Every finding on record at Rocky Mountain Care - Hunter Hollow

Based on interview and record review, the facility failed to ensure newly ordered hospice comfort medications were promptly implemented and administered as ordered by the physician. Specifically, for 1 out of 11 sampled residents, staff failed to enter and administer newly ordered end-of-life pain and anxiety medications, resulting in multiple missed doses over a two-day period.The facility developed and implemented a correction action plan before the survey start date. The facility's correction action plan, which was developed and implemented by [DATE], included the following measures: individual education for Nurse 1, facility wide education on end-of-life care and entering physician orders, resident interview and record review to identify any other medication error concerns, daily medication error audits, and implementation of a triple-check process for entering in physician orders. Resident identifier: 4.Resident 4 was admitted on [DATE] and again on [DATE] with a diagnosis of lymphocytic leukemia. Resident 4 was admitted to hospice services on [DATE] and expired on [DATE]. A facility reported incident revealed that on [DATE], Resident 4's spouse reported that the nursing staff failed to implement newly ordered hospice comfort medications, which were ordered on [DATE]. The assigned nurse reported that they received the first order from the hospice provider in the morning, did not get a chance to enter them, and received a second set or order at approximately 1:00 pm on the same day. The nurse acknowledged they reviewed the hospice orders, but stated he interpreted the latter orders as replacing the former scheduled medication orders. On [DATE], the surveyor reviewed Resident 4's Hospice orders.The hospice orders, dated [DATE], were reviewed and documented the following, Morphine 20 mg/mL concentrate 1 milliliter orally every 4 hours for moderate pain and Lorazepam 2 mg/mL concentrate 0.5 milliliter orally every 4 hours for anxiety/restlessness. Resident 4's Medication Administration Record was reviewed and the following medication errors were identified. Morphine 20 mg/mL concentrate 1 milliliter orally every 4 hours for moderate pain was not administered on [DATE] and 3 doses on the morning of [DATE]. Lorazepam 2 mg/mL concentrate 0.5 milliliter orally every 4 hours for anxiety/restlessness was not administered on [DATE] and 3 doses on the morning of [DATE]. On [DATE], the surveyor interviewed the Director of Nursing (DON), who stated that facility policy required floor nurses to enter new resident orders into the chart. The floor nurses must then provide the order to the unit manager or the Assistant DON (ADON) to verify that it was entered correctly. The DON also noted that if a nurse questioned an order, they should call to request clarification and refrain from entering the order until they are certain of its details. The facility's Performance Improvement Plan was reviewed and had been implemented by [DATE]. The plan included the following: Individual education for Nurse 1 was conducted on [DATE].Residents were interviewed to identify any concerns with missed medications or neglect on [DATE].All staff education on end-of-life care was conducted between [DATE]-[DATE].All staff education on clarification of orders was conducted between [DATE]-[DATE]. Daily medication audit reports and order listing reports in the electronic health records. were conducted every morning to identify missed medications and ensure orders matched. Daily meetings were conducted with corporate leadership to review medication error data and that a triple-check process (floor nurse entry, manager review, and DON review) had been established.

Based on observation and interview, the facility failed to ensure that an emergency call system was available and accessible in 5 out of 5 public and staff-accessible restrooms located in common areas used by residents. This failure created a risk that residents who utilized these restrooms would be unable to summon staff assistance in the event of an emergency or fall.Findings included: On 2/9/26 at 9:08 AM, an observation was made of the public restroom located in the Winder Lane hallway; the restroom was accessible to the public and a call light was not located within.On 2/9/26 at 9:09 AM, an observation was made of the public restroom located in the [NAME] Blvd (Boulevard) hallway, adjacent to the conference room; the restroom was accessible to the public and a call light was not located within.On 2/12/26 at 9:40 AM, an observation was made of the public restroom near the door labeled, About Hair; the restroom was accessible to the public and a call light was not located within.On 2/12/26 at 9:46 AM, an observation was made of the staff restroom located in the pass-through from the main common area to the Harmon's Way hallway; the restroom was accessible to the public and a call light was not located within.On 2/12/26 at 9:50 AM, an observation was made of an additional public restroom located in the [NAME] Blvd hallway, near the Director of Nursing's Office; the restroom was accessible to the public and a call light was not located within.On 2/12/26 at 10:08 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated the residents who are more independent would utilize the public restrooms. UM 1 further recalled a past incident where a resident became stuck in a public restroom.On 2/12/26 at 1:27 PM, an interview was conducted with the Administrator (ADM). The ADM stated that these bathrooms are accessible to residents but do not contain call lights. The ADM acknowledged that residents would not be unable to call for help if needed. The ADM stated he had notified corporate ownership via email regarding this issue on 12/22/25, but it had not yet been rectified.

Based on interview and record review it was determined, for 1 out of 30 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, blood sugar results were not recorded in the medical record for a resident who was given unprescribed insulin. Resident identifiers: 126. Findings included: Resident 126 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis of the right dominant side, dysphagia, acute kidney failure and chronic congestive heart failure. Resident 126's medical record was reviewed on 2/11/26. A progress note dated 11/23/25 at 8:35 AM documented, Med [medication] error, Pt [patient] mistakenly given 50 units glargine insulin. Pt is t2 [type 2] diabetic. Called DON [Director of Nursing], and [medical provider]. Will hold dapagliflozin and monitor BG [blood glucose] every hour for 24 hours. Any BG under 100 to be reported to [medical provider]. A progress note dated 11/23/25 at 7:32 PM documented, Patient on alert charting r/t [related to] administration of Insulin Glargine. BS and vital signs WNL [within normal limits]. POA [Power of Attorney], [name omitted], notified of incident and encouraged to call back with any follow up questions. Patient at baseline, no c/o [complaints of] discomfort. BS continues to be monitored Q [every] hour for 24 hours. Blood glucose levels were documented in the medical record on 11/23/25 at 8:35 AM, 11:36 AM and 2:31 PM. No other blood glucose records could be located in the medical record for 11/23/25 and were not provided by the facility. On 2/12/26 at 11:39 AM, an interview was conducted with the Director of Nursing (DON) who stated she kept binders in her office of the paper items that were completed by the staff. The DON stated she kept the original copy of the blood sugars and then a copy was given to the medical records department to scan into resident 126's medical record. The DON stated she kept copies in her office in case something happened with the computer system and that she was the only one who had access to the binders. The DON stated she was unable to find the blood sugar log in the binders. On 2/12/26 at 11:45 AM, a follow up interview was conducted with the DON who stated the staff did the blood sugar checks and she remembered writing them down. The DON stated there was only one person in the medical records department who would scan the resident documents into the medical record and she was unsure if she was behind. On 2/12/26 at 11:52 AM, an interview was conducted with the Regional Nurse Consultant (RNC) who stated she had spoken to offsite staff earlier in the week who helped with scanning documents into the medical records about needing more help with scanning in records. On 2/12/26 at 11:52 AM, an interview was conducted with a Medical Records (MR) staff member who stated that she scanned everything into the computer. MR stated there was a box at every nurses station for medical records that she would check every day and scan those items into the medical record. MR stated that she was not caught up on everything and it was a lot for one person but MR did not feel like she was horribly behind. MR stated that they recently changed their system, where the DON kept the original and MR would scan a copy into the medical record. MR stated that she only scanned something if it was in the box, otherwise she did not know it needed to be scanned. MR stated there was no one offsite that helped her scan documents into the medical records, it was only her. MR stated she was unsure where the blood sugar log was located.

Based on interview, observation, and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, the facility did not implement policies to address the underlying cause of the problems or identify how corrective actions were taken and monitored in regard to feeding tubes. Resident identifier: 90 Findings included: During the previous recertification survey completed on 1/11/24, Federal tag 693 was cited at a D level for feeding tube noncompliance. Resident 90 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, spastic quadripalegic cerebral palsy, epilepsy, gastrostomy, and dysphagia. A physician order dated 9/19/25, documented, Isosource 1.5 CAL (calorie) 0.07 G (gram) - 1.5 Liquid. Give 40 ml/hr (milliliter/hour) via G-Tube [gastrostomy] two times a day for Nutrition Tube Feed to run continuously X (times) 22 hrs (hours)/day with water flushes of 45mL/hr x 22 hours. Resident 90's feeding tube was observed to be running at the incorrect rate of 34 ml/hr on 2/9/26 at 8:50 AM, 2/10/26 at 9:28 AM and 2:45 PM, and 2/11/26 at 10:20 AM. On 2/11/26 at 10:37 AM, an interview was conducted with the Director of Nursing (DON) who stated the staff should always follow the rate the provider prescribed for the tube feeding. The DON stated resident 90's feeding rate should have been running at 40ml/hr and flushed with 45ml and to infuse for 22 hours. The DON stated the staff should label the tube feeding with the date, formula/flush, rate of the feeding, rate of flush, and their initials. The DON stated she would do education again and she would provide the facility policy. On 2/12/26 at 1:17 PM, an interview was conducted with the Administrator (ADM) who stated he thought the feeding tube issue had been resolved in their QAPI (Quality Assurance and Performance Improvement) meetings but he was not sure. The ADM stated in February of 2024 there was a QAPI note about compliance for feeding tubes, nursing charting, and life safety. The ADM stated there was nothing in the March 2024 QAPI that referenced feeding tubes. The ADM stated he was unable to find any audits or education that was completed. The ADM stated it was definitely something the QAPI team would discuss. [Cross reference 693]

Based on observation, interview, and record review, it was determined that, for 1 out of 30 sampled residents, the facility failed to ensure that each resident's environment remained as free of accident hazards as possible, and received adequate supervision and assistance with devices to prevent accidents. Specifically, a resident who had significant dysphagia was coughing while eating with no staff supervision or assistance. Resident identifier: 122.Findings included:On 2/10/26 at 12:26 PM, resident 122 was observed sitting upright in his wheelchair at a table and eating lunch in the dining room, staff member 1 was sitting with him. Resident 122 had a productive wet cough while he was drinking his milk. At 12:27 PM, staff member 1 got up, walked across the large dining room, got a clothing protector, and then returned and put the clothing protector on resident 122 and sat down next to him. Resident 122 was observed to have a productive wet cough after drinking milk. He then ate a spoonful of what looked like mashed potatoes with gravy and had another productive wet cough. At 12:34 PM, resident 122 could be heard grunting and clearing his throat as he continued to have a productive wet cough. At 12:42 PM, staff member 1 left the residents side and assisted another resident with their oxygen tank with resident 122 continuing drinking milk and coughing. While coughing he was observed to be grabbing the arm of his wheelchair with his left arm and trying to sit himself up. It should be noted that resident 122's right arm had weakness and was laying on a board that was placed on the right arm of the wheelchair. While coughing, food particles were observed to be propelled out of his mouth into the air and onto his chin and chest. Resident 122 started to clear his throat, took more sips of milk and continued to cough. The resident could be heard gurgling when coughing. Resident 122 was observed attempting to sit himself up again, milk was dribbling down his chin as he continued to have a productive wet cough. No staff were present with the resident during this time. At 12:44 PM, staff member 1 said resident 122's name as she walked by and left the dining room with an oxygen tank. At 12:45 PM, staff member 2 came up to the resident while the resident was gurgling and had milk going down his face. Staff member 2 wiped his mouth and asked the resident if he was done eating. Resident 122 was coughing and gurgling while he attempted to communicate with staff member 2. Staff member 2 removed the resident's clothing protector and asked him if he was okay. Resident 122 was leaning forward at this time and continued coughing. Staff member 2 called for Registered Nurse (RN) 3, who was down the hall and told her that resident 122 had a lot of mucus and that she thought he was choking on his milk or mucus. RN 3 stated that she was going to take him to his room. RN 3 and staff member 2 took resident 122 to his room and the staff shut the door. It should be noted that there was no documentation of this event in the medical record. Resident 122's medical record was reviewed from 2/9/26 through 2/12/26. Resident 122 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, facial weakness, dysarthria, dysphagia, aphasia, muscle weakness, dementia, cognitive communication deficit, contracture right knee, and ataxia. A physician's order dated 10/3/25 indicated a mechanical soft ground texture, thin consistency, minced and moist diet. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated resident 122 had moderately impaired cognitive skills for daily decision making. It further indicated resident 122 had impairment to the upper extremity on one side, was provided supervision or touching assistance with eating, was provided substantial/maximal assistance to go from a lying position to a sitting position and to go from a sitting position to a standing position. It further indicated resident 122 had a loss of liquids/solids from mouth when eating or drinking, held food in mouth/cheeks or residual food in mouth after meals, and did not cough or choke during meals or when swallowing medications. The Care Plan Report with a Focus dated 10/4/25 indicated, [Resident 122] is at risk for nutritional deficits secondary to stroke, dysphagia, aphasia, ataxia, dementia, anxiety, insomnia, restless/agitation, pruritus, lupus anticoagulant syndrome, gout, afib [atrial fibrillation], dysarthria, facial weakness Diet NAS [no added salt] Regular diet, Mechanical Soft MM5 [Minced and Moist], Thins liquids Updated likes and dislikes NKFA [no known food allergies] will assist as needed or requested; with an intervention that included, Provide assistance with meals, PRN [as needed]. A provider progress note dated 1/19/26 at 11:00 AM indicated, .Patient experienced clinical deterioration since last visit on 01/13/2026 with development of acute respiratory symptoms.Given patient's documented dysphagia and high risk for aspiration pneumonia maintained on mechanical soft ground texture diet, clinical presentation is most consistent with aspiration pneumonia.Patient continues with significant dysphagia as a direct result of cerebral infarction, placing him at high risk for aspiration pneumonia. Maintaining aspiration precautions during all meals. Patient is maintained on mechanical soft ground texture diet for safety. Continuing speech therapy for swallowing exercises and techniques.Current acute pneumonia presentation is consistent with aspiration event given documented dysphagia and aspiration risk. Will continue strict aspiration precautions and dietary modifications .Speech therapy continues to work with patient on swallowing exercises and techniques to improve oropharyngeal function. Maintaining aspiration precautions during all meals with mechanical soft ground texture diet. Patient demonstrated ability to feed himself with left hand during today's visit without difficulty, though significant dysphagia persists. It should be noted that resident 122 was discharged from SLP (Speech-Language Pathology) services on 11/10/25 and had an evaluation completed on 12/22/25 which indicated that no skilled SLP services were warranted at that time. No other speech therapy treatment documents were provided. A provider progress note dated 2/3/26 at 1:00 PM indicated, .Significant post-stroke dysphagia with high aspiration risk. Recent aspiration pneumonia on 01/19/2026 treated with levofloxacin, completed 01/25/2026 with resolution. Now presents with acute bronchitis on 02/03/2026 likely related to aspiration risk. Maintained on mechanical soft ground texture diet with aspiration precautions during all meals. Patient feeds himself with left hand. Continue speech therapy for swallowing exercises. Monitor closely for recurrent aspiration events. A provider progress note dated 2/5/25 at 8:30 AM indicated, The patient is currently on doxycycline 100 mg [milligrams] PO [by mouth] twice daily for presumed pneumonia following significant symptoms of fever, coughing, and malaise a couple of days ago concerning for aspiration pneumonia. The patient has a well-documented history of aspiration pneumonia due to significant dysphagia and is unable to follow directions for meals, frequently not sitting up properly during eating. A provider progress note dated 2/9/26 at 1:15 PM indicated, .The patient's significant aspiration risk secondary to dysphagia from cerebrovascular accident continues to require close monitoring with maintenance of mechanical soft ground texture diet and strict aspiration precautions during all meals. On 2/11/26 at 1:12 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she was over the RNA (Restorative Nursing Assistant) program and that if a resident was supposed to be supervised while eating they were supposed to be in the dining area during meal times and that one staff member needed to be in the room. The MDS Coordinator stated that there was a document that listed residents who received physical and occupational therapy recommendations for the RNAs to follow but was not sure if that included speech therapy recommendations because those did not usually come through the signed paperwork. On 2/12/26 at 11:00 AM, an interview was conducted with RNA 1 and she stated that as an RNA she watched dining and passed out food trays. RNA 1 stated that they used to have a table in the dining room where residents who needed assistance to eat would sit at but that they were not doing that anymore. On 2/12/26 at 11:05 AM, an interview was conducted with RNA 2 and she stated that MDS provided a list of residents who needed supervision or assistance with eating but that resident 122 was not on her list. RNA 2 stated the resident needed to be watched but he was not on the list. RNA 2 stated resident 122 coughed up food a lot, everyday, and that RNA 2 noticed it was getting worse last week and that she notified the nurse last week. RNA 2 stated that before last week resident 122 was eating fine. On 2/12/26 at 11:21 AM, an interview was conducted with the Director of Rehabilitation (DOR) and she stated that resident 122 was not currently receiving speech therapy services. The DOR stated that nursing should have notified them if the resident had any changes of condition, and then speech therapy would evaluate them and do their own assessment. The DOR stated she would have expected staff to watch him eat. The DOR stated RNAs have a designated restorative dining table where residents who needed an additional level of support for eating, like strict aspiration precautions, would sit and had staff there to supervise and assist them. The DOR stated she recently heard that the restorative dining table was not being used anymore but that she recently confirmed with the Administrator that it was still being used. The DOR stated if a resident needed strict aspiration precautions staff should have been ensuring the resident was awake and alert, swallowing before taking another bite, making sure the resident was sitting upright, and watching for any overt signs of aspiration. The DOR stated resident 122 had zero awareness of his abilities. The DOR stated that nobody had reported to her that resident 122 was coughing more while eating or had aspiration pneumonia and that if they had they would have reevaluated him. On 2/12/26 at 11:39 AM, an interview was conducted with Registered Nurse (RN) 2 and she stated resident 122 was to receive supervision when eating but that he would feed himself. RN 2 stated he usually went to the dining area to eat, but no CNA (Certified Nursing Assistant) or RNA was designated to watch him. RN 2 stated he coughed off and on when he ate and that he was put on antibiotics for possible pneumonia or bronchitis. RN 1 stated nobody had reported to her that resident 122 was choking or coughing more than normal lately. On 2/12/26 at 11:46 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated she was notified by a nurse last week that resident 122 was having increased difficulty eating and spitting out food and that she was planning on calling his daughter. The NP stated resident 122 had two strokes and was likely to aspirate and that there was nothing to do with him. When asked what strict aspiration precautions from her charting meant, she stated that it was put in by AI (Artificial Intelligence) and that staff were to follow what the facility protocol was. On 2/12/26 at 12:13 PM, an interview was conducted with MDS Support and she stated that there were no directions for resident 122 to be watched and that he was not on dining observations but he should have been. On 2/12/26 at 12:20 PM, an interview was conducted with the Director of Nursing (DON) and she stated resident 122 had intermittent confusion and dysphagia so he was on a mechanical soft diet to help him with swallowing. The DON stated they usually had staff in the dining room and they oversaw everyone in the dining room. The DON stated staff watched him for coughing and choking while eating. The DON stated that they were going to have speech therapy reevaluate him and update the care plan with interventions for what staff needed to do to assist him with eating.

