an interview was conducted with the DON. The DON was asked what interventions had been put in to place to prevent and address resident 1's behaviors. The DON stated that resident 1 had been placed on one on one, and then changed to a line of sight observation. The DON also stated that the facility had been purchasing cigarettes for resident 1, in case the behaviors were transactional in nature. The DON also stated that resident 1's medications had been evaluated. The DON confirmed that resident 1's care plan should have been updated with interventions to prevent and address behaviors.

Based on observation, interview and record review it was determined, for 8 out of 20 residents sampled, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, during a COVID-19 outbreak the facility did not perform contact and droplet precautions for COVID-19 positive residents; perform hand hygiene upon exit of a COVID-19 positive rooms; post notification to visitors that the facility was in a COVID-19 outbreak; utilize disposable utensils and dishware for COVID-19 positive residents; and isolate, transport, and launder COVID-19 positive residents linen's separately. Resident identifier 4, 8, 15, 16, 17, 18, 19, and 20. Findings included: 1. On 11/7/23 at 8:00 AM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that the facility was currently in a COVID-19 outbreak and that all COVID-19 positive residents were isolated in their rooms on the 100 and 200 hallways. The front entrance of the facility did not have signs posted notifying visitors that the facility was currently in a COVID-19 outbreak. On 11/8/23 at 8:00 AM, the front entrance of the facility was observed without signs posted notifying visitors that the facility was currently in a COVID-19 outbreak. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, osteoarthritis, weight loss, bipolar disorder, anxiety disorder, major depressive disorder, dysphagia, insomnia, cachexia and a history of transient ischemic attack. On 11/1/23, the facility COVID-19 tracking documented that resident 15 tested positive for COVID-19. Resident 16 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower extremity, Alzheimer's disease, acute duodenal ulcer with hemorrhage and perforation, anemia, dysphagia, insomnia, depression, history of Non-ST elevation myocardial infarction, delirium, mood disorder, pain, hypertension, and gastro-esophageal reflux disease. On 11/3/23, the facility COVID-19 tracking documented that resident 16 tested positive for COVID-19. On 11/7/23 at approximately 8:15 AM, an observation was made of resident 15 and resident 16's room. It should be noted that resident 15 and resident 16 resided in the same room and were roommates. A sign was posted outside the door that stated Isolation Precautions and anyone who entered the room was to donn a gown, gloves, and mask. The door to the room was observed open and both residents were observed inside the room from the hallway. 3. Resident 17 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower extremity, low back pain, morbid obesity, lymphedema, acute kidney failure, cerebral infarction, edema, venous insufficiency, chronic venous hypertension, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, hypomagnesemia, apnea and sespis. On 11/3/23, the facility COVID-19 tracking documented that resident 17 tested positive for COVID-19. Resident 18 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, hypertension, type 2 diabetes mellitus with polyneuropathy, morbid obesity, pain, Non-ST elevation myocardial infarction, pressure ulcer of buttocks, metabolic encephalopathy, and hypovolemic shock. On 11/3/23, the facility COVID-19 tracking documented that resident 18 tested positive for COVID-19. On 11/7/23 at approximately 8:15 AM, an observation was made of resident 17 and resident 18's room. It should be noted that resident 17 and resident 18 resided in the same room and were roommates. A sign was posted outside the door that stated Isolation Precautions and anyone who entered the room was to donn a gown, gloves, and mask. An observation was made of Registered Nurse (RN) 3 inside resident 18's room administering medication to resident 18. RN 3 was observed with a surgical mask donned and no other Personal Protective Equipment (PPE) was worn. On 11/7/23 at 8:20 AM, an interview was conducted with RN 3. RN 3 stated that both resident 17 and 18 were COVID-19 positive. RN 3 stated that all the rooms with isolation precaution signs posted outside the door were for COVID-19 positive residents. RN 3 stated that all isolation rooms were on contact and droplet precautions. RN 3 stated that staff entering the isolation rooms should donn a mask, gown, and gloves. RN 3 stated that staff should wear an N95 mask inside the isolation rooms. RN 3 stated that she was not wearing a N95 mask inside the isolation rooms because she did not see any on the PPE carts outside of the rooms. RN 3 stated that she forgot to donn a gown and gloves when she entered resident 18's room. On 11/7/23 at 9:15 AM, an observation was made of Certified Nurse Assistant (CNA) 2 exiting resident 17 and resident 18's room. CNA 2 was observed inside the doorway talking to resident 17 within close proximity of each other. CNA 2 and resident 17 were both observed without a facemask donned. CNA 2 was observed carrying a dirty garbage sack. No gloves were donned and no hand hygiene was performed upon exit of the room. 4. Resident 8 was admitted on [DATE] with diagnoses which included quadriplegia Cervical (C)1-C4 incomplete, type 2 diabetes mellitus, stage 4 pressure ulcer of right buttocks, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, chest pain, insomnia, pain, major depressive disorder, and sepsis. On 11/5/23, the facility COVID-19 tracking documented that resident 8 tested positive for COVID-19. Resident 20 was admitted to the facility on [DATE] with diagnoses which included septic shock, embolism and thrombosis of unspecified artery, urinary tract infection, atrial fibrillation, acute kidney failure, acute respiratory failure with hypoxia, subdural hemorrhage, acute pyelonephritis, type 2 diabetes mellitus, with neuropathy, borderline intellectual functioning, pain, fracture of rib, morbid obesity, hyperlipidemia, insomnia, hypertension, rhabdomyolysis and cellulitis of left lower extremity. On 11/1/23, the facility COVID-19 tracking documented that resident 20 tested positive for COVID-19. On 11/7/23 at approximately 8:15 AM, an observation was made of resident 8 and resident 20's room. It should be noted that resident 8 and resident 20 resided in the same room and were roommates. A sign was posted outside the door that stated isolation precautions and anyone who entered the room was to donn a gown, gloves, and mask. CNA 2 was observed changing resident 20's bed linen. CNA 2 did not have a mask, gown, gloves or eye protection while inside the room. 5. On 11/7/23 at approximately 8:30 AM, an observation was made of the CNA Coordinator (CNAC) and RN 4 at the central nurse's station. Both staff members did not have a face mask donned. On 11/7/23 at 8:32 AM, an observation was made of Licensed Practical Nurse (LPN) 1 going room to room on the 200 hallway checking to see if there were gloves in each resident room. LPN 1 was observed to enter room [ROOM NUMBER], where signage was on the door stating the resident was on isolation/droplet precautions. LPN did not don any Personal Protective Equipment (PPE) before entering the room. LPN 1 exited the room and continued on to other rooms in the hallway. An interview was conducted with LPN 1. LPN 1 stated that one resident in room [ROOM NUMBER] was COVID positive, but he did not think the other resident in that room was COVID positive. LPN 1 stated staff were required to wear a gown, gloves, and masks whenever entering a COVID positive room. LPN 1 then asked a nurse in the hallway about the second resident in 209, and was told that both residents were COVID positive. On 11/7/23 at 8:52 AM, an observation was made of Certified Nursing Assistant (CNA) 4. CNA 4 entered room [ROOM NUMBER], where the resident was on isolation/droplet precautions. CNA 4 was observed to deliver a glass of juice to the resident in room [ROOM NUMBER]. CNA 4 did not don any PPE when entering room [ROOM NUMBER]. Upon exiting the room, CNA 4 proceeded to deliver water and juice to other residents on the 100 hallway who were not on isolation precautions. An interview was conducted. CNA 4 stated staff were supposed to put on gowns, gloves, and N-95 masks. CNA 4 stated she was an agency CNA, but worked often at the facility. On 11/7/23 at 8:56 AM, an interview was conducted with CNA 5. CNA 5 stated that his understanding was that staff were only supposed to be donning PPE when they were entering a room and would be at the resident's bedside. On 11/7/23 at 9:01 AM, an observation was made of CNA 6, who entered room [ROOM NUMBER] to deliver a meal tray. CNA 6 did not don any PPE. Upon exiting the room an interview was conducted. CNA 6 stated for residents who were on isolation precautions, staff should be putting on gowns, gloves, N-95 masks, and eye protection. CNA 6 stated she did not think the facility had any eye protection. CNA 6 stated she was unsure if PPE was required only when providing care in isolation rooms, or if staff should be putting PPE on for any reason when entering an isolation room. On 11/7/23 at 9:06 AM, an observation was made of CNA 5 entering room [ROOM NUMBER], which was on isolation precautions. CNA 5 donned a surgical mask, a gown, and gloves before entering the resident's room. Upon exiting the room, CNA 5 had doffed the gown and gloves but did not doff his mask. He was then observed to walk to the nurses station. On 11/7/23 at 9:09 AM, an observation was made of CNA 2 entering room [ROOM NUMBER] to answer a call light. CNA 2 was not wearing any PPE when entering the room. CNA 2 was observed to help the resident closest to the door into the bathroom. CNA 2 then exited the bathroom to get some personal items from the resident's bedside table. CNA 2 shut the resident's door as she entered the bathroom again. On 11/7/23 at 9:10 AM, an observation was made of CNA 5 who entered room [ROOM NUMBER], which had a resident on isolation precautions. CNA 5 was not observed to put on an N-95 mask, but kept the surgical mask he was wearing on. On 11/7/23 at 9:16 AM, a resident exited room [ROOM NUMBER], which was on isolation precautions, wearing a surgical mask. The resident stated she was not COVID positive, but her roommate was. The resident stated she was allowed to come out of the room. The resident stated she was going to the nurses station to be tested for COVID. On 11/7/23 at 9:17 AM, an observation was made of CNA 2 entering room [ROOM NUMBER] to deliver a meal and answer a call light. CNA 2 did not don any PPE before entering the room. On 11/7/23 at 9:18 AM, an observation was made of the facility Social Worker (SW) entering room [ROOM NUMBER] to answer a call light. The SW did not don any PPE prior to entering the resident's room. On 11/7/23 at 9:25 AM, an observation was made of CNA 2 entering room [ROOM NUMBER] to answer the call light of the COVID positive resident. CNA 2 was observed not to don any PPE prior to entering the resident's room. On 11/7/23 at 9:34 AM, an observation was made of CNA 2 entering room [ROOM NUMBER]. CNA 2 did not don any PPE. CNA 2 stated she was going into the room to do the hair of one of the residents. CNA 2 stated to one of the nurses in the hallway that she was supposed to be gowning up when entering COVID positive residents' rooms. CNA 2 stated she had been gone for a week and asked the nurse for a rundown of all the residents who were COVID positive. CNA 2 stated she was going to get everyone tagged because she did not know she was supposed to be wearing PPE. The Certified Nursing Assistant Coordinator (CNAC) heard the conversation and approached CNA 2. The CNAC and CNA 2 entered room [ROOM NUMBER] without donning any PPE and shut the door. The CNAC was observed to exit room [ROOM NUMBER] after a brief period and enter room [ROOM NUMBER], which was not a COVID positive room. On 11/7/23 at 10:21 AM, an observation was made of CNA 2 riding in a resident's motorized wheelchair from the central nurse's station towards the 200 hallway. CNA 2 did not have a face mask donned. On 11/7/23 at 10:54 AM, an observation was made of CNA 7 and RN 4 at the nurse's station without a face mask donned. On 11/7/23 at 1:54 PM, an observation was made of CNA 8 at the nurse's station without a face mask donned. On 11/8/23 at 8:00 AM, an observation was made Licensed Practical Nurse (LPN) 2 seated at the nurse's station without a face mask donned. On 11/8/23 at 9:34 AM, an observation was made of CNA 2 walking from the 100 hallway to the 200 hallway without a face mask donned. On 11/8/23 at 10:52 AM, an observation was made of RN 4 seated at the nurse's station without a face mask donned. On 11/8/23 at 12:37 PM, an interview was conducted with RN 4. RN 4 stated that he was told that it was up to personal preference if he should wear a facemask in the facility during a COVID-19 outbreak. RN 4 stated that when he entered a COVID-19 positive resident's room he should donn all PPE including a face mask, gown and gloves. On 11/8/23 at 2:15 PM, an interview was conducted with a laundry and housekeeping (LH) staff member. The LH stated that CNAs brought laundry to the laundry room. The LH stated laundry staff sorted the colored clothing from the white clothing. The LH stated one washer was designated for colors and the other for whites. The LH stated clothing was folded in the laundry room and then returned items to the linen closet, hang items in the laundry hall or return the items to the resident's rooms. The LH stated laundry was done every day. The LH stated no special handling of laundry was taking place with the COVID outbreak. The LH stated laundry went through a high temperature wash that would kill germs. The LH stated laundry staff were not wearing Personal Protective Equipment (PPE) while sorting laundry. The LH stated all laundry was put into plastic bags, then put in the laundry closet into barrels and eventually taken to the laundry area. The LH stated sometimes she would go to pick up the laundry. The LH stated she would wear a surgical mask and gloves when providing housekeeping in resident's rooms. The LH stated there was just one room that required staff to put on a gown, gloves and mask before entering. The LH stated she was not doing any environmental cleaning throughout the facility. The LH stated when she had help she would wipe down the railing in the hallways, but has not had help for a long time. The LH stated laundry and housekeeping staff were at the facility on Fridays, Saturdays, and Sundays. On 11/8/23 at 3:03 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON stated that the outbreak started on November 1st. The DON stated that the ADON was responsible for the COVID-19 tracking. The ADON stated that the Business Office Manager (BOM) tested positive at home and last worked in the facility on 10/27/23. The ADON stated that the first resident that tested positive for COVID-19 was resident 15 and her symptoms were a sore throat, nausea, vomiting, and diarrhea. The ADON stated that she informed the DON and Administrator (ADM) and then began testing residents for COVID-19. The ADON stated that they tested resident 15's roommate first and then proceeded to test the entire facility on November 1st. The ADON stated that they distributed masks to the residents that wanted them and to the COVID-19 positive residents. The ADON stated staff were educated on frequent hand washing, and were instructed that masks were not required, only optional, in an outbreak. The ADON stated that the staff were encouraged to wear a face mask. The ADON stated she did not go to the Centers for Disease Control and Prevention website for guidance on COVID-19. The ADON stated that they instructed COVID positive residents that they needed to stay inside their room, but many were confused and they could not prevent them from moving about. The ADON stated that the staff informed the residents of any COVID-19 positive residents or residents in the building and then the residents informed any visitors or family when they called or visited. The DON stated that they were told by corporate that they were not required to notify family of any COVID-19 outbreak in the facility. The DON stated she was not sure if it was documented or not. The ADON stated they did not have a designated COVID-19 area, and at the time of the outbreak they only had 3 available rooms. The DON stated that the directive from corporate was if they were not able to isolate a resident then to follow precautions for PPE. The DON stated that they made sure that isolation carts and PPE were directly outside of the resident rooms. The DON stated that they did not have dedicated staff for COVID positive residents. The DON stated that staff on the 200 hallway did not go to the 300 hallway. The DON stated that the aides on the 100 and 200 hallway could not go help on the 300 hallway. The DON stated that they were trying to keep staff on the 300 hallway from mingling with the staff on the 100 and 200 hallway. The DON confirmed that all nurses use the same station and staff from all hallways assisted residents into the main dining room. The DON stated that the PPE that should be donned for the contact/droplet isolation rooms should be a gown, N95 mask, gloves, and goggles. The ADON stated that the goggles were in the cart but she was not sure if they were being used. The DON stated that staff should be doffing the gown and gloves inside the isolation room. The DON stated that once staff exited the room they should change their mask and clean the goggles with bleach wipes. The DON stated that staff should be performing hand hygiene upon exit of isolation rooms. The DON stated that they should have dedicated equipment but staff had been educated to wipe the entire vital sign cart down between use with bleach wipes. The DON stated that the meal tray, utensils, and water mugs should be disposable for the COVID-19 positive residents. The DON stated that laundry of COVID-19 positive residents should be handled separately, laundered separately, and laundry staff should wear PPE while handling. The DON stated that cleaning of COVID positive rooms had a stricter procedure, and they could not use any reusable cleaning items in those rooms. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Implement Source Control Measure that source control referred to the use of respirators or well-fitting facemasks and was recommended for those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 outbreak and universal use of the source control could be discontinued as a mitigation measure once the outbreak is over, . The guidance documented under Patient Placement that a patient with suspected or confirmed SARS-CoV-2 infection should have the door to their room kept closed; if cohoring only residents with the same respiratory pathogen should be in the same room; and if safe to do so limit transport and movement of the patient in and out of the room to medically essential purposes. The guidance further documented under Personal Protective Equipment that HCP [healthcare personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The guidance documented under Visitation that Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. The guidance stated that duing indoor visitation during an outbreak response Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility. The guidance documented under Environmental Infection Control that dedicated medical equipment should be used when caring for patients with suspected or confirmed SARS-CoV-2. The guidance was last updated on May 8, 2023. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 43212

Based on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 of 15 sampled residents, facility did not promptly respond with resident presented with signs and symptoms of a UTI and they did not ensure the resident received antibiotics timely, resulting in the resident being sent out to a local hospital for treatment. This will be at a HARM level. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 3, personal history of urinary tract infections, muscle weakness, and need for assistance with personal care. Resident 2's medical record was reviewed on 9/20/23. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 2 was always incontinent of bladder and always incontinent of bowel. Resident 2 was not on a toileting program. In addition, resident 2 required extensive assistance of two persons for toileting. A care plan Problem initiated on 8/22/23, documented [Resident 2] is at risk for infection secondary to weakness/HO [history of] UTI/ incontinence . Goals documented [Resident 2] will have no untreated s/s [signs/symptoms] of infection through next review. Approaches included: a. Notify MD [medical director] of s/s of infection. Date Initiated: 8/22/23. b. Universal precautions. Date Initiated: 8/22/23. c. Monitor labs as prescribed. Date Initiated:8/22/23. On 8/28/23 at 6:36 AM, a Nursing note documented, Resident has c/o [complained of] dysuria, bladder/suprapubic pain, and increased urgency. A urinalysis was obtained per standing orders based on McGreer's (sic) criteria (unable to determine if resident has leukocytosis in the facility). [A local lab] was notified that a urine sample was obtained an order for it to be picked up. On 8/31/23 at 7:38 AM, a nurse practitioner note documented that resident 2 reports pain in her back and says she thinks it's in her kidneys . We will check a urine for C&S given history of diarrhea and using a brief. On 8/31/23 at 3:27 PM, a nursing note documented resident 2 was complaining of more back pain and burning with urinating, more episodes of urgency and frequency . NP notified. Spoke with patient and gave order to collect UA with culture and sensitivity. On 9/1/23 at 4:42 PM, a Nursing note documented Nurse . notified NP[nurse practitioner] of a normal UA[urine analysis] lab received on 8/31/23. On 9/2/23 at 6:59 AM, a nursing note documented Resident has continued to c/o urethral pain and bladder pain/itching. The provider ordered a UA and a one time order of Pyridium 200 mg[milligrams] r/t [related to] pain. Resident's urine was collected and [a local lab] was notified . On 9/2/23 at 7:35 PM, a nursing note documented, Pt's [patient's] urine culture result has arrived. It is positive and says E. cloacae and Escherichia coli detected. Notified to on call [physician] . [the physician] replied and said he wants urine culture and sensitivity. Report given to night nurse. On 9/2/23 a UA molecular lab result interpretation completed by the lab. The lab documented UA was collected on 9/2/23, received 9/2/23 and resulted 9/2/23. The urinalysis documented organisms detected E. cloacae and Escherichia coli. The lab recommended the antibiotic Nitrofurantoin (Macrobid) 100 mg PO [by mouth] BID [twice a day] for 5 days for possible simple UTI. On 9/4/23 at 6:48 AM, a nursing note documented, Nurse reported to nursing staff that pt refused to give another urine sample. Urine specimen was not collected. On 9/5/23 at 1:46 PM, a nursing note documented, Contacted [local lab] twice today regarding UA & C&S [culture and sensitivity] collected on 9/2. They do not have the culture that required by MD. The MD order to collect another UA today. Pt convinced to get another UA after a few refusals tries. UA collected today 9/5 via[by] straight cath [catheterization] and sent out with [local lab] phlebotomist for culture and sensitivity. On 9/6/23 at 11:17 PM, a nursing note documented UA results sent to [physician]. Positive nitrates and trace leukocytes. No response from provider. On 9/6/23 a UA molecular lab result interpretation completed by the lab. The lab documented UA was collected on 9/5/23, received 9/6/23 and resulted 9/6/23. The urinalysis documented organisms detected E. cloacae, Escherichia coli and Klebsiella pneumoniae. The lab recommended the antibiotic Nitrofurantoin (Macrobid) 100 mg PO [by mouth] BID [twice a day] for 5 days for possible simple UTI. On 9/9/23 at 6:44 PM, a nursing note documented In computer it says to do a urine culture, nurse went to do her straight cath. And pt refused. Pt said 'I don't want to do it . I don't want to do a urine check anymore'. On 9/12/23 a physician progress documented a follow up visit on pt to review lab- had UA collected, nitrate +[positive] ; weak leucocytes [local lab] had Enterobacter and E coli. pt states she has had abdominal cramping; odor to urine- no fever, chills, confusion . The treatment plan documented Pt is at significant risk of worsening medical and behavioral status and risk for readmission to the hospital . Lab review- minimal symptoms- abdominal and bladder exam normal- she does not have an indwelling catheter- sample was collect 1 week ago- would continue to monitor; vitals have remained normal and stable. On 9/12/23 at 8:56 PM, a nursing note documented that resident 2 complained of some abdominal cramping and requested to use the restroom. Staff assisted her to the restroom . had an episode of diarrhea. Staff put [resident 2] back into bed and within a few minutes staff noted a significant change. CNA [certified nursing assistant] got DON [Director of nursing] at approximately 6:30pm. [Resident 2] was unresponsive . 911 called and arrived within minutes. [Resident 2] was transferred to [a local hospital] .MD notified by DON. [Note: The positive results from the UA was received ten days before hospitalization [DATE] and 9/6/23 with no interventions put in place.] On 9/13/23 a nursing note documented that resident 2 was admitted to [a local hospital] on 9/12/23. On 9/19/23 at 3:16 PM, a nursing note documented resident 2 was admitted to [a local hospital] for UTI/Sepsis and Cdiff [clostridioides difficile]. On 9/20/23 at 1:15 PM, an interview was conducted with registered nurse (RN) 4. RN 4 stated if a resident is complaining of dysuria and frequency the staff will as the provider for a UA order. The urine is sent to the lab and when the results are received the staff will inform the provider. If the provider does not respond, the nursed will let management know. RN 4 stated that she assisted in obtaining urine samples from resident 2. RN 4 stated that the physician was not happy with the lab company being used and kept ordering UA for resident 2 to get the culture and sensitivity. RN 4 stated that resident 2 was not prescribed antibiotics while the UA results were positive. On 9/20/23 at 2:35 PM, an interview was conducted with RN 5. RN 5 stated that if the lab result for a UA is positive, the RN staff will inform the provider. RN 5 stated if they are unable to get a hold of the provider or the provider does not respond, the RN's will notify the DON or the NP of the results. On 9/20/23 at 2:40 PM, an interview was conducted with the (DON). The DON stated the nurses are to look for the three symptoms of Mcgreer's if these symptoms are present then the nurses should contact the doctor to report the symptoms, then the nurses should collect a UA and send it to the lab. The DON stated that the facility has been using [a local laboratory] for labs and were not receiving a range for the results on the culture and sensitivity. The DON stated the lab was not getting the correct information to the facility. The DON stated that when lab results are received the nurses should contact the provider. If the nurse cannot get a hold of the provider, the nurses should contact the DON. On 9/20/23 at 3:56 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the facility currently uses [a local laboratory]. The ADM stated that he had concerns about a previous laboratory they were using. The ADM stated they had had problems with one of the laboratory companies and saw issues that had been occurring. On 9/21/23 at 1:40 PM, an interview was conducted with the Medical Director (MD) 1. MD 1 stated if a resident has a UA completed, he we will wait for the c/s. MD 1 stated that he will not treat based on urine analysis. If the culture and sensitivity are positive and the resident has dysuria, fever then he will start an antibiotic. He stated that he will often not get the notification on [the facilities communication text]. He stated that if the staff is unable to reach him and they have positive cultures the expectation is for the staff to call him. If a resident has positive culture and sensitivity results, then they should be started on antibiotics right away.