Based on observation, interview, and record review, it was determined that, for 1 out of 30 sampled residents, the facility failed to provide the required specialized rehabilitation services, speech-language pathology. Specifically, one resident experienced a change in his eating abilities and speech therapy was not notified. Resident identifier: 122. Findings included: On 2/10/26 at 12:26 PM, resident 122 was observed sitting upright in his wheelchair at a table and eating lunch in the dining room, staff member 1 was sitting with him. Resident 122 had a productive wet cough while he was drinking his milk. At 12:27 PM, staff member 1 got up, walked across the large dining room, got a clothing protector, and then returned and put the clothing protector on resident 122 and sat down next to him. Resident 122 was observed to have a productive wet cough after drinking milk. Resident 122 then ate a spoonful of what looked like mashed potatoes with gravy and had another productive wet cough. At 12:34 PM, resident 122 could be heard grunting and clearing his throat as he continued to have a productive wet cough. At 12:42 PM, staff member 1 left the residents side and assisted another resident with their oxygen tank; resident 122 continued drinking milk and coughing. While coughing he was observed to be grabbing the arm of his wheelchair with his left arm and trying to sit himself up. It should be noted that resident 122's right arm had weakness and was laying on a board that was placed on the right arm of the wheelchair. While coughing, food particles were observed to be propelled out of his mouth into the air and onto his chin and chest. Resident 122 started to clear his throat, took more sips of milk and continued to cough. The resident could be heard gurgling when coughing. Resident 122 was observed attempting to sit himself up again, milk was dribbling down his chin as he continued to have a productive wet cough. No staff were present with the resident during this time. At 12:44 PM, staff member 1 said the resident's name as she walked by and left the dining room with an oxygen tank. At 12:45 PM, staff member 2 came up to the resident while the resident was gurgling and had milk going down his face. Staff member 2 wiped the resident's mouth and asked the resident if he was done eating. Resident 122 was coughing and gurgling while he attempted to communicate with staff member 2. Staff member 2 removed resident 122's clothing protector and asked him if he was okay. Resident 122 was leaning forward at this time and continued coughing. Staff member 2 called for Registered Nurse (RN) 3, who was down the hall and told RN 3 that resident 122 had a lot of mucus and that she thought the resident was choking on his milk or mucus. RN 3 stated that she was going to take the resident to his room. RN 3 and staff member 2 took resident 122 to his room and the staff shut the door.It should be noted that there was no documentation of this event in the medical record.Resident 122's medical record was reviewed from 2/9/26 through 2/12/26.Resident 122 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, facial weakness, dysarthria, dysphagia, aphasia, muscle weakness, dementia, cognitive communication deficit, contracture right knee, and ataxia.A physician's order dated 10/3/25 indicated speech therapy to evaluate and treat as needed.A significant change in status Minimum Data Set (MDS) dated [DATE] indicated resident 122 had moderately impaired cognitive skills for daily decision making. It further indicated resident 122 had impairment to the upper extremity on one side, was provided supervision or touching assistance with eating, was provided substantial/maximal assistance to go from a lying position to a sitting position and to go from a sitting position to a standing position. It further indicated resident 122 had a loss of liquids/solids from mouth when eating or drinking, held food in mouth/cheeks or residual food in mouth after meals, and did not cough or choke during meals or when swallowing medications.The Care Plan Report with a Focus dated 10/4/25 indicated, [Resident 122] is at risk for nutritional deficits secondary to stroke, dysphagia, aphasia, ataxia, dementia, anxiety, insomnia, restless/agitation, pruritus, lupus anticoagulant syndrome, gout, afib [atrial fibrillation], dysarthria, facial weakness Diet NAS [no added salt] Regular diet, Mechanical Soft MM5 [Minced and Moist], Thins liquids Updated likes and dislikes NKFA [no known food allergies] will assist as needed or requested; with an intervention that included, Provide assistance with meals, PRN [as needed].A provider progress note dated 1/19/26 at 11:00 AM indicated, .Patient experienced clinical deterioration since last visit on 01/13/2026 with development of acute respiratory symptoms.Given patient's documented dysphagia and high risk for aspiration pneumonia maintained on mechanical soft ground texture diet, clinical presentation is most consistent with aspiration pneumonia.Patient continues with significant dysphagia as a direct result of cerebral infarction, placing him at high risk for aspiration pneumonia. Maintaining aspiration precautions during all meals. Patient is maintained on mechanical soft ground texture diet for safety. Continuing speech therapy for swallowing exercises and techniques.Current acute pneumonia presentation is consistent with aspiration event given documented dysphagia and aspiration risk. Will continue strict aspiration precautions and dietary modifications .Speech therapy continues to work with patient on swallowing exercises and techniques to improve oropharyngeal function. Maintaining aspiration precautions during all meals with mechanical soft ground texture diet. Patient demonstrated ability to feed himself with left hand during today's visit without difficulty, though significant dysphagia persists.It should be noted that resident 122 was discharged from SLP (Speech-Language Pathology) services on 11/10/25 and had an evaluation completed on 12/22/25 which indicated that no skilled SLP services were warranted at that time. No other speech therapy treatment documents were provided. A provider progress note dated 2/3/26 at 1:00 PM indicated, .Significant post-stroke dysphagia with high aspiration risk. Recent aspiration pneumonia on 01/19/2026 treated with levofloxacin, completed 01/25/2026 with resolution. Now presents with acute bronchitis on 02/03/2026 likely related to aspiration risk. Maintained on mechanical soft ground texture diet with aspiration precautions during all meals. Patient feeds himself with left hand. Continue speech therapy for swallowing exercises. Monitor closely for recurrent aspiration events.A provider progress note dated 2/5/25 at 8:30 AM indicated, The patient is currently on doxycycline 100 mg [milligrams] PO [by mouth] twice daily for presumed pneumonia following significant symptoms of fever, coughing, and malaise a couple of days ago concerning for aspiration pneumonia. The patient has a well-documented history of aspiration pneumonia due to significant dysphagia and is unable to follow directions for meals, frequently not sitting up properly during eating.A provider progress note dated 2/9/26 at 1:15 PM indicated, .The patient's significant aspiration risk secondary to dysphagia from cerebrovascular accident continues to require close monitoring with maintenance of mechanical soft ground texture diet and strict aspiration precautions during all meals.On 2/12/26 at 11:05 AM, an interview was conducted with Restorative Nursing Assistant (RNA) 2 and she stated that MDS provided a list of residents who needed supervision or assistance with eating but that resident 122 was not on her list. RNA 2 stated resident 122 needed to be watched but he was not on the list of people who needed supervision or assistance with eating RNA 2 stated resident 122 coughed up food a lot, everyday, and that she noticed it was getting worse last week and that she notified the nurse last week. RNA 2 stated that before last week resident 122 was eating fine.On 2/12/26 at 11:21 AM, an interview was conducted with the Director of Rehabilitation (DOR) and she stated that resident 122 was not currently receiving speech therapy services. The DOR stated that nursing should have notified them if the resident had any changes of condition, and then speech therapy would evaluate them and do their own assessment. The DOR stated that nobody had reported to her that resident 122 was coughing more while eating or had aspiration pneumonia and that if they had they would have evaluated him.On 2/12/26 at 11:46 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated she was notified by a nurse last week that resident 122 was having increased difficulty eating and spitting out food and that she was planning on calling the resident's daughter. The NP stated resident 122 had two strokes and was likely to aspirate and that there was nothing to do with him.On 2/12/26 at 12:20 PM, an interview was conducted with the Director of Nursing (DON) and she stated resident 122 had intermittent confusion and dysphagia so he was on a mechanical soft diet to help him with swallowing. The DON stated staff watched the resident for coughing and choking while eating. The DON stated that they were going to have speech therapy reevaluate him and update the care plan with interventions for what staff needed to do to assist him with eating.

Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 30 sampled residents, a resident who received medication for diabetes mellitus did not have those medications available from the pharmacy for administration. Resident identifier: 97. Findings included: On 2/9/26 at 9:38 AM, an interview was conducted with resident 97 and he stated that he had not received his GLP1 (glucon-like peptide-1) shot (a medication for diabetes) that was due three days ago. Resident 97 stated he was told by staff that it was always given late because the pharmacy did not deliver it.Resident 97's medical record was reviewed from 2/9/26 through 2/12/26.Resident 97 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy and chronic kidney disease.The current physician's order dated 2/9/26 at 2:43 AM indicated, Tirzepatide Subcutaneous Solution Auto-injector 10 MG [milligrams]/0.5ML [milliliters] (Tirzepatide) Inject 10 mg subcutaneously at bedtime every Mon [Monday] for Diabetes.The Medication Administration Record (MAR) indicated resident 97 was administered Tirzepatide late 3 times between 9/1/25 through 2/11/26 and missed doses for the weeks of 1/1/26 and 1/31/26.Orders- Administration Notes were reviewed from 9/18/25 through 2/8/26 with multiple notes that indicated Tirzepatide was not given due to it not being available.On 2/12/26 at 10:53 AM, an interview was conducted with Registered Nurse (RN) 2 who stated that Tirzepatide was hard to get from the pharmacy because it needed insurance to approve of it. RN 2 stated it should have been administered weekly and usually on Fridays but the pharmacy did not send it on time. RN 2 stated when medications get close to running low they were supposed to reorder it from the pharmacy before it ran out.On 2/12/26 at 12:36 PM, an interview was conducted with the Director of Nursing (DON) who stated that the nurses needed to contact the pharmacy to order the medication and that the residents should be getting their medications on time, and if it was not, the nurses should have notified the doctor.

Based on observation, interview and record review the facility failed to ensure 1 out of 30 residents receiving a tube feeding received appropriate treatment and services to prevent complications. Specifically, observations revealed the tube feeding was not infusing at the rate prescribed by the provider. Resident identifier: 90 Findings included: Resident 90 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spastic quadripalegic cerebral palsy, epilepsy, gastrostomy and dysphagia. Resident 90 was NPO (nothing by mouth).A physician order dated 9/19/25 documented, Isosource 1.5 CAL (calorie) 0.07 G (gram) - 1.5 Liquid. Give 40 ml/hr (milliliter/hour) via G-Tube [gastrostomy tube] two times a day for Nutrition Tube Feed to run continuously X (times) 22 hrs (hours)/day with water flushes of 45mL/hr x 22 hours.On 2/9/26 at 8:50 AM, an observation was made of the tube feeding at resident 90's bedside. The tube feeding pump was infusing at 34 ml/hr. A sticker was observed on the bag that documented the feeding was started on 2/8/26 at 2:15, no initials and no information of the type of feeding that was in the bag were observed. A bag of fluid was also observed with a date of 2/8/26, no indication of what the fluid was, the time it was hung, or initials were observed. On 2/10/26 at 9:28 AM, an observation was made of the tube feeding at resident 90's bedside. The tube feeding was observed to be infusing at 34 ml/hr. There was a sticker on the bag that documented the feeding was started on 2/9/26 at 2:19, AM or PM was not documented on the bag, no initials and no information of the type of feeding that was in the bag were observed. A bag of fluid was also observed with a date of 2/9/26; no indication of what the fluid was, the time it was hung, or initials were observed. On 2/10/26 at 2:45 PM, resident 90's feeding tube was observed to be infusing at 34ml/hr. The label on the feeding bag did not indicate what type of feeding was in the bag. On 2/11/26 at 10:20 AM, an interview was conducted with Registered Nurse (RN) 1 who stated the tube feeding for resident 90 was supposed to be running Isosource at 34-36 ml/hr. RN 1 stated that she had just changed resident 90's tube feeding bag. RN 1 stated the nurses were supposed to look in the orders for the feeding rate. An observation was made of RN 1 looking in resident 90's medical record orders and stated the feeding should be infused at 40ml/hr with a 45ml/hr flush. RN 1 and this surveyor entered resident 90's room and the tube feeding was observed to be infusing at 34ml/hr. RN 1 stated the feeding rate was wrong and should have been 40ml/hr. RN 1 stated the staff should put the name of the feeding, the date and time and who hung the feeding on the sticker of the bag. RN 1 was observed to change the rate of the feeding to 40ml/hr. She stated she did not know how long the resident had only been getting 34ml/hr instead of 40ml/hr.On 2/11/26 at 10:37 AM, an interview was conducted with the Director of Nursing (DON) who stated the staff should always follow the rate the provider prescribed for the tube feeding. The DON stated resident 90's feeding rate should have been running at 40ml/hr, flushed with 45ml and to run for 22 hours. The DON stated the staff should label the tube feeding with the date, formula/flush, rate of the feeding, rate of flush, and their initials. The DON stated she would do staff education again.Review of a facility policy titled, Care and Treatment of Feeding Tubes with a revision date of April 2025, revealed .1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. 9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided: . e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders.

Based on interview and record review it was determined, for 1 of 11 sampled residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident was not provided two person assistance during a brief change, which led to a fall and subsequent fractures. This resulted in a finding of harm for resident 5. Resident identifiers: 5. Findings included: Resident 5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included multiple sclerosis, wedge compression fracture of third lumbar vertebra, paraplegia, and neuromuscular dysfunction of bladder. Resident 5's medical record was reviewed on 12/22/25. A progress note dated 11/15/25 at 12:12 PM stated Aide came to nurse stating that [resident 5] was on the floor, nurse found her on her side next to her bed. She stated she rolled to be changed and was rolled too far and rolled off the bed. Scratches on face from metal side rail seen on face. When this nurse said she would assess she said 'No, I just want to be sent to the hospital; I know what I need' she also refused staff help from getting her off the floor and said she would wait for [ambulance service]. Notified NP [Nurse Practitioner], DON [Director of Nursing], and admin [Administrator], sent with [ambulance service]. A progress note dated 11/15/25 at 8:52 PM documented that the hospital intended to admit resident 5 due to bilateral femur fractures. On 11/15/2025 at 9:21 pm, the facility reported the incident to the State Survey Agency. The facility investigation, reviewed on 12/22/25, contained the following statement: [Resident 5] was interviewed about the incident before she left for the [local hospital] on 11/15/2025 and she was interviewed further at the hospital on [DATE]. [Resident 5] stated that she was being changed by her CNA [Certified Nursing Assistant] and she was rolling to her left side. [Resident 5] states she was holding on to the positioning bar but let go of the positioning bar to grab her catheter, then lost control sliding off the bed. Her lower body fell off the bed first, then her face scraped the position bar. [Resident 5] was asked if she was to [sic] close to the edge of the bed and she said she could have been. The facility investigation contained the following interview with CNA 1: I was changing [Resident 5's] brief and when she rolled over I helped her hold her leg, but she let go of the bed rail to grab her catheter and that's when she lost control and fell from her side. I tried to hold her but she had lost control from her hips down. The facility investigation contained the following statements: [DON] was interviewed about the allegation and stated that [Resident 5] was at risk of falling due to having Multiple Sclerosis, past falls, depression, and opioid use. [Resident 5] was also on an air mattress and had bilateral side rails to help with bed mobility. [Resident 5] had a care plan for 2 person assist for transferring due to being at risk of falling. [Resident 5] did not have a care plan for 2-person bed mobility, and she should have had one because she was using a [sic] air mattress. The conclusion of the facility investigation was verified due to Resident 5 being on an air mattress but not having a care plan for 2 person assist for bed mobility. As a result of the verified investigation the facility listed the following corrective actions taken: The facility has completed a building audit on all residents that are on an air mattress on 11/17/2025 and an in-service has been done with CNA's to educate them on all residents that are on an air mattress need to be 2 person assist for bed mobility. Observe 5 staff during care (bed mobility, transfer, repositioning) weekly X4 weeks; then 5 staff monthly X2 months. Any resident that is on an air mattress will have a care plan for a 2 person assist for bed mobility. On 10/10/25, resident 5's provider ordered an air mattress. A care plan intervention dated 5/2/25 initiated the intervention: Hoyer lift for transferring with two person total assist. A care plan intervention dated 11/15/25 initiated the intervention: [Resident 5] has Air Mattress, needs two person assisted cares. On 12/22/25 at 2:57 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that she was notified of residents requiring a two person assist when she received report at shift change. NA 1 was unaware of any changes in care for residents with an air mattress, noting that the only resident she cared for who had an air mattress required a one person assist. On 12/22/25 at 3:06 PM, an interview was conducted with CNA 2. CNA 2 stated that she knew resident requirements for a two person assist from the shift change report or based on her observations of the resident. CNA 2 stated if a resident was unable to hold themselves up during care that she would request help from another CNA. CNA 2 stated that a resident on an air mattress could require a one- or two-person assist, depending on their individual ability to help with positioning. CNA 2 stated that she cared for a resident who used an air mattress and required a one person assist because he could roll over and support himself. On 12/22/25 at 2:00 PM, an interview was conducted with the DON. The DON stated that because resident 5 was on an air mattress she should have been a two person assist at the time of the incident. The DON stated that following the incident, the facility updated the care plans for all residents using an air mattress to require a two person assist. The DON stated that they provided education at an all staff meeting and nursing management went to individual staff to educate them. The DON stated that staff could use the Kardex tool in the electronic medical records to determine if a resident is a one person or a two person assist. The DON stated that after CNAs were provided the education management had been making observations of cares and transfers to make sure they were doing the two person assist when care planned.

Based on interview, observation, and record review, it was determined that the facility failed to adhere to its established infection prevention and control program. Specifically, a staff member was observed not to wash or sanitize their hands between resident rooms. On June 26, 2025 at 10:50 AM, the surveyor observed certified nursing assistant (CNA) 1. CNA 1 exited a resident's room designated by posted signage for enhanced barrier precautions. The displayed signage required hand hygiene upon entry and exit, as well as the use of gowns and gloves for high-contact resident care, including tasks such as dressing, bathing, transferring, linen changes, hygiene, and toileting assistance. CNA 1 was observed to be carrying a bag of garbage, which appeared to be soiled briefs or linens, and a water mug. After CNA 1 handed the mug to another staff member and discarded the garbage, CNA 1 did not perform hand hygiene. Subsequently, CNA 1 entered a different resident's room without sanitizing hands prior to entry. The surveyor interviewed CNA 1 on June 26, 2025, at 1:05 PM. CNA 1 stated that the room with enhanced barrier precautions was for a resident with a wound, and CNA 1 stated that the wound had healed and she did not think the resident required the enhanced barrier precautions. CNA 1 stated that she did not wear a gown or gloves when providing cares to the resident in that room. The surveyor interviewed the Director of Nursing (DON) on June 26, 2025, at 1:30 PM. The DON stated that the resident in the room with enhanced barrier precautions had a wound, so if staff were to enter the room and provide cares, the staff member should be wearing a gown and gloves. The surveyor reviewed the facility's Enhanced Barrier Precaution policy, which was last updated in April of 2025. The policy stated that enhanced barrier precautions are initiated for residents with wounds. The policy stated that all staff are expected to comply with all designated precautions. The surveyor reviewed the facility's Hand Hygiene Policy, which was last updated in April of 2025. The Hand Hygiene Policy stated that staff must either clean their hands with soap and water or an alcohol based hand rub between resident contacts, after handling contaminated objects, and before and after handling clean or soiled dressings.

Based on observation, interview, record review, and policy review, the facility failed to ensure 1 (Resident #91) of 10 residents receiving tube feeding received appropriate treatment and services to prevent complications. Specifically, observations revealed the tube feeding formula bottle for Resident #91 was not dated or timed when it was initiated to ensure the formula was not administered beyond 24 hours. Findings included: Review of a facility policy titled, Enteral Medication Administration, dated March 2022, revealed, Supplies should be dated when opened and must be replaced every 24 hours. Review of a facility policy titled, Care and Treatment of Feeding Tubes, revised in June 2023, revealed, 9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided: e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders. f. Ensuring that the product has not exceeded the expiration date. A review of Resident #91's Resident Face Sheet indicated the facility admitted Resident #91 on 04/12/2023 with diagnoses that included dysphagia (difficulty swallowing foods or liquids) and dysarthria (slurred speech) following a cerebral infarction (stroke). A review of Resident #91's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2023, revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had difficulty swallowing or pain when swallowing. The MDS also revealed the resident utilized a feeding tube and received 51 percent or more calories and liquids through tube feeding. A review of Resident #91's Care Plan problem area, initiated 04/12/2023, revealed the resident required a feeding tube, which put the resident at risk for nutritional deficits and other medical complications. The facility developed interventions that directed staff to ensure the tube feeding supplies, formula, and tubing were changed as ordered. A review of Resident #91's physician Orders revealed an order started on 01/03/2024 for Jevity 1.2 Cal (lactose-reduced tube feeding formula with fiber) to run at 60 milliliters per hour (ml/hr) via gastric tube and a water flush at 20 ml/hr, continuously, 24 hours per day. The order indicated the tube feeding may be disconnected for therapy as needed. A review of Resident #91's Medication Administration Record [MAR], dated 01/01/2024 through 01/11/2024, revealed staff documented that Jevity tube feeding was administered as ordered. On 01/08/2024 at 2:35 PM, an observation revealed Resident #91's Jevity tube feeding formula was infusing at 60 ml/hr. The observation revealed the tube feeding formula was not labeled with the date or time the formula was initiated. On 01/10/2024 at 8:55 AM, an observation revealed Resident #91's Jevity tube feeding formula was infusing at 60 ml/hr and a bag of water was present. There was no label with the date or time the tube feeding formula was initiated. During an interview on 01/10/2024 at 9:00 AM, Registered Nurse (RN) #8 indicated both the tube feeding formula and the water bag were changed every 24 hours. RN #8 noted that, once the formula and water bag were changed, it was documented in the resident's electronic health record (EHR). RN #8 indicated the date and time was also documented on the formula container and the water bag. RN #8 stated the documentation of the date and time was important because the formula was only good for 24 hours. RN #8 indicated she remembered she changed Resident #91's formula and water bag at approximately 6:30 AM because the infuser was beeping when she came in for her shift. However, RN #8 indicated she forgot to document the date or time on Resident #91's formula container or water bag. During an interview on 01/11/2024 at 9:03 AM, RN #9 indicated the frequency to change a tube feeding was dependent on the physician's order. RN #9 indicated all residents were currently on a continuous feeding 24 hours per day. RN #9 stated once the feeding was changed, staff documented in the EHR and documented the date and time on the formula container and water bag. RN #9 indicated it was important to document the date and time because staff needed to know how long the feeding had been running because it was only good for 24 hours. During an interview on 01/11/2024 at 9:47 AM, the Director of Nursing (DON) indicated the resident's name, the date and time the tube feeding formula started, and the flow rate should be documented on a tube feeding formula container. During a follow up interview on 01/11/2024 at 10:16 AM, the DON indicated her expectation was for staff to follow physician orders for tube feedings. The DON stated there should be a label on the tube feeding container that indicated what type of formula was being used, the ordered rate, and the date and time it was started. She stated the information was important because the tube feeding was only good for 24 hours. During an interview on 01/11/2024 at 10:25 AM, the Administrator indicated her expectation was for a tube feeding to be labeled when it was started, noting this was important because they did not want the feeding to infuse beyond its expiration. The Administrator indicated the time an infusion started could not be tracked if it was not labeled.

Based on observation, interview, record review, and policy review, it was determined the facility failed to develop a care plan for 1 (Resident #80) of 7 sampled residents who were dependent on respiratory ventilators. Findings included: A review of a facility policy titled, Comprehensive Care Plans, revised in June 2023, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents' comprehensive assessment. An observation of Resident #80 on 01/08/2024 at 10:58 AM revealed the resident had a tracheostomy and was utilizing a mechanical ventilator. A review of Resident #80's Face Sheet revealed the facility admitted the resident on 06/11/2022. Per the Face Sheet, the resident had diagnoses that included acute respiratory failure, dependence on a respiratory ventilator, a tracheostomy (a surgical opening through the neck into the trachea to provide an airway to the lungs), and cognitive communication deficit. A review of Resident #80's significant change Minimum Data Set (MDS), with an Assessment Reference Date of 08/25/2023, revealed the resident had severely impaired cognitive skills for daily decision making. Per the MDS, the resident was totally dependent on staff to provide activities of daily living (ADLs). The MDS also revealed Resident #80 was dependent on an invasive mechanical ventilator. A review of Resident #80's physician Orders revealed orders, dated 08/18/2023, directing staff to conduct ventilator respiratory rounds every four hours, to change the ventilator as needed, and to provide ventilator weaning as needed. There were also physician orders, dated 06/11/2022, directing staff to provide tracheostomy care twice per day, change the tracheostomy supplies on the twenty-fifth of every third month, provide respiratory equipment/cleaning/maintenance on the tenth of every month, and to change all disposable respiratory supplies on the fifth of every month. A review of Resident #80's Care Plan, dated 03/25/2022, revealed Resident #80 required respiratory support secondary to acute respiratory failure and a tracheostomy. The listed goal was for the resident to have no unaddressed complications due to respiratory needs. The facility developed interventions that directed staff to monitor the resident's oxygen level, administer oxygen as prescribed, change the oxygen tubing and supplies as prescribed, and suction the resident airway as needed. There was no documented evidence the facility developed a care plan for Resident #80 that addressed the care of the resident's tracheostomy or the use of an invasive mechanical ventilator. During an interview on 01/10/2024 at 1:00 PM, MDS Coordinator #12 stated she and nursing staff were responsible for developing care plans. MDS Coordinator #12 stated nursing staff should have reported that Resident #80 was on a ventilator and a care plan should have been developed. During an interview on 01/10/2024 at 2:30 PM, the Director of Nursing (DON) stated a care plan had not been created for the use of a ventilator for Resident #80. During an interview on 01/10/2024 at 3:13 PM, the Administrator stated she expected staff to develop a care plan to address Resident #80's ventilator dependency.