Based on interview and record review, it was determined, the facility did not provide or obtain laboratory (lab) services to meet the needs of its residents. Specifically, for 2 of 15 sampled residents, a urinalysis took multiple attempts and the lab used did not supply all the orders needed for a culture and sensitivity, which resulted in residents not receiving antibiotics timely, and the residents being sent out to a local hospital for treatment. This will be at a HARM level. Resident identifier: 2, 11. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 3, personal history of urinary tract infections, muscle weakness, and need for assistance with personal care. Resident 2's medical record was reviewed on 9/20/23. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 2 was always incontinent of bladder and always incontinent of bowel. Resident 2 was not on a toileting program. In addition, resident 2 required extensive assistance of two persons for toileting. A care plan Problem initiated on 8/22/23, documented [Resident 2] is at risk for infection secondary to weakness/HO [history of] UTI/ incontinence . Goals documented [Resident 2] will have no untreated s/s [signs/symptoms] of infection through next review. Approaches included: a. Notify MD [medical director] of s/s of infection. Date Initiated: 8/22/23. b. Universal precautions. Date Initiated: 8/22/23. c. Monitor labs as prescribed. Date Initiated:8/22/23. On 8/28/23 at 6:36 AM, a Nursing note documented, Resident has c/o [complained of] dysuria, bladder/suprapubic pain, and increased urgency. A urinalysis was obtained per standing orders based on McGreer's (sic) criteria (unable to determine if resident has leukocytosis in the facility). [A local lab] was notified that a urine sample was obtained an order for it to be picked up. On 8/31/23 at 7:38 AM, a nurse practitioner note documented that resident 2 reports pain in her back and says she thinks it's in her kidneys . We will check a urine for C&S given history of diarrhea and using a brief. On 8/31/23 at 3:27 PM, a nursing note documented resident 2 was complaining of more back pain and burning with urinating, more episodes of urgency and frequency . NP notified. Spoke with patient and gave order to collect UA with culture and sensitivity. On 9/1/23 at 4:42 PM, a Nursing note documented Nurse . notified NP[nurse practitioner] of a normal UA[urine analysis] lab received on 8/31/23. On 9/2/23 at 6:59 AM, a nursing note documented Resident has continued to c/o urethral pain and bladder pain/itching. The provider ordered a UA and a one time order of Pyridium 200 mg[milligrams] r/t [related to] pain. Resident's urine was collected and [a local lab] was notified . On 9/2/23 at 7:35 PM, a nursing note documented, Pt's [patient's] urine culture result has arrived. It is positive and says E. cloacae and Escherichia coli detected. Notified to on call [physician] . [the physician] replied and said he wants urine culture and sensitivity. Report given to night nurse. On 9/2/23 a UA molecular lab result interpretation completed by the lab. The lab documented UA was collected on 9/2/23, received 9/2/23 and resulted 9/2/23. The urinalysis documented organisms detected E. cloacae and Escherichia coli. The lab recommended the antibiotic Nitrofurantoin (Macrobid) 100 mg PO [by mouth] BID [twice a day] for 5 days for possible simple UTI. On 9/4/23 at 6:48 AM, a nursing note documented, Nurse reported to nursing staff that pt refused to give another urine sample. Urine specimen was not collected. On 9/5/23 at 1:46 PM, a nursing note documented, Contacted [local lab] twice today regarding UA & C&S [culture and sensitivity] collected on 9/2. They do not have the culture that required by MD. The MD order to collect another UA today. Pt convinced to get another UA after a few refusals tries. UA collected today 9/5 via[by] straight cath [catheterization] and sent out with [local lab] phlebotomist for culture and sensitivity. On 9/6/23 at 11:17 PM, a nursing note documented UA results sent to [physician]. Positive nitrates and trace leukocytes. No response from provider. On 9/6/23 a UA molecular lab result interpretation completed by the lab. The lab documented UA was collected on 9/5/23, received 9/6/23 and resulted 9/6/23. The urinalysis documented organisms detected E. cloacae, Escherichia coli and Klebsiella pneumoniae. The lab recommended the antibiotic Nitrofurantoin (Macrobid) 100 mg PO [by mouth] BID [twice a day] for 5 days for possible simple UTI. On 9/9/23 at 6:44 PM, a nursing note documented In computer it says to do a urine culture, nurse went to do her straight cath. And pt refused. Pt said 'I don't want to do it . I don't want to do a urine check anymore'. On 9/12/23 a physician progress documented a follow up visit on pt to review lab- had UA collected, nitrate +[positive] ; weak leucocytes [local lab] had Enterobacter and E coli. pt states she has had abdominal cramping; odor to urine- no fever, chills, confusion . The treatment plan documented Pt is at significant risk of worsening medical and behavioral status and risk for readmission to the hospital . Lab review- minimal symptoms- abdominal and bladder exam normal- she does not have an indwelling catheter- sample was collect 1 week ago- would continue to monitor; vitals have remained normal and stable. On 9/12/23 at 8:56 PM, a nursing note documented that resident 2 complained of some abdominal cramping and requested to use the restroom. Staff assisted her to the restroom . had an episode of diarrhea. Staff put [resident 2] back into bed and within a few minutes staff noted a significant change. CNA [certified nursing assistant] got DON [Director of nursing] at approximately 6:30pm. [Resident 2] was unresponsive . 911 called and arrived within minutes. [Resident 2] was transferred to [a local hospital] .MD notified by DON. [Note: The positive results from the UA was received ten days before hospitalization [DATE] and 9/6/23 with no interventions put in place.] On 9/13/23 a nursing note documented that resident 2 was admitted to [a local hospital] on 9/12/23. On 9/19/23 at 3:16 PM, a nursing note documented resident 2 was admitted to [a local hospital] for UTI/Sepsis and Cdiff [clostridioides difficile]. On 9/20/23 at 1:15 PM, an interview was conducted with registered nurse (RN) 4. RN 4 stated if a resident is complaining of dysuria and frequency the staff will as the provider for a UA order. The urine is sent to the lab and when the results are received the staff will inform the provider. If the provider does not respond, the nursed will let management know. RN 4 stated that she assisted in obtaining urine samples from resident 2. RN 4 stated that the physician was not happy with the lab company being used and kept ordering UA for resident 2 to get the culture and sensitivity. RN 4 stated that resident 2 was not prescribed antibiotics while the UA results were positive. On 9/20/23 at 2:35 PM, an interview was conducted with RN 5. RN 5 stated that if the lab result for a UA is positive, the RN staff will inform the provider. RN 5 stated if they are unable to get a hold of the provider or the provider does not respond, the RN's will notify the DON or the NP of the results. On 9/20/23 at 2:40 PM, an interview was conducted with the (DON). The DON stated the nurses are to look for the three symptoms of Mcgreer's if these symptoms are present then the nurses should contact the doctor to report the symptoms, then the nurses should collect a UA and send it to the lab. The DON stated that the facility has been using [a local laboratory] for labs and were not receiving a range for the results on the culture and sensitivity. The DON stated the lab was not getting the correct information to the facility. The DON stated that when lab results are received the nurses should contact the provider. If the nurse cannot get a hold of the provider, the nurses should contact the DON. On 9/20/23 at 3:56 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the facility currently uses [a local laboratory]. The ADM stated that he had concerns about a previous laboratory they were using. The ADM stated they had had problems with one of the laboratory companies and saw issues that had been occurring. The ADM stated that the facility was using two different laboratory companies and around the second week of September 2023 the facility expressed concerns about one of the laboratory companies not providing the culture and sensitivity on labs. On 9/21/23 at 12:10 PM, An interview was conducted with the Unit Manager (UM) 1. UM 1 stated if staff suspect a possible UTI, staff will get an order for the UA and then send the UA out. UM 1 stated the facility had been using 2 different laboratory companies. One of the lab companies did not send the information the facility needed to start a resident on an antibiotic, this company was less expensive to use. UM 1 stated now we are using just one laboratory company, stated using just one company the end of August 2023. UM 1 stated that during the end of August and September 2023 the facility was having a lot of issues with their labs, she stated that during that time there was not a process for following up and checking on labs. 30563 2. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, chronic kidney disease, urge incontinence, overflow incontinence, neuralgia and neuritis, pain, cellulitis, and diabetes mellitus. On 9/21/23 at 1:34 PM, an interview was conducted with resident 11. Resident 11 stated that she had a urinary tract infection (UTI) that turned septic and she had to be admitted to the hospital. Resident 11 stated the only symptoms that she had of a UTI was strong smelling urine and her feet heat up. Resident 11 stated her kidneys have shut down three times. Resident 11 stated she had a PICC line placed in the hospital to have antibiotics because she had sepsis. Resident 11 stated she had a history of UTI's. Resident 11's medical record was reviewed on 9/21/23. A. A physician's order dated 7/6/23 urinanalysis C and S if indicated. A nursing progress note dated 7/7/23 at 8:11 AM, Resident had a new 16 french 10 mL balloon foley catheter placed at 0755 [7:55 AM] with no issues noted. A clean catch urine sample was obtained after placing the new catheter and catheter bag r/t [related to] a new order for a urinalysis with culture and sensitivity if indicated. Sample was placed in the lab fridge and [name of lab] was called to pick up the lab. A nursing progress note dated 7/7/23 at 6:15 PM, [Name of lab] confirmation number for urinalysis . A UA[urinanalysis]/M [micro] w [with]/rflx [reflux] culture, routine revealed the sample was collected on 7/7/23 and received at the lab on 7/7/23 revealed a reported date of 7/9/23. The results were signed 7/13/23. The lab revealed pH was high at 8.5 with a reference interval of 5.0 to 7.5. The protein was 2+ which was abnormal with a reference interval of negative/trace. The occult blood was trace which was abnormal with a reference interval of negative. The white blood cells were 11-30 which was abnormal with a reference range of 0-5. There was no culture. There was another UA/M w/flx culture, routine revealed the sample was collected on 7/7/23 and received on 7/7/23. The lab was reported on 7/12/23 at 12:09 PM. A nursing progress note dated 7/13/23 at 12:13 PM, NP reviewed labs (UA/M w/reflux culture, routine) done on 07/07/2023. New orders to come. Lab paperwork placed in medical records to be scanned into resident's chart. A nursing progress note dated 7/13/23 at 12:27 PM, revealed NP reviewed labs (UA/M w/ reflx culture, routine. the final report with sensitivity) done on 07/07/2023. New orders given to floor nurse. Lab paperwork placed in medical records to be scanned into resident's chart. A nursing progress note on 7/13/23 at 1:25 PM, New orders as follows: 1. Start 1 gram Ertapenen x 1 IM [intramuscular] for complicated UTI. 2. Then Bactrim DS- 1 tab PO [oral] BID [twice daily] x 10 days. 3. Change catheter after IM antibiotic dose. Orders imputed and all parties aware. A nursing progress note dated 7/13/23 at 3:00 PM, . Afebrile. Has a foley catheter. No complaints of bladder pain. Complained of flank pain. A progress note dated 7/13/23 at 6:38 PM, Client received ordered IM injection of antibiotic with lidocaine. Client tolerated injection well with no signs or symptoms of adverse reaction. Client received help with medication administration by handing medications as well as drinks to clients due to inability to reach or get up on time for administration. Client has been complaining of pain and was given PRN [as needed] narcotic as well as cyclobenzaprine. Client has new orders in place for PO [oral] antibiotics. Client was informed of reasoning for antibiotics as well as duration and frequency of administration. A progress note dated 7/14/23 at 7:05 AM, Resident received their IM injection of their Ertapenem and began their first dose of oral bactrim DS at HS [hours of sleep] 7/13/23. Resident notified of orders to replace their foley catheter after receiving their IM antibiotic injection. Resident refused to have a new catheter placed during the shift stating they did not want it changed at any time during the night. Res [resident] has shown no noted adverse side effects or allergic reactions to the antibiotic therapy. A nursing progress note dated 7/20/23 at 8:40 AM revealed, Resident was brought their HS medications at approximately 2200 [10:00 PM] 7/19/23. When the medications were brought, resident was alert and oriented to person, place, time and situation, and resident had c/o [complained of] nausea. Resident was given a prn zofran to help with the nausea. At approximately 0100 [1:00 AM], resident began to state, 'oh my god' multiple times, and then pull the curtain between them and there roommate and asking the roommate who they were (resident generally knows their roommates name). Resident was able to state their name. They also stated that they were 'home' when asked where they were at. Resident was unable to state the time or situation. Resident stated they felt fine, but resident became lethargic and was unable to stay awake. Resident's pupils were noted at 5 mm [millimeters] and equal with little response to light, their pupils only constricted to approximately 4 mm bilaterally. Resident's vital signs and blood sugar were taken, but were noted to be within normal limits. At this time the on call provider was sent a secure message r/t resident's change in condition. Resident began to vomit, and the vomit was dark in color. Resident was also throwing their items in the garbage or on the floor, which is not a behavior that is resident's baseline. Vital signs were reassessed and remained within normal limits, and another secure message was sent to the on call provider to notify of the change. On call provider was also called and left a voice message. Provider called back stating to monitor the resident and obtain a CBC[complete blood count] and BMP [basic metabolic panel]. After speaking with provider, resident vomited again after transferring themselves to the toilet, and res had the episode of emesis on their bathroom floor. The emesis was dark brown in color, and a secure message was sent to the provider. Provider ordered a BNP [B-type natriuretic peptide] lab test at this time. Resident continued to be lethargic and only alert and oriented to self. The labs were obtained in resident's posterior right hand after a blood draw attempt to their left forearm. The CBC and BMP labs were refrigerated, and the BNP lab was centrifuged with the serum separated at frozen. [Name of lab company] was notified that the blood specimens need to be picked up from the facility. Resident had another episode of emesis with dark brown emesis with a foul odor. On call provider stated to guaiac test the emesis. The emesis was tested and showed positive results for occult blood in the emesis. Provider was notified of those results with no further orders made at of 0830 [8:30 AM] 7/20/23. The oncoming day nurse was notified of the ongoing situation. A physician's progress note recorded as a late entry on 7/21/23 at 2:18 PM revealed, .Seen for FU [follow up] on multi phone calls last the night. Nurse reported that she was confused, throwing things, and that she vomited dark emesis. Then called ro [sic] report coffee ground emesis. Orders given for STAT CBC, BMP, BNP. Pt [patient] is seen sitting on the side of the bed looking confused. She can not answer any orientation questions. STAT labs have not come back. Nurse reports that they were not drawn until 0730 [7:30 AM] this am and at 1030 [10:30 AM] had not been picked up. She was treated last week for UTI with an IM injection of Ertapenem and PO Bactrim DS for 10 days which she is still on. She denies pain today which is abnormal for her. Suspect that kidney function has worsened with the infection and baclofen is built up causing confusion. Phone call to her daughter and POA [name removed] who said that she would like us to treat her here if possible but if she gets worse or needs treatment we cannot provide she wants her to go to the hospital. She says that her mother did not want hospice and that she would like to proceed with full treatment. Nurse sent picture in the am of emesis that was coffee ground. Order IV pantoprazole and then BID PPI. Nursing unable to get IV. At 2000 labs returned showed AKI [acute kidney injury] on CKD [chronic kidney disease], hyperkalemia, leukocytosis 14.3. Given staff cannot get IV in and multiple lab abnormalities she will need to be sent to the hospital for high risk dx [diagnosis]. Nurse to notify admin [administration] and family. A nursing progress note dated 7/25/23 at 10:56 PM, Nurse was able to assess pts arms and BLE [bilateral extremities]. pt has bruising on both arms, scabs on right posterior fore arms. pts legs are discolored and pt has wound to lower left leg that is wrapped. pt also had PIC [sic] [peripherally inserted central catheter] line location in upper left arm. Resident 11's hospital discharge orders revealed resident 11 was admitted to the hospital on 7/20/23. The discharge diagnosis were toxic encephalopathy, acute kidney injury, sepsis, and COPD without exacerbation. B. A progress note dated 8/21/23 at 1:10 PM but recorded as a late entry on 8/22/23 at 1:13 PM, New orders as follows: 1. Check urine for C&S for UTI. Resident is aware. There were no other notes regarding why resident 11 needed to be tested for a UTI. A physician's order dated 8/21/23 revealed Urinalysis, C&S (if indicated); Other Test: (UA and culture) Once - One 8/21/23 check c and S for UTI. A urinalysis form revealed the sample was collected on 8/21/23 and the laboratory received the sample on 8/26/23. The lab reported the results to the facility on [DATE]. There was a request problem on the form which revealed Test not performed. Specimen not received at refrigerated temperature. A nursing progress note dated 8/30/23 at 5:48 PM, DON [Director of Nursing] clarified diagnosis for Macrobid order. NP ordered Macrobid 100mg x5 days on 8/29/23 due to positive escherichia coli in the urine. End date clarified. Both end date and diagnosis added to order. Will continue with POC [Plan of Care] at this time. A form from the laboratory revealed the urine sample was collected on 8/28/23 and was received on 8/29/23. The form was faxed to the facility on [DATE]. The form revealed the organism detected was escherichia coli and Nurtofurantoin (Macrobid) 100 mg PO BID for 5 days was recommended. A physician's order dated 8/30/23 revealed Macrobid (nitrofurantoin monohyd/m-cryst) 100 mg twice daily until 9/2/23. Resident 11's Medication Administration Record for August and September 2023 was reviewed. Resident 11's first dose was administered on 8/30/23 between 6:00 PM and 10:00 PM and the last dose of Macrobid was administered on 9/2/23 between 6:00 PM and 10:00 PM. A nursing progress note dated 8/31/23 at 12:51 PM, NP reviewed the UA results the came back on 8/30/23. This lab was already redrawn on 8/28/23, since this lab stated it was not able to be processed. NP had been notified on 8/28/23 of this. No new orders at this time. A nursing progress note dated 9/1/23 at 11:31 AM, New order per NP as follows: 1. UA with C&S. Order entered at this time. Resident is aware. Another laboratory form revealed the urine sample was collected on 9/1/23 and received by the laboratory on 9/2/23. The results were faxed to the facility on [DATE]. The form revealed escherichia coli was the organism detected and Nurtofurantoin (Macrobid) 100 mg PO BID for 5 days was recommended. A nursing progress note dated 9/1/23 at 4:03 PM was recorded as a late entry on 9/5/23 at 4:04 PM, Nurse [name removed] notified NP [name removed] of an abnormal lab received on 09/01/23. No new orders at this time and lab paperwork placed in medical records to be scanned into resident's chart. A nursing progress note dated 9/2/23 at 5:02 PM, Resident continues to receive Macrobid r/t a dx of a UTI. Resident has no noted adverse side effects r/t the antibiotic therapy. A nursing progress note dated 9/4/23 at 5:29 PM revealed, Client received morning dose of antibiotic. No adverse reactions. Client tolerated well. [It should be noted that resident 11's last Macrobid dose was 9/2/23 according to the September 2023 MAR.] On 9/21/23 at 12:45 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated when she started as UM the facility had 2 laboratory companies. UM 1 stated the facility learned that one of the laboratory companies did not complete stat labs or labs on the weekends. UM 1 stated the same lab company was not completing culture and sensitivity tests on urine. UM 1 stated the physician was frustrated and decided to use the other lab. UM 1 stated when she first started as UM, nurses were having trouble documenting in nurses notes about the labs and results. UM 1 stated education was provided about documenting when the sample was collected, which lab it was sent to and the results of the lab. UM 1 stated if there were not nurses notes, then she completed nurses notes when lab results were returned. UM 1 stated the urinanalysis results were not provided to the facility until 7/12/23. UM 1 stated there should not have been a delay in the results. UM 1 stated on another urine sample was obtained on 8/21/23 and the laboratory showed to the facility right after the nurse had placed it in the fridge, so the sample was not refrigerated long enough. UM 1 stated for the lab draws at the end of August, there was no DON or Assistant Director of Nursing in the facility. UM 1 stated the NP stated to just re-draw all labs because they were having trouble with lab companies. UM 1 stated that there was a new protocol since the new DON started this week. UM 1 stated prior to the changes from the new DON there was not a process to track laboratory results. UM 1 stated it was the nurses job to check for the lab results within 2 days and notify management if the nurse was unable to get the results.