Based on observation, interview, record review, and policy review, the facility failed to obtain a physician order for 1 (Resident #30) of 3 sampled residents receiving supplemental oxygen administration. Findings included: A review of a facility policy titled, Oxygen Administration, last revised in June 2023, indicated, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. The policy also revealed 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. A review of Resident #30's Resident Face Sheet revealed the facility admitted the resident on 11/16/2023 with diagnoses that included acute respiratory failure, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen. A review of Resident #30's 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident utilized oxygen therapy while a resident at the facility. A review of Resident #30's Care Plan problem area, dated 11/16/2023, revealed the resident required respiratory support secondary to hypoxic episodes. The facility developed interventions that directed staff to provide oxygen as prescribed. A review of Resident #30's active physician Orders, with orders dated 11/16/2023 through 01/09/2024, revealed no orders for oxygen administration. A review of Resident #30's Treatment Administration History, dated 12/17/2023 through 01/11/2024, revealed that, despite no active physician order for supplemental oxygen, the resident had a treatment listed for staff to assess the resident's oxygen saturation level every shift and to titrate the oxygen flow rate between zero to five liters per minute (LPM) via nasal cannula to keep the resident's oxygen saturation above 90 percent. The oxygen treatment history revealed staff did not administer oxygen to the resident on 01/08/2024 or on 01/09/2024. The record had an x documented for the resident's oxygen saturation and oxygen flow rate for those dates. During observations of Resident #30 on 01/08/2024 at 11:20 PM, 01/09/2024 at 8:31 AM, and 01/09/2024 at 3:55 PM, the resident was observed wearing oxygen at 2 LPM. During an interview on 01/10/2024 at 7:28 AM, Certified Nursing Assistant (CNA) #5 stated Resident #30 had utilized supplemental oxygen since admission to the facility. During an interview on 01/10/2024 at 8:40 AM, Registered Nurse (RN) #1 stated a physician's order was required for supplemental oxygen. During an interview on 01/10/2024 at 8:00 AM, RN #4 stated Resident #30 had worn supplemental oxygen since admission to the facility. She stated all residents who received supplemental oxygen should have a physician's order. After reviewing the resident's electronic medical record, RN #4 confirmed Resident #30 did not have an order for supplemental oxygen administration. During an interview on 01/11/2024 at 8:56 AM, the Director of Nursing (DON) revealed a physician's order was required for supplemental oxygen. The DON stated that, upon admission from the hospital, Resident #30 requested oxygen. The DON stated the resident had been utilizing supplemental oxygen, but noted the facility did not have a physician's order to administer supplemental oxygen to the resident until 01/10/2024. During an interview on 01/11/2024 at 9:24 AM, the Administrator stated she expected staff to have a physician order before administering supplemental oxygen.

Based on observation, interview, record review, and policy review, the facility failed to provide nail care for 2 (Resident #76 and Resident #98) of 10 residents who were dependent on staff for personal hygiene. Findings included: A review of a facility policy titled, Nail Care, revised June 2023, indicated, 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule and as needed. Nail care will be provided between scheduled occasions as the need arises. 1. A review of Resident #76's Resident Face Sheet revealed the facility admitted the resident on 08/27/2022 with diagnoses that included dementia with other behavioral disturbance, anxiety, and need for assistance with personal care. A review of Resident #76's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/2023, revealed the resident could not complete a Brief Interview for Mental Status (BIMS) assessment. A Staff Assessment for Mental Status (SAMS) indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #76 required significant/maximum assistance with showering and required partial/moderate assistance with personal hygiene. A review of Resident #76's Care Plan problem area, dated 08/27/2022, revealed the resident was at risk for altered activities of daily living (ADL) function secondary to weakness and dementia. The facility developed care plan approaches that directed staff to assist the resident in completing ADL tasks each day. A review of Resident #76's Shower Sheet/Skin Observation forms revealed staff could choose Yes or No to answer whether the resident's nails had been clipped. The forms revealed staff documented No to indicate the resident's nails were not clipped on 12/11/2023, 12/20/2023, 12/22/2023, 12/27/2023, 01/03/2024, or 01/05/2024. The forms revealed staff did not document whether nail care was provided on 12/13/2023, 12/18/2023, 12/29/2023, 01/01/2024, 01/08/2024, or 01/10/2024. During a telephone interview on 01/08/2024 at 4:02 PM, Resident #76's family member stated Resident #76 was not aware of the need to complete personal hygiene tasks. The resident's family member expressed that staff needed to be more observant of Resident #76's personal hygiene. Resident #76's family member stated the resident's fingernails needed to be trimmed more frequently. Observation on 01/09/2024 at 12:21 PM revealed Resident #76 was in the dining room eating lunch. The observation revealed Resident #76's fingernails were long. The resident's right thumb nail was approximately one-fourth inch long. Observation on 01/10/2024 at 11:14 AM revealed Resident #76 sat in a hallway. Resident #76's fingernails continued to be long, with a light brown substance underneath the right thumb nail and right pointer finger nail. The resident stated they thought they received showering assistance that morning. During an interview on 01/10/2024 at 11:18 AM, Registered Nurse (RN) #1 stated Resident #76 received a shower that morning, noting she usually cut Resident #76's fingernails. RN #1 stated she had observed Resident #76's nails and identified they needed to be clipped. She stated she needed time to sit and talk to the resident when she cut the resident's nails but was discharging another resident at the time. RN #1 stated the certified nursing assistants (CNAs) could also cut Resident #76's fingernails. During an interview on 01/10/2024 at 1:25 PM, CNA #2 stated a nurse usually trimmed residents' fingernails but, if the CNAs had time, they could also trim them. CNA #2 stated that Resident #76 usually had long nails and it had probably been approximately two weeks since Resident #76's nails had been clipped. During an interview on 01/10/2024 at 1:43 PM, CNA #3 stated she offered to trim residents' fingernails when she provided showers if the resident did not have a diagnosis of diabetes. During an interview on 01/11/2024 at 8:56 AM, the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) was responsible for monitoring to ensure residents' nails were trimmed. The DON stated residents' nails should be trimmed on days the resident received a shower. The DON stated her expectation was for a resident's fingernails to be trimmed and cleaned and, if a resident refused nail trimming, it should be documented. During an interview on 01/11/2024 at 9:23 AM, the Administrator stated residents' fingernails should be trimmed on a consistent basis while respecting a resident's right to refuse. The Administrator stated if a resident refused nail care, it should be documented by staff. 46659 2. A review of Resident #98's Resident Face Sheet revealed the facility admitted the resident on 12/01/2023 with diagnoses that included contracture of the muscle of the right upper arm and hemiplegia and hemiparesis (paralysis and weakness) following a cerebrovascular disease affecting the right dominant side. A review of Resident #98's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/08/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severely impaired cognition. The MDS indicated the resident required partial/moderate assistance with personal hygiene. According to the MDS, showers/bathing had not been attempted during the assessment period due to the resident's medical condition or safety concerns. A review of Resident #98's Care Plan problem area, dated 12/01/2023, revealed the resident was at risk for altered activities of daily living (ADL) function secondary to weakness, debility, and a history of cerebral vascular accident (CVA; stroke) with right-sided weakness/hemiparesis. The facility developed care plan interventions that directed staff to assist Resident #98 with completing ADL tasks each day. On 01/08/2024 at 1:39 PM, Resident #98 was observed with long fingernails on both hands. An observation on 01/09/2024 at 3:30 PM revealed Resident #98 had long, dirty nails on both hands. Observations on 01/10/2024 at 8:50 AM and on 01/10/2024 at 3:33 PM revealed Resident #98's fingernails were long. A review of Resident #98's Shower Sheet/Skin Observation forms, dated 01/06/2024, revealed staff documented the resident's nails were clipped. However, during an observation of Resident #98's fingernails on 01/10/2024 at 3:51 PM, the Assistant Director of Nursing (ADON) stated it appeared Resident #98's nails were not trimmed on 01/06/2024. During an interview on 01/10/2024 at 7:15 AM with Registered Nurse (RN) #4, she stated the certified nursing assistants (CNA) were responsible for trimming the fingernails of residents who did not have a diagnosis of diabetes. According to RN #4, a podiatrist trimmed the fingernails for residents who had a diagnosis of diabetes. During an interview on 01/10/2024 at 7:28 AM, CNA #5 stated trimming fingernails was included in ADL care for residents without a diagnosis of diabetes. She said if a resident refused nail care, she documented the refusal on the resident's shower sheets. CNA #5 also stated a podiatrist trimmed the fingernails and toenails for residents who had a diabetes diagnosis. During an interview on 01/10/2024 at 1:25 PM, CNA #6 stated that nail trimming/cleaning was provided during showers for residents who did not have a diagnosis of diabetes. CNA #6 stated he did not trim residents' nails if they were too long. He stated if a resident refused to have their nails trimmed, the refusal was documented on the resident's shower sheets. During an interview on 01/10/2024 at 1:30 PM, CNA #7 stated she asked residents about trimming their fingernails during showers. CNA #7 stated Resident #98 did not normally refuse nail care. She stated she was unsure how long it had been since the resident's nails were trimmed, but stated they needed to be trimmed. During an interview on 01/11/2024 at 8:57 AM, the ADON she stated she expected staff to trim residents' fingernails on days the resident received a shower and as needed. She stated she expected nurses to monitor to ensure residents' fingernails were trimmed and to review the shower sheets to ensure they were accurate. She stated she expected residents' nails to be trimmed and cleaned. During an interview on 01/11/2024 at 9:24 AM, the Administrator stated she expected staff to keep residents' nails trimmed on a consistent basis.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assess 1 (Resident #74) of 10 sampled residents to ensure the resident was safe to self-administer inhaled medications. Finding included: A review of a facility policy titled, Resident Self-Administration of Medication, revised in June 2023, revealed, It is the policy of this facility to support the resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The policy revealed 1. Each resident is offered the opportunity to self-administer medications during routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. The resident's physical capacity to: swallow without difficulty, open medication bottles, administer injections; c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; d. The resident's capability to follow directions and tell time to know when medications need to be taken; e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff. f. The resident's ability to understand what refusal of medications, and the appropriate steps taken by staff to educate when this occurs. g. The resident's ability to ensure that medication is stored safely and securely. The policy also revealed 12. The care plan must reflect resident self-administration and storage arrangements for such medications. During an interview on 01/09/2024 at 2:27 PM, the Director of Nursing (DON) stated the facility did not have any residents who were allowed to self-administer medications or inhalers. She stated the facility had a policy that prohibited residents to keep medicines and inhalers in their rooms. A review of Resident #74's Resident Face Sheet revealed the facility admitted Resident #74 on 12/03/2023. The resident had diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure, shortness of breath-air hunger, and dependence on supplemental oxygen. A review of Resident #74's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/2023, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition. Per the MDS, the resident's vision and hearing were adequate. The MDS revealed the resident required setup or clean up assistance with oral hygiene and supervision or touching assistance with transfers and bed mobility. A review of Resident #74's Care Plan problem area, dated 12/03/2023, revealed the resident required respiratory support secondary to a history of subdural hematoma and chronic respiratory failure with hypoxia. The goal was for Resident #74 to have no unaddressed complications secondary to respiratory needs. The facility developed interventions that directed staff to monitor oxygen levels every shift and as needed and to administer oxygen as prescribed. Resident #74's Care Plan did not address the self-administration of medications. A review of Resident #74's physician Active Orders revealed an order dated 01/09/2024 for Ventolin HFA (albuterol sulfate was an inhaled medication used to treat spasms or narrowing of the airways in the lungs) two puffs every six hours as needed. Further review of the Active Orders revealed an order started on 12/05/2023 for budesonide suspension for nebulization (medication used to prevent asthma attacks), 0.5 milligram/2 milliliter inhalation, twice a day. On 01/09/2024 at 2:11 PM, Resident #74 was observed to have three inhalers labeled albuterol and one single dose ampule of budesonide on the bedside table. The resident stated the inhaler marked 12-14-23 indicated that was the date the nurse left the inhaler at the bedside. The resident stated they used the inhalers when they were short of breath. The resident stated nurses brought the resident the inhalers and no nurse was present when they self-administered the inhalers. The resident further stated they did not notify a nurse when the inhalers were self-administered. On 01/10/2024 at 8:43 AM, during the medication administration pass with Licensed Practical Nurse (LPN) #10, an observation revealed Resident #74 had an inhaler on the bedside table. An interview with LPN #10 revealed she was aware Resident #74 kept inhalers at the bedside. However, she noted she was unaware of the facility's procedure for a resident to self-administer medications. She stated if a resident reported they had used an inhaler, she documented that she administered the medication but made a note that the resident reported the medication was self-administered. LPN #10 stated she did not know whether the resident was informing nurses when the inhalers were used. Further interview with the LPN revealed Resident #74 had a physician order to administer an inhaler but she did not see an order for the resident to self-administer medications. LPN #10 stated she did not know whether the facility had assessed the resident for self-administration of medications. A review of Resident #74's January 2024 Medication Administration Record [MAR] revealed staff documented budesonide treatments were provided twice daily from 01/01/2024 through 10:00 AM on 01/11/2024. There was no note indicating the resident had self-administered the medication. Further review of the January 2024 MAR revealed staff documented an X for the albuterol inhaler from 01/09/2024 through 01/11/2024, and there was no indication the resident had self-administered the medication. During an interview on 01/10/2024 at 8:50 AM, LPN #11 verbalized she was aware Resident #74 had inhalers at the bedside. She stated if the resident was alert and had a care plan, it was okay to have inhalers at the bedside. LPN #11 stated she did not know if a care plan for self-administration had been developed, if there was a physician order for self-administration, or if an assessment for the self-administration of medications had been conducted for Resident #74. She stated the resident was alert and could use the inhaler but did not know whether the resident notified nurses when the inhalers were used. She stated if the resident told a nurse they had used the inhaler, the nurse would sign off the medication and add a note that the resident had self-administered the inhaler. During an interview on 01/10/2024 at 9:00 AM, the DON stated staff should have informed her that a resident was self-administering inhalers and nebulizer treatments. She stated that, in order for the resident to self-administrator medications, there should be a physician's order, an assessment, resident training, and a care plan, noting the inhalers should also be secured in a locked box. During an interview on 01/10/2024 at 3:13 PM, the Administrator stated she would have expected staff to inform the DON about Resident #74 being allowed to keep inhalers/medicines at the bedside so the facility could initiate the proper procedures to allow the resident to safely self-administrator medications. During an interview on 01/11/2024 at 10:07 AM, the nurse practitioner stated she had not previously written an order for Resident #74 to self-administer inhalers.

Based on observation, 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 3 sampled residents, a resident that was a quadriplegic received second degree burns on his body after being served hot water by a Certified Nursing Assistant (CNA) and the resident was not supervised while drinking the hot water. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, quadriplegia, type 1 diabetes mellitus, neuromuscular dysfunction of bladder, anxiety disorder, and burn of unspecified body region. Resident's medical record was reviewed on 11/8/23. On 11/18/22, a Hot Beverage Evaluation documented that resident 1 DOES NOT demonstrate the ability to self serve hot liquids, but wishes to have hot liquids and can do so with interventions. The interventions included, Staff will assist to serve hot liquids and assist with proper positioning during hot beverage consumption. A quarterly Minimum Data Set assessment dated [DATE], documented a brief interview for mental status (BIMS) score of 15. A BIMS score of 13 to 15 would suggest cognitive intactness. On 11/3/23 at 11:58 PM, a Nursing Progress Note documented Date 11/3/2023 reported at 2300 [11:00 PM]: [Resident 1] sustained burns to right upper chest, right inner arm, right posterior lateral back, left groin, left hip and abdomen. CNA on PM shift reported to nurse at 2300 that [resident 1] had blisters and would I look at them. I spoke with [resident 1], he stated, his CNA filled his mug with water at approx [approximately]. 10 PM. [Resident 1] states as he was drinking his water, it was so hot that he pushed the straw from his mouth so that it would not burn him. [Resident 1] explained that when taking a drink out of his personal straw set up for his water, it is like siphoning gas, only stops when he puts his tongue back on the straw to stop it from flowing. [Resident 1] said due to it being so hot, he was not able to put his tongue on the straw to stop it. That's when the water poured out of the mug it went all over his chest & body. [Resident 1] could not feel the water as he has not [sic] feeling from the neck down. CNA's and nurse removed clothing and linens and changed to new gown and linens. Body check was completed. NP [Nurse Practitioner] [name removed] was notified; orders were given to clean burns with NS [normal saline], and apply Bacitracin, keep wounds clean and dry. Monitor patient closely for any changes or concerns. [Resident 1] denies pain at this time. temperature 98.1 [degrees Fahrenheit (F)], refused any additional vital signs. Education given, verbalizes understanding. Call light within reach. Hydration encouraged-CNA's informed to keep [resident 1] with fluids, no hot water. Staff education provided. On 11/4/23 at 12:10 AM, a Nursing Progress Note documented [Resident 1] sustained burns from hot water-order for Clean with NS, pat dry, apply bacitracin cream and protect with gauze. Monitor for infection. Do not apply cover [sic] blisters. This has been completed, nursing will continue to monitor patient condition-vital signs refused per patient, temp [temperature] 98.1 [degrees F]-No pain r/t [related to] quadriplegic-staff will be vigilant to monitor through the night-Linens, gown C/D [clean and dry]. [Resident 1] is aware of the situation, drinking well at this time. On 11/4/23 at 2:07 AM, a Nursing Progress Note documented Patient during bs [blood sugar] check dressings changed per order. Patient drinking well and urine output is good. Mucous membranes moist. VSS [vital signs stable] at this time patient is afebrile 98.4 [degrees F]. Patient pulse 88 bp [blood pressure] 103/71. Patient offered at this time to be evaluated at hospital related to surface area. Patient content with POC [plan of care]. Hydration and nutritional needs reinforced. Patient spent whole time telling pirate jokes. WCTM [will continue to monitor]. On 11/4/23 at 4:10 AM, a Nursing Progress Note documented Patient mugged [sic] filled with tap water per his request. Patient dressing changed and reinforced per order. Patient has had serous drainage from distal and posterior chest. Patient dressings otherwise intact and without irritation. Patient resting at this time. WCTM. On 11/4/23 at 6:13 AM, a Nursing Progress Note documented Patient bs 114 temp 98.5 [degrees F]. Mucous membranes moist. Patient urine is clear yellow. Patient has had no further drainage thus far. Patient dressing are intact without s/s [signs and symptoms] of irritation. Patient educated on need to continue fluids and to increase protein to promote healing. Patient educated on s/s to report. Discussed ways patient his [sic] body expresses infection ie increased bs, inability to maintain body temp, decreased intake and output. Patient content with care and progress thus far. Patient demonstrated ability to push call light. WCTM. On 11/4/23 at 9:29 AM, a Hot Beverage Evaluation documented that resident 1 was able to drink lukewarm beverages with straw. DOES NOT demonstrate the ability to self serve hot liquids, but wishes to have hot liquids and can do so with interventions. The interventions included, Staff will assist to serve hot liquids and assist with proper positioning during hot beverage consumption. Provide cups with lids, Use only mugs appropriate for hot liquids, DO NOT refill resident's cup while they are holding it, Educated on safe handling techniques, and Other - only lukewarm beverages, per pt [patient]. On 11/4/23 at 10:37 AM, a Nursing Progress Note documented new order per NP to Clean burns with chlorohexidine (NO ALCHOLOL [sic]), Apply silvadene to red and blistered areas BID [twice daily], Cover with Adaptic or xeroform, then place non adherent pad on top and wrap with kerlix, and secure with dry dressing on the unable to wrap areas of the body BID and PRN [as needed] and to have wound team evaluate for further treatment and monitoring. Res [Resident] aware. On 11/4/23 at 11:04 AM, a Nursing Progress Note documented Skin assessment done with wound nurse. Resident with second degree burns d/t [due to] scalding from hot liquid R [right] inner arm measurements 14x7 [centimeters (cm)] R back side posterior lateral measurements 22x18 [cm] Chest measurements 20x20 [cm] Abdomen 20x32 [cm] with a large blister on R side measuring 8.0x7.0 [cm] L [left] groin multiple small blisters measuring 3.0x13.0 [cm] L hip blister 1.0x1.5 [cm] All scaled areas are red with some denuded areas, and multiple blisters. Wound team and NP notified. New orders in place. On 11/4/23 at 11:49 AM, a Nursing Progress Note documented Resident in good mood this morning. Temperature check this morning 98.0 [degrees F]. Resident denies any pain. Repositioned for comfort. Offered prn pain medications resident refused. Skin treatment done. Continue monitoring for any changes. Continue staff education about hot beverages to be mindful and careful of the temperature when assisting a resident with food or drinks. For [resident 1] serve only lukewater per [resident 1] request. On 11/4/23 at 12:06 PM, a Nursing Progress Note documented Follow up with resident related to burns sustained from warm water and ask resident if he wants to go to the hospital. Resident refused, stating he wants to be treated here in facility, agrees with skin treatment order. Resident stated that he feel [sic] safe in facility, and that nobody hurt or abuse him, and complimented staff for prompt action and providing exceptional care. On 11/4/23 at 12:41 PM, a Nursing Progress Note documented New order received from NP to monitor and encourage hydration, monitor vitals and notify provider with any concerns. Resident notified. Fluids encouraged as tolerated. On 11/4/23 at 4:46 PM, a Nursing Progress Note documented [Resident 1] burn wounds changed per order/[resident 1] states he feels a little weak/Midodrine given prn as ordered to elevate BP of 60's-next BP 79 systolic-after second dosing of Midodrine, BP > [greater than] 130. [Resident 1] is increasing his fluids. Tylenol for general well being-no temp at this time/call light within reach. On 11/4/23 at 9:10 PM, a Nursing Progress Note documented [Resident 1] states he is a little cold-some mild shivering-no temperature,vss. NP [name removed] notified of BP improving with Midodrine and increaseing [sic] fluids as well as his overal [sic] fatigue. Dressings to burns C/D/I [clean, dry, and intact] call light within reach-repositioned as requested. On 11/5/23 at 3:15 PM, a Nursing Progress Note documented Resident received Tx [treatment] for burn on torso, front/inner lateral, right arm, right posterior lateral back, left groin and L hip per order BID wound care. Not [sic] c/o [complaints of] pain or discomfort noted. Fluids intake as tolerated. Recorded as Late Entry on 11/5/23 at 9:17 PM. On 11/5/23 at 9:00 PM, a Nursing Progress Note documented Resident's burn dressing change BID. Not [sic] c/o pain at this time. Resident is encourage to drinks fluids. Reposition done. assist with feeding, appetite is fair to good. Not [sic] fever noted. WCM [will continue monitor]. Recorded as Late Entry on 11/6/23 at 6:02 PM. On 11/6/23 at 5:03 PM, a Nursing Progress Note documented Resident received partial bed bath. Burn dressing changed. Not [sic] s/s of infection. Not [sic] c/o pain noted. Fluids [sic] intakes is tolerated well. Supra Foley in place DD [down drain] well. Resident participated in therapy session . Appetite is good. WCM. Recorded as Late Entry on 11/6/23 at 6:06 PM. On 11/6/23 at 9:55 PM, a Nursing Progress Note documented Dressings changed to burns this evening. Tolerated well. No s/s of infection noted. All needs met at this time. Call light within reach. On 11/7/23 at 12:15 PM, a Nursing Progress Note documented New order received from wound team and approved by NP: Silvadene (silver sulfadiazine) cream; 1 %; amt [amount]: 1 application; topical Special Instructions: Clean burns with chlorohexidine (NO ALCHOLOL), Apply silvadene to red and blistered areas daily, Cover with Adaptic, then place non adherent pad on top and wrap with kerlix, and secure with dry dressing on the unable to wrap areas of the body daily and PRN. Avoid areas drying out. Resident made aware. Wound burn dressing done by wound team. Resident tolerated dressing change well. Recorded as Late Entry on 11/8/23 at 9:16 AM. On 11/7/23 at 4:37 PM, a Nursing Progress Note documented Resident remain in bed. Wound burn dressing changed. Not [sic] c/o pain at this time. Resident is encourage to drink fluids. Foley Cath [catheter] in place DD well. Encourage to use call light within to reach. WCM. Recorded as Late Entry on 11/7/23 at 6:38 PM. On 11/7/23 at 11:43 PM, a Nursing Progress Note documented Resident resting in bed this shift. He is A&O [alert and oriented] at his baseline. Compliant with medication administration and cares offered. Dressing in place, CDI. He has no c/o pain. Resident encouraged to use call light. Within reach. Will continue with current plan of care. On 11/8/23 at 9:16 AM, a Nursing Progress Note documented Spoke with resident this morning. Resident is in good spirit and making jokes and laughing. Wound burn dressing in place, intact. Resident denies any pain or discomfort. Encouraged fluids as tolerated. Educated resident to use call light and ask for help if needed. On 11/8/23 at 10:35 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 1 asked for the hot water and not thinking any thing of it CNA 1 gave resident 1 the hot water and the straw. CNA 1 stated that she came back later and resident 1 stated that the water was to hot. CNA 1 stated that she had noticed the blisters on resident 1 and told the nurse. CNA 1 stated that she was doing cares for resident 1 when she noticed the blisters. CNA 1 stated the Creamery was where she usually got the hot water for residents. CNA 1 stated there was a tap by the hot chocolate machine labeled Hot Water. CNA 1 stated that she had put the hot water in resident 1's water mug and could not remember if there was a lid for the mug. CNA 1 stated that resident 1 had a personal drinking straw that was hooked up to suction. CNA 1 stated the suction helped resident 1 to drink from the straw. CNA 1 stated that she had given resident 1 hot water in the past. CNA 1 stated she did not know if the protocol was to temp the water prior to giving the hot water to a resident. CNA 1 stated she did not temp the hot water prior to giving the mug to resident 1. On 11/8/23 at 10:47 AM, an interview was conducted with resident 1. Resident 1 stated that suction had nothing to do with the drinking straw. An observation was conducted of resident 1's water mug. A long straw that appeared to be suction tubing came out of the water mug and was attached to a arm device that resident 1 could reach with his mouth. The suction canister tubing was observed to be attached to the same arm device but separate from the drinking straw. Resident 1 stated that he would request warm water when he was cold. Resident 1 stated that he was a quadriplegic and when he got cold the warm water would warm him up. Resident 1 stated the other CNAs would get the hot water from the nurses station and would fill his water mug with half hot water and half cold water. Resident 1 stated that CNA 1 was his CNA the night he got burned. Resident 1 stated he did not specify on the water and when he got a drink it was burning hot water. Resident 1 stated that he tried to blow the water back in the straw but the water was to hot and it came out of the straw and he felt the hot water on his chest. Resident 1 stated that he thought the water was only on the blanket but it had poured onto his skin. Resident 1 stated the water had burned under the side of his right arm, right side of his genitals, and along side the right of his hip. Resident 1 stated that he had blistered and the blisters bursted for two nights. Resident 1 stated the NP which was the wound nurse seen him once a week. Resident 1 stated he had a racking headache over the weekend after the incident. Resident 1 stated that he was not sure if the headache was a response to the pain. Resident 1 stated by Monday he was feeling better and yesterday the NP described the wound areas were looking much better. Resident 1 stated the NP had prescribed saline and silvadene cream for the burns and to cover the burns with protective pads. Resident 1 stated that yesterday the NP changed the dressing order to once a day. Resident 1 stated that he has not had a headache for two days. Resident 1 stated that he had received compassionate and effective care from the facility since the hot water incident. Resident 1 stated that CNA 1 had not brought him hot water before. Resident 1 stated that though it was a mistake it was out of ignorance or lack of communication. Resident 1 stated that the hot water was not out of negligence. On 11/8/23 at 11:24 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 1 was a quadriplegic. RN 1 stated that resident 1 had been at the facility for four years. RN 1 stated that resident 1 was respectful but sarcastic and very specific with cares. RN 1 stated that resident 1 did not like ice water and the CNAs have told RN 1 that resident 1 would ask for hot water. RN 1 stated that the CNAs have told RN 1 that they would mix hot and cold water so the water was warm. RN 1 stated that resident 1's suction was for congestion and respiratory would see resident 1 twice a day and empty the canister if needed. On 11/8/23 at 11:29 AM, resident 1's wound dressing change was observed with RN 2. RN 2 was observed to remove the dressings from the right lower back and right side. RN 2 stated she would clean the wounds in sections. The edges of the burns were observed to be bright red and the center was a creamy off-white color. RN 2 cleansed the burn areas with Hibiclens. A silver dollar sized area of skin came off near the lower back during the cleaning. RN 2 applied silvadene, covered the area with oil emulsion dressings, abdomen pads, and tapped the pads to resident 1's skin. Resident 1's right arm was observed to have some drainage on the bandage. The burn on resident 1's right side was observed to cover half way down the right side to the hip area and angled towards the middle of resident 1's back. RN 2 was observed to remove the dressings from the chest area and abdomen. The burn was observed to cover resident 1's chest and down toward resident 1's left side around the colostomy site. The burn was observed in the left hip crease area and towards the top of the pelvic area. The edges of the burns were observed to be bright red and the centers were a creamy off-white color. Blisters were observed on resident 1's left side near resident 1's ostomy. Resident 1's belly button was observed to be red. RN 2 was observed to remove the dressings from resident 1's right arm. The burn area covered under the bicep from the elbow to half way up the arm. RN 2 stated that the skin was starting to come off. On 11/8/23 at 12:50 PM, an observation of the hot water was conducted. In the Creamery the hot water tap was observed to be connected to the coffee machine. A resident coffee mug was filled with hot water. The temperature was obtained with a digital thermometer and read 158.7 F. On 11/8/23 at 12:54 PM, an interview was conducted with CNA 2. CNA 2 stated if a resident requested hot water she could get the hot water at the nurses station or the Creamery. CNA 2 stated that she would get the resident a new cup and a new straw. CNA 2 stated that she never used the hot water in the Creamery. CNA 2 stated if the resident was coherent she would remind them that the water was hot. CNA 2 stated if the resident was not coherent or oriented she would dilute the hot water. On 11/8/23 at 1:00 PM, an interview was conducted with CNA 3. CNA 3 was observed in the main dining area near the Creamery. CNA 3 stated that when dining was finished there was a chain that was put up so the residents were not able to access the Creamery. CNA 3 stated that during dining a staff member would be present and the residents would ask for what they needed. A resident was observed to wander into the Creamery and filled her water mug with ice. CNA 3 was observed to assist the resident and escorted her out of the Creamery. On 11/8/23 at 1:12 PM, an interview was conducted with the Administrator (Admin). The Admin stated that he had tested the hot water on Saturday and it was coming out at 176 F. The Admin stated the company that owns the coffee machine came to the facility on Monday and the coffee machine was set at 196 F. The Admin stated he was told by the company that the coffee machine needed to be set in the 180's to be able to make coffee. The Admin stated the company made adjustments on the coffee machine for 180 F. The Admin stated the kitchen staff were temping the coffee mugs before the mugs went to the residents and monitoring was conducted once a day. On 11/8/23 at 1:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there had not been any other burns in the facility. The DON stated the residents usually rarely ask for hot water, but the residents would usually ask for tea or coffee. The DON stated the staff were to pour the water and if the water was hot the staff would put cold water or ice in the cup. The DON stated the staff should make sure the temperature was good and the water was in a proper cup with a lid. The DON stated when the staff bring the warm water to the resident room the staff need to reposition the residents and ask the resident how they would like to drink. The DON stated the staff need to supervise the resident. The DON stated that resident 1 was the only resident that would ask for hot water. The DON stated she did education for the entire facility regarding hot water. The DON stated that resident 1 at this moment has requested luke warm water and the care plan had been updated.