Based on observation, interview, and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 29 sampled residents, a resident that was unable to reposition on their own and was not frequently repositioned by staff developed a pressure ulcer. Resident identifier: 21. Findings included: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, encounter with orthopedic aftercare, chronic diastolic heart failure, type two diabetes mellitus with foot ulcer, complication of kidney transplant, moderate protein-calorie malnutrition, chronic kidney disease stage 4, repeated falls, essential hypertension, and dementia. Resident 21's medical record was reviewed on 6/13/23. A care plan Problem with a start date of 9/22/22, documented Category: Skin Integrity [resident 21] is at risk for alteration to skin integrity secondary to Weakness/ulcers/DM [diabetes mellitus]/HLD [high-density lipoprotein]. Edited: 06/12/2023. A care plan Goal documented Long Term Goal Target Date: 09/12/2023 [resident 21] will have no unaddressed alteration to skin integrity, through next review. Edited: 06/12/2023. The care plan interventions included: a. Approach start date 9/22/22. Assist with turning/frequent repositioning, as needed (PRN). b. Approach start date 9/22/22. Provide skin and incontinence care assistance, PRN. c. Approach start date 9/22/22. Standard facility Pressure Reduction mattress. d. Approach start date 9/22/22. Weekly skin check per facility schedule, notify Medical Doctor of alterations for prompt/proper intervention. A Braden Scale for Predicting Pressure Sore Risk dated 12/23/22, documented that resident 21 was at Moderate Risk for pressure sores with a score of 14. A score of 13 to 14 indicated Moderate Risk. [Note: This was the most recent Braden Scale for Predicting Pressure Sore Risk in resident 21's medical record.] A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 21 required extensive assistance of two persons for bed mobility and resident 21 was always incontinent of bladder and bowel. Bed mobility included how a resident moved to and from a lying position, turned side to side, and positioned body while in bed or alternate sleep furniture. In addition, the MDS assessment documented that resident 21 was at risk of developing pressure ulcers and resident 21 had no unhealed pressure ulcers. A care plan Problem with a start date of 4/4/23, documented Category: Skin Integrity [resident 21] has an actual skin impairment/wound. Left lateral lower extremity. Edited: 06/12/2023. A care plan Goal documented Short Term Goal Target Date: 09/12/2023 [resident 21] will have no unaddressed complications to skin/wound or prescribed treatments through next review. Edited: 06/12/2023. The care plan interventions included: a. Approach start date 4/4/23. In house wound care provider to assess and treat once a day. b. Approach state dated 4/4/23. Treatments as prescribed once a day. On 6/8/23 at 11:29 AM, a Nursing progress note documented Nurse found a wound that looks like a bedsore on her lt. [sic] back/ coccyx area. Cleaned with NS [normal saline] and applied meta honey [sic] and covered it with boarded gauze. A physician's order dated 6/8/23, documented Clean bedsore on lt. [sic] coccyx area and apply dressing on. Once A Day Clean bedsore on lt. [sic] coccyx area with NS, apply med honey and cover with optifoam nonboarded dressing 06/08/2023 - Open Ended. On 6/9/23 at 2:40 PM, a Dietary progress note documented . Nursing reports resident has possible new skin impairment to back/coccyx area- wound care team to assess. On 6/9/23 at 3:47 PM, a Nursing progress note documented Bandage to coccyx wound changed per orders. Site had scant drainage present and no odor. Patient tolerated treatment okay with some signs of pain present. Pain medication given per orders. On 6/10/23 at 1:44 PM, a Nursing progress note documented Bandage changed to coccyx wound site after patients shower. No drainage present but site is still open. On 6/10/23 at 4:49 PM, a Certified Nursing Assistant (CNA) progress note documented [Resident 21] had a hard time sitting upright due to pain on coccyx and her demeanor appeared 'lethargic'. She was getting nervous and was yelling 'I'm going to fall.' I placed her back in bed and continued to give her a bed bath. She appeared more at ease and comfortable. On shower days, continue to do bed baths only. On 6/11/23 at 4:22 PM, a Nursing progress note documented Bandage changed to coccyx wound site during brief change. No drainage present but site is still open. Patient tolerated treatment well. On 6/14/23 at 2:46 PM, a Nursing progress note documented Professional wound clinic NP [Nurse Practitioner] into see resident, coccyx wound, left leg wound and toes, cleaned, measured and redressed. Resident tolerated well. WCTM [will continue to monitor]. The Point of Care History was reviewed. The following was documented regarding how the resident moved in bed. [Note: According to documentation resident 21 was not repositioned every two to three hours.] a. On 6/1/23 at 5:27 AM, extensive assistance. b. On 6/1/23 at 11:22 AM, activity did not occur. c. On 6/2/23 at 3:35 AM, limited assistance. d. On 6/2/23 at 7:56 AM, extensive assistance. e. On 6/4/23 at 3:15 AM, limited assistance. f. On 6/5/23 at 2:30 AM, limited assistance. g. On 6/5/23 at 11:39 AM, extensive assistance. h. On 6/5/23 at 9:36 PM, limited assistance. i. On 6/6/23 at 12:31 AM, extensive assistance. j. On 6/7/23 at 1:26 AM, extensive assistance. k. On 6/7/23 at 9:28 AM, extensive assistance. l. On 6/8/23 at 12:10 AM, extensive assistance. m. On 6/9/23 at 9:54 AM, extensive assistance. n. On 6/9/23 at 4:48 PM, total dependence. o. On 6/10/23 at 4:50 PM, activity did not occur and supervision. p. On 6/11/23 at 4:52 AM, limited assistance. q. On 6/11/23 at 1:52 PM, total dependence. r. On 6/11/23 at 2:33 PM, total dependence. s. On 6/12/23 at 1:43 PM, total dependence. t. On 6/12/23 at 11:27 PM, total dependence. On 6/13/23 at 10:37 AM, a continuous observation was conducted. Resident 21 was observed lying flat in the bed with her head turned to the right and the television on. At 11:41 AM, the nurse went into resident 21's room and obtained resident 21's blood sugar. Resident 21 was not repositioned at this time. At 12:04 PM, the NP was observed in resident 21's room listening to resident 21's lungs and talking with resident 21. Resident 21 was not repositioned at this time. At 1:04 PM, resident 21's lunch tray was delivered. The CNA provided meal tray set up, raised the head of the bed, and assisted resident 21 with eating. [Note: Resident 21 was not repositioned or provided a brief change during the 2 hour and 27 minute continuous observation.] On 6/14/23 at 11:08 AM, an observation of resident 21's wound care was conducted. Licensed Practical Nurse (LPN) 1 was observed to donn gloves and removed the old dressing from resident 21's coccyx. LPN 1 stated that resident 21 was not on an air mattress but the mattress was really soft. NP 1 stated that the area to resident 21's coccyx appeared to be open. NP 1 was observed to clean and dress resident 21's pressure ulcer. NP 1 stated to use medihoney with a boarder foam dressing on the coccyx pressure ulcer. NP 1 was observed to measure the coccyx pressure ulcer. NP 1 stated the pressure ulcer measured 0.8 by 0.6 centimeters and the depth was unable to be determined. NP 1 stated that the pressure ulcer was unstageable. NP 1 stated that she saw resident 21 last week for her legs but NP 1 did not know resident 21 had a coccyx wound. NP 1 asked LPN 1 who had set the wound orders. [Note: LPN 1 did not state who had set the wound orders.] On 6/14/23 at 12:07 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 21 was incontinent of bowel and bladder. CNA 1 stated that he would change resident 21's brief every three hours. CNA 1 stated that resident 21 did not eat or drink a lot so resident 21 had very little output. CNA 1 stated that he would check on resident 21 every twoish hours and would change resident 21 every threeish hours. CNA 1 stated when he changed resident 21 he would but a pillow underneath her other side and reposition. CNA 1 stated that he had noticed that the other CNAs had not been repositioning resident 21 as much. CNA 1 stated if he told resident 21 to reposition while he were standing next to her resident 21 would reposition, but to tell resident 21 to reposition herself every two hours resident 21 would not do that. On 6/14/23 at 2:10 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 21 was incontinent of bowel and bladder. CNA 2 stated that resident 21 was suppose to be changed every two hours but sometimes resident 21 did not have a lot of output. CNA 2 stated that resident 21 was suppose to be repositioned every two hours. CNA 2 stated that resident 21 would allow the staff to reposition her because she would get uncomfortable. On 6/14/23 at 2:15 PM, a follow up interview was conducted with LPN 1. LPN 1 stated the NP would send the notes from today to the Assistant Director of Nursing (ADON) and the ADON would input the changes. LPN 1 stated that the mattress resident 21 was on was not the standard mattress but the next mattress up for those residents that stay in bed a lot. LPN 1 stated that she had thought that resident 21 may have refused the air mattress. LPN 1 was not sure if resident 21's pressure ulcer was preventable. LPN 1 stated that resident 21 did not eat well and the staff would position resident 21 and resident 21 would move herself back to a different position. LPN 1 stated that resident 21's coccyx area was open at one time, it was fairly large, and the area had closed. On 6/15/23 at 9:07 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a wound was identified in house she would take a picture of the wound and send the picture to the NP. RN 1 stated that she would offer suggestions regarding the wound if she had any. RN 1 stated that usually the NP would refer to the wound team. RN 1 stated if the floor nurse found the wound first they would stage the wound but usually the wound team would do that. RN 1 stated that she thought resident 21 was on a standard mattress but she would need to check. RN 1 was observed to check resident 21's mattress and RN 1 stated that resident 21 was on a regular mattress. RN 1 stated that if the nurse received the wound care order they would set interventions or the management team if they received the orders. RN 1 stated that resident 21 was to receive wound care daily to her coccyx. RN 1 stated that resident 21 was to be repositioned and changed every two to three hours. RN 1 stated that resident 21 was incontinent of bowel and bladder. RN 1 stated that resident 21 was not really able to reposition herself. On 6/15/23 at 10:24 AM, an interview was conducted with the ADON. The ADON stated that more often than not resident 21 refused meals and cares. The ADON stated management had approached resident 21 about enrolling in hospice cares on several occasions. The ADON stated resident 21's family had pushed physical therapy and resident 21 failed because she would not participate. The ADON stated the mattress that resident 21 was on was a four layer foam mattress. The ADON stated that all the residents in the facility had the four layer foam mattress. The facility policy regarding Pressure Injury Prevention Guidelines was reviewed. Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses). 6. Guidelines for prevention may be utilized in obtaining physician orders. The facility may use facility specific guidelines. a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. When physician orders are present, the facility will follow the specific physician orders. 7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record. a. For at-risk residents: treatment or medication administration records. b. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

Based on interview and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 29 sampled residents, a resident who was a two-person assist with bed mobility was rolled out of bed and sustained a rib fracture during a brief change with one staff member. Resident identifier: 11. Findings included: Resident 11 was initially admitted to the facility on [DATE] and again on 12/2/20 with medical diagnoses which included acute chronic diastolic heart failure, obesity, vitamin deficiency, type 2 diabetes mellitus, muscle weakness, hypothyroidism, edema, hyperuricemia, cystitis, urinary tract infection (UTI), cellulitis, abdominal pain, dizziness, insomnia, hypokalemia, pain, acute recurrent sinusitis, personal history of UTIs, neuralgia, morbid obesity, major depressive disorder, sleep apnea, pure hypercholesterolemia, constipation, pain, erythematous, hypomagnesemia, gout, muscle weakness, hypokalemia, atypical femoral fracture, pain, long term use of anticoagulants, constipation, and bradycardia. On 6/12/23 at 10:13 AM, an interview with resident 11 was conducted. Resident 11 stated that on 3/17/23, a Certified Nursing Assistant (CNA) accidentally pushed her off the bed during a brief change. Resident 11 stated that the CNA was supposed to wait for another CNA because resident 11 required at least two people during brief changes. Resident 11 stated that she was rolled off the bed, hit her nose on the bedside table, and fell on to the floor. Resident 11 stated that she was sent to the hospital where it was discovered that she had fractured her rib from the fall. Resident 11's medical record was reviewed. Resident 11's annual Minimum Data Set assessment dated [DATE], revealed that resident 11 required a two-person physical assist with bed mobility and toilet use. A progress note dated 3/17/23 at 12:37 AM, revealed Resident rolled out of bed to floor, EMS [Emergency Medical Services] called, pt [patient] transported to ER [emergency room ]. A progress note from 3/17/23 at 11:38 AM stated, Pt returned via stretcher, MD [Medical Doctor] notified. Request for records have been made from ER. A facility reported incident dated 3/17/23, was reviewed. The report revealed that CNA 3 was with resident 11 during the bed mobility when resident 11 fell out of the bed and was sent to the hospital. A follow-up investigation was completed by the facility. The investigation included an interview with resident 11 that stated, [resident 11] states that while doing cares staff member [CNA 3] had her roll over and she pushed her side to assist the move but it was too much momentum from her and [resident 11] pulling on bed rails that she fell . She doesn't feel as if she did it on purpose but she does need to be more careful. The investigation included a summary of the interview with CNA 3 that stated, [CNA 3] states that her and another aid [CNA] saw her call light and went in and [resident 11] stated she made a bowel movement. [CNA 3] decided she would start cleaning as the other aid got the proper supplies. When cleaning she asked [resident 11] to roll over and she complied asking [CNA 3] to push on her hip to help. [CNA 3] complied and it went smoothly. After cleaning that part she asked [resident 11] to roll again and [resident 11] asked her to push on her hip as well and she pulled on the side rails. She then got rolled off the bed from too much momentum and her lower half hit the floor and she lowered herself the rest via rails [sic]. Notified nurse while res. [resident 11] was lowering herself [CNA 3] also tried to catch her but she was too heavy and out of arms reach. The investigation reported, Hospital diagnosed right rip fracture, fracture of transverse process of thoracic vertebra, acute lower back pain, and facial contusion. Last weight took was 3/15/23 and was 350lbs [pounds]. The investigation concluded that there was no abuse or neglect, and there was no malintent from CNA 3. On 6/13/23, an interview with the Corporate Resource Nurse (CRN) was conducted. The CRN stated that CNA 3 had been educated on two-person transfers prior to the incident on 3/17/23, with resident 11. The CRN stated that after the incident, the facility decided to stop working with CNA 3. On 6/14/23 at 9:17 AM, the State Survey Agency attempted to interview CNA 3 via a phone call. The State Survey Agency was unable to contact CNA 3. On 6/14/23 at 9:43 AM, an interview with CNA 4 and CNA 5 was conducted. CNA 4 and CNA 5 stated that resident 11 should always have two staff members during a brief change. On 6/14/23 at 11:16 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that CNA 3 was completing a brief change for resident 11 without the assistance of another CNA. The ADON stated that the fall resulted in resident 11 obtaining a fractured rib. The ADON stated that the facility was unable to obtain the hospital records from 3/17/23, for resident 11. The ADON stated that the facility requested the hospital records multiple times. The ADON stated that CNA 3 should have waited for assistance during the brief change and after the incident the facility let CNA 3 go.

Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 7 of 39 sample residents. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to investigate abuse. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant Vice President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F610. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 until new interventions can be evaluated for effectiveness. Residents 11, 18, 41, interviewed about potential abuse and notified of new safety interventions. Social worker or designee will continue to follow up with residents ' 11, 41, 18, 29, and any other potential affected resident to ensure safety and privacy needs continue to be met. Skin evaluations completed and reviewed on residents 11, 18, 41, and 29 by 6/10/22. Abuse reports submitted for residents ' 11, 41, 18, 29, 250, 7 on 6/10/2022, investigations will be completed. All residents interviewed to assess potential abuse on 6/10/2022 Any additional allegations of abuse will be reported as applicable Starting 6/10/2022 all nurses ' notes, events, and 24 hour report will be reviewed daily for documentation of potential abuse. Starting 6/10/2022 nursing management will obtain daily report from the nurses. Education provided to all residents regarding how to report concerns and grievances on 6/10/2022 Education provided to administrator and facility leadership team by regional nurse and facility nurse educator on 6/10/2022 Social services or designee will review concern and grievance process during initial IDT. A regional team member will visit the facility weekly to provide oversight, audits, and additional training as needed. The administrator or designee will complete an audit of abuse investigations monthly. The findings of these interviews will be presented monthly to the QAPI Committee. On 6/13/22, 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 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/22 at 11:25 AM, an observation was made of resident 29 in her room. There was no staff member present in the room or outside the room. Resident 29 was observed sitting up in bed. An interview was attempted with resident 29, however resident 29 simply repeated back what the surveyor had asked. On 6/8/22 at 3:06 PM, an observation was made of resident 29 sitting in the lobby. Resident 29 was observed to be listening to music in her native language while kissing a doll in the face. Resident 29 then proceeded to put her left index finger up her own nose. Resident 29 then proceeded to get up from her chair and started to wander down the hall. Facility staff was observed to approach resident 29, who was standing outside of another resident's door. Resident 29 was subsequently offered snacks and redirected back to her room. Resident 29's medical record was reviewed on 6/9/22. Hospital records dated 3/30/22 revealed that resident 29 had severe dementia and tended to eat inappropriate items frequently. Resident 29 was brought to the hospital by her son due to concerns of ingesting antifreeze or bedbug chemicals. Resident 29 was intubated and taken to the Intensive Care Unit (ICU) in critical condition due to ingestion of Diacetome, an organic pest control agent. It was noted during her hospitalization that resident 29 would pull out her nasojejunal (NJ) tube if not restrained due to her mental state of confusion. An Minimum Data Set (MDS) dated [DATE] revealed resident 29 did not have a brief interview for mental status (BIMS) completed. The BIMS score was unknown but resident 29 was identified as severely impaired in making decisions, regarding tasks of daily living. Resident 29 was not identified as a wandering risk or having any kinds of behavioral symptoms. Resident 29's care plans revealed the following behavioral problems and approaches taken by facility: a. On 6/9/22 a problem identified was resident 29 ingests non edible items RT (related to) [NAME]. The goal was resident 29 will be kept safe from all hazards items she could ingest. Approaches included: We will place resident 29 on 1 to 1 to provide the constant amount of care resident 29 requires to prevent harm. [Note: This intervention was developed after the facility was notified of an IJ on 6/9/22] b. On 6/9/22 a problem identified was resident 29 is resistant to brief changes and cares at times. The goal was Resident 29 will accept assistance with cares. Approaches included: 1. Assess her resistance. Actively involve the resident in care. Express willingness to adjust regimen. 2. Respect and try to incorporate her culture in her daily cares. 3. Follow familiar routines/ staff when possible. 4. Convey an attitude of acceptance toward the resident. 5. Allow resident to choose options. [Note: This intervention was developed before the facility was notified of an IJ, but after the survey had been initiated]. c. On 6/8/22 a problem identified was resident 29 experiences restlessness and fidgetiness at times. The goal was resident 29 will have no negative outcomes r/t (related to) restless and fidgetiness. Approach(s) included: 1. Offer her activities, music, her doll, walk PRN (as needed). 2. Assure basic needs are assessed. [Note: This intervention was developed after the survey had been initiated.] d. On 6/7/22 a problem identified was resident 29 experiences wandering and will rummage through others' belongings at times. The goal was resident 29 will not injure/harm self secondary to wandering. Approach(s) included: 1. Involve significant support persons. 2. Remove resident from other resident's rooms and unsafe situations. 3. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). 4. Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. 5. Follow familiar routines when possible. [Note: This intervention was developed after the survey had been initiated.] e. On 5/1/22 a problem identified was resident 29 spits on desks, floors, and people. The goal was resident 29 will not spit on desk, floors, and people. Approach(s) developed on 6/3/22 included: 1. Resident 29 will be redirected PRN (as needed). Resident 29 will be offered a snack PRN. Resident 29 will be given a busy box PRN. No documentation could be located to indicate which residents were affected by the behavior. f. On 4/15/22 problems identified were resident 29 exhibits alteration in thought process manifested by cognitive impairment r/t (related to) dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; mood problem: anxiety; has little interest/pleasure in doing things; on hospice. The goals developed included: 1. Resident 29 will participate in activities of importance/interest daily, as desired, through next review date. 2. Resident will engage, as desired, in activities of interest at least: 1 cognitive activity per week for retention of cognitive abilities as evidence by recalling memories during activities; 1 social activity per week for communication as evidence by verbalizing thoughts and ideas during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities through next review date. Approach(s) included: 1.1 PRN (as needed). Support independent leisure choices. 2.1 Invite, involve and encourage participation in activities of importance/interest including: family/ friend phone calls/visits, TV/movies, Native American (sic) music, pets, socials, outdoors, spiritual support, reminisce, &/or special events. 2.2 Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. 2.3 Provide with opportunities to recall long/short term memories to retain cognitive abilities during activities. 2.4 Provide adaptations to activities PRN (as needed): cognition: task segmentation; physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities. No elopement assessment was done at on admission. No significant change MDS was documented about resident 29's behavior. A psychosocial assessment dated [DATE] indicated that resident 29 would hide and eat non food items. The assessment also indicated that resident 29 would steal other residents' food items to eat them, and did not like to give up the items once she had them. The assessment listed resident 29's behaviors as theft, wandering and combativeness. Resident 29's progress notes revealed the following entities: a. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. b. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice was notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. c. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. d. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made. No documentation could be located to indicate which residents were affected by the behavior. e. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings as well as sometimes spitting on them. No documentation could be located to indicate which residents were affected by the behavior. f. A nursing note dated 6/5/22 documented that resident 29 wandered into another residents room. The resident was awakened by [resident 29] rummaging through her room and told [resident 29] to leave. [Resident 29] began hitting and also spit on that resident. g. A nursing note dated 6/7/22 documented that I explained to hospice nurse again how resident (29)'s wandering (sic), spitting, playing with her feces, hitting and biting others is very disruptive to the other residents and that the other residents are/have been very upset. [Note: This note was later marked as invalid.] No documentation could be located to indicate which residents were affected by the behavior. [Note: Monitoring for spitting on residents was implemented by facility staff on 6/3/22.] On 6/1/22 a grievance form was completed by resident 41 indicating that she was spit on by resident 29. Resident 29's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident 250 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 250's MDS dated [DATE] revealed a BIMS score of 10. On 6/6/22 at 2:33 PM, an interview was conducted with resident 250. Resident 250 stated that there was a resident who wandered into her room at night and helped themselves to anything when her door is open. Resident 250 stated that resident 29 had come into her room while she was sleeping and had unhooked her oxygen. Resident 250 stated that she had reported the issues to staff, but that staff is doing nothing about it. Resident 250 stated that she is afraid resident 29 will steal her things, and that she doesn't feel safe around resident 29. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 4 On 6/7/22 around 9:00 AM, an interview was conducted with resident 18. Resident 18 stated that someone had come into her room recently and was bashing her. Resident 18 could not indicate which resident had hit her. Resident 18 was tearful when describing the incident, and stopped the interview. 4. Resident 35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 15 was cognitively intact. On 6/7/22 around 9:30 AM, an interview was conducted with resident 35. Resident 35 stated that she was resident 18's roommate and had witnessed multiple incidents between resident 18 and resident 29. Resident 35 stated approximately a week ago, resident 29 came into her room and scratched and hit resident 18. Resident 35 stated that they reported it to a CNA, but I don't think the CNA told anyone. Resident 35 stated that approximately 3 to 4 days ago at 1:30 AM, resident 29 came into her room again and was hitting resident 18 again. Resident 35 stated that a night nurse came in and stayed with resident 18 until she felt better. On 6/9/22 at 4:01 PM, a phone interview was conducted with employee 7. Employee 7 stated they did not visualize what happened between resident 29 and resident 18 but was told by the CNA that resident 29 had been in resident 18's room spitting and hitting resident 18. Employee 7 stated that the CNA was able to separate the two residents and take resident 29 back to her room. Employee 7 stated they checked on resident 18 as soon as resident 29 was taken out of the room. Employee 7 stated there were no visible injuries identified on resident 18. Employee 7 was told by resident 35, who was the roommate to resident 18, that resident 18 was woken up by resident 29 rummaging through her belongings. Employee 7 stated that resident 35 said that resident 18 was upset. Employee 7 stated that it did not take long for the CNA to respond because resident 35 pushed the call light as soon as she noticed resident 29 was in the room. Employee 7 stated that LPN (Licensed Practical Nurse) 4 was notified and was told they have to do something with resident 29 but was unsure of the exact wording used by LPN 4. Employee 7 stated that they had never seen resident 29 be aggressive and that resident 29 was pretty redirectable as long as she had her baby doll. Employee 7 stated that resident 29 had been receiving extra medication that had helped her sleep better. Employee 7 stated resident 29 was just started on a new medication named [MEDICATION(S)]. 5. Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 11 was cognitively intact. On 6/9/22 at 10:05 AM, an interview was conducted with resident 11. Resident 11 stated that resident 29 spit all over his arm and mug while he was right outside his room and that it made him feel sick and mad. Resident 11 stated that he had to take his mug to the kitchen and have it washed out and sanitized. Resident 11 stated that resident 29 did not know what she was doing and he had told resident 29 she was not suppose to spit on other people but resident 29 cannot understand him since she did not speak English. Resident 11 stated they went to the DON and told them they needed to get resident 29 out of the facility and resident 11 was told by the Administrator that he was trying but having a hard time finding the appropriate placement that could handle resident 29. Resident 11 stated that he did not believe them. Resident 11 stated that since that encounter, he made sure he did not come in contact with resident 29 by avoiding her and keeping his door shut when he was not in his room because he was afraid resident 29 would enter his room and steal items. Resident 11 stated that he had to be rough and gruff with resident 29 when she tried to enter resident 11's room. Resident 11 stated that he had seen resident 29 eat paper, spit on the floor and go into other resident's rooms and take things out. Resident 11 stated that staff had chased resident 29 to get the stuff back from resident 29 and return it to the proper owner. 6. Resident 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 41 was cognitively intact. On 6/6/22 an interview was conducted with resident 41. Resident 41 stated that 29 wandered into multiple resident rooms, spits on residents, breaks things, and steals items. Resident 41 stated that she had repeatedly told resident 29 to stop. On 6/9/22 at 10:37 AM, another interview was conducted with resident 41. Resident 41 stated while she ate dinner in her room one night, resident 29 came in a spat on her shoulder and down her back. Resident 41 stated they told resident 29 not to spit on her again and to leave her room. Resident 41 stated she felt so violated after what resident 29 did and she should not be living in a place where she was worried that someone was going to spit on her. Resident 41 stated that resident 29 did not belong at the facility, resident 29 needed to be in a facility where they had 1 on 1 care. Resident 41 stated that resident 29 was like a child and did not know what she was doing. Resident 41 stated that resident 29 had been in her room and broken things. Resident 41 stated at one point resident 29 was able to take resident 41's instruction book for her wheel chair. Resident 41 stated that the instruction book was not something resident 29 could just pick up, resident 29 had to get inside a bag and go looking for it. Resident 41 stated that she felt pissed and frustrated. Resident 41 also stated that there was another resident that would call resident 29 stupid and crazy and would yell get that crazy lady out of here while resident 29 was close by. Resident 41 stated that if resident 29 was treated with disrespect or talked to in a tough voice, resident 29 would be mean. Resident 41 stated resident 29 did not appreciate people being mean to her. Resident 41 stated this was the first time that she had seen staff babysitting resident 29. On 6/9/22 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she was aware that resident 29 likes to spit, and had witnessed resident 29 spitting on a facility staff member's desk. LPN 4 also stated that she had heard that resident 29 had spit on resident 9. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:10 PM, an interview was conducted with Employee 3. Employee 3 stated they received yearly abuse training and continuing education. Employee 3 stated that an action may or may not be considered abuse if the confused resident knew what they were doing. Employee 3 stated that they would consider it a form of bullying if a confused resident were to spit on another resident. Employee 3 stated staff made a note if someone was being bullied in the facility and they would monitor that resident more often and possibly move the resident who did the bullying to a different facility. On 6/8/22 at 2:48 PM, an interview was conducted with Employee 1. Employee 1 stated they used to have a 1 on 1 supervision for resident 29 but it depended on staffing. Employee 1 stated that resident 29 had a behavior issue where she liked to touch people's stuff. Employee 1 stated if resident 29 started to exhibit any kind of behavior issues, then they initiate a 1 on 1 care until the behavior was better. Employee 1 stated that other residents have complained about resident 29 going into their rooms. Employee 1 stated they tried to keep resident 29 away from other residents and prevent her from going into other rooms, residents had to make sure they closed their doors. Employee 1 stated that other residents should not have to be worried about resident 29 going into their rooms. Employee 1 stated that they received training on abuse and if abuse was identified, they had to report it to the administrator or manager. Employee 1 stated that abuse depended on the resident's mental status. Employee 1 defined a confused mental status as the resident not being in their right mind and unaware of what they were doing. Employee 1 stated if they were confused then they did not mean to, that was not considered abuse. Employee 1 stated if a confused resident hit another resident then staff opened a resident to resident event, notified the doctor and looked for any injuries. Employee 1 stated that they followed up with the resident for about 3 to 5 days if no injury was identified. Employee 1 stated if there was an injury then staff continued to follow until the injury was healed. On 6/8/22 at 3:24 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 29 was a little confused. CNA 1 stated that normally with confused residents, staff kept a closer eye on them and made sure they were not causing issues with other residents. CNA 1 stated she had not seen resident 29 be aggressive towards other staff or residents. CNA 1 stated normally when resident 29 was in the hallway, staff tried and talked to her and then redirected her by giving her a snack or taking her to an activity. CNA 1 stated she had abuse training and stated that she first report the abuse to the nurse and then to the DON. CNA 1 stated if a resident was being abused by another resident, she would first separate the two residents and then inform the nurse, so they can document what was happening. CNA 1 stated that if a confused resident were to spit on another, she would not consider it abuse because the resident was confused. CNA 1 stated that when the resident was all there mentally and they act purposefully then it would be considered abuse. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated there was not enough staff to keep resident 29 safe and other residents safe from resident 29. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 9:32 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated she had never seen resident 29 hurt anyone. RN 4 stated they were doing their best to redirect resident 29 by providing her with activities and giving her snacks. RN 4 stated there was no one to one care for resident 29 but stated the staff were on high alert when resident 29 was out of their room. RN 4 stated that resident 29's level of confusion exacerbates her communication barrier but they try to communicate with her using hand gestures and some staff have tried using google translate. On 6/9/22 at 9:42 AM, an interview was conducted with Employee 5. Employee 5 stated that they were aware of resident 29 behaviors such as confusion and being combative with staff. Employee 5 stated they will redirect resident 29 by using a calm voice and offering her snacks and a blanket. Employee 5 stated that they were aware of resident 29 spitting on resident 11 and believed it happened sometime last week. Employee 5 told resident 11 that resident 29 did not mean it and it probably was not personal that resident 29 had spit on him. Employee 5 stated they heard that resident 29 may have drank some body wash. Employee 5 stated they went into resident 29 room and put items out of resident 29's reach. Employee 5 stated that resident 29 liked to sit on the couch and spit on the floors and the other residents complained about resident 29 spitting. Employee 5 stated they would consider resident 29 spitting on other residents as abuse, especially on the other residents that can not protect themselves or get away from her. Employee 5 stated that administration was aware of resident 29's behavior. On 6/9/22 at 4:18 PM, an interview was conducted with LPN 3. LPN 3 stated they felt bad for resident 29 since she wasn't able to communicate and she spent a great deal of time in her room. LPN 3 stated that resident 29 would do better in a memory care unit than where she was at now. LPN 3 stated that resident 29 had a really nasty habit of spitting but believed it might be a part of resident 29 culture. LPN 3 stated that resident 29 did not spit at anyone directly, resident 29 spits to clean things with. LPN 3 stated they had heard other residents threaten to hit resident 29. LPN 3 stated that communication was the biggest problem with resident 29. LPN 3 stated they had given [MEDICATION(S)] to help resident 29 sleep and keep her out of other residents' rooms. On 6/9/22 at 3:05 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 is very quiet and you can see why she scares the residents when she goes into their rooms at night. CNA 3 also stated that resident 29 is very strong and can hurt somebody. During this interview, resident 29 was observed to wander into another resident's room and observed to get upset while being redirected by CNA 3. Resident 29 was observed to hit CNA 3. CNA 3 stated that resident 29 needed one to one care. CNA 3 also stated that resident 7 had a back scratcher/stick and had threatened to hit resident 29 once she entered into resident 7's room. CNA 3 also stated that resident 18 became aggressive and was prepared to fight resident 29 once she entered resident 18's room. On 6/8/22 at 2:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 29 was on her death bed when she was admitted to the facility and then she woke up which led to her wandering and having behaviors. The DON stated that he had never seen resident 29 be aggressive but that did not mean it had not happened. On 6/9/22 at 12:14 PM, a follow up interview was conducted with the DON. The DON stated that he was not aware that resident 29 had hit any other resident until 6/7/22 when he reviewed the nurses notes entered over the weekend. The DON stated that they were conducting an investigation on what happened the night of 6/5/22. The DON stated he had never seen resident 29 be violent. The DON stated he was uncertain of what happened but stated it could had been a reaction from resident 18 being approached by resident 29, that could of caused resident 18 to hit resident 29. The DON stated neither, residents 18 and resident 29, had any signs or symptoms of any injuries. The DON stated that both residents were severely demented and no one was able to tell staff if it was a reaction so they did not know who hit who. The DON stated that resident 29 could not act willfully to abuse other residents because she did not have ill intent, but then later stated if resident 29 hit resident 18, then it would have been willful. The DON defined willful in two ways; first it was an aggressive movement towards another and secondly, it was an action the resident chose to do with an understanding of what has happened. The DON stated that resident 29 was a wanderer and will go where the wind takes her. The DON stated that resident 29 went into other resident rooms, squatted in the rooms and looked at the resident in the room. The DON stated that he was aware that resident 29 spat on other residents and that they were in the process of trying a new medication with resident 29 that would help reduce secretions so resident 29's spitting episodes would occur less frequently. The DON stated that spitting was not ever ill intent. The DON stated that resident 41 approached him a week or two ago and stated that resident 29 had walked up behind her and spit down her back. In addition, the DON stated that resident 11 had made an accusation against resident 29 for spitting on her. The DON stated that he apologized to resident 11 for resident 29's behavior. The DON stated that he was sorry residents were victims of resident 29 spitting. The DON stated that these were the only complaints he had received about resident 29's abuse toward other residents. The DON stated he had tried to discharge resident 29 to a memory care unit and knew that resident 29 had not been receiving the appropriate level of care at the facility. When asked how the DON was protecting other residents from resident 29, the DON stated he had been attempting to discharge the resident. On 6/9/22 at 1:30 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was aware that resident 41 reported that resident 29 had spit on her back. The ADM stated that he did not identify this as abuse because resident 29 didn't know what she was doing. The ADM stated that resident 41 told the ADM that resident 29 should not be residing in the building, but I feel like that was her opinion but I feel like other residents feel the same way. The ADM stated that when resident 41 reported this to him, he felt like the resident was just venting frustrations, not making an allegation of abuse. The ADM stated that he was not aware that resident 29 was hitting other residents as documented in the nursing note on 6/5/22 until surveyors brought it to his attention. The ADM was unaware what interventions had been put into place to prevent residents from further abuse. The ADM stated that if the victim of abuse did not have any fears or was emotionally harmed, then the incident would not be considered abuse. The ADM stated that if someone reported a resident was a victim of abuse, he would ask the resident how their stay was, and if they did not mention the alleged abuse he would unsubstantiated the allegation. When asked if the ADM would ask the alleged victim of abuse about the alleged incident, the ADM stated he felt that would be a leadin [TRUNCATED]