Based on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a staff member had an allegation of sexual abuse toward resident 1 that was not thoroughly investigated in July 2022. An additional allegation of sexual abuse of resident 1 was made against the same staff member in September 2023 that substantiated abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access to the resident by the alleged perpetrator. This was found to have occurred at an immediate jeopardy (IJ) level. Resident identifier: 1. NOTICE On 10/25/23 at 3:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally and in writing to the facility Administrator (ADM), the Skilled Nursing Facility Social Work Director for Quality, the [NAME] President of Clinical Quality, the Regional Director, the Director of Nursing, and the Assistant Director of Nursing. On 10/26/23 at 1:24 PM, the Regional Director provided the following abatement plan for the removal of the Immediate Jeopardy effective on 10/26/23 at 2:30 PM. Allegation of Compliance to abate immediate jeopardy: RE: Complaint Survey 10/24/23 Survey findings: COTA [Certified Occupational Therapy Assistant] 1 was not supposed to be working with resident 1, but was seen on multiple occasions in her room. These incidents were not reported to the facility administration. In addition, COTA 1 was allowed to work with resident 1 in June 2023. An investigation completed 7/6/22 was incomplete and safeguards not followed. We respectfully assert that we have removed the immediate jeopardy on 10/26/23 at 2:30 pm. Immediate corrective action: F600 Freedom from Abuse Protection of Resident from alleged perpetrator: Suspended COTA 1 immediately on 9/21/2023 and terminated. Involvement with Police and investigators and according to investigator on 10/25/23 was arrested. Responsible Person: Administrator Date of Completion: 9/21/23 Resident 1 was interviewed by Social Service Staff and determined to not show signs of psychosocial distress. Social services offered to Resident 1's mother to set up counseling and her mother declined at that time. Social Services will continue to partner for counseling with Resident 1 and advocate for this to occur with her mothers consent. Responsible Person: Social Services Date of completion: 9/22/23 and 10/26/23 at 1:30 pm. COTA 1 has been arrested and charged. Staff have signs posted at nursing area's and at the front desk with COTA 1's picture to deny visit's and call the police. Pictures posted on 10/25/23 at 3:30 pm At the time it was discovered that COTA 1 had violated the trespass order police were immediately called and a staff member was placed outside of Resident 1's room until it was assured that COTA 1 was arrested. Staff member placed outside of room on 10/25/23 at 8:45 am Director of Therapy has been suspended and will no longer be allowed to be a Director or Therapist in the facility. Inserviced therapy staff to report abuse and any concerns such as these immediately to the Administrator. Responsible Person: Regional Director of Therapy Date of Completion: 10/26/23 at 9:00 am Female Residents that COTA 1 had treated and other female residents were interviewed about abuse to ensure they felt safe and ensure other issues similar were identified. No other concerns were raised. Responsible Person: Director of Nursing or Designee Date of Completion: 9/22/23 and again on 10/25/23 All other residents in the facility interviewed about abuse to ensure issues similar with abuse were not evident with any other resident. Responsible Person: Director of Nursing or Designee Date of Completion 10/26/23 at 2:00 pm Abuse, neglect training completed for staff including therapy which included situational concerns similar to Resident 1 and COTA 1 this included exploitative behaviors such as taking advantage of a resident for personal gain or having relationships that appear inappropriate. Responsible person: Director of Nursing or Designee Date of Completion: 9/27/23, 9/26/23, 9/28/23 Abuse and Grooming signs to our staff with Abuse training for staff completed to include: Victim selection: Abusers often observe possible victims and select them based on ease of access to them or their perceived vulnerability.Gaining access and isolating the victim: Abusers will attempt to physically or emotionally separate a victim from those protecting them and often seek out positions in which they have contact with minors.Trust development and keeping secrets: Abusers attempt to gain trust of a potential victim through gifts, attention, sharing secrets and other means to make them feel that they have a caring relationship and to train them to keep the relationship secret. Desensitization to touch and discussion of sexual topics: Abusers will often start to touch a victim in ways that appear harmless, such as hugging, wrestling and tickling, and later escalate to increasingly more sexual contact, such as massages or showering together. Abusers may also show the victim pornography or discuss sexual topics with them, to introduce the idea of sexual contact.Attempt by abusers to make their behavior seem natural, to avoid raising suspicions. For teens, who may be closer in age to the abuser, it can be particularly hard to recognize tactics used in grooming. Be alert for signs that your teen has a relationship with an adult that includes secrecy, undue influence or control, or pushes personal boundaries. Most importantly to report any concerns immediately to the Administrator. Responsible Person: Administrator Date of Completion: 10/26/23 these were completed in small groups with discussion at 11:30 am F609-Reporting Abuse Abuse identification and reporting, neglect training completed for staff including therapy which included situational concerns similar to Resident 1 and COTA 1 this included exploitative behaviors such as taking advantage of a resident for personal gain or having relationships that appear inappropriate. Responsible person: Director of Nursing or Designee Date of Completion: 9/27/23, 9/26/23, 9/28/23 Director of Therapy has been suspended and will no longer be allowed to be a Director or Therapist in the facility. Inserviced therapy staff to report abuse and any concerns such as these immediately to the Administrator. Responsible Person: Regional Director of Therapy Date of Completion: 10/26/23 at 9:00 am Female Residents that COTA 1 had treated and other female residents were interviewed about abuse to ensure they felt safe and ensure other issues similar were identified. No other concerns were raised. Responsible Person: Director of Nursing or Designee Date of Completion: 9/22/23 and again on 10/25/23 All other residents in the facility interviewed about abuse to ensure issues similar with this abuse situation was identified. Date of Completion: 10/26/23 at 2:30 pm Abuse and Grooming signs to our staff with Abuse training for staff completed to include: Victim selection: Abusers often observe possible victims and select them based on ease of access to them or their perceived vulnerability.Gaining access and isolating the victim: Abusers will attempt to physically or emotionally separate a victim from those protecting them and often seek out positions in which they have contact with minors.Trust development and keeping secrets: Abusers attempt to gain trust of a potential victim through gifts, attention, sharing secrets and other means to make them feel that they have a caring relationship and to train them to keep the relationship secret. Desensitization to touch and discussion of sexual topics: Abusers will often start to touch a victim in ways that appear harmless, such as hugging, wrestling and tickling, and later escalate to increasingly more sexual contact, such as massages or showering together. Abusers may also show the victim pornography or discuss sexual topics with them, to introduce the idea of sexual contact.Attempt by abusers to make their behavior seem natural, to avoid raising suspicions. For teens, who may be closer in age to the abuser, it can be particularly hard to recognize tactics used in grooming. Be alert for signs that your teen has a relationship with an adult that includes secrecy, undue influence or control, or pushes personal boundaries. Staff inserviced if they see any of these signs to report to the Administrator immediately. Responsible Person: Administrator Date of Completion: 10/26/23 these were completed in small groups with discussion at 11:30 am. F610-Investigation Correction for incomplete investigation: Former Administrator who was engaged with prior investigation dated July 2022 no longer works with Rocky Mountain Care. Responsible Person: Regional [NAME] President of Rocky Mountain Care: Date of Completion: 5/1/2023 Current Facility management who completes abuse investigations were inserviced on the completing abuse training and assuring that interventions are implemented and effective to prevent abuse. Responsible Person: [NAME] President of Quality with Rocky Mountain Care Date of Completion: 10/26/23 at 8:30 am All Abuse files were reviewed for completion and to ensure interventions have been implemented. Responsible Person: Administrator Date of Completion: 10/25/2023 at 9:00 pm Monitoring: Administrator or designee will audit all abuse reports monthly for four months reviewing interventions and investigation material to assure appropriate interventions are being followed to ensure prevention of abuse. Nursing Administration will interview 10% of active employees and therapy staff each week for four months to determine if they have witnessed staff who may have an inappropriate relationship with other residents and if so ensuring they had been reported. Audits will be reviewed monthly in QAPI for sustained substantial compliance. On 10/26/23, while completing an abbreviated complaint survey, and an extended 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 10/26/23. Findings include: Immediate Jeopardy Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anoxic brain damage, quadriplegia, epilepsy, and anxiety disorder. Resident 1's medical record was reviewed on 10/25/23. On 9/26/23, a Montreal Cognitive Assessment (MOCA) was completed for resident 1. The MOCA indicated that resident was oriented to the correct month, date, place, and city; but not the year. The MOCA also indicated that resident 1 had a score of 8 out of 22, indicating severe cognitive impairment. On 8/31/22, a quarterly minimum data set (MDS) revealed resident 1 completed a brief interview for mental status (BIMS). Resident 1's scored a BIMS of 14 out of 15 meaning resident 1 had intact cognition. The MDS also revealed that resident 1 required extensive two person assistance with bed mobility. The MDS indicated that resident 1 was totally dependent on 2 staff for transfers. The MDS also indicated that resident 1 required extensive one person assistance with dressing, toileting, and personal hygiene. Per the MDS, the resident also required limited one person assistance with eating. The MDS indicated that resident 1 was totally dependent on one staff member for bathing. The MDS additionally indicated that resident 1 required the use of a wheelchair, and had an impairment in her range of motion on both the upper and lower right and left extremeties. Two separate allegations of abuse were investigated by the facility regarding COTA 1's actions with resident 1. Those allegations are described as follows: ALLEGATION 1: A Concern Form dated 7/6/22 at 4:45 PM was completed by RN 2. The Concern Form staff members reported to [RN 2] the following: [RN 1] observed [COTA 1] was in [resident 1's] room and had his hand on her leg and when the nurse came in for cares he left. In a separate observation, [CNA 1] observed [COTA 1's] arm around [resident 1's] top/around area . The immediate actions taken: COTA 1 has been removed from her (resident 1's) cares. The concern form documented the concern was reported to the administrator, DON (director of nursing)/ unit manager, social services, and therapy. The area of the form titled Actions taken to prevent recurrence was left blank. An initial entity report was filed with the State Survey Agency (SSA) on 7/7/22 at 12:05 PM. The initial entity report revealed that on an unknown date and time an incident allegedly occurred between resident 1 and COTA 1. The initial entity report indicated that Registered nurse (RN) 1 observed COTA 1 in resident 1's room and COTA 1 had his hand on her leg and when RN 1 came in to provide cares COTA 1 left. The incident was reported to Social Services Worker (SSW) 2. In a separate observation reported to SSW 2, a certified nursing assistant (CNA) 1 observed COTA 1's arm around resident 1's top area. The entity report documented the dates of incident's (sic) are under investigation. [Note: The initial entity report date is 7/7/22 at 12:05 PM, over 11 hours after the concern form was filed.] On 7/8/22, RN 2 wrote a statement of what he witnessed. RN 2 stated that COTA 1 was seated on resident 1's bed, and resident 1 was seated in her wheelchair, in a slightly reclined position. RN 2 stated that he witnessed COTA 1 massaging resident 1's left leg. RN 1 stated that this had occurred on 7/5/22 at 12:00 PM. On 7/12/23, CNA 1 wrote the following statement, I [CNA 1] on two occasions seen (sic) [COTA 1] getting a little to (sic) close to [resident 1], On the first occasion which was on July, 5, 2022 right before dinner I notice (sic) [COTA 1] hand on [resident 1] thigh. Then on July 6, 2022 I do not recall around what time I walk (sic) in [resident 1] room because her roomate (sic) called for help. As I am walking in I seen (sic) [COTA 1] squatting over [resident 1] and he had his arm wrapped around her waist. [Resident 1] was laying in her bed with a T-shirt and brief. When I went back to see what was going (sic) [COTA 1] had left and he had forgot his laptop. A review of the final investigation dated 7/14/22 revealed the following: a. A documented witness summary revealed, RN 1 stated on 7/5/22, [RN 1] walked by [resident 1's room] and saw COTA [1] sitting on [resident 1's] bed. Resident 1 was sitting in her wheelchair. [RN 1] saw COTA [1] touching [resident 1's] legs, like a massage her left thigh. [RN 1] does not know if that is part of therapy or not. RN 1 informed the nurse over that hall. [Upon review of the witness statement, RN 2 stated that this incident had occurred on 7/5/23 at 12:00 PM.] b. A second witness summary revealed, [CNA 1] stated on two occasions has seen [COTA 1] getting a little close to [resident 1]. First occasion on 7/5/22, [CNA 1] saw [COTA 1's] hand on [resident 1's] thigh. Second occasion on 7/6/22, she walked in the room and saw [COTA 1] squatting next to [resident 1] and had his arm wrapped around [resident 1's] waist. [Resident 1] was laying in bed with a T-shirt and brief and when [CNA 1] returned, [COTA 1] had left and forgotten his laptop. c. An account of the resident involved revealed, on 7/7/22, SSW 2 interviewed resident 1. Resident 1 said she felt safe in the facility and denied any staff touching her inappropriately. On 7/12/22 resident 1 was re-interviewed and again stated she felt safe in the facility and staff members are nice to her and feels safe with everyone who cares for her. Denied any staff member touching her inappropriately and is comfortable around all staff. [Note: The investigation did not indicate if direct questions were asked of resident 1, or if she was simply asked about inappropriate touch and feeling safe. It is unclear if direct questions about COTA 1 and his behaviors were asked of resident 1.] d. An interview was conducted with COTA 1 on 7/12/22. COTA 1 denied touching resident 1 in a non-therapeutic way. COTA 1 reports that when he works with patients with poor cognition, he will tell them what he is doing and is respectful. When interacting with [resident 1] he will ask her if it is okay to do something before he does anything and she has never disagreed or reacted adversely during their interactions.[COTA 1] reported he has touched her on the thigh, poked her and tickled her jokingly but is cautious in not touching her in an inappropriate way. [COTA 1] said he has a tendency of resting his hands on her legs but is cautious to not move it where it does not belong. Stated he has hugged her and in the presence of her mom and there had not been an adverse reaction. When he interacts with her in her room, he always leaves the door open. e. A summary of evidence documented based on witness accounts and alleged perpetrators statements the abuse allegation is unsubstantiated. f. The corrective action summary stated COTA 1 will not be assigned to work with resident 1 and education will be provided on professional boundaries and appropriate ways to interact with residents. g. The administrative decision stated, at this time, we believe that the allegation of abuse is unsubstantiated, as it does not rise to the level of abuse. [It should be noted that upon review of COTA 1's assignments, COTA 1 was not assigned to work with resident 1 during this time period of June and July 2022. Therefore, the intervention of instructing COTA 1 to not work with resident 1 was not an effective intervention.] [Note: The investigation into the allegation of abuse in July 2022 did not include interviews with other staff members regarding interactions between COTA 1 and resident 1.] A review of the corrective action document dated 7/20/22, written by COTA 1's supervisor/manager the director of therapy (DoT), the document revealed. In reviewing the events and investigation outcomes, we have determined professional boundaries have been crossed and need to be addressed . The action plan to correct the incident documented: a. Employee will complete additional training on the [therapy group] abuse policies. b. Employee will no longer work with the patient as a therapist. c. Employee will complete additional training regarding creating and maintaining professional boundaries in a healthcare setting. d. Employee will demonstrate professional behavior and use professional language with patients, staff and other at all times in compliance with our sexual abuse, abuse, and professional ethics policies. [It should be noted COTA 1 refused to sign the corrective action plan.] e. Employee comments revealed an attached letter from COTA 1. The letter read as follows: To whom it may concern: This letter is in answer to your incident action plan in relation to [resident 1]. First, let me say that I hold no ill feelings for whomever reported what they thought they saw as abuse, reporting assumed abuse is not easy, but knowing that other's (sic) care enough about our pt's [patients], especially [resident 1], to report anything they see as a potential wrong, is to be admired, not (criticized). [Resident 1] means a lot to me, I have always told her she is like the granddaughter I have always wanted, but did not have, or even like a daughter. I have never, in any way, abused my children nor have I ever taken advantage of or abused [resident 1]. However, to understand the relationship I have had with [resident 1], you need to learn from the beginning. I do not remember who was here first, [resident 1] or myself, all I know is that [resident 1] was torn away from her kids, her mom and her grandma, mostly because she needed more assistance than they were able to provide, and put into a foreign place filled with 'older people' that were not family. So every or nearly every night she was initially here, she would lie in her bed and weep and wail and cry out for her kids and family, it was one of the most gut-wrenching sound (sic) I have ever heard, but I seldom ever saw anyone go in and try to comfort her, so I started going in when I could and sit on the side of her bed and talk to her, wipe away her tears and hold her hand or rub her shoulders or back, to give her some comfort and let her know she was loved and cared for. Sometimes it helped and sometimes not, but I tried to help! But since that time, [resident 1] and I seemed to have a connection. At some point along the way, I heard she liked Cheetos, so I started bringing in big bags to share with her and anyone else that wanted some. so I became the 'Cheeto man!' Along the way I became acquainted with her mom and grandma, occasionally getting hugs and thanks for being here for her. Then the 'nightmare of nightmares' hit 'Covid!' Covid is and was a rough time for everyone, but especially the patients and especially the first two years when no one knew for sure what we were dealing with, so many were dying, and the 'so called experts' changed the rules every other day, it seemed. They, our patients were suddenly 'physically' cut off from their families and eventually from even leaving their rooms. Everybody stepped up and did what they could for all the patients, within the limitations and stress that were also on us, (some of us more than others), and despite taking every precaution, both at work and at home, some of us were unfortunately unlucky enough to get it anyway, including me. While I never needed to be hospitalized , it kicked my butt for more than a month and it had a profound and lasting affect (sic) on me, and I still have lingering affects (sic) from it to this very day (the doctor calls it 'long covid'). I still have a naggy cough, fatigue easily, more frequent and severe headaches and memory loss/concentration. However, it was the second bout that brings us to today. While the second time was much less severe, it still messed with my head, not only do I struggle at times with my concentration, but I get distracted really easy and it can be tough to refocus. When I would lose my focus, I often went for a walk, on one occasion, I ran into [resident 1], still not sure why, but just being with her and talk to her (maybe it's because she is hard to understand so you really have to concentrate), I don't know, I only know that it helped to get my head back together so I could go and finish my work. That became my routine, when I got distracted, I would go and find [resident 1] and she would help me refocus. Once refocused, I would go back to work. Often before leaving, I would do something that I feel like I have been doing my entire life, I have done it with my kids, my wife, even my parents (I remember my father doing it to us kids and get it from his father and so on), namely, drum or slap our hands on the knees/distal thighs, then rub it better. I have never touched [resident 1] without asking if it is alright if I touch her, rarely do I touch anybody without permission. I can only assume that (the drumming and rubbing) is what was observed, to me it has always been a simple sign of affection, nothing more and nothing cynical about it. The first time [resident 1] told me she loved me, I asked her if this means she wanted to be my girlfriend, Her reply was 'You ' re too old!' I repled 'You are so right there!' It has become somewhat of a joke between us. [Resident 1] is like a daughter or granddaughter to me, as I have told her many times. I have always belived (sic) that Hell is, being somewhere without our families and those we love. Telling me that I can have no contact with her is like a stab in the heart, I can follow most everything you suggested, i.e. not being alone or visit her in her room, not drum and rub her legs/knees, etc., but telling me that I cannot have her as a patient, I cannot touch her face or hair and tell her I care, I cannot hug her if she wants one or anyone else for that matter, will be Hell! I probably do get too involved and/or close to my people (especially the residents), but that is how I have always been, I do not apologise (sic) for loving my patients, they are my family away from my family who are away from their family. You told me, after your investigation that I was exonerated, yet, you continue treating me like I am really guilty or at least you think I am, putting me on a 3 month probation, restricting my movements, 'telling me when I can breathe and where' and since covid, it is all quite suffocating! I am not saying I will not follow your rules, if you insist, I will try my best, but [AGE] years of being this way as a therapist is a tough habit to break and I feel your rules are unfair, especially to my pt's (patients) and to anyone that is found 'Not Guilty!' It is like any relationship, it is never instantaneous, it takes time to grow and develop. Talk to [resident 1], talk to her mother or grandmother. If you insist on this course of action it will be like ripping my heart out and then stomping on it! Sincerely, [COTA 1]. No record of an interview that was conducted in person with COTA 1 could be located in the facility's abuse investigation documents. [Note: It should be noted that the corrective action document and COTA 1's letter was in COTA 1's HR file with the therapy department. The documents were not included in the final abuse investigation.] [Note: Review of resident 1's therapy service records revealed that resident 1 was on therapy services from 10/1/21 through 6/3/22 then started services again 9/1/22. Resident 1 was without therapy services July and August 2022. No evidence could be located to indicate that the staff members investigating the abuse allegation verified if resident 1 was on therapy services at the time of the allegation.] [Note: A review of therapy staff that worked with resident 1 documented COTA 1 was scheduled to work with resident 1 on the following dates despite being specifically instructed not to work with her: 6/9/23, 6/1/23, 6/14/23, 6/15/23.] On 10/26/23 at 2:18 PM, an interview was conducted with SSW 2. SSW 2 stated that she conducted the investigation for the incident with COTA 1 and resident 1 in July 2022. SSW 2 stated that she asked resident 1 screening questions about abuse. SSW 2 stated that if she asked screening questions regarding abuse and the resident says no then she would not ask any other questions, but if the resident says yes she would follow up. SSW 2 stated that in July 2022, she asked resident 1 if she had been abused or neglected by staff, and resident 1 answered no. When SSW 2 was asked if she thought resident 1 knew what abuse was, SSW 2 said yes. SSW 2 stated that she suspected that resident 1's understanding of abuse was someone hitting her and not giving her what she wanted. SSW 2 stated that COTA 1 was nice to resident 1 and would give her cheetos. SSW 2 stated she conducted an interview with COTA 1 in July 2022 and when SSW 2 was asked about the statement regarding COTA 1 tickling and poking resident 1, SSW 2 stated that the context was stated in a playing around manner. SSW 2 stated that if the resident consented to it, but if it was in a private setting then it would not be okay. SSW 2 stated that after the allegation in July 2022 resident 1 was taken off of COTA 1's therapy schedule and COTA 1 was required to complete an abuse training. SSW 2 stated that the Director of Therapy (DoT) would arrange COTA 1's hours to be in the facility during the day. SSW 2 stated that she was not aware of who was informed that COTA 1 was not supposed to be working with resident 1. SSW 2 stated that the DoT would oversee the corrective action since DoT was COTA 1's direct supervisor. When SSW 2 was asked how an abuse investigation was determined inconclusive or not, she stated it is substantiated if a victim says there is something going on or if there is proof. SSW 2 stated that she informed the previous administrator ADM 2 of the findings for the July 2022 incident. SSW 2 stated that when she presented the information to ADM 2, he said to unsubstantiate the allegation because there was no proof of abuse. SSW 2 stated that she also contacted the corporate social services (CSS) regarding the incident, and the CSS stated there was not enough evidence to substantiate the allegation. Multiple staff stated that they had witnessed COTA 1 interacting with resident 1 after the first allegation had been made in July 2022. Those interviews are as follows: On 10/24/23 at 1:40 PM, an interview was conducted with RN 2. RN 2 stated she had noticed COTA 1 would visit resident 1 in her room and bring her cheetos. RN 2 stated that she had not witnessed any inappropriate behavior between COTA 1 and resident 1. On 10/25/23 at 8:55 AM, an interview was conducted with the nursing scheduler (NS) 1. NS 1 stated she had seen COTA 1 in residents 1 room multiple times and had seen him taking resident 1 to the therapy room. NS 1 stated the therapy team was usually out of the facility by 4:00 PM, and that NS 1 would see COTA 1 in the facility around 6:00 PM. ALLEGATION 2: On 9/21/23 at 6:09 PM, the facility submitted a form 358, initial entity report, indicating that earlier that day, at 2:30PM, CNA 2 witnessed COTA 1 in resident 1's room touching the resident inappropriately. On 9/22/23 at 10:31 AM, the facility submitted a form 359, that alleged that Resident 1 stated that COTA 1 had touched her breast, twice before and over her shirt, kisses her on the lips and tells her that he loves her. [Resident 1] also confirms that [COTA 1] does not make her feel uncomfortable, and that he visits her every day. The form 359 indicated that on 9/21/23, CNA 2 reported that she saw COTA 1 in resident 1's room when CNA 2 went in to answer resident 1's roommate's call light. When CNA 2 entered the room, she saw COTA 1 with his hand on resident 1's hand caressing it. CNA 2 left the room and returned with coffee for resident 1's roommate, when she returned she saw [COTA 1] sitting on her (resident 1's) bed with his hand on [resident 1's] breast and the other hand still on hers. [CNA 2] confronted [COTA 1] and told him that what he is doing is not appropriate, and he should not be touching her like that. At that time [COTA 2] was walking by and asked [CNA 2] if everything was ok. [CNA 2] told her what she observed. [COTA 2] also went in to confront [COTA 1], and he agreed to leave the room. [COTA 2] reports that she was walking down the 100 hall and could hear [CNA 2] questioning [COTA 1] in [resident 1's] room, and was really upset. She stood outside the door and waited for [CNA 2] to come out of the room, and asked her if everything was ok? [CNA 2] told [COTA 2] what she had observed and asked [COTA 2] if [COTA 1] should be in there. [COTA 2] told her 'no he shouldn't be in there, [resident 1] is my patient, and she had already been seen that day ' . [COTA 2] went into the room with [CNA 2] and asked [COTA 1] what he was doing (she saw him standing on [resident 1's] left side stretching her left arm), and he said that he was trying to get her thumb out (it was contracted). [COTA 2] told him that he shouldn't be in here, she is my patient and I have already seen her today. He agreed to leave. [CNA 2] and [COTA 2] to [Physical Therapist (PT) 1] a PT covering for the therapy director that day. When [COTA 2] returned to the therapy office, [COTA 1] went in and sat down on the counter and said to her just what was it you are accusing me of? He then said the reason I was leaning across her breast was because I was doing therapy and needed to, which made no sense to [COTA 2] because [resident 1's] affected arm is on the left, and there's no reason to lay across her chest. The form 359 included a summary of an interview with COTA 1. [COTA 1] states th [TRUNCATED]

Based on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a resident was sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access and abuse of the resident by the alleged perpetrator. This requirement was determine to be out of compliance at the severity level of immediate jeopardy. Due to the ongoing access to resident 1, by the alleged perpetrator, the scope of the noncompliance is determined to be a pattern. Resident identifier: 1. NOTICE On 10/25/23 at 3:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally and in writing to the facility Administrator (ADM), the Skilled Nursing Facility Social Work Director for Quality, the [NAME] President of Clinical Quality, the Regional Director, the Director of Nursing, and the Assistant Director of Nursing. On 10/26/23 at 1:24 PM, the Regional Director provided the following abatement plan for the removal of the Immediate Jeopardy effective on 10/26/23 at 2:30 PM. Allegation of Compliance to abate immediate jeopardy: RE: Complaint Survey 10/24/23 Survey findings: COTA [Certified Occupational Therapy Assistant] 1 was not supposed to be working with resident 1, but was seen on multiple occasions in her room. These incidents were not reported to the facility administration. In addition, COTA 1 was allowed to work with resident 1 in June 2023. An investigation completed 7/6/22 was incomplete and safeguards not followed. We respectfully assert that we have removed the immediate jeopardy on 10/26/23 at 2:30 pm. Immediate corrective action: F600 Freedom from Abuse Protection of Resident from alleged perpetrator: Suspended COTA 1 immediately on 9/21/2023 and terminated. Involvement with Police and investigators and according to investigator on 10/25/23 was arrested. Responsible Person: Administrator Date of Completion: 9/21/23 Resident 1 was interviewed by Social Service Staff and determined to not show signs of psychosocial distress. Social services offered to Resident 1's mother to set up counseling and her mother declined at that time. Social Services will continue to partner for counseling with Resident 1 and advocate for this to occur with her mothers consent. Responsible Person: Social Services Date of completion: 9/22/23 and 10/26/23 at 1:30 pm. COTA 1 has been arrested and charged. Staff have signs posted at nursing area's and at the front desk with COTA 1's picture to deny visit's and call the police. Pictures posted on 10/25/23 at 3:30 pm At the time it was discovered that COTA 1 had violated the trespass order police were immediately called and a staff member was placed outside of Resident 1's room until it was assured that COTA 1 was arrested. Staff member placed outside of room on 10/25/23 at 8:45 am Director of Therapy has been suspended and will no longer be allowed to be a Director or Therapist in the facility. Inserviced therapy staff to report abuse and any concerns such as these immediately to the Administrator. Responsible Person: Regional Director of Therapy Date of Completion: 10/26/23 at 9:00 am Female Residents that COTA 1 had treated and other female residents were interviewed about abuse to ensure they felt safe and ensure other issues similar were identified. No other concerns were raised. Responsible Person: Director of Nursing or Designee Date of Completion: 9/22/23 and again on 10/25/23 All other residents in the facility interviewed about abuse to ensure issues similar with abuse were not evident with any other resident. Responsible Person: Director of Nursing or Designee Date of Completion 10/26/23 at 2:00 pm Abuse, neglect training completed for staff including therapy which included situational concerns similar to Resident 1 and COTA 1 this included exploitative behaviors such as taking advantage of a resident for personal gain or having relationships that appear inappropriate. Responsible person: Director of Nursing or Designee Date of Completion: 9/27/23, 9/26/23, 9/28/23 Abuse and Grooming signs to our staff with Abuse training for staff completed to include: Victim selection: Abusers often observe possible victims and select them based on ease of access to them or their perceived vulnerability.Gaining access and isolating the victim: Abusers will attempt to physically or emotionally separate a victim from those protecting them and often seek out positions in which they have contact with minors. Trust development and keeping secrets: Abusers attempt to gain trust of a potential victim through gifts, attention, sharing secrets and other means to make them feel that they have a caring relationship and to train them to keep the relationship secret. Desensitization to touch and discussion of sexual topics: Abusers will often start to touch a victim in ways that appear harmless, such as hugging, wrestling and tickling, and later escalate to increasingly more sexual contact, such as massages or showering together. Abusers may also show the victim pornography or discuss sexual topics with them, to introduce the idea of sexual contact. Attempt by abusers to make their behavior seem natural, to avoid raising suspicions. For teens, who may be closer in age to the abuser, it can be particularly hard to recognize tactics used in grooming. Be alert for signs that your teen has a relationship with an adult that includes secrecy, undue influence or control, or pushes personal boundaries. Most importantly to report any concerns immediately to the Administrator. Responsible Person: Administrator Date of Completion: 10/26/23 these were completed in small groups with discussion at 11:30 am F609-Reporting Abuse Abuse identification and reporting, neglect training completed for staff including therapy which included situational concerns similar to Resident 1 and COTA 1 this included exploitative behaviors such as taking advantage of a resident for personal gain or having relationships that appear inappropriate. Responsible person: Director of Nursing or Designee Date of Completion: 9/27/23, 9/26/23, 9/28/23 Director of Therapy has been suspended and will no longer be allowed to be a Director or Therapist in the facility. Inserviced therapy staff to report abuse and any concerns such as these immediately to the Administrator. Responsible Person: Regional Director of Therapy Date of Completion: 10/26/23 at 9:00 am Female Residents that COTA 1 had treated and other female residents were interviewed about abuse to ensure they felt safe and ensure other issues similar were identified. No other concerns were raised. Responsible Person: Director of Nursing or Designee Date of Completion: 9/22/23 and again on 10/25/23 All other residents in the facility interviewed about abuse to ensure issues similar with this abuse situation was identified. Date of Completion: 10/26/23 at 2:30 pm Abuse and Grooming signs to our staff with Abuse training for staff completed to include: Victim selection: Abusers often observe possible victims and select them based on ease of access to them or their perceived vulnerability.Gaining access and isolating the victim: Abusers will attempt to physically or emotionally separate a victim from those protecting them and often seek out positions in which they have contact with minors.Trust development and keeping secrets: Abusers attempt to gain trust of a potential victim through gifts, attention, sharing secrets and other means to make them feel that they have a caring relationship and to train them to keep the relationship secret. Desensitization to touch and discussion of sexual topics: Abusers will often start to touch a victim in ways that appear harmless, such as hugging, wrestling and tickling, and later escalate to increasingly more sexual contact, such as massages or showering together. Abusers may also show the victim pornography or discuss sexual topics with them, to introduce the idea of sexual contact.Attempt by abusers to make their behavior seem natural, to avoid raising suspicions. For teens, who may be closer in age to the abuser, it can be particularly hard to recognize tactics used in grooming. Be alert for signs that your teen has a relationship with an adult that includes secrecy, undue influence or control, or pushes personal boundaries. Staff inserviced if they see any of these signs to report to the Administrator immediately. Responsible Person: Administrator Date of Completion: 10/26/23 these were completed in small groups with discussion at 11:30 am. F610-Investigation Correction for incomplete investigation: Former Administrator who was engaged with prior investigation dated July 2022 no longer works with Rocky Mountain Care. Responsible Person: Regional [NAME] President of Rocky Mountain Care: Date of Completion: 5/1/2023 Current Facility management who completes abuse investigations were inserviced on the completing abuse training and assuring that interventions are implemented and effective to prevent abuse. Responsible Person: [NAME] President of Quality with Rocky Mountain Care Date of Completion: 10/26/23 at 8:30 am All Abuse files were reviewed for completion and to ensure interventions have been implemented. Responsible Person: Administrator Date of Completion: 10/25/2023 at 9:00 pm Monitoring: Administrator or designee will audit all abuse reports monthly for four months reviewing interventions and investigation material to assure appropriate interventions are being followed to ensure prevention of abuse. Nursing Administration will interview 10% of active employees and therapy staff each week for four months to determine if they have witnessed staff who may have an inappropriate relationship with other residents and if so ensuring they had been reported. Audits will be reviewed monthly in QAPI for sustained substantial compliance. On 10/26/23, while completing an abbreviated complaint survey, and an extended 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 10/26/23. Findings include: Immediate Jeopardy Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anoxic brain damage, quadriplegia, epilepsy, and anxiety disorder. Resident 1's medical record was reviewed on 10/25/23. On 9/26/23, a Montreal Cognitive Assessment (MOCA) was completed for resident 1. The MOCA indicated that resident was oriented to the correct month, date, place, and city; but not the year. The MOCA also indicated that resident 1 had a score of 8 out of 22, indicating severe cognitive impairment. On 8/31/22, a quarterly minimum data set (MDS) revealed resident 1 completed a brief interview for mental status (BIMS). Resident 1's scored a BIMS of 14 out of 15 meaning resident 1 had intact cognition. The MDS also revealed that resident 1 required extensive two person assistance with bed mobility. The MDS indicated that resident 1 was totally dependent on 2 staff for transfers. The MDS also indicated that resident 1 required extensive one person assistance with dressing, toileting, and personal hygiene. Per the MDS, the resident also required limited one person assistance with eating. The MDS indicated that resident 1 was totally dependent on one staff member for bathing. The MDS additionally indicated that resident 1 required the use of a wheelchair, and had an impairment in her range of motion on both the upper and lower right and left extremities. Two separate allegations of abuse were investigated by the facility regarding COTA 1's actions with resident 1. Those allegations are described as follows: ALLEGATION 1: A Concern Form dated 7/6/22 at 4:45 PM was completed by RN 2. The Concern Form staff members reported to [RN 2] the following: [RN 1] observed [COTA 1] was in [resident 1's] room and had his hand on her leg and when the nurse came in for cares he left. In a separate observation, [CNA 1] observed [COTA 1's] arm around [resident 1's] top/around area . The immediate actions taken: COTA 1 has been removed from her (resident 1's) cares. The concern form documented the concern was reported to the administrator, DON (director of nursing)/ unit manager, social services, and therapy. The area of the form titled Actions taken to prevent recurrence was left blank. An initial entity report was filed with the State Survey Agency (SSA) on 7/7/22 at 12:05 PM. The initial entity report revealed that on an unknown date and time an incident allegedly occurred between resident 1 and COTA 1. The initial entity report indicated that Registered nurse (RN) 1 observed COTA 1 in resident 1's room and COTA 1 had his hand on her leg and when RN 1 came in to provide cares COTA 1 left. The incident was reported to Social Services Worker (SSW) 2. In a separate observation reported to SSW 2, a certified nursing assistant (CNA) 1 observed COTA 1's arm around resident 1's top area. The entity report documented the dates of incident's (sic) are under investigation. [Note: The initial entity report date is 7/7/22 at 12:05 PM, over 11 hours after the concern form was filed.] On 7/8/22, RN 2 wrote a statement of what he witnessed. RN 2 stated that COTA 1 was seated on resident 1's bed, and resident 1 was seated in her wheelchair, in a slightly reclined position. RN 2 stated that he witnessed COTA 1 massaging resident 1's left leg. RN 1 stated that this had occurred on 7/5/22 at 12:00 PM. On 7/12/23, CNA 1 wrote the following statement, I [CNA 1] on two occasions seen (sic) [COTA 1] getting a little to (sic) close to [resident 1], On the first occasion which was on July, 5, 2022 right before dinner I notice (sic) [COTA 1] hand on [resident 1] thigh. Then on July 6, 2022 I do not recall around what time I walk (sic) in [resident 1] room because her roommate (sic) called for help. As I am walking in I seen (sic) [COTA 1] squatting over [resident 1] and he had his arm wrapped around her waist. [Resident 1] was laying in her bed with a T-shirt and brief. When I went back to see what was going (sic) [COTA 1] had left and he had forgot his laptop. A review of the final investigation dated 7/14/22 revealed the following: a. A documented witness summary revealed, RN 1 stated on 7/5/22, [RN 1] walked by [resident 1's room] and saw COTA [1] sitting on [resident 1's] bed. Resident 1 was sitting in her wheelchair. [RN 1] saw COTA [1] touching [resident 1's] legs, like a massage her left thigh. [RN 1] does not know if that is part of therapy or not. RN 1 informed the nurse over that hall. [Upon review of the witness statement, RN 2 stated that this incident had occurred on 7/5/23 at 12:00 PM.] b. A second witness summary revealed, [CNA 1] stated on two occasions has seen [COTA 1] getting a little close to [resident 1]. First occasion on 7/5/22, [CNA 1] saw [COTA 1's] hand on [resident 1's] thigh. Second occasion on 7/6/22, she walked in the room and saw [COTA 1] squatting next to [resident 1] and had his arm wrapped around [resident 1's] waist. [Resident 1] was laying in bed with a T-shirt and brief and when [CNA 1] returned, [COTA 1] had left and forgotten his laptop. c. An account of the resident involved revealed, on 7/7/22, SSW 2 interviewed resident 1. Resident 1 said she felt safe in the facility and denied any staff touching her inappropriately. On 7/12/22 resident 1 was re-interviewed and again stated she felt safe in the facility and staff members are nice to her and feels safe with everyone who cares for her. Denied any staff member touching her inappropriately and is comfortable around all staff. [Note: The investigation did not indicate if direct questions were asked of resident 1, or if she was simply asked about inappropriate touch and feeling safe. It is unclear if direct questions about COTA 1 and his behaviors were asked of resident 1.] d. An interview was conducted with COTA 1 on 7/12/22. COTA 1 denied touching resident 1 in a non-therapeutic way. COTA 1 reports that when he works with patients with poor cognition, he will tell them what he is doing and is respectful. When interacting with [resident 1] he will ask her if it is okay to do something before he does anything and she has never disagreed or reacted adversely during their interactions.[COTA 1] reported he has touched her on the thigh, poked her and tickled her jokingly but is cautious in not touching her in an inappropriate way. [COTA 1] said he has a tendency of resting his hands on her legs but is cautious to not move it where it does not belong. Stated he has hugged her and in the presence of her mom and there had not been an adverse reaction. When he interacts with her in her room, he always leaves the door open. e. A summary of evidence documented based on witness accounts and alleged perpetrators statements the abuse allegation is unsubstantiated. f. The corrective action summary stated COTA 1 will not be assigned to work with resident 1 and education will be provided on professional boundaries and appropriate ways to interact with residents. g. The administrative decision stated, at this time, we believe that the allegation of abuse is unsubstantiated, as it does not rise to the level of abuse. [It should be noted that upon review of COTA 1's assignments, COTA 1 was not assigned to work with resident 1 during this time period of June and July 2022. Therefore, the intervention of instructing COTA 1 to not work with resident 1 was not an effective intervention.] [Note: The investigation into the allegation of abuse in July 2022 did not include interviews with other staff members regarding interactions between COTA 1 and resident 1.] A review of the corrective action document dated 7/20/22, written by COTA 1's supervisor/manager the director of therapy (DoT), the document revealed. In reviewing the events and investigation outcomes, we have determined professional boundaries have been crossed and need to be addressed . The action plan to correct the incident documented: a. Employee will complete additional training on the [therapy group] abuse policies. b. Employee will no longer work with the patient as a therapist. c. Employee will complete additional training regarding creating and maintaining professional boundaries in a healthcare setting. d. Employee will demonstrate professional behavior and use professional language with patients, staff and other at all times in compliance with our sexual abuse, abuse, and professional ethics policies. [It should be noted COTA 1 refused to sign the corrective action plan.] e. Employee comments revealed an attached letter from COTA 1. The letter read as follows: To whom it may concern: This letter is in answer to your incident action plan in relation to [resident 1]. First, let me say that I hold no ill feelings for whomever reported what they thought they saw as abuse, reporting assumed abuse is not easy, but knowing that other's (sic) care enough about our pt's [patients], especially [resident 1], to report anything they see as a potential wrong, is to be admired, not (criticized). [Resident 1] means a lot to me, I have always told her she is like the granddaughter I have always wanted, but did not have, or even like a daughter. I have never, in any way, abused my children nor have I ever taken advantage of or abused [resident 1]. However, to understand the relationship I have had with [resident 1], you need to learn from the beginning. I do not remember who was here first, [resident 1] or myself, all I know is that [resident 1] was torn away from her kids, her mom and her grandma, mostly because she needed more assistance than they were able to provide, and put into a foreign place filled with 'older people' that were not family. So every or nearly every night she was initially here, she would lie in her bed and weep and wail and cry out for her kids and family, it was one of the most gut-wrenching sound (sic) I have ever heard, but I seldom ever saw anyone go in and try to comfort her, so I started going in when I could and sit on the side of her bed and talk to her, wipe away her tears and hold her hand or rub her shoulders or back, to give her some comfort and let her know she was loved and cared for. Sometimes it helped and sometimes not, but I tried to help! But since that time, [resident 1] and I seemed to have a connection. At some point along the way, I heard she liked Cheetos, so I started bringing in big bags to share with her and anyone else that wanted some. so I became the 'Cheeto man!' Along the way I became acquainted with her mom and grandma, occasionally getting hugs and thanks for being here for her. Then the 'nightmare of nightmares' hit 'Covid!' Covid is and was a rough time for everyone, but especially the patients and especially the first two years when no one knew for sure what we were dealing with, so many were dying, and the 'so called experts' changed the rules every other day, it seemed. They, our patients were suddenly 'physically' cut off from their families and eventually from even leaving their rooms. Everybody stepped up and did what they could for all the patients, within the limitations and stress that were also on us, (some of us more than others), and despite taking every precaution, both at work and at home, some of us were unfortunately unlucky enough to get it anyway, including me. While I never needed to be hospitalized , it kicked my butt for more than a month and it had a profound and lasting affect (sic) on me, and I still have lingering affects (sic) from it to this very day (the doctor calls it 'long covid'). I still have a naggy cough, fatigue easily, more frequent and severe headaches and memory loss/concentration. However, it was the second bout that brings us to today. While the second time was much less severe, it still messed with my head, not only do I struggle at times with my concentration, but I get distracted really easy and it can be tough to refocus. When I would lose my focus, I often went for a walk, on one occasion, I ran into [resident 1], still not sure why, but just being with her and talk to her (maybe it's because she is hard to understand so you really have to concentrate), I don't know, I only know that it helped to get my head back together so I could go and finish my work. That became my routine, when I got distracted, I would go and find [resident 1] and she would help me refocus. Once refocused, I would go back to work. Often before leaving, I would do something that I feel like I have been doing my entire life, I have done it with my kids, my wife, even my parents (I remember my father doing it to us kids and get it from his father and so on), namely, drum or slap our hands on the knees/distal thighs, then rub it better. I have never touched [resident 1] without asking if it is alright if I touch her, rarely do I touch anybody without permission. I can only assume that (the drumming and rubbing) is what was observed, to me it has always been a simple sign of affection, nothing more and nothing cynical about it. The first time [resident 1] told me she loved me, I asked her if this means she wanted to be my girlfriend, Her reply was 'You ' re too old!' I repled 'You are so right there!' It has become somewhat of a joke between us. [Resident 1] is like a daughter or granddaughter to me, as I have told her many times. I have always belived (sic) that Hell is, being somewhere without our families and those we love. Telling me that I can have no contact with her is like a stab in the heart, I can follow most everything you suggested, i.e. not being alone or visit her in her room, not drum and rub her legs/knees, etc., but telling me that I cannot have her as a patient, I cannot touch her face or hair and tell her I care, I cannot hug her if she wants one or anyone else for that matter, will be Hell! I probably do get too involved and/or close to my people (especially the residents), but that is how I have always been, I do not apologise (sic) for loving my patients, they are my family away from my family who are away from their family. You told me, after your investigation that I was exonerated, yet, you continue treating me like I am really guilty or at least you think I am, putting me on a 3 month probation, restricting my movements, 'telling me when I can breathe and where' and since covid, it is all quite suffocating! I am not saying I will not follow your rules, if you insist, I will try my best, but [AGE] years of being this way as a therapist is a tough habit to break and I feel your rules are unfair, especially to my pt's (patients) and to anyone that is found 'Not Guilty!' It is like any relationship, it is never instantaneous, it takes time to grow and develop. Talk to [resident 1], talk to her mother or grandmother. If you insist on this course of action it will be like ripping my heart out and then stomping on it! Sincerely, [COTA 1]. No record of an interview that was conducted in person with COTA 1 could be located in the facility's abuse investigation documents. [Note: It should be noted that the corrective action document and COTA 1's letter was in COTA 1's HR file with the therapy department. The documents were not included in the final abuse investigation.] [Note: Review of resident 1's therapy service records revealed that resident 1 was on therapy services from 10/1/21 through 6/3/22 then started services again 9/1/22. Resident 1 was without therapy services July and August 2022. No evidence could be located to indicate that the staff members investigating the abuse allegation verified if resident 1 was on therapy services at the time of the allegation.] [Note: A review of therapy staff that worked with resident 1 documented COTA 1 was scheduled to work with resident 1 on the following dates despite being specifically instructed not to work with her: 6/9/23, 6/1/23, 6/14/23, 6/15/23.] On 10/26/23 at 2:18 PM, an interview was conducted with SSW 2. SSW 2 stated that she conducted the investigation for the incident with COTA 1 and resident 1 in July 2022. SSW 2 stated that she asked resident 1 screening questions about abuse. SSW 2 stated that if she asked screening questions regarding abuse and the resident says no then she would not ask any other questions, but if the resident says yes she would follow up. SSW 2 stated that in July 2022, she asked resident 1 if she had been abused or neglected by staff, and resident 1 answered no. When SSW 2 was asked if she thought resident 1 knew what abuse was, SSW 2 said yes. SSW 2 stated that she suspected that resident 1's understanding of abuse was someone hitting her and not giving her what she wanted. SSW 2 stated that COTA 1 was nice to resident 1 and would give her cheetos. SSW 2 stated she conducted an interview with COTA 1 in July 2022 and when SSW 2 was asked about the statement regarding COTA 1 tickling and poking resident 1, SSW 2 stated that the context was stated in a playing around manner. SSW 2 stated that if the resident consented to it, but if it was in a private setting then it would not be okay. SSW 2 stated that after the allegation in July 2022 resident 1 was taken off of COTA 1's therapy schedule and COTA 1 was required to complete an abuse training. SSW 2 stated that the Director of Therapy (DoT) would arrange COTA 1's hours to be in the facility during the day. SSW 2 stated that she was not aware of who was informed that COTA 1 was not supposed to be working with resident 1. SSW 2 stated that the DoT would oversee the corrective action since DoT was COTA 1's direct supervisor. When SSW 2 was asked how an abuse investigation was determined inconclusive or not, she stated it is substantiated if a victim says there is something going on or if there is proof. SSW 2 stated that she informed the previous administrator ADM 2 of the findings for the July 2022 incident. SSW 2 stated that when she presented the information to ADM 2, he said to unsubstantiate the allegation because there was no proof of abuse. SSW 2 stated that she also contacted the corporate social services (CSS) regarding the incident, and the CSS stated there was not enough evidence to substantiate the allegation. Multiple staff stated that they had witnessed COTA 1 interacting with resident 1 after the first allegation had been made in July 2022. Those interviews are as follows: On 10/24/23 at 1:40 PM, an interview was conducted with RN 2. RN 2 stated she had noticed COTA 1 would visit resident 1 in her room and bring her cheetos. RN 2 stated that she had not witnessed any inappropriate behavior between COTA 1 and resident 1. On 10/25/23 at 8:55 AM, an interview was conducted with the nursing scheduler (NS) 1. NS 1 stated she had seen COTA 1 in residents 1 room multiple times and had seen him taking resident 1 to the therapy room. NS 1 stated the therapy team was usually out of the facility by 4:00 PM, and that NS 1 would see COTA 1 in the facility around 6:00 PM. ALLEGATION 2: On 9/21/23 at 6:09 PM, the facility submitted a form 358, initial entity report, indicating that earlier that day, at 2:30PM, CNA 2 witnessed COTA 1 in resident 1's room touching the resident inappropriately. On 9/22/23 at 10:31 AM, the facility submitted a form 359, that alleged that Resident 1 stated that COTA 1 had touched her breast, twice before and over her shirt, kisses her on the lips and tells her that he loves her. [Resident 1] also confirms that [COTA 1] does not make her feel uncomfortable, and that he visits her every day. The form 359 indicated that on 9/21/23, CNA 2 reported that she saw COTA 1 in resident 1's room when CNA 2 went in to answer resident 1's roommate's call light. When CNA 2 entered the room, she saw COTA 1 with his hand on resident 1's hand caressing it. CNA 2 left the room and returned with coffee for resident 1's roommate, when she returned she saw [COTA 1] sitting on her (resident 1's) bed with his hand on [resident 1's] breast and the other hand still on hers. [CNA 2] confronted [COTA 1] and told him that what he is doing is not appropriate, and he should not be touching her like that. At that time [COTA 2] was walking by and asked [CNA 2] if everything was ok. [CNA 2] told her what she observed. [COTA 2] also went in to confront [COTA 1], and he agreed to leave the room. [COTA 2] reports that she was walking down the 100 hall and could hear [CNA 2] questioning [COTA 1] in [resident 1's] room, and was really upset. She stood outside the door and waited for [CNA 2] to come out of the room, and asked her if everything was ok? [CNA 2] told [COTA 2] what she had observed and asked [COTA 2] if [COTA 1] should be in there. [COTA 2] told her 'no he shouldn't be in there, [resident 1] is my patient, and she had already been seen that day ' . [COTA 2] went into the room with [CNA 2] and asked [COTA 1] what he was doing (she saw him standing on [resident 1's] left side stretching her left arm), and he said that he was trying to get her thumb out (it was contracted). [COTA 2] told him that he shouldn't be in here, she is my patient and I have already seen her today. He agreed to leave. [CNA 2] and [COTA 2] to [Physical Therapist (PT) 1] a PT covering for the therapy director that day. When [COTA 2] returned to the therapy office, [COTA 1] went in and sat down on the counter and said to her just what was it you are accusing me of? He then said the reason I was leaning across her breast was because I was doing therapy and needed to, which made no sense to [COTA 2] because [resident 1's] affected arm is on the left, and there's no reason to lay across her chest. The form 359 included a summary of an interview with COTA 1. [COTA 1] sta [TRUNCATED]