Based on interview and record review, it was determined for 7 of 39 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, one resident with severe cognitive impairment was found to be hitting and spitting on other residents. Additionally, interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify and prevent abuse. Specifically, the facility failed to identify certain behaviors as abuse and or potential abuse, failed to properly investigate and document the incidences, failed to develop interventions to prevent the recurrence of abuse and failed to provide the necessary supervision to protect residents from abuse by other residents. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant Vice President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F600. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 (7:00 PM) until new interventions can be evaluated for effectiveness. Resident 29's IDT (interdisciplinary team) with hospice team completed on 6/10/2022 @ 0900 (9:00 AM) Resident 29's Labs scheduled to be obtained for medical evaluation 6/10/2022 Resident 29's IDT with son scheduled for 6/10/2022 [Name of local crisis facility] team evaluation utilizing [name of Translation services]completed on 6/9/2022 @ 2050 (8:50 PM) Resident 29's Care plans updated to reflect current interventions on 6/9/2022 Resident 29's behavior tracking updated to reflect current potential behaviors on 6/9/2022 All resident elopement risk assessments updated by 6/10/2022 All dietary care plans assessed for residents with potential for [NAME] behaviors on 6/10/2022. Housekeeping cart locks updated on 6/10/2022 Education provided to all staff regarding securing cleaning supplies, [NAME] symptoms, redirection techniques for wandering, non-pharmacological interventions in a staff meeting on 6/10/2022. Staff will complete post-test after training to ensure understanding. Staff unable to attend staff meeting will be required to complete training prior to their next scheduled shift. Agency staff will be required to complete education at the start of their shift. Staff will complete post-test after training to ensure understanding. Nurse management team will utilize admission checklist to review elopement risk for all new admissions. Dietician or designee to assess for [NAME] concerns with each new admission. A regional team member will visit the facility weekly to provide oversight, audits, and additional training as needed. On 6/13/22, 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 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/22 at 11:25 AM, an observation was made of resident 29 in her room. There was no staff member present in the room or outside the room. Resident 29 was observed sitting up in bed. An interview was attempted with resident 29, however resident 29 simply repeated back what the surveyor had asked. On 6/8/22 at 3:06 PM, an observation was made of resident 29 sitting in the lobby. Resident 29 was observed to be listening to music in her native language while kissing a doll in the face. Resident 29 then proceeded to put her left index finger up her own nose. Resident 29 then proceeded to get up from her chair and started to wander down the hall. Facility staff was observed to approach resident 29, who was standing outside of another resident's door. Resident 29 was subsequently offered snacks and redirected back to her room. Resident 29's medical record was reviewed on 6/9/22. Hospital records dated 3/30/22 revealed that resident 29 had severe dementia and tended to eat inappropriate items frequently. Resident 29 was brought to the hospital by her son due to concerns of ingesting antifreeze or bedbug chemicals. Resident 29 was intubated and taken to the Intensive Care Unit (ICU) in critical condition due to ingestion of Diacetome, an organic pest control agent. It was noted during her hospitalization that resident 29 would pull out her nasojejunal (NJ) tube if not restrained due to her mental state of confusion. An Minimum Data Set (MDS) dated [DATE] revealed resident 29 did not have a brief interview for mental status (BIMS) completed. The BIMS score was unknown but resident 29 was identified as severely impaired in making decisions, regarding tasks of daily living. Resident 29 was not identified as a wandering risk or having any kinds of behavioral symptoms. Resident 29's care plans revealed the following behavioral problems and approaches taken by facility: a. On 6/9/22 a problem identified was resident 29 ingests non edible items RT (related to) [NAME]. The goal was resident 29 will be kept safe from all hazards items she could ingest. Approaches included: We will place resident 29 on 1 to 1 to provide the constant amount of care resident 29 requires to prevent harm. [Note: This intervention was developed after the facility was notified of an IJ on 6/9/22] b. On 6/9/22 a problem identified was resident 29 is resistant to brief changes and cares at times. The goal was Resident 29 will accept assistance with cares. Approaches included: 1. Assess her resistance. Actively involve the resident in care. Express willingness to adjust regimen. 2. Respect and try to incorporate her culture in her daily cares. 3. Follow familiar routines/ staff when possible. 4. Convey an attitude of acceptance toward the resident. 5. Allow resident to choose options. [Note: This intervention was developed before the facility was notified of an IJ, but after the survey had been initiated]. c. On 6/8/22 a problem identified was resident 29 experiences restlessness and fidgetiness at times. The goal was resident 29 will have no negative outcomes r/t (related to) restless and fidgetiness. Approach(s) included: 1. Offer her activities, music, her doll, walk PRN (as needed). 2. Assure basic needs are assessed. [Note: This intervention was developed after the survey had been initiated.] d. On 6/7/22 a problem identified was resident 29 experiences wandering and will rummage through others' belongings at times. The goal was resident 29 will not injure/harm self secondary to wandering. Approach(s) included: 1. Involve significant support persons. 2. Remove resident from other resident's rooms and unsafe situations. 3. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). 4. Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. 5. Follow familiar routines when possible. [Note: This intervention was developed after the survey had been initiated.] e. On 5/1/22 a problem identified was resident 29 spits on desks, floors, and people. The goal was resident 29 will not spit on desk, floors, and people. Approach(s) developed on 6/3/22 included: 1. Resident 29 will be redirected PRN (as needed). Resident 29 will be offered a snack PRN. Resident 29 will be given a busy box PRN. No documentation could be located to indicate which residents were affected by the behavior. f. On 4/15/22 problems identified were resident 29 exhibits alteration in thought process manifested by cognitive impairment r/t (related to) dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; mood problem: anxiety; has little interest/pleasure in doing things; on hospice. The goals developed included: 1. Resident 29 will participate in activities of importance/interest daily, as desired, through next review date. 2. Resident will engage, as desired, in activities of interest at least: 1 cognitive activity per week for retention of cognitive abilities as evidence by recalling memories during activities; 1 social activity per week for communication as evidence by verbalizing thoughts and ideas during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities through next review date. Approach(s) included: 1.1 PRN (as needed). Support independent leisure choices. 2.1 Invite, involve and encourage participation in activities of importance/interest including: family/ friend phone calls/visits, TV/movies, Native American (sic) music, pets, socials, outdoors, spiritual support, reminisce, &/or special events. 2.2 Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. 2.3 Provide with opportunities to recall long/short term memories to retain cognitive abilities during activities. 2.4 Provide adaptations to activities PRN (as needed): cognition: task segmentation; physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities. No elopement assessment was done at on admission. No significant change MDS was documented about resident 29's behavior. A psychosocial assessment dated [DATE] indicated that resident 29 would hide and eat non food items. The assessment also indicated that resident 29 would steal other residents' food items to eat them, and did not like to give up the items once she had them. The assessment listed resident 29's behaviors as theft, wandering and combativeness. Resident 29's progress notes revealed the following entities: a. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. b. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice was notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. c. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. d. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made. No documentation could be located to indicate which residents were affected by the behavior. e. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings as well as sometimes spitting on them. No documentation could be located to indicate which residents were affected by the behavior. f. A nursing note dated 6/5/22 documented that resident 29 wandered into another residents room. The resident was awakened by [resident 29] rummaging through her room and told [resident 29] to leave. [Resident 29] began hitting and also spit on that resident. g. A nursing note dated 6/7/22 documented that I explained to hospice nurse again how resident (29)'s wandering (sic), spitting, playing with her feces, hitting and biting others is very disruptive to the other residents and that the other residents are/have been very upset. [Note: This note was later marked as invalid.] No documentation could be located to indicate which residents were affected by the behavior. [Note: Monitoring for spitting on residents was implemented by facility staff on 6/3/22.] On 6/1/22 a grievance form was completed by resident 41 indicating that she was spit on by resident 29. Resident 29's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident 250 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 250's MDS dated [DATE] revealed a BIMS score of 10. On 6/6/22 at 2:33 PM, an interview was conducted with resident 250. Resident 250 stated that there was a resident who wandered into her room at night and helped themselves to anything when her door is open. Resident 250 stated that resident 29 had come into her room while she was sleeping and had unhooked her oxygen. Resident 250 stated that she had reported the issues to staff, but that staff is doing nothing about it. Resident 250 stated that she is afraid resident 29 will steal her things, and that she doesn't feel safe around resident 29. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 4 On 6/7/22 around 9:00 AM, an interview was conducted with resident 18. Resident 18 stated that someone had come into her room recently and was bashing her. Resident 18 could not indicate which resident had hit her. Resident 18 was tearful when describing the incident, and stopped the interview. 4. Resident 35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 15 was cognitively intact. On 6/7/22 around 9:30 AM, an interview was conducted with resident 35. Resident 35 stated that she was resident 18's roommate and had witnessed multiple incidents between resident 18 and resident 29. Resident 35 stated approximately a week ago, resident 29 came into her room and scratched and hit resident 18. Resident 35 stated that they reported it to a CNA, but I don't think the CNA told anyone. Resident 35 stated that approximately 3 to 4 days ago at 1:30 AM, resident 29 came into her room again and was hitting resident 18 again. Resident 35 stated that a night nurse came in and stayed with resident 18 until she felt better. On 6/9/22 at 4:01 PM, a phone interview was conducted with employee 7. Employee 7 stated they did not visualize what happened between resident 29 and resident 18 but was told by the CNA that resident 29 had been in resident 18's room spitting and hitting resident 18. Employee 7 stated that the CNA was able to separate the two residents and take resident 29 back to her room. Employee 7 stated they checked on resident 18 as soon as resident 29 was taken out of the room. Employee 7 stated there were no visible injuries identified on resident 18. Employee 7 was told by resident 35, who was the roommate to resident 18, that resident 18 was woken up by resident 29 rummaging through her belongings. Employee 7 stated that resident 35 said that resident 18 was upset. Employee 7 stated that it did not take long for the CNA to respond because resident 35 pushed the call light as soon as she noticed resident 29 was in the room. Employee 7 stated that LPN (Licensed Practical Nurse) 4 was notified and was told they have to do something with resident 29 but was unsure of the exact wording used by LPN 4. Employee 7 stated that they had never seen resident 29 be aggressive and that resident 29 was pretty redirectable as long as she had her baby doll. Employee 7 stated that resident 29 had been receiving extra medication that had helped her sleep better. Employee 7 stated resident 29 was just started on a new medication named [MEDICATION(S)]. 5. Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 11 was cognitively intact. On 6/9/22 at 10:05 AM, an interview was conducted with resident 11. Resident 11 stated that resident 29 spit all over his arm and mug while he was right outside his room and that it made him feel sick and mad. Resident 11 stated that he had to take his mug to the kitchen and have it washed out and sanitized. Resident 11 stated that resident 29 did not know what she was doing and he had told resident 29 she was not suppose to spit on other people but resident 29 cannot understand him since she did not speak English. Resident 11 stated they went to the DON and told them they needed to get resident 29 out of the facility and resident 11 was told by the Administrator that he was trying but having a hard time finding the appropriate placement that could handle resident 29. Resident 11 stated that he did not believe them. Resident 11 stated that since that encounter, he made sure he did not come in contact with resident 29 by avoiding her and keeping his door shut when he was not in his room because he was afraid resident 29 would enter his room and steal items. Resident 11 stated that he had to be rough and gruff with resident 29 when she tried to enter resident 11's room. Resident 11 stated that he had seen resident 29 eat paper, spit on the floor and go into other resident's rooms and take things out. Resident 11 stated that staff had chased resident 29 to get the stuff back from resident 29 and return it to the proper owner. 6. Resident 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 41 was cognitively intact. On 6/6/22 an interview was conducted with resident 41. Resident 41 stated that 29 wandered into multiple resident rooms, spits on residents, breaks things, and steals items. Resident 41 stated that she had repeatedly told resident 29 to stop. On 6/9/22 at 10:37 AM, another interview was conducted with resident 41. Resident 41 stated while she ate dinner in her room one night, resident 29 came in a spat on her shoulder and down her back. Resident 41 stated they told resident 29 not to spit on her again and to leave her room. Resident 41 stated she felt so violated after what resident 29 did and she should not be living in a place where she was worried that someone was going to spit on her. Resident 41 stated that resident 29 did not belong at the facility, resident 29 needed to be in a facility where they had 1 on 1 care. Resident 41 stated that resident 29 was like a child and did not know what she was doing. Resident 41 stated that resident 29 had been in her room and broken things. Resident 41 stated at one point resident 29 was able to take resident 41's instruction book for her wheel chair. Resident 41 stated that the instruction book was not something resident 29 could just pick up, resident 29 had to get inside a bag and go looking for it. Resident 41 stated that she felt pissed and frustrated. Resident 41 also stated that there was another resident that would call resident 29 stupid and crazy and would yell get that crazy lady out of here while resident 29 was close by. Resident 41 stated that if resident 29 was treated with disrespect or talked to in a tough voice, resident 29 would be mean. Resident 41 stated resident 29 did not appreciate people being mean to her. Resident 41 stated this was the first time that she had seen staff babysitting resident 29. On 6/9/22 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she was aware that resident 29 likes to spit, and had witnessed resident 29 spitting on a facility staff member's desk. LPN 4 also stated that she had heard that resident 29 had spit on resident 9. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:10 PM, an interview was conducted with Employee 3. Employee 3 stated they received yearly abuse training and continuing education. Employee 3 stated that an action may or may not be considered abuse if the confused resident knew what they were doing. Employee 3 stated that they would consider it a form of bullying if a confused resident were to spit on another resident. Employee 3 stated staff made a note if someone was being bullied in the facility and they would monitor that resident more often and possibly move the resident who did the bullying to a different facility. On 6/8/22 at 2:48 PM, an interview was conducted with Employee 1. Employee 1 stated they used to have a 1 on 1 supervision for resident 29 but it depended on staffing. Employee 1 stated that resident 29 had a behavior issue where she liked to touch people's stuff. Employee 1 stated if resident 29 started to exhibit any kind of behavior issues, then they initiate a 1 on 1 care until the behavior was better. Employee 1 stated that other residents have complained about resident 29 going into their rooms. Employee 1 stated they tried to keep resident 29 away from other residents and prevent her from going into other rooms, residents had to make sure they closed their doors. Employee 1 stated that other residents should not have to be worried about resident 29 going into their rooms. Employee 1 stated that they received training on abuse and if abuse was identified, they had to report it to the administrator or manager. Employee 1 stated that abuse depended on the resident's mental status. Employee 1 defined a confused mental status as the resident not being in their right mind and unaware of what they were doing. Employee 1 stated if they were confused then they did not mean to, that was not considered abuse. Employee 1 stated if a confused resident hit another resident then staff opened a resident to resident event, notified the doctor and looked for any injuries. Employee 1 stated that they followed up with the resident for about 3 to 5 days if no injury was identified. Employee 1 stated if there was an injury then staff continued to follow until the injury was healed. On 6/8/22 at 3:24 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 29 was a little confused. CNA 1 stated that normally with confused residents, staff kept a closer eye on them and made sure they were not causing issues with other residents. CNA 1 stated she had not seen resident 29 be aggressive towards other staff or residents. CNA 1 stated normally when resident 29 was in the hallway, staff tried and talked to her and then redirected her by giving her a snack or taking her to an activity. CNA 1 stated she had abuse training and stated that she first report the abuse to the nurse and then to the DON. CNA 1 stated if a resident was being abused by another resident, she would first separate the two residents and then inform the nurse, so they can document what was happening. CNA 1 stated that if a confused resident were to spit on another, she would not consider it abuse because the resident was confused. CNA 1 stated that when the resident was all there mentally and they act purposefully then it would be considered abuse. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated there was not enough staff to keep resident 29 safe and other residents safe from resident 29. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 9:32 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated she had never seen resident 29 hurt anyone. RN 4 stated they were doing their best to redirect resident 29 by providing her with activities and giving her snacks. RN 4 stated there was no one to one care for resident 29 but stated the staff were on high alert when resident 29 was out of their room. RN 4 stated that resident 29's level of confusion exacerbates her communication barrier but they try to communicate with her using hand gestures and some staff have tried using google translate. On 6/9/22 at 9:42 AM, an interview was conducted with Employee 5. Employee 5 stated that they were aware of resident 29 behaviors such as confusion and being combative with staff. Employee 5 stated they will redirect resident 29 by using a calm voice and offering her snacks and a blanket. Employee 5 stated that they were aware of resident 29 spitting on resident 11 and believed it happened sometime last week. Employee 5 told resident 11 that resident 29 did not mean it and it probably was not personal that resident 29 had spit on him. Employee 5 stated they heard that resident 29 may have drank some body wash. Employee 5 stated they went into resident 29 room and put items out of resident 29's reach. Employee 5 stated that resident 29 liked to sit on the couch and spit on the floors and the other residents complained about resident 29 spitting. Employee 5 stated they would consider resident 29 spitting on other residents as abuse, especially on the other residents that can not protect themselves or get away from her. Employee 5 stated that administration was aware of resident 29's behavior. On 6/9/22 at 4:18 PM, an interview was conducted with LPN 3. LPN 3 stated they felt bad for resident 29 since she wasn't able to communicate and she spent a great deal of time in her room. LPN 3 stated that resident 29 would do better in a memory care unit than where she was at now. LPN 3 stated that resident 29 had a really nasty habit of spitting but believed it might be a part of resident 29 culture. LPN 3 stated that resident 29 did not spit at anyone directly, resident 29 spits to clean things with. LPN 3 stated they had heard other residents threaten to hit resident 29. LPN 3 stated that communication was the biggest problem with resident 29. LPN 3 stated they had given [MEDICATION(S)] to help resident 29 sleep and keep her out of other residents' rooms. On 6/9/22 at 3:05 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 is very quiet and you can see why she scares the residents when she goes into their rooms at night. CNA 3 also stated that resident 29 is very strong and can hurt somebody. During this interview, resident 29 was observed to wander into another resident's room and observed to get upset while being redirected by CNA 3. Resident 29 was observed to hit CNA 3. CNA 3 stated that resident 29 needed one to one care. CNA 3 also stated that resident 7 had a back scratcher/stick and had threatened to hit resident 29 once she entered into resident 7's room. CNA 3 also stated that resident 18 became aggressive and was prepared to fight resident 29 once she entered resident 18's room. On 6/8/22 at 2:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 29 was on her death bed when she was admitted to the facility and then she woke up which led to her wandering and having behaviors. The DON stated that he had never seen resident 29 be aggressive but that did not mean it had not happened. On 6/9/22 at 12:14 PM, a follow up interview was conducted with the DON. The DON stated that he was not aware that resident 29 had hit any other resident until 6/7/22 when he reviewed the nurses notes entered over the weekend. The DON stated that they were conducting an investigation on what happened the night of 6/5/22. The DON stated he had never seen resident 29 be violent. The DON stated he was uncertain of what happened but stated it could had been a reaction from resident 18 being approached by resident 29, that could of caused resident 18 to hit resident 29. The DON stated neither, residents 18 and resident 29, had any signs or symptoms of any injuries. The DON stated that both residents were severely demented and no one was able to tell staff if it was a reaction so they did not know who hit who. The DON stated that resident 29 could not act willfully to abuse other residents because she did not have ill intent, but then later stated if resident 29 hit resident 18, then it would have been willful. The DON defined willful in two ways; first it was an aggressive movement towards another and secondly, it was an action the resident chose to do with an understanding of what has happened. The DON stated that resident 29 was a wanderer and will go where the wind takes her. The DON stated that resident 29 went into other resident rooms, squatted in the rooms and looked at the resident in the room. The DON stated that he was aware that resident 29 spat on other residents and that they were in the process of trying a new medication with resident 29 that would help reduce secretions so resident 29's spitting episodes would occur less frequently. The DON stated that spitting was not ever ill intent. The DON stated that resident 41 approached him a week or two ago and stated that resident 29 had walked up behind her and spit down her back. In addition, the DON stated that resident 11 had made an accusation against resident 29 for spitting on her. The DON stated that he apologized to resident 11 for resident 29's behavior. The DON stated that he was sorry residents were victims of resident 29 spitting. The DON stated that these were the only complaints he had received about resident 29's abuse toward other residents. The DON stated he had tried to discharge resident 29 to a memory care unit and knew that resident 29 had not been receiving the appropriate level of care at the facility. When asked how the DON was protecting other residents from resident 29, the DON stated he had been attempting to discharge the resident. On 6/9/22 at 1:30 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was aware that resident 41 reported that resident 29 had spit on her back. The ADM stated that he did not identify this as abuse because resident 29 didn't know what she was doing. The ADM stated that resident 41 told the ADM that resident 29 should not be residing in the building, but I feel like that was her opinion but I feel like other residents feel the same way. The ADM stated that when resident 41 reported this to him, he felt like the resident was just venting frustrations, not making an allegation of abuse. The ADM stated that he was not aware that resident 29 was hitting other residents as documen [TRUNCATED]

Based on record review and interview it was determined for 7 of 39 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to report all allegations of resident abuse. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant Vice President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F609. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 until new interventions can be evaluated for effectiveness. Resident 250 discharged on [DATE] Residents 11, 18, 41, interviewed about potential abuse and notified of new safety interventions. Social worker or designee will continue to follow up with residents ' 11, 41, 18, 29, and any other potential affected resident to ensure safety and privacy needs continue to be met. Skin evaluations completed and reviewed on residents 11, 18, and 41, 29 by 6/10/22. Abuse reports submitted for residents ' 11, 41, 18, 29, 250, 7 on 6/9/2022 All residents interviewed to assess potential abuse on 6/10/2022 Any additional allegations of abuse will be reported as applicable. Starting 6/10/2022 all nurses ' notes, events, and 24 hour report will be reviewed daily for documentation of potential abuse. Starting 6/10/2022 nursing management will obtain daily report from the nurses. Education provided to all residents regarding how to report concerns and grievances on 6/10/2022. Staff will complete post-test after training to ensure understanding. Education provided to administrator and facility leadership team by regional nurse and facility nurse educator on 6/10/2022 Education provided to all staff regarding abuse prevention and reporting in a staff meeting on 6/10/2022. Staff will complete post-test after training to ensure understanding. Staff unable to attend staff meeting will be required to complete training prior to their next scheduled shift. Staff will complete post-test after training to ensure understanding. Agency staff will be required to complete education at the start of their shift. Staff will complete post-test after training to ensure understanding. Social services or designee will review concern and grievance process during initial IDT (interdisciplinary team). A regional team member will visit the facility weekly to provide oversight, audits of resident interviews and reports, and additional training as needed. The administrator or designee will continue to interview residents on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the QAPI Committee. On 6/13/22, 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 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/22 at 11:25 AM, an observation was made of resident 29 in her room. There was no staff member present in the room or outside the room. Resident 29 was observed sitting up in bed. An interview was attempted with resident 29, however resident 29 simply repeated back what the surveyor had asked. On 6/8/22 at 3:06 PM, an observation was made of resident 29 sitting in the lobby. Resident 29 was observed to be listening to music in her native language while kissing a doll in the face. Resident 29 then proceeded to put her left index finger up her own nose. Resident 29 then proceeded to get up from her chair and started to wander down the hall. Facility staff was observed to approach resident 29, who was standing outside of another resident's door. Resident 29 was subsequently offered snacks and redirected back to her room. Resident 29's medical record was reviewed on 6/9/22. Hospital records dated 3/30/22 revealed that resident 29 had severe dementia and tended to eat inappropriate items frequently. Resident 29 was brought to the hospital by her son due to concerns of ingesting antifreeze or bedbug chemicals. Resident 29 was intubated and taken to the Intensive Care Unit (ICU) in critical condition due to ingestion of Diacetome, an organic pest control agent. It was noted during her hospitalization that resident 29 would pull out her nasojejunal (NJ) tube if not restrained due to her mental state of confusion. An Minimum Data Set (MDS) dated [DATE] revealed resident 29 did not have a brief interview for mental status (BIMS) completed. The BIMS score was unknown but resident 29 was identified as severely impaired in making decisions, regarding tasks of daily living. Resident 29 was not identified as a wandering risk or having any kinds of behavioral symptoms. Resident 29's care plans revealed the following behavioral problems and approaches taken by facility: a. On 6/9/22 a problem identified was resident 29 ingests non edible items RT (related to) [NAME]. The goal was resident 29 will be kept safe from all hazards items she could ingest. Approaches included: We will place resident 29 on 1 to 1 to provide the constant amount of care resident 29 requires to prevent harm. [Note: This intervention was developed after the facility was notified of an IJ on 6/9/22] b. On 6/9/22 a problem identified was resident 29 is resistant to brief changes and cares at times. The goal was Resident 29 will accept assistance with cares. Approaches included: 1. Assess her resistance. Actively involve the resident in care. Express willingness to adjust regimen. 2. Respect and try to incorporate her culture in her daily cares. 3. Follow familiar routines/ staff when possible. 4. Convey an attitude of acceptance toward the resident. 5. Allow resident to choose options. [Note: This intervention was developed before the facility was notified of an IJ, but after the survey had been initiated]. c. On 6/8/22 a problem identified was resident 29 experiences restlessness and fidgetiness at times. The goal was resident 29 will have no negative outcomes r/t (related to) restless and fidgetiness. Approach(s) included: 1. Offer her activities, music, her doll, walk PRN (as needed). 2. Assure basic needs are assessed. [Note: This intervention was developed after the survey had been initiated.] d. On 6/7/22 a problem identified was resident 29 experiences wandering and will rummage through others' belongings at times. The goal was resident 29 will not injure/harm self secondary to wandering. Approach(s) included: 1. Involve significant support persons. 2. Remove resident from other resident's rooms and unsafe situations. 3. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). 4. Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. 5. Follow familiar routines when possible. [Note: This intervention was developed after the survey had been initiated.] e. On 5/1/22 a problem identified was resident 29 spits on desks, floors, and people. The goal was resident 29 will not spit on desk, floors, and people. Approach(s) developed on 6/3/22 included: 1. Resident 29 will be redirected PRN (as needed). Resident 29 will be offered a snack PRN. Resident 29 will be given a busy box PRN. No documentation could be located to indicate which residents were affected by the behavior. f. On 4/15/22 problems identified were resident 29 exhibits alteration in thought process manifested by cognitive impairment r/t (related to) dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; mood problem: anxiety; has little interest/pleasure in doing things; on hospice. The goals developed included: 1. Resident 29 will participate in activities of importance/interest daily, as desired, through next review date. 2. Resident will engage, as desired, in activities of interest at least: 1 cognitive activity per week for retention of cognitive abilities as evidence by recalling memories during activities; 1 social activity per week for communication as evidence by verbalizing thoughts and ideas during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities through next review date. Approach(s) included: 1.1 PRN (as needed). Support independent leisure choices. 2.1 Invite, involve and encourage participation in activities of importance/interest including: family/ friend phone calls/visits, TV/movies, Native American (sic) music, pets, socials, outdoors, spiritual support, reminisce, &/or special events. 2.2 Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. 2.3 Provide with opportunities to recall long/short term memories to retain cognitive abilities during activities. 2.4 Provide adaptations to activities PRN (as needed): cognition: task segmentation; physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities. No elopement assessment was done at on admission. No significant change MDS was documented about resident 29's behavior. A psychosocial assessment dated [DATE] indicated that resident 29 would hide and eat non food items. The assessment also indicated that resident 29 would steal other residents' food items to eat them, and did not like to give up the items once she had them. The assessment listed resident 29's behaviors as theft, wandering and combativeness. Resident 29's progress notes revealed the following entities: a. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. b. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice was notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. c. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. d. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made. No documentation could be located to indicate which residents were affected by the behavior. e. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings as well as sometimes spitting on them. No documentation could be located to indicate which residents were affected by the behavior. f. A nursing note dated 6/5/22 documented that resident 29 wandered into another residents room. The resident was awakened by [resident 29] rummaging through her room and told [resident 29] to leave. [Resident 29] began hitting and also spit on that resident. g. A nursing note dated 6/7/22 documented that I explained to hospice nurse again how resident (29)'s wandering (sic), spitting, playing with her feces, hitting and biting others is very disruptive to the other residents and that the other residents are/have been very upset. [Note: This note was later marked as invalid.] No documentation could be located to indicate which residents were affected by the behavior. [Note: Monitoring for spitting on residents was implemented by facility staff on 6/3/22.] On 6/1/22 a grievance form was completed by resident 41 indicating that she was spit on by resident 29. 2. Resident 250 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 250's MDS dated [DATE] revealed a BIMS score of 10. On 6/6/22 at 2:33 PM, an interview was conducted with resident 250. Resident 250 stated that there was a resident who wandered into her room at night and helped themselves to anything when her door is open. Resident 250 stated that resident 29 had come into her room while she was sleeping and had unhooked her oxygen. Resident 250 stated that she had reported the issues to staff, but that staff is doing nothing about it. Resident 250 stated that she is afraid resident 29 will steal her things, and that she doesn't feel safe around resident 29. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 4 On 6/7/22 around 9:00 AM, an interview was conducted with resident 18. Resident 18 stated that someone had come into her room recently and was bashing her. Resident 18 could not indicate which resident had hit her. Resident 18 was tearful when describing the incident, and stopped the interview. 4. Resident 35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 15 was cognitively intact. On 6/7/22 around 9:30 AM, an interview was conducted with resident 35. Resident 35 stated that she was resident 18's roommate and had witnessed multiple incidents between resident 18 and resident 29. Resident 35 stated approximately a week ago, resident 29 came into her room and scratched and hit resident 18. Resident 35 stated that they reported it to a CNA, but I don't think the CNA told anyone. Resident 35 stated that approximately 3 to 4 days ago at 1:30 AM, resident 29 came into her room again and was hitting resident 18 again. Resident 35 stated that a night nurse came in and stayed with resident 18 until she felt better. On 6/9/22 at 4:01 PM, a phone interview was conducted with employee 7. Employee 7 stated they did not visualize what happened between resident 29 and resident 18 but was told by the CNA that resident 29 had been in resident 18's room spitting and hitting resident 18. Employee 7 stated that the CNA was able to separate the two residents and take resident 29 back to her room. Employee 7 stated they checked on resident 18 as soon as resident 29 was taken out of the room. Employee 7 stated there were no visible injuries identified on resident 18. Employee 7 was told by resident 35, who was the roommate to resident 18, that resident 18 was woken up by resident 29 rummaging through her belongings. Employee 7 stated that resident 35 said that resident 18 was upset. Employee 7 stated that it did not take long for the CNA to respond because resident 35 pushed the call light as soon as she noticed resident 29 was in the room. Employee 7 stated that LPN (Licensed Practical Nurse) 4 was notified and was told they have to do something with resident 29 but was unsure of the exact wording used by LPN 4. Employee 7 stated that they had never seen resident 29 be aggressive and that resident 29 was pretty redirectable as long as she had her baby doll. Employee 7 stated that resident 29 had been receiving extra medication that had helped her sleep better. Employee 7 stated resident 29 was just started on a new medication named [MEDICATION(S)]. 5. Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 11 was cognitively intact. On 6/9/22 at 10:05 AM, an interview was conducted with resident 11. Resident 11 stated that resident 29 spit all over his arm and mug while he was right outside his room and that it made him feel sick and mad. Resident 11 stated that he had to take his mug to the kitchen and have it washed out and sanitized. Resident 11 stated that resident 29 did not know what she was doing and he had told resident 29 she was not suppose to spit on other people but resident 29 cannot understand him since she did not speak English. Resident 11 stated they went to the DON and told them they needed to get resident 29 out of the facility and resident 11 was told by the Administrator that he was trying but having a hard time finding the appropriate placement that could handle resident 29. Resident 11 stated that he did not believe them. Resident 11 stated that since that encounter, he made sure he did not come in contact with resident 29 by avoiding her and keeping his door shut when he was not in his room because he was afraid resident 29 would enter his room and steal items. Resident 11 stated that he had to be rough and gruff with resident 29 when she tried to enter resident 11's room. Resident 11 stated that he had seen resident 29 eat paper, spit on the floor and go into other resident's rooms and take things out. Resident 11 stated that staff had chased resident 29 to get the stuff back from resident 29 and return it to the proper owner. 6. Resident 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 41 was cognitively intact. On 6/6/22 an interview was conducted with resident 41. Resident 41 stated that 29 wandered into multiple resident rooms, spits on residents, breaks things, and steals items. Resident 41 stated that she had repeatedly told resident 29 to stop. On 6/9/22 at 10:37 AM, another interview was conducted with resident 41. Resident 41 stated while she ate dinner in her room one night, resident 29 came in a spat on her shoulder and down her back. Resident 41 stated they told resident 29 not to spit on her again and to leave her room. Resident 41 stated she felt so violated after what resident 29 did and she should not be living in a place where she was worried that someone was going to spit on her. Resident 41 stated that resident 29 did not belong at the facility, resident 29 needed to be in a facility where they had 1 on 1 care. Resident 41 stated that resident 29 was like a child and did not know what she was doing. Resident 41 stated that resident 29 had been in her room and broken things. Resident 41 stated at one point resident 29 was able to take resident 41's instruction book for her wheel chair. Resident 41 stated that the instruction book was not something resident 29 could just pick up, resident 29 had to get inside a bag and go looking for it. Resident 41 stated that she felt pissed and frustrated. Resident 41 also stated that there was another resident that would call resident 29 stupid and crazy and would yell get that crazy lady out of here while resident 29 was close by. Resident 41 stated that if resident 29 was treated with disrespect or talked to in a tough voice, resident 29 would be mean. Resident 41 stated resident 29 did not appreciate people being mean to her. Resident 41 stated this was the first time that she had seen staff babysitting resident 29. On 6/9/22 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she was aware that resident 29 likes to spit, and had witnessed resident 29 spitting on a facility staff member's desk. LPN 4 also stated that she had heard that resident 29 had spit on resident 9. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:10 PM, an interview was conducted with Employee 3. Employee 3 stated they received yearly abuse training and continuing education. Employee 3 stated that an action may or may not be considered abuse if the confused resident knew what they were doing. Employee 3 stated that they would consider it a form of bullying if a confused resident were to spit on another resident. Employee 3 stated staff made a note if someone was being bullied in the facility and they would monitor that resident more often and possibly move the resident who did the bullying to a different facility. On 6/8/22 at 2:48 PM, an interview was conducted with Employee 1. Employee 1 stated they used to have a 1 on 1 supervision for resident 29 but it depended on staffing. Employee 1 stated that resident 29 had a behavior issue where she liked to touch people's stuff. Employee 1 stated if resident 29 started to exhibit any kind of behavior issues, then they initiate a 1 on 1 care until the behavior was better. Employee 1 stated that other residents have complained about resident 29 going into their rooms. Employee 1 stated they tried to keep resident 29 away from other residents and prevent her from going into other rooms, residents had to make sure they closed their doors. Employee 1 stated that other residents should not have to be worried about resident 29 going into their rooms. Employee 1 stated that they received training on abuse and if abuse was identified, they had to report it to the administrator or manager. Employee 1 stated that abuse depended on the resident's mental status. Employee 1 defined a confused mental status as the resident not being in their right mind and unaware of what they were doing. Employee 1 stated if they were confused then they did not mean to, that was not considered abuse. Employee 1 stated if a confused resident hit another resident then staff opened a resident to resident event, notified the doctor and looked for any injuries. Employee 1 stated that they followed up with the resident for about 3 to 5 days if no injury was identified. Employee 1 stated if there was an injury then staff continued to follow until the injury was healed. On 6/8/22 at 3:24 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 29 was a little confused. CNA 1 stated that normally with confused residents, staff kept a closer eye on them and made sure they were not causing issues with other residents. CNA 1 stated she had not seen resident 29 be aggressive towards other staff or residents. CNA 1 stated normally when resident 29 was in the hallway, staff tried and talked to her and then redirected her by giving her a snack or taking her to an activity. CNA 1 stated she had abuse training and stated that she first report the abuse to the nurse and then to the DON. CNA 1 stated if a resident was being abused by another resident, she would first separate the two residents and then inform the nurse, so they can document what was happening. CNA 1 stated that if a confused resident were to spit on another, she would not consider it abuse because the resident was confused. CNA 1 stated that when the resident was all there mentally and they act purposefully then it would be considered abuse. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated there was not enough staff to keep resident 29 safe and other residents safe from resident 29. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 9:32 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated she had never seen resident 29 hurt anyone. RN 4 stated they were doing their best to redirect resident 29 by providing her with activities and giving her snacks. RN 4 stated there was no one to one care for resident 29 but stated the staff were on high alert when resident 29 was out of their room. RN 4 stated that resident 29's level of confusion exacerbates her communication barrier but they try to communicate with her using hand gestures and some staff have tried using google translate. On 6/9/22 at 9:42 AM, an interview was conducted with Employee 5. Employee 5 stated that they were aware of resident 29 behaviors such as confusion and being combative with staff. Employee 5 stated they will redirect resident 29 by using a calm voice and offering her snacks and a blanket. Employee 5 stated that they were aware of resident 29 spitting on resident 11 and believed it happened sometime last week. Employee 5 told resident 11 that resident 29 did not mean it and it probably was not personal that resident 29 had spit on him. Employee 5 stated they heard that resident 29 may have drank some body wash. Employee 5 stated they went into resident 29 room and put items out of resident 29's reach. Employee 5 stated that resident 29 liked to sit on the couch and spit on the floors and the other residents complained about resident 29 spitting. Employee 5 stated they would consider resident 29 spitting on other residents as abuse, especially on the other residents that can not protect themselves or get away from her. Employee 5 stated that administration was aware of resident 29's behavior. On 6/9/22 at 4:18 PM, an interview was conducted with LPN 3. LPN 3 stated they felt bad for resident 29 since she wasn't able to communicate and she spent a great deal of time in her room. LPN 3 stated that resident 29 would do better in a memory care unit than where she was at now. LPN 3 stated that resident 29 had a really nasty habit of spitting but believed it might be a part of resident 29 culture. LPN 3 stated that resident 29 did not spit at anyone directly, resident 29 spits to clean things with. LPN 3 stated they had heard other residents threaten to hit resident 29. LPN 3 stated that communication was the biggest problem with resident 29. LPN 3 stated they had given [MEDICATION(S)] to help resident 29 sleep and keep her out of other residents' rooms. On 6/9/22 at 3:05 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 is very quiet and you can see why she scares the residents when she goes into their rooms at night. CNA 3 also stated that resident 29 is very strong and can hurt somebody. During this interview, resident 29 was observed to wander into another resident's room and observed to get upset while being redirected by CNA 3. Resident 29 was observed to hit CNA 3. CNA 3 stated that resident 29 needed one to one care. CNA 3 also stated that resident 7 had a back scratcher/stick and had threatened to hit resident 29 once she entered into resident 7's room. CNA 3 also stated that resident 18 became aggressive and was prepared to fight resident 29 once she entered resident 18's room. On 6/8/22 at 2:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 29 was on her death bed when she was admitted to the facility and then she woke up which led to her wandering and having behaviors. The DON stated that he had never seen resident 29 be aggressive but that did not mean it had not happened. On 6/9/22 at 12:14 PM, a follow up interview was conducted with the DON. The DON stated that he was not aware that resident 29 had hit any other resident until 6/7/22 when he reviewed the nurses notes entered over the weekend. The DON stated that they were conducting an investigation on what happened the night of 6/5/22. The DON stated he had never seen resident 29 be violent. The DON stated he was uncertain of what happened but stated it could had been a reaction from resident 18 being approached by resident 29, that could of caused resident 18 to hit resident 29. The DON stated neither, residents 18 and resident 29, had any signs or symptoms of any injuries. The DON stated that both residents were severely demented and no one was able to tell staff if it was a reaction so they did not know who hit who. The DON stated that resident 29 could not act willfully to abuse other residents because she did not have ill intent, but then later stated if resident 29 hit resident 18, then it would have been willful. The DON defined willful in two ways; first it was an aggressive movement towards another and secondly, it was an action the resident chose to do with an understanding of what has happened. The DON stated that resident 29 was a wanderer and will go where the wind takes her. The DON stated that resident 29 went into other resident rooms, squatted in the rooms and looked at the resident in the room. The DON stated that he was aware that resident 29 spat on other residents and that they were in the process of trying a new medication with resident 29 that would help reduce secretions so resident 29's spitting episodes would occur less frequently. The DON stated that spitting was not ever ill intent. The DON stated that resident 41 approached him a week or two ago and stated that resident 29 had walked up behind her and spit down her back. In addition, the DON stated that resident 11 had made an accusation against resident 29 for spitting on her. The DON stated that he apologized to resident 11 for resident 29's behavior. The DON stated that he was sorry residents were victims of resident 29 spitting. The DON stated that these were the only complaints he had received about resident 29's abuse toward other residents. The DON stated he had tried to discharge resident 29 to a memory care unit and knew that resident 29 had not been receiving the appropriate level of care at the facility. When asked how the DON was protecting other residents from resident 29, the DON stated he had been attempting to discharge the resident. On 6/9/22 at 1:30 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was aware that resident 41 reported that resident 29 had spit on her back. The ADM stated that he did not identify this as abuse because resident 29 didn't know what she was doing. The ADM stated that resident 41 told the ADM that resident 29 should not be residing in the building, but I feel like that was her opinion but I feel like other residents feel the same way. The ADM stated that when resident 41 reported this to him, he felt like the resident was just venting frustrations, not making an allegation of abuse. The ADM stated that he was not aware that resident 29 was hitting other residents as documented in the nursing note on 6/5/22 until surveyors brought it to his attention. The ADM was unaware what interventions had been put into place to prevent residents from further abuse. The ADM stated that if the victim of abuse did not have any fears or was emotionally harmed, then the incident would not be considered abuse. The ADM stated that if someone reported a resident was a victim of abuse, he would ask the resident how their stay was, and if they did not mention the alleged abuse he would unsubstantiated the allegation. When asked if the ADM would ask the alleged victim of abuse about the alleged incident, the ADM stated he felt that would be a leading question. The ADM stat [TRUNCATED]