Based on confidential and non-confidential interviews with administrative staff, therapy staff, licensed and unlicensed nursing staff, and record review, it was determined, for 1 of 9 sampled residents, the facility failed to ensure that all suspected or alleged violations involving abuse were reported immediately to the administrator and other officials in accordance with State law through established procedures. Specifically, when interviewed by surveyors, multiple staff reported observing Certified Occupational Therapy Assistant (COTA) 1 interacting with resident 1 in a suspicious manner and did not report their concerns, thereby, allowing COTA 1 ongoing access to resident 1. The facility's noncompliance relative to identifing and reporting abuse was determined to be at the severity level of immediate jeopardy. Due to the repeated occurrence and number of staff who failed to report their concern, the scope was determined to be a pattern. Resident identifier: 1. NOTICE On 10/25/23 at 3:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally and in writing to the facility Administrator (ADM), the Skilled Nursing Facility Social Work Director for Quality, the [NAME] President of Clinical Quality, the Regional Director, the Director of Nursing, and the Assistant Director of Nursing. On 10/26/23 at 1:24 PM, the Regional Director provided the following abatement plan for the removal of the Immediate Jeopardy effective on 10/26/23 at 2:30 PM. Allegation of Compliance to abate immediate jeopardy: RE: Complaint Survey 10/24/23 Survey findings: COTA [Certified Occupational Therapy Assistant] 1 was not supposed to be working with resident 1, but was seen on multiple occasions in her room. These incidents were not reported to the facility administration. In addition, COTA 1 was allowed to work with resident 1 in June 2023. An investigation completed 7/6/22 was incomplete and safeguards not followed. We respectfully assert that we have removed the immediate jeopardy on 10/26/23 at 2:30 pm. Immediate corrective action: F600 Freedom from Abuse Protection of Resident from alleged perpetrator: Suspended COTA 1 immediately on 9/21/2023 and terminated. Involvement with Police and investigators and according to investigator on 10/25/23 was arrested. Responsible Person: Administrator Date of Completion: 9/21/23 Resident 1 was interviewed by Social Service Staff and determined to not show signs of psychosocial distress. Social services offered to Resident 1's mother to set up counseling and her mother declined at that time. Social Services will continue to partner for counseling with Resident 1 and advocate for this to occur with her mothers consent. Responsible Person: Social Services Date of completion: 9/22/23 and 10/26/23 at 1:30 pm. COTA 1 has been arrested and charged. Staff have signs posted at nursing area's and at the front desk with COTA 1's picture to deny visit's and call the police. Pictures posted on 10/25/23 at 3:30 pm At the time it was discovered that COTA 1 had violated the trespass order police were immediately called and a staff member was placed outside of Resident 1's room until it was assured that COTA 1 was arrested. Staff member placed outside of room on 10/25/23 at 8:45 am Director of Therapy has been suspended and will no longer be allowed to be a Director or Therapist in the facility. Inserviced therapy staff to report abuse and any concerns such as these immediately to the Administrator. Responsible Person: Regional Director of Therapy Date of Completion: 10/26/23 at 9:00 am Female Residents that COTA 1 had treated and other female residents were interviewed about abuse to ensure they felt safe and ensure other issues similar were identified. No other concerns were raised. Responsible Person: Director of Nursing or Designee Date of Completion: 9/22/23 and again on 10/25/23 All other residents in the facility interviewed about abuse to ensure issues similar with abuse were not evident with any other resident. Responsible Person: Director of Nursing or Designee Date of Completion 10/26/23 at 2:00 pm Abuse, neglect training completed for staff including therapy which included situational concerns similar to Resident 1 and COTA 1 this included exploitative behaviors such as taking advantage of a resident for personal gain or having relationships that appear inappropriate. Responsible person: Director of Nursing or Designee Date of Completion: 9/27/23, 9/26/23, 9/28/23 Abuse and Grooming signs to our staff with Abuse training for staff completed to include: Victim selection: Abusers often observe possible victims and select them based on ease of access to them or their perceived vulnerability.Gaining access and isolating the victim: Abusers will attempt to physically or emotionally separate a victim from those protecting them and often seek out positions in which they have contact with minors.Trust development and keeping secrets: Abusers attempt to gain trust of a potential victim through gifts, attention, sharing secrets and other means to make them feel that they have a caring relationship and to train them to keep the relationship secret. Desensitization to touch and discussion of sexual topics: Abusers will often start to touch a victim in ways that appear harmless, such as hugging, wrestling and tickling, and later escalate to increasingly more sexual contact, such as massages or showering together. Abusers may also show the victim pornography or discuss sexual topics with them, to introduce the idea of sexual contact.Attempt by abusers to make their behavior seem natural, to avoid raising suspicions. For teens, who may be closer in age to the abuser, it can be particularly hard to recognize tactics used in grooming. Be alert for signs that your teen has a relationship with an adult that includes secrecy, undue influence or control, or pushes personal boundaries. Most importantly to report any concerns immediately to the Administrator. Responsible Person: Administrator Date of Completion: 10/26/23 these were completed in small groups with discussion at 11:30 am F609-Reporting Abuse Abuse identification and reporting, neglect training completed for staff including therapy which included situational concerns similar to Resident 1 and COTA 1 this included exploitative behaviors such as taking advantage of a resident for personal gain or having relationships that appear inappropriate. Responsible person: Director of Nursing or Designee Date of Completion: 9/27/23, 9/26/23, 9/28/23 Director of Therapy has been suspended and will no longer be allowed to be a Director or Therapist in the facility. Inserviced therapy staff to report abuse and any concerns such as these immediately to the Administrator. Responsible Person: Regional Director of Therapy Date of Completion: 10/26/23 at 9:00 am Female Residents that COTA 1 had treated and other female residents were interviewed about abuse to ensure they felt safe and ensure other issues similar were identified. No other concerns were raised. Responsible Person: Director of Nursing or Designee Date of Completion: 9/22/23 and again on 10/25/23 All other residents in the facility interviewed about abuse to ensure issues similar with this abuse situation was identified. Date of Completion: 10/26/23 at 2:30 pm Abuse and Grooming signs to our staff with Abuse training for staff completed to include: Victim selection: Abusers often observe possible victims and select them based on ease of access to them or their perceived vulnerability.Gaining access and isolating the victim: Abusers will attempt to physically or emotionally separate a victim from those protecting them and often seek out positions in which they have contact with minors.Trust development and keeping secrets: Abusers attempt to gain trust of a potential victim through gifts, attention, sharing secrets and other means to make them feel that they have a caring relationship and to train them to keep the relationship secret. Desensitization to touch and discussion of sexual topics: Abusers will often start to touch a victim in ways that appear harmless, such as hugging, wrestling and tickling, and later escalate to increasingly more sexual contact, such as massages or showering together. Abusers may also show the victim pornography or discuss sexual topics with them, to introduce the idea of sexual contact.Attempt by abusers to make their behavior seem natural, to avoid raising suspicions. For teens, who may be closer in age to the abuser, it can be particularly hard to recognize tactics used in grooming. Be alert for signs that your teen has a relationship with an adult that includes secrecy, undue influence or control, or pushes personal boundaries. Staff inserviced if they see any of these signs to report to the Administrator immediately. Responsible Person: Administrator Date of Completion: 10/26/23 these were completed in small groups with discussion at 11:30 am. F610-Investigation Correction for incomplete investigation: Former Administrator who was engaged with prior investigation dated July 2022 no longer works with Rocky Mountain Care. Responsible Person: Regional [NAME] President of Rocky Mountain Care: Date of Completion: 5/1/2023 Current Facility management who completes abuse investigations were inserviced on the completing abuse training and assuring that interventions are implemented and effective to prevent abuse. Responsible Person: [NAME] President of Quality with Rocky Mountain Care Date of Completion: 10/26/23 at 8:30 am All Abuse files were reviewed for completion and to ensure interventions have been implemented. Responsible Person: Administrator Date of Completion: 10/25/2023 at 9:00 pm Monitoring: Administrator or designee will audit all abuse reports monthly for four months reviewing interventions and investigation material to assure appropriate interventions are being followed to ensure prevention of abuse. Nursing Administration will interview 10% of active employees and therapy staff each week for four months to determine if they have witnessed staff who may have an inappropriate relationship with other residents and if so ensuring they had been reported. Audits will be reviewed monthly in QAPI for sustained substantial compliance. On 10/26/23, while completing an abbreviated complaint survey, and an extended 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 10/26/23. Findings include: Immediate Jeopardy Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anoxic brain damage, quadriplegia, epilepsy, and anxiety disorder. Resident 1's medical record was reviewed on 10/25/23. On 9/26/23, a Montreal Cognitive Assessment (MOCA) was completed for resident 1. The MOCA indicated that resident was oriented to the correct month, date, place, and city; but not the year. The MOCA also indicated that resident 1 had a score of 8 out of 22, indicating severe cognitive impairment. On 8/31/22, a quarterly minimum data set (MDS) revealed resident 1 completed a brief interview for mental status (BIMS). Resident 1's scored a BIMS of 14 out of 15 meaning resident 1 had intact cognition. The MDS also revealed that resident 1 required extensive two person assistance with bed mobility. The MDS indicated that resident 1 was totally dependent on 2 staff for transfers. The MDS also indicated that resident 1 required extensive one person assistance with dressing, toileting, and personal hygiene. Per the MDS, the resident also required limited one person assistance with eating. The MDS indicated that resident 1 was totally dependent on one staff member for bathing. The MDS additionally indicated that resident 1 required the use of a wheelchair, and had an impairment in her range of motion on both the upper and lower right and left extremeties. Two separate allegations of abuse were investigated by the facility regarding COTA 1's actions with resident 1. Those allegations are described as follows: ALLEGATION 1: An initial entity report was filed with the State Survey Agency (SSA) on 7/7/22 at 12:05 PM. The initial entity report revealed that on an unknown date and time an incident allegedly occurred between resident 1 and COTA 1. The initial entity report indicated that Registered nurse (RN) 1 observed COTA 1 in resident 1's room and COTA 1 had his hand on her leg and when RN 1 came in to provide cares COTA 1 left. The incident was reported to Social Services Worker (SSW) 2. In a separate observation reported to SSW 2, a certified nursing assistant (CNA) 1 observed COTA 1's arm around resident 1's top area. The entity report documented the dates of incident's (sic) are under investigation. [Note: The initial entity report date is 7/7/22 at 12:05 PM, over 11 hours after the concern form was filed.] A review of the final investigation dated 7/14/22 revealed the following: a. A documented witness summary revealed, RN 1 stated on 7/5/22, [RN 1] walked by [resident 1's room] and saw COTA [1] sitting on [resident 1's] bed. Resident 1 was sitting in her wheelchair. [RN 1] saw COTA [1] touching [resident 1's] legs, like a massage her left thigh. [RN 1] does not know if that is part of therapy or not. RN 1 informed the nurse over that hall. [Upon review of the witness statement, RN 2 stated that this incident had occurred on 7/5/23 at 12:00 PM.] b. A second witness summary revealed, [CNA 1] stated on two occasions has seen [COTA 1] getting a little close to [resident 1]. First occasion on 7/5/22, [CNA 1] saw [COTA 1's] hand on [resident 1's] thigh. Second occasion on 7/6/22, she walked in the room and saw [COTA 1] squatting next to [resident 1] and had his arm wrapped around [resident 1's] waist. [Resident 1] was laying in bed with a T-shirt and brief and when [CNA 1] returned, [COTA 1] had left and forgotten his laptop. c. An account of the resident involved revealed, on 7/7/22, SSW 2 interviewed resident 1. Resident 1 said she felt safe in the facility and denied any staff touching her inappropriately. On 7/12/22 resident 1 was re-interviewed and again stated she felt safe in the facility and staff members are nice to her and feels safe with everyone who cares for her. Denied any staff member touching her inappropriately and is comfortable around all staff. [Note: The investigation did not indicate if direct questions were asked of resident 1, or if she was simply asked about inappropriate touch and feeling safe. It is unclear if direct questions about COTA 1 and his behaviors were asked of resident 1.] d. An interview was conducted with COTA 1 on 7/12/22. COTA 1 denied touching resident 1 in a non-therapeutic way. COTA 1 reports that when he works with patients with poor cognition, he will tell them what he is doing and is respectful. When interacting with [resident 1] he will ask her if it is okay to do something before he does anything and she has never disagreed or reacted adversely during their interactions.[COTA 1] reported he has touched her on the thigh, poked her and tickled her jokingly but is cautious in not touching her in an inappropriate way. [COTA 1] said he has a tendency of resting his hands on her legs but is cautious to not move it where it does not belong. Stated he has hugged her and in the presence of her mom and there had not been an adverse reaction. When he interacts with her in her room, he always leaves the door open. e. A summary of evidence documented based on witness accounts and alleged perpetrators statements the abuse allegation is unsubstantiated. f. The corrective action summary stated COTA 1 will not be assigned to work with resident 1 and education will be provided on professional boundaries and appropriate ways to interact with residents. g. The administrative decision stated, at this time, we believe that the allegation of abuse is unsubstantiated, as it does not rise to the level of abuse. [It should be noted that upon review of COTA 1's assignments, COTA 1 was not assigned to work with resident 1 during this time period of June and July 2022. Therefore, the intervention of instructing COTA 1 to not work with resident 1 was not an effective intervention.] [Note: The investigation into the allegation of abuse in July 2022 did not include interviews with other staff members regarding interactions between COTA 1 and resident 1.] A review of the corrective action document dated 7/20/22, written by COTA 1's supervisor/manager the director of therapy (DoT), the document revealed. In reviewing the events and investigation outcomes, we have determined professional boundaries have been crossed and need to be addressed . The action plan to correct the incident documented: a. Employee will complete additional training on the [therapy group] abuse policies. b. Employee will no longer work with the patient as a therapist. c. Employee will complete additional training regarding creating and maintaining professional boundaries in a healthcare setting. d. Employee will demonstrate professional behavior and use professional language with patients, staff and other at all times in compliance with our sexual abuse, abuse, and professional ethics policies. [It should be noted COTA 1 refused to sign the corrective action plan.] e. Employee comments revealed an attached letter from COTA 1. The letter read as follows: No record of an interview that was conducted in person with COTA 1 could be located in the facility's abuse investigation documents. [Note: It should be noted that the corrective action document and COTA 1's letter was in COTA 1's HR file with the therapy department. The documents were not included in the final abuse investigation.] [Note: Review of resident 1's therapy service records revealed that resident 1 was on therapy services from 10/1/21 through 6/3/22 then started services again 9/1/22. Resident 1 was without therapy services July and August 2022. No evidence could be located to indicate that the staff members investigating the abuse allegation verified if resident 1 was on therapy services at the time of the allegation.] [Note: A review of therapy staff that worked with resident 1 documented COTA 1 was scheduled to work with resident 1 on the following dates despite being specifically instructed not to work with her: 6/9/23, 6/1/23, 6/14/23, 6/15/23.] On 10/26/23 at 2:18 PM, an interview was conducted with SSW 2. SSW 2 stated that after the allegation in July 2022 resident 1 was taken off of COTA 1's therapy schedule and COTA 1 was required to complete an abuse training. SSW 2 stated that the Director of Therapy (DoT) would arrange COTA 1's hours to be in the facility during the day. SSW 2 stated that she was not aware of who was informed that COTA 1 was not supposed to be working with resident 1. SSW 2 stated that the DoT would oversee the corrective action since DoT was COTA 1's direct supervisor. Multiple staff stated that they had witnessed COTA 1 interacting with resident 1 after the first allegation had been made in July 2022. Those interviews are as follows: On 10/24/23 at 1:40 PM, an interview was conducted with RN 2. RN 2 stated she had noticed COTA 1 would visit resident 1 in her room and bring her cheetos. RN 2 stated that she had not witnessed any inappropriate behavior between COTA 1 and resident 1. On 10/25/23 at 8:55 AM, an interview was conducted with the nursing scheduler (NS) 1. NS 1 stated she had seen COTA 1 in residents 1 room multiple times and had seen him taking resident 1 to the therapy room. NS 1 stated the therapy team was usually out of the facility by 4:00 PM, and that NS 1 would see COTA 1 in the facility around 6:00 PM. ALLEGATION 2: On 9/21/23 at 6:09 PM, the facility submitted a form 358, initial entity report, indicating that earlier that day, at 2:30PM, CNA 2 witnessed COTA 1 in resident 1's room touching the resident inappropriately. On 9/22/23 at 10:31 AM, the facility submitted a form 359, that alleged that Resident 1 stated that COTA 1 had touched her breast, twice before and over her shirt, kisses her on the lips and tells her that he loves her. [Resident 1] also confirms that [COTA 1] does not make her feel uncomfortable, and that he visits her every day. The form 359 indicated that on 9/21/23, CNA 2 reported that she saw COTA 1 in resident 1's room when CNA 2 went in to answer resident 1's roommate's call light. When CNA 2 entered the room, she saw COTA 1 with his hand on resident 1's hand caressing it. CNA 2 left the room and returned with coffee for resident 1's roommate, when she returned she saw [COTA 1] sitting on her (resident 1's) bed with his hand on [resident 1's] breast and the other hand still on hers. [CNA 2] confronted [COTA 1] and told him that what he is doing is not appropriate, and he should not be touching her like that. At that time [COTA 2] was walking by and asked [CNA 2] if everything was ok. [CNA 2] told her what she observed. [COTA 2] also went in to confront [COTA 1], and he agreed to leave the room. [COTA 2] reports that she was walking down the 100 hall and could hear [CNA 2] questioning [COTA 1] in [resident 1's] room, and was really upset. She stood outside the door and waited for [CNA 2] to come out of the room, and asked her if everything was ok? [CNA 2] told [COTA 2] what she had observed and asked [COTA 2] if [COTA 1] should be in there. [COTA 2] told her 'no he shouldn't be in there, [resident 1] is my patient, and she had already been seen that day ' . [COTA 2] went into the room with [CNA 2] and asked [COTA 1] what he was doing (she saw him standing on [resident 1's] left side stretching her left arm), and he said that he was trying to get her thumb out (it was contracted). [COTA 2] told him that he shouldn't be in here, she is my patient and I have already seen her today. He agreed to leave. [CNA 2] and [COTA 2] to [Physical Therapist (PT) 1] a PT covering for the therapy director that day. When [COTA 2] returned to the therapy office, [COTA 1] went in and sat down on the counter and said to her just what was it you are accusing me of? He then said the reason I was leaning across her breast was because I was doing therapy and needed to, which made no sense to [COTA 2] because [resident 1's] affected arm is on the left, and there's no reason to lay across her chest. The form 359 indicated that abuse had been verified. In a second witness statement, COTA 2 stated . Sometimes when I am working with [resident 1], [COTA 1] will walk by and she will ask him for Cheetos. (He gives her Cheetos). He always tells her I will bring them to your room later. Facility staff documented an interview with resident 1 on 9/22/23. During the interview, resident 1 indicated that COTA 1 touched me. Resident 1 indicated that COTA 1 just came in to her room, and that it did not make her feel uncomfortable. Resident 1 also indicated that COTA 1 comes in to visit her every day, and shut her door so no one would see him in her room. Resident 1 stated that COTA 1 had kissed her on the lips, touched her on the breast multiple times, and had told her he loved her. INTERVIEWS On 10/24/23 at 11:38 AM, an interview was conducted with resident 1. When resident 1 was asked about a guy she liked, she responded that it was COTA 1. Resident 1 stated that COTA 1 had kissed her on the lips. When asked if he had touched her anywhere inappropriately she stated yes he touched me on my boobs. under my shirt .inside my bra. he was rubbing them. Resident 1 further stated that COTA 1 touched her boobs a lot. Resident 1 stated that COTA 1 touched under her pants and put 2 fingers inside. She said that she consented and he touched her vagina just once. She said COTA 1 would come into her room when her roommate was asleep and he would close the door. Resident 1 stated that COTA 1 told her that he loved her. Resident 1 stated the thing she loved most about COTA 1 was the Cheetos. When asked if she had ever told anyone about COTA 1 touching her, she stated that she had not because she did not want him to get in trouble. On 10/25/23 at 9:08 AM, an interview was conducted with CNA 2. CNA 2 stated that she had been working in the facility for about a month prior to her reporting the 9/21/23 incident. CNA 2 stated leading up to the incident on 9/21/23, COTA 1 would frequently be seen sitting in resident 1's room with her. COTA 1 would be seen touching resident 1's upper arm or face. CNA 2 stated that when she saw COTA 1 sitting with resident 1 it didn't feel right to her. CNA 2 stated that she did not know that COTA 1 was not resident 1's therapist because he was with her a lot. CNA 2 stated that she told two of the nurses that she worked with about her concerns, and they said just keep an eye on her and watch her. CNA 2 stated that on 9/21/23 she saw COTA 1 sitting on resident 1's right side, COTA 1 had his left hand on top of resident 1's breast and COTA 1's right hand was touching resident 1's left hand. CNA 2 stated that she asked COTA 1 to perform her therapy on resident 1's left side and not sit to the right of her. CNA 1 stated she said you should not be touching her that way. CNA 2 stated she told CNA 3, and RN 2 about what was happening. CNA 2 stated that COTA 2 came into resident 1's room and said what are you doing here [COTA 1], you are not her therapist. CNA 2 stated that COTA 1's face turned red and that he did not say anything and left the room. On 10/25/23 at 9:30 AM, an interview was conducted with CNA 3. CNA 3 stated that she was often assigned the hall resident 1 was in. CNA 3 stated that when she saw COTA 1 in resident 1's room, COTA 1 would be in there alone and would seem closer than a normal therapist is when working with a resident. CNA 3 stated on 9/21/23 CNA 2 asked her to check on resident 1. CNA 3 stated that when she entered resident 1's room she saw COTA 1's sitting on the bed near resident 1, his hand was placed on her upper thigh and could see they were talking. CNA 3 stated that she and CNA 2 reported what they had seen to resident 1's nurse, RN 2. CNA 3 stated that since the incident in September, the staff have received abuse training, including what to report and to report as soon as possible. On 10/25/23 at 12:49 PM, an interview was conducted with COTA 2. COTA 2 stated that she currently worked with resident 1 as her therapist, and had worked with her on 9/21/23. COTA 2 stated that on 9/21/23 she was walking near resident 1's room and could hear CNA 2 speaking and CNA 2 sounded upset. She stated she could hear CNA 2 asking someone are you her therapist? Do you need to be in here right now?. COTA 2 stated that she saw CNA 2 leave resident 1's room and asked her if she was okay, CNA 2 stated she could not get that therapy man out of resident 1 room. COTA 2 stated she went into resident 1's room and saw COTA 1. She asked COTA 1 what he was doing in resident 1's room, COTA 2 stated she had done therapy with resident 1 earlier that day. COTA 2 stated that COTA 1 said he was working on her thumb, it is really tight. COTA 2 replied I know she lost her brace, I'm working on that, but she is my patient and I have already worked with her today. COTA 2 stated that she told COTA 1 that he should not be in her room at that time since she had already worked with resident 1 that day. COTA 2 stated that COTA 1 stood up and said I guess they want me to leave and left the room. COTA 2 stated that she was never informed that COTA 1 was not supposed to be with resident 1. COTA 2 stated on a few occasions while working with resident 1 in the therapy room, resident 1 would ask COTA 1 for cheetos, COTA 1 would state that he would bring them to her room. COTA 2 also stated she witnessed COTA 1 touching resident 1's hair and rubbing her shoulders while she was working with resident 1 in the therapy room. At that time COTA 2 asked him what he was doing and he left the room. COTA 2 stated that COTA 1 was often in the facility later than any of the other therapy staff. COTA 2 stated that she had spoken with the DoT regarding COTA 1 being in the facility late, and that the DoT had informed COTA 1 multiple times to come in earlier. COTA 2 stated COTA 1 did not change the times he worked. COTA 2 stated that she had often seen resident 1 and COTA 1 talking near the nursing station and asked the DoT about it. COTA 2 stated that the DoT told her that as long as COTA 1 and resident 1 were in a public area, it was allowed. COTA 2 stated that if she would have known that COTA 1 was not supposed to be with resident 1 she would have spoken up sooner about her concerns. COTA 2 stated that she was concerned about COTA 1 doing inappropriate things with resident 1. COTA 2 stated that resident 1 was mentally disabled, cognitively impaired and is very vulnerable and could easily be taken advantage of. On 10/26/23 at 11:47 AM, an interview was conducted with COTA 3. COTA 3 stated that in approximately February 2023, a nurse had informed him that COTA 1 had been seen rubbing resident 1's leg in July 2022. COTA 3 stated that at the time he found out about the allegation, he was resident 1's therapist, and had been working with resident 1 every day. COTA 3 stated that in February 2023 he approached the DoT and said, this is what I heard, is this true, because this is my patient. Is there something I need to be aware of? COTA 3 stated that the DoT told him that there had been issues in the past and that COTA 1 could not be one on one with resident 1. COTA 3 stated that he had never seen anything inappropriate between COTA 1 and resident 1, I had only seen that they were good friends. COTA 3 stated that COTA 1 was constantly bringing cheetos and ice cream to resident 1. COTA 3 further stated that he had witnessed COTA 1 rubbing resident 1 on her leg, shoulders and head. COTA 3 stated that COTA 1 typically arrived for work between 11:00 AM and 12:00 PM, so he assumed COTA 1 would stay until at least 9:00 PM in order to work a full day. COTA 3 stated he was unaware of any restrictions placed on COTA 1 regarding staying after typical work hours. COTA 3 stated that COTA 1 treated the majority of his patients in their room, instead of bringing them to the therapy room like other therapists did. COTA 3 stated lots of times, we wouldn't be able to find COTA 1, because he was working with patients in their room behind closed doors. On 10/26/23 an interview was conducted with Staff Member (SM) 1. SM 1 stated that they felt like the DoT looked the other way on COTA 1's behaviors as long as COTA 1 got his hours and they got the numbers. On 10/25/23 at 12:30 PM, an interview was conducted with the director or therapy (DoT). The DoT stated that he was COTA 1's direct supervisor and recalled the July 2022 investigation. DoT stated that in July 2022, two staff members alleged they saw COTA 1's hand on resident 1's thigh and that the staff members felt uncomfortable with COTA 1's contact when he worked with resident 1. The DoT stated that SSW 2 oversaw the July 2022 investigation, and that the contracted therapy group he worked for did not conduct their own independent investigation. The DoT stated that the investigation was unsubstantiated by the facility and he worked with the SSW 2 to draw up a corrective action plan. The DoT stated the plan indicated that COTA 1 was not to work as a therapist for resident 1 and would not enter her room or have any physical contact. The DoT stated that the corporate management recommended that COTA 1 could communicate with resident 1 in open common spaces. The DoT stated that COTA 1 would work later than the other therapists, with hours typically from 10:00 AM until 7:00 PM, occasionally working as late as 11:00 PM at night in the facility. The DoT stated he and the cor [TRUNCATED]