Based on observation, interview and record review it was determined, for 1 of 39 sample residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident with a diagnoses of dementia and [NAME] was found with hazardous liquids and foreign objects. This was found to have occurred at an Immediate Jeopardy (IJ) level. In addition, a resident sustained an injury during a transfer with a Hoyer lift. This was found to have occurred at a harm level. Resident identifiers: 11 and 29. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure a resident with dementia and [NAME] had supervision and interventions to prevent the resident from eating or drinking hazardous chemicals and foreign objects. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant Vice President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F689. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 until new interventions can be evaluated for effectiveness. Resident 29's IDT with hospice team completed on 6/10/2022 @ 0900 Resident 29's Labs scheduled to be obtained for medical evaluation 6/10/2022 Resident 29's IDT with son scheduled for 6/10/2022 [name removed] crisis team evaluation utilizing [name removed]Translation services completed on 6/9/2022 @ 2050 Resident 29's Care plans updated to reflect current interventions on 6/9/2022 Resident 29's behavior tracking updated to reflect current potential behaviors on 6/9/2022 All resident elopement risk assessments updated by 6/10/2022 All dietary care plans assessed for residents with potential for [NAME] behaviors on 6/10/2022. Housekeeping cart locks updated on 6/10/2022 Education provided to all staff regarding securing cleaning supplies, [NAME] symptoms, redirection techniques for wandering, non-pharmacological interventions in a staff meeting on 6/10/2022. Staff will complete post-test after training to ensure understanding. Staff unable to attend staff meeting will be required to complete training prior to their next scheduled shift. Agency staff will be required to complete education at the start of their shift. Staff will complete post-test after training to ensure understanding. Nurse management team will utilize admission checklist to review elopement risk for all new admissions. Dietician or designee to assess for [NAME] concerns with each new admission. A regional team member will visit the facility weekly to provide oversight, audits, and additional training as needed. On 6/13/22, 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 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses that included cerebral infarction, Alzheimer's disease, dysphagia, failure to thrive, anxiety disorder and [NAME]. On 6/7/22 at 1:00 PM, resident 29 was observed in her room with no staff supervision. On 6/8/22 at 2:10 PM, resident 29 was observed in the lobby with music playing without staff supervision. Resident 29 was observed to be walking through the 100 hallway at 3:09 PM. The Medical Records staff member was observed redirecting resident 29 and speaking English to her. Resident 29's medical record was reviewed on 6/8/22. A history and physical dated 3/20/22 revealed that the resident's son was concerned resident 29 had gotten into antifreeze or debugging chemicals. Resident 29 was admitted to the intensive care unit and intubated in critical condition. It was noted in her hospitalization resident 29 pulled out her feeding tube because she had mental confusion. A Minimum Data Set (MDS) Admission Assessment note dated 4/15/22 revealed resident 29 had episodes of [NAME]. Resident 29 used a manual wheelchair for locomotion on the unit. Resident 29 was alert to self only and speech was mumbled with a primary language of Malayalam. A care plan dated 4/15/22 for resident 29 eats/sucks on non-edible items. The goal was resident 29 will refrain from eating non-edible items. The approach was staff will not give resident 29 items that she may eat. Another care plan dated 6/7/22 revealed resident 29 experienced wandering and rummaging through others' belongings at time. The goal was that resident 29 would not injure/harm self secondary to wandering. Approaches included to remove resident from other resident rooms and unsafe situations, when resident begins to wander. Additional approaches were to administer medications, follow familiar routines when possible, involve significant support persons, when resident begins to wander provide comfort measures for basic needs. A nurses note dated 4/1/22 revealed that resident 29's son stated she did not understand when spoken to in English. A nurses note dated 4/6/22 revealed that resident 29 pulled out her catheter. A skilled nursing note dated 4/12/22 revealed that staff were educated on need to keep items such as Styrofoam, paper, etc out of patient reach and staff understood the teaching. A social service admission note dated 4/14/22 revealed that resident 29 had been known to eat non-food items. A recreational therapy note dated 4/15/22 revealed that resident 29 had anxiety and little interest/pleasure in doing things. In addition, [Resident 29] is able to participate in activities of importance. Impaired mobility, mood, and cognitive impairment are potential barriers to leisure participation. An abdominal X-ray dated 4/20/22 at 8:31 PM, revealed that resident 29 may have eaten thumb tacks about 2 hours ago. There were no evidence of items in abdomen. A hospice progress note 4/25/22 revealed resident 29 liked to eat paper and Styrofoam. A dietary note dated 4/29/22 revealed that resident 29 was gaining weight which was desirable due to oral intake meeting/exceeding nutritional needs. A dietary department note dated 5/3/22 revealed a concern resident 29 was observed in dining area consuming unsafe items when asked to spit out resident 29 refused and began pushing staff away. Several attempts were made before items were removed and disposed of. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made and resident 29 was at her baseline. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings. A nursing note dated 6/5/22 revealed resident 29 wandered into other resident rooms and was seen rummaging through a resident's room. On 6/9/22 at 10:20 AM, the Housekeeping (HK) Supervisor was interviewed. The HK supervisor stated that all chemicals were locked in the utility room. The HK Supervisor stated that the housekeepers used carts. A HK cart was observed in the utility room. The HK cart was observed to have a compartment with chemicals and a spring latch on the outside. The HK Supervisor stated there was no lock on the compartment with the chemicals. The HK cart was observed to have a cleaner and disinfectant with beach in a bottle. The bottle revealed to Keep out of reach of children. There was a cleaner degreaser that contained sodium hydroxide that revealed If swallowed: Call a poison control center or doctor for treatment advice. Sip a glass of water if able to swallow. There was multisheen concentrated glass cleaner which revealed on the label to Keep out of reach of children. At 10:31 AM, the HK cart was observed unsupervised in the dining room. The cart was not locked and had a spring latch on the compartment the chemicals were stored in. At 11:11 AM, an observation was made of the housekeeping cart in the 200 hallway. The cart was observed to have a spring latch without a lock on the outside of the chemicals compartment. HK 1 was observed in a resident room and the cart was not within HK 1 line of sight. At 11:45 AM, the housekeeping cart was observed outside room 210. The cart was observed to have a clear chemical on top of the cart labeled with a black marker #2 on the container. There was a toilet brush in a container with a clear chemical not secured in the cart. HK 1 was interviewed. HK 1 stated that she usually put chemicals inside her cart in a compartment that was not locked. HK 1 stated that she put a chemical inside the container with the toilet brush that was not secured inside her cart. HK 1 stated that she did not leave a resident alone with her cart. HK 1 stated that if resident 29 was by her chart and touching everything she did not leave her cart. HK 1 stated resident 29 did not listen and was confused. HK 1 stated that resident 29 ate toilet paper so she did not leave toilet paper in her room. HK 1 stated that another staff member left toilet paper in her room after she took it out. On 6/9/22 at 3:23 PM, resident 29 was observed to touch things on the medication cart and then walked behind the nurses station. Staff were observed to redirect her. Resident 29 was observed to walk to the front door and 2 staff were observed to redirect her. On 6/9/22 at 9:41 AM, an interview was conducted with CNA 9. CNA 9 stated she had heard that resident 29 tried eating a glove. CNA 9 stated that they suspected resident 29 drank body wash. CNA 9 stated there was a full bottle of body wash and then it was gone. CNA 9 stated that was about a week ago. CNA 9 stated that she notified the nurse on duty. CNA 9 stated that staff tried to put things outside of her reach. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated she had witnessed resident 29 eat the small plastic cups with butter in them. CNA 10 stated resident 29 messed with the cup with her fingers, broke it down and then plopped it in her mouth. CNA 10 stated resident 29 had not choked, Luckily she pulled it out. CNA 10 stated she tried to substitute the plastic container with something she could actually eat. CNA 10 stated she saw resident 29 eat large amounts of orange peels. CNA 10 stated that she then tried to spit because she was pocketing the orange peels in her mouth. CNA 10 stated the language barrier made it hard to communicate with resident 29 to spit out the non-edible items. CNA 10 stated that she tried use her finger to sweep resident's mouth to get out the orange peels. CNA 10 stated one of the orange peels in her mouth was dime sized and some smaller ones. CNA 10 stated that resident 29 wandered and it was hard to find her because she like to crouch down. CNA 10 stated she had not heard anything about resident 29 drinking hazardous liquids and had not been provided education to prevent resident 29 from eating or drinking non-food items. CNA 10 stated there was not enough staff to keep the residents safe. CNA 10 stated there was an aide on the 200 hallway and a shared aide from the 100 hallway. CNA 10 stated 2 CNA's needed to transfer residents with Hoyer lifts, so when 2 CNAs were in a room that left resident 29 to wander in the hallways without supervision. CNA 10 stated that today there was a nursing student that sat with her and that really helped. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 10:25 AM, a follow up interview was conducted with the HK Supervisor. The HK Supervisor stated there was bleach in the laundry room. The HK Supervisor stated that no residents have been able to get a hold of chemicals. The HK stated that resident 29 might have gotten bleach off the HK cart because she was into everything. The HK stated that resident 29 drank a chemical named Contender but thankfully it wasn't harmful. The HK stated she was told resident 29 was found drinking bleach but determined it was contender. The HK supervisor stated she looked it up in the Material Safety Data Sheet and it revealed there was no known significant side effects or critical hazards. The HK Supervisor stated that resident 29 drank the chemical sometime last month. The HK stated the chemical was probably on top of a cart and not inside the cart. The HK stated there was no investigation and there were no changes to the process to prevent residents from getting the chemicals. The HK stated if there was an investigation the Director of Nursing (DON) or Administrator (ADM) would have conducted the investigation. On 6/9/22 at 4:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 29 drank bleach on 5/20/22. LPN 3 stated that apparently somebody had the bleach in her restroom and did not take it out. LPN 3 stated she saw the bottle in resident 29's hand and made the assumption that she drank it. LPN 3 stated that was the first time she was aware of resident 29 eating something that she was not supposed to. LPN 3 stated she notified the physician and hospice about what happened and was instructed to monitor her. LPN 3 stated she talked to the DON the next day about it. LPN 3 stated that the DON told her to make sure everybody knew to put things away from resident 29. On 6/15/22 at 3:05 PM, an interview was conducted with Employee 7. Employee 7 stated that resident 29 had thumbtacks in her mouth, and staff pulled them out of her mouth. Employee 7 stated that the thing that bothered her was that Administration knew and did not move the thumb tacks. Employee 7 stated that a CNA removed a glove from resident 29's mouth and the CNA had to reach her fingers down her throat. Employee 7 stated the CNA could barely reach the glove out of her mouth. Employee 7 stated she was not aware of resident 29 drinking chemicals but stated that resident 29 had had plastic plants in her mouth. Employee 7 stated resident 29 had drank shampoo and lotion. Employee 7 stated she reported the glove incident to LPN 4. On 6/9/22 at 11:36 AM, an interview was conducted with LPN 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she witnessed a staff member retrieve a rubber glove out of resident 29's mouth. LPN 4 stated that she reported that incident to the Director of Nursing and the Social Worker. LPN 4 stated that it was reported to me the other night that she (resident 29) was in another resident's room trying to drink lotion. LPN 4 stated that she reported that incident to the Director of Nursing. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:59 PM, an interview was conducted with the DON. The DON stated that resident 29 admitted to the facility on her death bed. The DON stated that resident 29 woke up and started wandering. The DON stated that resident 29 then started behaviors of spitting and eating non-food items. On 6/9/22 at 12:32 PM, a follow-up interview was conducted with the DON. The DON stated he was not sure resident 29 ingested bleach or a chemical. The DON stated that resident 29 found a bottle in her room and she was holding it. The DON stated we believe a CNA borrowed the chemical and put it in resident 29's room or resident 29 found it on the housekeeping cart. The DON stated he was not aware if the housekeeping carts were locked because that would be the HK Supervisors job. The DON stated hospice was notified and the DON believed housekeepers were given education about safety. The DON stated he did not provide education and would assume that the Administrator or HK Supervisor would do that. The DON stated there was no documentation that CNA's were provided education to prevent resident 29 from getting hazardous liquids. The DON stated that resident 29 got a glove and it was pulled out of her mouth by a CNA. The DON stated there was no investigation because they knew the glove came from resident 29's room. The DON stated the glove was allegedly in her mouth. The DON stated that the gloves were removed from her room. The DON stated he was really strict with the CNA's having gloves in the hallways. The DON stated there was no education for staff to protect resident 29 from eating gloves and choking on them. The DON stated he was aware that resident 29 put things in her mouth. The DON stated staff have reported that resident 29 had put paper towels in her mouth. The DON stated that as of yesterday the staff were being educated that when resident 29 was rummaging she was hungry and to offer her a snack. The DON stated he had been working to discharge resident to a memory care unit because she needed the correct level of care. The DON stated that the facility was unable to provide the correct level of care. On 6/9/22 at 1:30 PM, an interview was conducted with the ADM. The ADM stated he was made aware that resident 29 had a bottle of chemicals the day after the incident occurred. The ADM stated that it was reported during their morning stand-up meeting that resident 29 had a bottle of chemicals that she drank. The ADM stated staff looked at the MSDS form to see what interventions would be needed and what harm the chemical would cause. The ADM stated the MSDS revealed to just monitor resident 29. The ADM stated he was not sure how resident 29 got a hold of the chemical. The ADM stated there were no changes made after the incident to ensure resident 29 did not obtain chemicals again. The ADM stated that it was reported a nurse took a glove out of resident 29's mouth. The ADM stated nursing staff removed gloves from resident 29's room. HARM 2. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included [CONDITION(S)], C1-C4 incomplete, type 2 diabetes mellitus without complications, [CONDITION(S)], [CONDITION(S)], autonomic [CONDITION(S)], pain, major depressive disorder, muscle weakness, and muscle spasm. On 6/7/22 at 9:24 AM, an interview was conducted with resident 11. Resident 11 stated that recently a CNA from an agency was assisting him to get out of bed using a Hoyer lift. Resident 11 stated his foot got caught between the Hoyer lift and the bed. Resident 11 stated the staff thought his foot was broken, but he did not break any bones with this incident. Resident 11 stated an x-ray was done and showed he had broken some of the bones in his foot sometime before this incident. On 6/13/22 at 2:29 PM, a review of resident 11's medical record was conducted. The nursing progress notes revealed the following: a. On 4/17/22 at 4:36 PM: The afternoon CNA came to the nurse and said that [resident 11's] R [right] feet was hit by Hoyer lift this morning, per [resident 11] report. The nurse went to assess him immediately. Swelling noted to bilateral feet as his norm [normal]. C/o [complaint of] pain while the nurse move his foot and abrasion noted on the top of the feet. PRN [as needed] [MEDICATION(S)] was administered. Wrapped foot and applied ice pack. [Resident 11] and his daughter .wanted to wait until tomorrow for X-ray if he still is in pain. Nursing will continue to monitor and follow up. b. On 4/18/22 at 8:30 PM: When the nurse assess his R foot this morning, he was still in pain. PRN [MEDICATION(S)] was administered. NP [nurse practitioner] was informed about the incident. Received new order for 3 view X-ray of R [right] foot . X-ray was done. Received result, possible acute fracture of the necks of the second, third and fourth metatarsals. NP and his daughter were informed. New order to apply ace-[NAME], lab, and Orthopedic consult. Applied wrapped and ice-pack. Nursing will continue to monitor. c. On 4/18/22 at 11:03 PM: Patient is noted to have a boot to RLE [right lower extremity] related to recent fractures to RLE [right lower extremity]. Patient continues on prn acetaminophen and prn [MEDICATION(S)] which appears to be effective at this time. Patient did not c/o [complain of] pain during this shift and appears to be comfortable in bed. He is laying down with even and unlabored breathing. Call light is within reach and functioning. d. On 4/19/22 at 8:04 PM: Continue to have pain in R foot. PRN [MEDICATION(S)] was administered X2 [twice] today and applied ice-pack. Tolerated well. e. On 4/20/22 at 9:48 PM: Medicated for pain in right foot, x1 [one time]. Stated it helped. Will continue to monitor. f. On 4/25/22 at 1:58 PM: Resident went to his [NAME] [orthopedic] appointment today, MD [medical doctor] note of acute vs. Chronic fx [fracture] of right distal metarsals 2,3,4,5 with soft tissue injury of foot/ankle. It's non-surgical treatment as the recommendation. Non WB [weight bearing] right LE [lower extremity], continue with multi podus boot, compression and elevation. F/u [follow up] in 5 weeks with repeat imaging. Transportation .aware of appointment needed. g. 5/9/22 1:06 PM: Per [resident 11] Foot (sic) cna have been educated properly on how to use the hoyer properly [Note: this nursing progress note dated 5/9/22 is the only record that education was provided to the CNAs on the proper use of the Hoyer lift after the incident with resident 11.] The Event Report dated 4/17/22 was reviewed and each section of the report revealed the following: a. Event Information: completed b. Description: R foot got it by Hoyer lift, painful and abrasion on the top of the R foot c. Event Details: Physical Observation, Mental Status, Possible Contributing Factors, and Interventions were not completed. Notifications were made in a timely manner. d. Vital Signs: not completed e. Orders: no orders recorded f. Notes: progress notes from 4/17/22 until 5/9/22 included g. Evaluation: no further pain foot remains in protected boot and incident resolved with no further intervention needed Resident 11's medication administration record (MAR) showed the following documented pain scores for resident 11 from 4/17/22 through 4/29/22 [It should be noted that resident 11 experienced increased pain scores after the incident that occurred on 4/17/22]: a. On 4/17/22 at 9:02 AM, resident 11 reported a pain score of 4/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective b. On 4/17/22 at 4:13 PM, resident 11 reported a pain score of 5/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective c. On 4/18/22 at 6:42 AM resident 11 reported a pain score of 5/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective d. On 4/18/22 at 5:07 PM resident 11 reported a pain score of 6/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective e. On 4/19/22 at 6:56 AM resident 11 reported a pain score of 6/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective f. On 4/19/22 at 7:57 PM resident 11 reported a pain score if 6/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective g. On 4/20/22 at 7:30 PM resident 11 reported a pain score of 5/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective h. On 4/21/22 at 7:44 PM resident 11 reported a pain score of 5/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective i. On 4/22/22 at 7:46 AM resident 11 reported a pain score of 6/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective j. On 4/24/22 at 5:18 PM resident 11 reported a pain score of 8/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective k. On 4/25/22 at 7:58 PM resident 11 reported a pain score of 7/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective l. On 4/27/22 at 7:40 AM resident 11 reported a pain score of 5/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective m. On 4/27/22 at 10:20 PM resident 11 reported a pain score of 6/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective n. On 4/29/22 at 4:10 PM resident 11 reported a pain score of 8/10 and received [MEDICATION(S)]-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective Resident 11's x-ray results completed on 4/18/22 were reviewed. The x-ray findings stated profound osteopenia. Deformed the forefoot. Possible acute fractures of the necks of the second, third, and fourth metatarsals without laceration no radiodense foreign bodies. The x-ray impression stated possible acute fractures of the necks of the second, third, and fourth metatarsals. On 6/13/22 at 1:34 PM, an interview was conducted with the DON. The DON stated nobody claimed the incident with resident 11, so the investigation was started with the x-ray to see what injuries had occurred. The DON stated it was concluded that resident 11 had medical conditions that put him at risk for injury. The DON stated the facility provided education on proper use of the Hoyer lift with CNA's on a continual basis. The DON stated he was not able to educate the specific person involved in the incident because he was unable to determine which CNA caused the injury. The DON stated the facility had educated all CNAs in huddles and in-service meetings. On 6/13/22 at 4:22 PM, an interview was conducted with CNA 4 and CNA 5. CNA 4 stated they used the Hoyer lift to transfer resident 11. CNA 4 and CNA 5 both stated to use the Hoyer lift required two people. CNA 4 stated when she used 2 people when repositioning resident 11 using the Hoyer lift. CNA 4 stated she checked resident 11 to see if he needed his brief changed and would assist resident 11 to get dressed. CNA 4 stated resident 11 had to be rolled from side to side to get the sling for the Hoyer positioned correctly. CNA 4 stated they would bring in the Hoyer lift, hook resident 11 to the Hoyer, and lift him into his wheelchair. CNA 4 stated she ensured resident 11's catheter was safely in place and covered. CNA 4 stated resident 11 liked to have a gait belt around his knees and a strap around his left arm. CNA 5 stated two people were needed to get resident back in bed with the Hoyer. CNA 4 stated they made sure resident 11's arms were inside the sling for safety. CNA 4 stated she asked resident 11 if everything felt OK. CNA 4 stated resident 11 will say stop if he noticed something was wrong. CNA 5 stated they made sure the sling was in the right position before they lifted resident 11. CNA 4 and CNA 5 both stated they have had no accidents with resident 11.

Based on observation, interview, and record review, it was determined, for 3 of 39 sample residents, that the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was found to be at a harm level. Specifically, the facility was unable to demonstrate development and implementation of interventions for managing resident's dementia with behavioral disturbances. Resident identifiers: 9, 29 and 41. Findings include: Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/22 at 11:25 AM, an observation was made of resident 29 in her room. There was no staff member present in the room or outside the room. Resident 29 was observed sitting up in bed. An interview was attempted with resident 29, however resident 29 simply repeated back what the surveyor had asked. On 6/8/22 at 3:06 PM, an observation was made of resident 29 sitting in the lobby. Resident 29 was observed to be listening to music in her native language while kissing a doll in the face. Resident 29 then proceeded to put her left index finger up her own nose. Resident 29 then proceeded to get up from her chair and started to wander down the hall. Facility staff was observed to approach resident 29, who was standing outside of another resident's door. Resident 29 was subsequently offered snacks and redirected back to her room. Resident 29's records were reviewed on 6/9/22. Care plans revealed the following behavioral problems and approaches taken by facility: a. Problem: Resident 29 ingests non edible items related to [NAME]. Goal: Resident 29 will be kept safe from all hazards items she could ingest. Approach: We will place resident 29 on 1 to 1 to provide the constant amount of care resident 29 requires to prevent harm. Start Date: 6/9/22. [Note: This care plan was developed after the annual recertification survey was initiated.] b. Problem: Resident 29 was resistant to brief changes and cares at times. Goal: Resident 29 will accept assistance with cares. Approach(s): 1. Assess her resistance. Actively involve the resident in care. Express willingness to adjust regimen. 2. Respect and try to incorporate her culture in her daily cares. 3. Follow familiar routines/ staff when possible. 4. Convey an attitude of acceptance toward the resident. 5. Allow resident to choose options. Start Date: 6/9/22. [Note: This care plan was developed after the annual recertification survey was initiated.] c. Problem: Resident 29 experiences restlessness and fidgetiness at times. Goal: Resident 29 will have no negative outcomes related to restless and fidgetiness. Approach(s): 1. Offer her activities, music, her doll, walk PRN (as needed). 2. Assure basic needs are assessed. Start date: 6/8/22. [Note: This care plan was developed after the annual recertification survey was initiated.] d. Problem: Resident 29 experiences wandering and will rummage through others' belongings at times. Goal: Resident 29 will not injure/harm self secondary to wandering. Approach(s): 1. Involve significant support persons. 2. Remove resident from other resident's rooms and unsafe situations. 3. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). 4. Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. 5. Follow familiar routines when possible. Start date: 6/7/22. [Note: This care plan was developed after the annual recertification survey was initiated.] e. Problem: Resident 29 spits on desks, floors, and people. Start date: 5/1/22 Goals: Resident 29 will not spit on desk, floors, and people. Approach(s): 1. Resident 29 will be redirected PRN (as needed). Resident 29 will be offered a snack PRN. Resident 29 will be given a busy box PRN. Start date: 6/3/22. f. Problem: Resident 29 exhibits alteration in thought process manifested by cognitive impairment r/t (related to) dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; mood problem: anxiety; has little interest/pleasure in doing things; on hospice. Goals: 1. Resident 29 will participate in activities of importance/interest daily, as desired, through next review date. 2. Resident will engage, as desired, in activities of interest at least: 1 cognitive activity per week for retention of cognitive abilities as evidence by recalling memories during activities; 1 social activity per week for communication as evidence by verbalizing thoughts and ideas during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities through next review date. Approach(s): 1.1 Check for satisfaction with leisure choices. Supply with independent leisure materials PRN (as needed). Support independent leisure choices. 2.1 Invite, involve and encourage participation in activities of importance/interest including: family/ friend phone calls/visits, TV/movies, Native American (sic) music, pets, socials, outdoors, spiritual support, reminisce, &/or special events. 2.2 encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. 2.3 Provide with opportunities to recall long/short term memories to retain cognitive abilities during activities. 2.4 Provide adaptations to activities PRN (as needed): cognition: task segmentation; physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities. Start date: 4/15/22 An Minimum Data Set (MDS) dated [DATE] revealed resident 29 did not have a brief interview for mental status (BIMS) completed. The BIMS score was listed as unknown but resident 29 was identified as severely impaired in making decisions, regarding tasks of daily living. Resident 29 was not identified as a wandering risk or having any kinds of behavioral symptoms. No elopement assessment was done at upon admission. No significant change MDS document was completed about resident 29's behaviors. A hospital record dated 3/30/22 revealed that resident 29 had severe dementia and tended to eat inappropriate items frequently. The hospital record indicated that resident 29 was initially brought to the hospital by her son due to concern of ingesting antifreeze or bedbug chemicals. Resident 29 was subsequently intubated and taken to the Intensive Care Unit in critical condition due to ingestion of Diacetome, an organic pest control agent. It was noted during her hospitalization that resident 29 pulled out her nasojejunal (NJ) tube if not restrained due to her mental state of confusion. An xray report for resident 29 dated 4/20/22 indicated that there was Concern pstient (sic) swallowed thumb tacks about 2 hours ago patient was extremely combative and then the CNAs had to hold her in place. A skilled note dated 4/12/22 indicated that staff had been educated to keep items out of resident 29's reach due to her behaviors. A social services note dated 4/14/22 indicated that the resident rarely makes sense and eats non food items. A psychosocial assessment dated [DATE] indicated that resident 29 would hide and eat non food items. The assessment also indicated that resident 29 would steal other residents' food items to eat them, and did not like to give up the items once she had them. The assessment listed resident 29's behaviors as theft, wandering and combativeness. The facility dietary manager entered a note into resident 29's medical record on 5/3/22. The note indicated that resident 29 was observed by the dietary manager in the dining room eating unsafe items that she refused to spit out. Resident 29's progress note revealed the following entries: a. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. b. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. The Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice notified. Watched resident until she went to sleep. The staff checked on her again and she was found to be sound asleep. c. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. d. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made. e. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings as well as sometimes spitting on them. f. A nursing note dated 6/5/22 documented that resident 29 wandered into another residents room. The resident was awakened by [resident 29] rummaging through her room and told [resident 29] to leave. [Resident 29] began hitting and also spit on that resident. g. A nurse note dated 6/7/22 documented that I explained to hospice nurse again how resident (29)'s wondering (sic), spitting, playing with her feces, hitting and biting others is very disruptive to the other residents and that the other residents are/have been very upset. [Note: This note was later marked as invalid.] [Note: Monitoring for spitting on residents was implemented by facility staff on 6/3/22.] Resident 29's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/9/22 at 9:41 AM, an interview was conducted with CNA 9. CNA 9 stated she had heard that resident 29 tried eating a glove. CNA 9 stated that they suspected resident 29 had also drank body wash. CNA 9 stated there was a full bottle of body wash and then it was gone. CNA 9 stated that was about a week ago. CNA 9 stated that she notified the nurse on duty. CNA 9 stated that staff tried to put things outside of resident 29's reach. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated she had witnessed resident 29 eat the small plastic cups with butter in them. CNA 10 stated resident 29 messed with the cup with her fingers, broke it down and then plopped it in her mouth. CNA 10 stated resident 29 had not choked, Luckily she pulled it out. CNA 10 stated the language barrier made it hard to communicate with resident 29 to spit out the non-edible items. CNA 10 stated that resident 29 wandered and it was hard to find her because she liked to crouch down. CNA 10 stated she had not heard anything about resident 29 drinking hazardous liquids and had not been provided education to prevent resident 29 from eating or drinking non-food items. CNA 10 stated there was not enough staff to keep resident 29 safe and other residents safe from resident 29. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/6/22 an interview was conducted with resident 41. Resident 41 stated that 29 wandered into multiple resident rooms, spits on residents, breaks things, and steals items. Resident 41 stated that she had repeatedly told resident 29 to stop. On 6/9/22 a follow up interview was done with resident 41. Resident 41 stated that resident 29 had bitten staff members. Resident 41 stated that she felt violated that she had been spit on and pissed that resident 29 had been in her room going through her items. Resident 41 stated that another resident had been yelling at resident 29, calling her stupid. On 6/9/22 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she witnessed a staff member retrieve a rubber glove out of resident 29's mouth. LPN 4 stated that she reported that incident to the Director of Nursing and the Social Worker. LPN 4 stated that it was reported to me the other night that she (resident 29) was in another resident's room trying to drink lotion. LPN 4 stated that she reported that incident to the Director of Nursing. LPN 4 stated that she was aware that resident 29 likes to spit, and had witnessed resident 29 spitting on a facility staff member's desk. LPN 4 also stated that she had heard that resident 29 had spit on resident 9. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/9/22 at 4:18 PM, an interview was conducted with LPN 3. LPN 3 stated resident 29 drank bleach on 5/20/22. LPN 3 stated that apparently somebody had the bleach in her restroom and did not take it out. LPN 3 stated she saw the bottle in resident 29's hand and made the assumption that she drank it. LPN 3 stated that was the first time she was aware of resident 29 eating something that she was not suppose to. LPN 3 stated she notified the physician and hospice about what happened and was instructed to monitor her. LPN 3 stated she talked to the Director of Nursing (DON) the next day about it. LPN 3 stated that the DON told her to make sure everybody knew to put things away from resident 29. LPN 3 stated that resident 29 would do better in a memory care unit. On 6/8/22 at 2:59 PM, an interview was conducted with the DON. The DON stated that resident 29 admitted to the facility on her death bed. The DON stated that resident 29 woke up and started wandering. The DON stated that resident 29 then started behaviors of spitting and eating non-food items. On 6/9/22 at 12:43 PM, a follow up interview was conducted with the DON. The DON stated that resident 29 was a wanderer and will go where the wind takes her. The DON stated that resident 29 will go into rooms, squat in the rooms and look at the resident in the room. The DON stated that he was aware that resident 29 spat on other residents. The DON stated that facility staff were in the process of trying a new medication with resident 29 that would help reduce secretions so resident 29's spitting episodes would occur less frequently. The DON stated he is aware the resident 29 may have drank bleach but was unsure if she had actually ingested any. The DON stated they found resident 29 holding a bottle of bleach while in her room and believed resident 29 may have grabbed the bottle from the cleaning cart or a CNA may have left it in her room. The DON stated that the first thing they did was check the chemicals resident 29 may have ingested, and then they looked at the Material Safety Data Sheet (MSDS). The MSDS stated to monitor or nausea and vomiting. The DON stated the nurse did not call poison control because they were not sure if resident 29 had ingested it but stated they did call the resident's medical provider. The DON stated that the nurse was told by the provider to monitor for nausea and vomiting that night and according to documentation, resident 29 was able to sleep through the night. The DON stated that he believed education was provided to the housekeepers by someone else but he did not provide them with the education. The DON stated he educated CNAs that they were not allowed to pull anything from the housekeeping cart. In addition, the DON was also aware that a glove was pulled out of resident 29's mouth a couple of weeks ago. The DON stated that they knew the glove came from one of the rooms that had gloves in them. The DON stated that the only change after the incident was all the gloves were removed from resident 29's room. The DON stated that CNAs were educated to not have gloves in the hallway but then the DON stated that gloves were everywhere. The DON stated that no education was done with staff about preventing resident 29 from getting gloves in her mouth. The DON stated he had tried to discharge resident 29 to a memory care unit because resident 29 had not been receiving the appropriate level of care at the facility. [Cross refer to F600 and F689]

Based on interview, observation, and record review it was determined, for 1 of 28 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident. Specifically, the facility did not evaluate a resident for depression nor did the facility meet with the resident's family to discuss concerns the family might have in regards to the resident's behaviors and treatment by facility staff. Resident identifier: 27. HARM Findings include: Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 27 was interviewed on 10/10/17. Resident 27 stated that there was a Certified Nursing Assistant (CNA) that worked the graveyard shift that had been very rough with her and she did not like him to come into her room at all. Resident 27 stated that she had reported the incident to her son as well as one of the nurses. Resident 27 stated that the CNA was very mean when transferring her or moving her in bed and was rough with her and had hurt her when moving her. Resident 27 stated that she did not leave her room nor attend activities because, What's the point! No one cares about me, I might as well just remove my oxygen and see what happens. I wake up staring at these four walls and go to sleep staring at these four walls. There is no point in getting dressed to just lie in bed. Observations of resident 27 revealed an elderly woman in a hospital gown with disheveled hair. Resident 27 appeared angry and sad regarding her circumstances. On 10/11/17, the facility's abuse investigations were reviewed. No documentation could be found to show that the facility had investigated resident 27's concern or allegation that the CNA was rough and had hurt her. On 10/11/17 at 6:30 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 27 had reported to her, a couple of weeks ago, that a CNA had been rough while moving resident 27 in bed. RN 1 stated that she had not reported the allegation to anyone in Administration. RN 1 further stated that it was too hard to track down what CNA it was because the facility had been using Agency CNAs. RN 1 stated that she had just told resident 27 that she was in charge of her care and that if she (resident 27) was uncomfortable when a CNA was moving her to let them know she was uncomfortable. RN 1 further stated that she had passed the information onto other facility nurses and other CNAs. On 10/11/17 at 10:00 AM, resident 27's son and Power of Attorney (POA) was interviewed, via telephone. Resident 27's son stated that his mother (resident 27) had reported to him that a CNA, who worked the graveyard shift, had been rough with her and that she did not like the CNA or want him in her room. Resident 27's son stated that he had not said anything to the facility Administrator but he knew that his mother had reported the incident to a facility nurse. Resident 27's son further stated that he was not sure what to do with the information and had not had an IDT (Interdisciplinary Team) meeting with the facility so he could express his concerns. Resident 27's son stated that had the facility had an IDT with him, he would have had a forum in which to report the incident. Resident 27's son stated that he was currently trying to find a different facility in which to take his mother because he was unsatisfied with the care she had received and that his mother was now afraid to get out of bed because she only trusted the physical therapist to assist her in getting up. Resident 27's son further stated that he could not motivate his mother to get out of bed and do things for herself. He stated that she seemed to be feeling down and had expressed concerns of wanting to give up and not caring about anything. Resident 27's son stated that he did not know who to report those concerns to but was hoping he could figure out a way to motivate his mom so she could possibly get out of the facility. Resident 27's son further stated that had the facility discussed an anti-depressant, for his mother, with him, he would have agreed if it would have helped her. On 10/11/17 at approximately 1:45 PM, the facility Social Services Worker (SSW) and Corporate Licensed Clinical Social Worker (LCSW) were interviewed. The LCSW and SSW stated that the incident with resident 27 had not been reported to them and they had not investigated the concern/allegation. The LCSW stated that, We obviously have a reporting issue here. The LCSW confirmed that the facility had not been having IDTs nor updating care plans. Review of the facility SSW notes revealed the following notes: a. 8/17/17: .Upon interviewing resident, resident reported to not be depressed, but 'disgusted.' Resident did not know why she felt that way. Resident made many negative statements about herself and was self deprecating. Resident believes her children do not want to take care of her, that she is a burden to them, and she is being pushed from facility to facility. No documentation could be found to show that facility staff followed up on resident 27's feelings of disgust or her negative statements about herself. On 10/12/17, state survey staff were provided the following SSW note: Referred to assess possible depression, as (Resident 27) has said some things about why she is still living. Assessed suicidal ideation and completed the Geriatric Depression Scale. (Resident 27) scored just over normal (6). She has no plan for self harm. When I described clinical depression, she denied many of the trigger questions. Her son and POA was present in the room. I asked how he felt and he said she has changed due to the fall and worry about the future. (Resident 27) was in another rehab center and was recovering from a broken hip and she fell and broke her arm. She is afraid of moving and she feels the CNAs can not move her correctly. She said she only trusts (name) ((Physical Therapy Director)) to move her. She also said she does not get information on activities. Plan: I spoke with nursing about possible antidepressant based on her statements and her score on the GDS (Geriatric Depression Scale). Her son feels she could benefit from it and she is not making contact with other residents. I talked with (name) (( Assistant Director of Nursing)) about this and she will consult the physician. (Note: The above mentioned entry was made after state surveyors had discussed the concern, resident 27's depression, isolation, and negative statements, with the facility LCSW.)

Based on observation, interview and 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 and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident assessed as requiring the assistance of two staff members for transfers and locomotion in her room, only received the assistance of one staff member while ambulating in her room. Subsequently, the resident experienced a fall during ambulation and sustained a fractured fibula. Additionally, unidentified medications were observed in a resident's room for two consecutive days. Resident identifiers: 55 and 81. Findings include: 1. Resident 55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/6/16 at approximately 9:30 AM, resident 55 was interviewed. Resident 55 stated that she had fallen that morning, 6/6/16, walking back from the bathroom. Resident 55 stated that the Certified Nursing Assistant (CNA) was not holding the walker appropriately and that her legs had given out from underneath her and she had fallen. Resident 55 stated that she had told the CNA to hold onto the walker more securely due to feeling weak. On 6/7/16 resident 55's medical record was reviewed. Review of the medical record revealed a 5 day admission Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 55 as requiring extensive assistance with a 2 person physical assist with transfers and that resident 55 walked in her room with extensive assistance with a two person physical assist. Review of resident 55's care plan revealed a care plan initiated on 5/24/16 and modified on 6/7/16 for Falls. The care plan had an outcome of Will be free from Injury post fall. Facility staff implemented the following interventions dated 5/24/16: Morse Fall Risk Standard Precautions, Eval (evaluation) for Orthostatic hypotension, Slower position transition, Ensure glasses worn and lighting optimal, Consult physician for PT (Physical Therapy) or OT (Occupational Therapy), Intervene for Unsafe Behaviors effecting fall risk, Adjust medications if sedation affects mobility, Evaluate room for clutter, blocked pathways and intervene, Evaluate assistive devices for strength and safety, Evaluate routine and patterns to assist at times needed. On 6/7/16 facility staff added an additional intervention of 2 person transfer. It should be noted that the care plan did not contain the 2 person transfer intervention until after resident 55 fell and sustained the fracture. Additionally, resident 55 was assessed as requiring 2 people for assistance with ambulation and transfers prior to the fall. No documentation could be found in resident 55's care plan to indicate that facility staff were safe transferring or ambulating resident 55 with assistance from just one staff member. On 6/7/16 review of the progress notes revealed the following entries: 5/28/16: .She is extensive X1 (times 1) with ADLs (Activities of Daily Living) and setup for meals. She uses a wheelchair to ambulate. 6/2/16: .is WC (wheel chair) bound is a x2 (times 2) extensive assist to transfer and position change. ambulates in electric wc. 6/3/16: .is WC bound is a x2 extensive assist to transfer and position change. ambulates in electric wc. 6/4/16: .is WC bound is a x2 extensive assist to transfer and position change. ambulates in electric wc. 6/5/16: .WC bound is a x2 extensive assist to transfer and position change. ambulates in electric wc. 6/6/16: Pt (patient) was ambulating from bathroom to bed with walker and CNA (Certified Nursing Assistant). Pt. knees gave out, and she fell to the floor. ROM (range of motion) x4. She did not hit her head. Complained of pain in right ankle. She was able to bear weight on legs without difficulty. MD (Medical Doctor) notified via communication book. Has continued to complain of pain in R (right) ankle. Dialysis center called & said thay (sic) wanted to send her to the ER (emergency room ) for xrays after her dialysis. Received MD order for R ankle xray that can be done in facility when she returns. Information was relayed to dialysis. Daughter, (name of daughter) was notified by phone at 1130 (11:30 AM) of fall. 6/7/16: Received xray results of 'nondisplaced oblique distal fibular fracture extending into the distal tibiofibular joint. Ankle mortise is symmetric. Anterior and lateral ankle soft tissue swelling. No joint effusion. Small heel spur wiout (sic) erosion. No dislocations.' Called (name of physician) with results. New order received to send pt. to ER for stabilization of right leg. Notified daughter (name of daughter) by phone and she agreed twith (sic) plan of care. Facility van driver took pt to (name of local acute care hospital) ER with copy of x-ray, and a disc left by radiologist for ER staff to review. Copy of current medications and [DIAGNOSES REDACTED]. 6/7/16: Pt. returned to facility via RMC (Rocky Mountain Care) van driver in facility van. She returned with black walking boot intact to RLE (right lower extremity). She returned with papers stating to have pt. wear the boot at all times, even in bed. We are to have patient follow up with, (name) and orthopedic surgeon, as soon as possible. Paperwork states surgery is not likely, but that stabilization will be the goal for proper healing. Pt. assisted back to bed, and is non-weight bearing status on right lower extremity. On 6/7/16, resident 55 was re- interviewed. Resident 55 was tearful. Resident 55 stated that on 6/6/16 she was ambulating from the bathroom back to her bed using a walker. Resident 55 stated that a CNA was in the room with her and was not holding the walker securely. Resident 55 stated that she had been feeling weak. Resident 55 stated that her knees gave out and she went down. Resident 55 stated that the CNA then left the room. Resident 55 stated that the CNA did not say anything to her, she (the CNA) just left the room. Resident 55 stated that she was on the floor for about 15 to 20 minutes before facility staff came back and got her up off of the floor. On 6/7/16 at 10:00 AM, Certified Nursing Assistant (CNA) 6 was interviewed via telephone. CNA 6 stated that she had been assisting resident 55 when resident 55 fell . CNA 6 stated that resident 55 was using her walker to ambulate and that resident 55 had stated that she felt dizzy and then she (resident 55) fell down. CNA 6 stated that she was standing in front of resident 55's walker and holding onto the walker when resident 55 fell . CNA 6 stated that she left the room to get assistance from other staff members. CNA 6 stated that she asked another female CNA for assistance and was told by the other female CNA that she would not help her (CNA 6) and that she (CNA 6) needed to find someone else. CNA 6 stated that she then went and found a male CNA to assist her. CNA 6 stated that she thought that resident 55 waited five or less minutes on the floor before being assisted off of the floor. On 6/7/16 at 9:50 AM, CNA 7 was interviewed. CNA 7 stated that CNA 6 had come down to a patient room to get him so he could assist with getting resident 55 off of the floor. CNA 7 stated that he did not know how long resident 55 sat on the floor before being assisted back to bed as he (CNA 7) was helping another resident when the incident occurred and when he (CNA 7) came out of that resident's room he was asked by CNA 6 to assist with getting resident 55 off of the floor. On 6/7/16, the Minimum Data Set (MDS) Coordinator was interviewed. The MDS Coordinator stated that if a resident was assessed, on the MDS, as requiring two person extensive assistance, that was because the CNAs had charted the resident needed two person assistance. The MDS Coordinator stated that resident 55 was a two person assist and that she had assisted with toileting resident 55 previously and it had taken two staff members to assist resident 55 with the task. On 6/8/16, the facility Physical Therapy (PT) Director was interviewed. The PT Director stated that she had been working with resident 55 for some time. The PT Director stated that resident 55 was a resident at the facility previously and had been discharged home on home health. The PT Director stated that she had worked with resident 55 providing Physical Therapy at resident 55's home. The PT Director stated that she was glad when resident 55 decided to return to the facility because resident 55 had experienced a fall at home and was too weak to be at home. The PT Director stated that Physical Therapy had been working with resident 55 ambulating with her in the hallway using a walker. The PT Director stated that when they ambulated in the hallway with resident 55, one person would walk next to resident 55 utilizing a gait belt and another staff member would walk behind resident 55 with her motorized chair in case resident 55 became tired or weak she could sit in her motorized wheel chair. The PT Director stated that she had toileted resident 55 before, by herself, but she had also used a gait belt while providing assistance to resident 55. It should be noted that CNA 6 was not using a gait belt while providing assistance to resident 55 on the day that resident 55 fell in her room. 2. Resident 81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/6/16 at 10:41 AM, an observation was made of two halves of an unidentified white pill on resident 81's over the bed table. On 6/6/16 at 1:30 PM, an observation was made of two halves of an unidentified white pill on resident 81's over the bed table. On 6/7/16 at 7:30 AM, an observation was made of two halves of an unidentified white pill on resident 81's over the bed table. On 6/7/16 at 2:00 PM, an observation was made of two halves of an unidentified white pill on resident 81's over the bed table. On 6/7/16 at 12:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that leaving pills on residents' tables was not something that she would do. RN 1 stated that she would always make sure that residents would swallow their pills. On 6/7/16 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that should never happen. The DON stated that the medications should never be left at the resident's bedside.