Based on interview and record review it was determined, for 3 of 6 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. Specifically, a male resident entered female resident rooms without their permission. One female resident was touched by the male resident during the night and another female resident expressed to staff she would use [NAME] on the male resident if he entered her room again. The female resident later maced the male resident when he tried to enter her room. This resulted in the finding of harm for two residents. Resident identifiers: 1, 2 and 3. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery, hemiplegia and hemiparesis, dysarthria and dysphagia follow cerebral infarction, and sexual dysfunction not due to a substance or known physiological condition. Resident 1's medical record was reviewed on 3/2/23. A Pre-Admission Screening Applicant/Resident Review (PASRR) dated 7/2/22 revealed that resident 1 had hypersexual behaviors. The comment and notes section revealed New medication started on 9/17/2022 for hypersexuality. Resident 1 was screened out for a level II because the diagnosis was not considered to be a serious mental illness. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 1 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS further revealed resident 1 was not steady but able to stabilized without human assistance when moving from seated to standing, walking, turning around and facing the opposite direction while walking and transferring from surface to surface. A care plan dated 9/9/22 and edited on 12/7/22 revealed behavioral symptoms because resident 1 made sexually inappropriate comments/actions toward staff and others. The goal was that resident 1 would not exhibit inappropriate comments/actions. An approach dated 9/9/22 revealed Remind [resident 1] that his comments can make others uncomfortable, but do not alienate him. Two approaches with start dates of 10/28/22 revealed to Let resident know those types of comments are unwelcome, and to please stop. Make sure he is being appropriate around other residents. Praise resident for appropriate behaviors and [Resident 1] stated he will go to his room if he has an urge. An approach dated 12/5/22 was one on one supervision related to an incident on 12/5/22. A care plan dated 12/5/22 with a created date of 12/6/22 revealed that resident 1 had behavioral symptoms of making other residents feel unsafe by entering their rooms. The goal was to make other residents in the building feel safer and the approach was one on one care in place. Resident 1's progress notes were reviewed and revealed the following: a. On 9/4/22 at 5:43 AM, [Resident 1] had been trying all night to entice [name removed] the CNA [Certified Nursing Assistant] into his room. [Name removed] said he asked her if she can undress and do the 'nasty'. [Name removed] had refused to go into his room after which he got into his wheelchair and was wheeling himself in the hallway. [Resident 1] also approached me and asked me if [name removed] is allowed to go into his room. I said she is if there is a need for [name removed] to perform CNA duties. He asked if [name removed] is allowed to do sex I emphatically said NO. b. On 9/9/22 at 2:20 AM, CNA on 400 hall reported patient asked for sex, patient was assessed He agreed to ask staff member for sex [sic] and he apologized. An intervention was taken as to have a different CNA check on him for the rest of the night if he heeds help. c. On 9/12/22 at 7:28 AM, recorded as a late entry on 9/13/22 at 7:28 AM, the Nurse Practitioner (NP) documented .He has been more sexually inappropriate with staff and have more behaviors over the weekend. Treatment plan: .Add paroxetine and monitor behaviors. d. On 10/14/22 at 12:30 AM, Patient had incident of inappropriate behavior with CNA this evening. He asked CNA if she 'wanted to play nasty with him.' Resident was told this behavior is inappropriate and he is not to speak like this to the staff who are here to assist him. e. On 10/19/22 at 5:10 AM, '[Resident 1] has had multiple inappropriate behaviors with both nursing staff and residents stating he is 'looking for sex' Patient has been advised numerous times that his behavior will not be tolerated and continues to roam the hallways making sexual comments to CNA's and nurse and making multiple attempts to go into several patients rooms. f. On 10/19/22 at 3:45 PM, recorded as late entry on 10/20/22 at 1:47 AM revealed, Spoke with patient about inappropriate behaviors toward staff, explained that he was making staff and visitors uncomfortable. Patient verbalized understanding and agreed to stop behavior, MD [Medical Doctor] was notified. Social services to follow up. g. On 10/19/22 at 7:47 PM, SS [Social Services] spoke with resident this evening in regards to his recent sexual comments to staff, he says that 'he is sorry, and will stop'. Resident was also notified of a room change that will take place tomorrow. h. On 10/20/22 at 10:30 AM, Resident found in another residents room showing her his penis. SS reached out to his daughter [name removed], she sats [sic] that he has been a very sexual person his whole life. She is unsure what to do at this time. She states that she will come in and speak to him. SS has contacted police, they are on the way. Daughter is planning on coming by as well, she is questioning his mental state at this point and would like us to send him out for a psyche [psychological] eval [evaluation]. She states that he has been trying to leave the facility, and since his stroke she feels that he is not in his normal mental state. i. On 10/20/22 at 10:47 AM, Resident is on 1:1 care right now. k. On 10/20/22 at 11:51 AM, .She [daughter] had a conversation with her father today about his behavior and she says that he has agreed to stop, but she feels that he is not 'with it.' l. On 10/20/22 at 7:15 PM, Dipped urine that was collected and all values are within normal limits.Patient continues one on one but has made inappropriate comments to her. He stated to her that, he was waiting for a [NAME]. m. On 10/24/22 at 12:21 PM, Staff reports that resident continues to make inappropriate/sexual comments and advances towards them, and offers them money for sex. He is still 1:1 with staff. n. On 10/24/22 at 2:05 PM, resident was sent to local hospital for a psych evaluation. o. On 10/24/22 at 3:40 PM, was recorded as a late entry on 10/27/22 at 3:41 PM, Resident was offered a counseling referral, and refused it. He states that he doesn't need counseling. p. On 10/24/22 at 6:38 PM, resident returned from hospital. r. On 10/25/22 at 1:27 PM, resident was one on one. s. On 10/25/22 at 9:30 PM, Resident continues to have a one on one cna due to inappropriate sexual behaviors. Per CNA no inappropriate behaviors or comments made this shift. Resident currently in bed resting. t. On 10/26/22 at 5:09 PM, Psychotropic review.Per pharmacist recommendation and NP no changes at this time. u. On 10/26/22 at 6:24 PM, Resident continues to have one on one cna due to inappropriate sexual behaviors. Per CNA inappropriate behaviors or comments made this shift to staff started around 1800 (6:00 PM). Per CNA resident made comments such as 'Can you find a black [NAME]' and 'where are the chocolate girls at.' Educated [resident 1] on inappropriate comments and behaviors. Pt stated he understands. v. On 10/27/22 at 4:38 PM, MSW [Masters of Social Work] asked to consult on this [AGE] year old long term resident who has been making sexually inappropriate comments to staff and others. Pt was awake and alert when MSW entered room. Pt explained that he is a 'sex addict' and that he has been married 4 times. Pt states that he has been making sexually related comments in hopes of 'hooking up' with staff. MSW countered that would not occur in this building. Pt also stated that he enjoys making such comments because if [sic] makes people upset and gets 'a rise' out of them. MSW talked with pt about consequences of his behavior and how that could effect his long term placement. MSW reviewed with pt ways he could curb his behavior and the pt was able to come up by himself ways in which he could re-direct his sexual urges. The pt has had a change in his medication in hopes of reducing his urges. The staff have stated that they have seen minimal effects. w. On 11/2/22 at 1:12 PM and recorded as a late entry on 11/4/22 at 1:12 PM the NP documented, .Paxil helping with hypersexualy [sic] . x. On 11/10/22 at 6:45 AM, Aide answered patient's call light and he was partially undressed in his bed and his privates exposed. Patient asked aide to finish undressing him. Nurse reoriented patient and educated him on remaining as independent as possible, patient agreed he could undress himself and that he would alert nurse if he needed anything else. y. On 11/11/22 at 4:59 PM, Staff agency aide answered call light at 3AM [3:00 AM] and patient took off his blankets exposing himself and asked her to shower him. Nurse reoriented patient and reminded him that showers usually take place after 6am [6:00 AM] patient agreed with waiting until later in the morning and went back to bed. z. On 11/15/22 at 4:17 PM, SS went to talk with resident in regard to him continuing to offer staff money for sex, and trying to touch staffs bottoms. He was reminded that he cannot be doing that, and that if that type of harassment continues, we will be calling the police. aa. On 12/1/22 at 7:09 PM and was edited by the nurse on 12/13/22 at 10:34 AM revealed, Resident has been inappropriate all shift. Asking staff if 'anyone wants to hook up and if we can find someone to hook up with him he will be in room [ROOM NUMBER]'. Educated [resident 1] about inappropriate comments and behaviors. Staff will continue to monitor, documented, and educated [resident 1] on this behavior. No falls or injuries this shift. bb. On 12/1/22 at 9:39 PM and was edited by the nurse on 12/9/22 at 12:27 PM revealed, .Pt has been making inappropriate comments this shift. LN [Licensed Nurse] educated resident on making inappropriate comments. He verbalized understanding . cc. On 12/3/22 at 8:19 AM, Nurse went to patients room in 501 to administer medications to patient. Patient reports that [resident 1] was in here [sic] room pulling her covers off while she was asleep. Resident in 501 states she yelled 'get out of my room.' Nurse told patient in 501 she will talk to [resident 1] about the issue. After leaving 501 room, patient in 503 opened her door and reports that [resident 1] was in her room trying to mover [sic] her bedside table. Patient states she yelled at him to get out. Nurse told patient in 503 she will talk to patient. Administrator, DON, and MD notified. dd. On 12/5/22 at 7:17 AM, recorded as a late entry on 12/6/22 at 7:17 AM by the NP revealed, .Had pepper spray to eyes earlier today. He is resolved with eye wash. He continues to be inappropriate with other staff and residents requesting sex. ee. On 12/5/22 at 9:27 AM, LN was notified by another LN that resident was outside a room at the end of the hall with what appears to be orange colored substance on his glasses. LN went to assess and immediately started choking from something in the air. A nearby CNA informed LN that a [sic] this patient had attempted to enter the patients room uninvited and was sprayed with something. LN immediately knocked on the door and asked the patient what the substance was and was told it was pepper spray. This LN and another LN took him back to his room and started washing his face and eyes with saline. Patient recovered quickly. LN notified DON and administrator of event. The patient down the hall then called police. MD and daughter has been notified of event. Order to monitor for any side effects from pepper spray in the eyes for 3 days. Order carried out. ff. On 12/5/22 at 10:29 AM, SS called residents daughter and asked about a discharge plan, she is comfortable with her dad discharging home to her house today. Resident is a threat to other residents safety and well being here [name of facility]. gg. On 12/5/22 at 10:36 AM, the physician documented I was informed that [resident 1] entered a female patient's room uninvited and unwelcome. She warned him not to enter. The police were called and he is being charged with a misdemeanor trespassing. DHS [Department of Health Services], the ombudsman, and APS [Adult Protective Services] were also notified. It is my professional opinion that [resident 1] poses a threat to the patients at our facility and should be removed ASAP [as soon as possible]. hh. On 12/5/22 at 11:08 AM, Resident is currently on 1:1 supervision. ii. On 12/5/22 at 1:58 PM, SS has been working with daughter and his Utah Case management team, if he leaves today he will lose his New Choice Waiver. His daughter has teenage daughters, so him discharging to his daughters is not ideal. I then called mobile crisis unit and spoke to [name removed], they could not help either. jj. On 12/5/22 at 3:09 PM, SS and business office went down to issue resident discharge notice. he signed it and understood. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, hypo-osmolality and hyponatremia, chronic pain, fibromyalgia, and personal history of a transient ischemic attack. Resident 3's medical record was reviewed on 3/2/23. Resident 3's progress notes revealed the following entries: a. On 11/3/22 at 1:45 PM, Patient arrived via stretcher . Oriented to place, time, place [sic] and situation. Patient can't hear on the right ear and able to on the left ear. Patient has on hearing aide with case and charger .Patient states she only lays on left side because it hurts her to lay on her right side and on her back . b. On 11/17/22 at 5:03 PM, Type of MDS Assessment: Admit.She has adequate hearing in right ear. She is deaf in lef [Sic] ear and has hearing aides. She has clear speech. She is understood and she understands others. Her cognition is intact aeb [as evidenced by] BIMS score of 15/15 .Pt requires extensive assist of staff for most ADLs . c. On 12/3/22 at 8:29 AM, Residents discharge was pushed out to the 10th due to Covid +, however resident wants to leave the 12/3/22 as originally planned. SS reached out to [name of assisted living], they are fine with taking her Covid + . d. On 12/3/22 at 6:31 PM, Resident discharged today. e. On 12/5/22 at 3:20 PM, DON and SS went to [name of assisted living] where [resident 3] discharged to from facility to follow up with resident's report of male resident entering room on 12/3/22 and pulling down covers while resident was sleeping. [Resident 3] reported to DON and SS that while [resident 3] was in bed facing window a male resident in wheelchair stroked her back twice. On the first time she could not see anyone after turning head to look back after the second time she turned around to the other side facing the door and saw male resident in wheelchair next to bed who proceeded to touch her leg inappropriately and up to her breast. She then yelled for him to get out of her room and resident left. Resident did not report extent of abuse to nurse on Saturday before discharging. [Local police department] was called to report abuse and SS is reporting to state agency. It should be noted that there was a no note regarding the incident on 12/3/22 in resident 3's medical record but there was a note in resident 1's medical record. 3. Resident 2 was admitted to the facility on [DATE] with diagnoses which included infection following a procedure, sepsis, fusion of spine, diabetes mellitus, generalized anxiety disorder and depression. Resident 2's medical record was reviewed on 3/2/23. Resident 2's progress notes revealed the following entries: a. On 11/4/22 at 8:30 AM, .Patient is alert and oriented to person, place, time and situation. Hear [sic] adequate ob [sic] both sides no hearing aides. Has glasses. b. On 11/21/22 at 3:27 PM, Type of MDS Assessment: Admit .Her cognition is intact aeb BIMS score of 15/15 . c. On 11/29/22 at 8:45 AM, SS reached out to [name of behavioral health company] to follow up on referral for a psyche eval, [name removed] was going to come and complete it last Friday, however she has been very ill. [Name removed] responded to me this morning stating that she is not a provider for [resident 2's] insurance, and said that it may be best to refer her somewhere when she discharges. In the meantime, SS has received no reports of resident having any behaviors in the past week or so. She seems to have settled in, and spends a lot of time working on the puzzle in the dining area. d. On 11/30/33 at 12:09 AM, .Rapid COVID test done, with positive results . e. On 12/5/22 at 8:19 AM, recorded as late entry on 12/9/22 at 12:24 PM, LN went in to administer morning medications and asked resident how she was feeling about the situation. Resident stated she was angry that it happened. LN notified resident that the other patient would have a 1:1 supervision aide and she stated she felt better about that. Resident said she just wanted to go back to sleep. f. On 12/5/22 at 10:53 AM, LN was notified of an incident involving another resident this morning. LN went in to talk to this resident about what happened. Resident stated that another resident opened her door and tried to come in her room so she sprayed him with pepper spray. She stated she was fearful of what he might do so she called the police. LN assured resident that we will do all we can to prevent the other resident from going into her room. g. On 12/5/22 at 2:46 PM, recorded as a late entry on 12/5/22 at 6:56 PM, SS went to speak with resident in regards to the incident that happened this morning. SS asked resident how she was feeling, she started telling me that nobody cares about how she is feeling. I reassured resident that I care, and that's why I am here. I asked her if she feels safe and secure, she stated that she hasn't felt safe or secure since she arrived. I asked what I could do to help her feel safe, and her response was 'nothing could be done or it would be done already'. I offered her a counseling referral and she argued with me about how she would be able to do it, said she did not have correct technology for virtual visits . h. On 12/6/22 at 11:12 AM, Spoke with daughter [name removed] about how we could help [resident 2] feel safe in our facility, daughter stated she feels the best option is to have resident transferred to another facility. Ensured daughter and resident that we are taking every step to ensure resident feels safe, multiple options were refused by resident, SS working on finding facility that resident will approve. i. On 12/6/22 at 1:38 PM, UM [Unit Manager] went to check in with patient on how she was feeling after yesterdays events. Expressed that we want to make sure that she feels safe here and address any emotional concerns she may have at this time. Her reply was 'I'm fine, I'm fine.' . j. On 12/7/22 at 6:10 AM, Referral to LCSW [Licensed Clinical Social Worker] sent, SS will assist resident with choosing a counseling place today. k. On 12/7/22 at 2:16 PM, Due to recent events it was discovered that residents daughter had brought her in pepper spray because resident reported to daughter that she did not feel safe. However, resident and daughter failed to report that pepper spray was [NAME] [sic] in, or that [resident 2] felt unsafe during her stay. SS had been in [resident 2's] room over the past couple of weeks, and she had not said anything to me. Staff have not reported to myself or any other management that resident has not felt safe. It should be noted that there was a no note regarding the incident on 12/3/22 in resident 2's medical record but there was a note in resident 1's medical record. l. On 12/16/22 at 1:33 PM, Patient discharged home today. A review of the facility reported incidents to the State Survey Agency revealed the facility reported on 12/5/22 at 10:39 AM, the following incident. The initial report revealed on 12/5/22 with no time indicated, resident 1 tried to enter resident 2's room. The report revealed resident 2 told him no and sprayed him with pepper spray. The follow-up investigation report revealed that resident 1 was interviewed. [Resident 1] admitts [sic] to atempting [sic] to enter [resident 2's] room where she warned him and told him to leave. When he did not leave [resident 2] sprayed him. Through the day [resident 1] was on a one on one with staff and did not report or display any psychological harm or disstress [sic] as a result. According to the summary of interviews, [Resident 2] was interviewed. [Resident 2] stated she warned [resident 1] not to go into her room when [resident 1] did not leave she sprayed him with pepper spray. This was done is [sic] self defense. [Resident 1] reports that her daughter brought in the pepper spray and the daughter verified she did bring in the pepper spray. Staff were not notified that pepper spray was brought into the facility. The Summary of interviews with other residents who have had contact with the alleged perpetrator revealed During the course of this investigation another allegation came to light. It was reported by [resident 2] that a recently discharged resident [resident 3] told [resident 2] that [resident 1] had entered [resident 3's] room and touched her inappropiately [sic]. This was reported as a separate allegation. The conclusion was that the allegation was verified, It is verified that [resident 2] did spray [resident 1] in the face with a pepper spray like substance, but it was done out of self defense. The form further revealed that abuse training and in-service with staff sine [sic] incident. A review of the facility reported incident to the State Survey Agency revealed on 12/5/22 at 4:59 PM, the following incident occurred. The initial report revealed that on 12/3/22 at an unknown time resident 3 reported that resident 1 had allegedly entered her room and pulled her covers off. The follow-up investigation report revealed [Resident 3] accused [resident 1] of touching her inappropriately. [Resident 3] says that she feels safe and secure in her new home . The form further revealed [Resident 1] confirms that he was in [resident 3's] room, and that she was 'teasing him.' He confirms that he did touch her, and that he won't do it again. The allegation was verified The allegation of innapropriate [sic] touching was verified as evidenced by [resident 1] admitting to the action. The form further revealed that resident 1 was given a discharge notice but then passed away. Resident 3 was offered counseling services but felt safe in her new home. The systemic actions were Reviewed and provided abuse inservice. The facility provided abuse training and reporting with staff signatures from 12/7/22, 12/20/22, 1/19/23, 1/30/23, 2/21/23, 2/23/23 and 2/28/23. There was no specific education information provided. On 3/2/23 at 2:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 1 was alert and oriented to person, place, time and sometimes situation. RN 1 stated resident 1 did have times of confusion. RN 1 stated resident 1 was provided one on one supervision for being inappropriate with female staff. RN 1 stated resident 2 resided in room [ROOM NUMBER] and resident 3 resided in room [ROOM NUMBER]. RN 1 stated the first time she heard about any interactions, was on 12/3/22 when resident 2 told her that a man in an orange hat came into her room and moved her bedside table in the middle of the night. RN 1 stated resident 2 told her if he entered her room again she had [NAME]. RN 1 stated that resident 2 told her that her daughter brought her the [NAME]. RN 1 stated she reported what resident 2 had told her to the DON and Administrator (ADM). RN 1 stated that happened on 12/3/22. RN 1 stated resident 3 had told her that someone entered her room and tugged on her blanket in the middle of the night and she nudged him with her leg. RN 1 stated when she reported to the DON, she thought resident 1 was provided with one on one supervision after that incident but could not remember. RN 1 provided a text message sent to the DON on 12/3/22 with the nurses note from resident 1's medical record. The text message further revealed This is my note about [resident 1]. This was this morning. And awhile ago when I was discharging 501, I hear 503 [resident 2] yelling 'get out of here! I will [NAME] [sic] you if you come near my door or come in my room and call the cops after' While she was yelling at him, [resident 1] was holding his fist at her! I told [resident 1] to leave and while telling him to leave, [resident 3] 501 tells family members that, that was the guy I told was in my room this morning. Family member started to tell me you guys can't have him going into peoples room and that he shouldn't be here. Told them we are dealing with the issue. On 3/2/23 at 4:42 PM, a phone interview was conducted with RN 2. RN 2 stated resident 1 went into other resident rooms. RN 2 stated resident 1 lost his cell phone and went into everyone's room looking for it. RN 2 stated around 12/1/22 several residents told resident 1 to get out of their rooms. RN 2 stated resident 2 was aware that resident 1 was entering resident rooms. RN 2 stated she was working the morning that resident 1 was maced by resident 2. RN 2 stated he opened resident 2's door and she was ready and sprayed resident 1 in the doorway. RN 2 stated prior to resident 1 being maced resident 2 had complained that he had gone into her room because the information had been passed onto her in report by other nurses. RN 2 stated resident 1 was maced between 6:00 AM and 6:45 AM. On 3/2/23 at 2:42 PM, an interview was conducted with the Resident Advocate (RA) and the DON. The RA stated resident 1 had some behaviors/incidents. The RA stated resident 1 went into female rooms. The RA stated that he had entered 3 different female resident rooms including resident 2 and resident 3. The RA stated resident 1 exposed himself to a female resident in October 2022. The RA stated that resident 1 attempted to touch the female residents when he went into their rooms. The RA stated resident 2 and resident 3 were in rooms next to each other. The RA stated they found out resident 1 had entered resident 3's room and touched her from resident 2. The RA stated resident 1 entered resident 3's room and touched her leg or back and pulled the blankets off. The DON stated that she remembered the pepper spray happened on Monday 12/5/22 before their 9:00 AM meeting. The DON stated that the Saturday (12/2/22) before, Registered Nurse (RN) 1 reached out to her about resident 2 having [NAME] and was going to [NAME] resident 1 if he entered her room. The DON stated she was not sure why resident 2 needed [NAME]. The DON stated she instructed RN 1 to report it to the Administrator (ADM) who was the abuse coordinator. The DON stated resident 1 was moved to his own room and his behaviors calmed down a lot. The DON stated then his behaviors started again and he was put on one on one supervision. The DON stated resident 1 was placed on one on one on 10/20/22 after he exposed himself to a resident and did not come off of one one one supervision until he went to the hospital on 12/6/22. The DON was asked how resident 1 had been maced if he was provided one on one supervision. The DON stated if it was during shift change, a CNA might be late and the nurses should have kept an eye on him. The DON stated she did not know how long resident 1 was without a one on one on 12/5/22. The DON stated after resident 1 was maced, staff washed his eyes out and one on one supervision was continued. The RA stated she talked to resident 2 on 12/5/22 and resident 2 reported that resident 1 tried to go in and touch her beside table and she threw him out. The RA stated that resident 2 stated resident 1 tried to enter her room on 12/3/22 and told resident 1 she would pepper spray him if he entered her room again. The RA stated that resident 1 had been removed from one on one supervision at one point from the ADM. The DON stated there should have been a physician's order for residents to receive one on one supervision. The DON stated according to resident 1's medical record he received one one one supervision from 10/20/22 until 11/4/22. The DON stated resident 1's daughter reported that resident 1 had always been a sexual person. The DON stated that resident 1 had an increase in his medication Paxil on 10/14/22 because of hypersexual behaviors. On 3/2/23 at 3:55 PM, an interview was conducted with the ADM. The ADM stated he was the facility abuse coordinator. The ADM stated resident 1 had issues and was provided one on one supervision until his behavior improved and was taken off. The ADM stated there was another incident and resident 1 was put back on one on one supervision. The ADM stated resident 1's daughter informed staff that resident 1 had a history of being sexually inappropriate. The ADM stated he was notified that resident 1 tried to go into resident 2's room but resident 2 did not say anything prior to spraying resident 1 with [NAME]. The ADM stated police came to the facility and did not press charges against resident 2 because resident 1 was in her doorway, and she acted in self defense. The ADM stated after resident 1 was maced he was provided one on one supervision. The ADM stated that resident 2 told staff that resident 1 entered resident 3's room prior. The ADM stated he was not notified that resident 2 had [NAME] or that resident 1 had entered other residents' rooms prior to 12/5/22. The ADM stated even if he had been notified that resident 2 had [NAME], he would not have completed an abuse investigation but would probably have talked to resident 2 regarding why she needed it. On 3/6/23 at 12:28 PM, a follow up interview was conducted with the ADM. The ADM stated he was not aware of any events on 12/3/22 with resident 1 or that resident 2 had [NAME]. The ADM stated he was out to eat for his wife's birthday on 12/3/22. The ADM stated staff were probably not bugging him because of that. The ADM stated the DON did not know how to fill out the abuse reporting to the State Survey Agency. The ADM stated that the Social Service Director had completed abuse reporting and investigating in the past but he had taken that over so he was aware of issues in the facility. The ADM stated he looked back at his text messages and his tiger texts on 12/3/22 and there were no notification from RN 1 or the DON. On 3/7/23 at 2:33 PM, a phone interview was conducted with resident 2. Resident 2 stated that a few days after she was admitted , resident 1 came up to her in the dining room and asked her to have sex with him. Resident 2 stated she complained resident 1 was going in and out of her room for 2 weeks straight. Resident 2 stated he either entered her room or was knocking on the door between midnight and 2:00 AM most nights. Resident 2 stated he molested the resident in the room next to her who was resident 3. Resident 2 stated the nurses knew he was in and out of rooms. Resident 2 stated resident 3 told her that resident 1 entered resident 3's room in the middle of the night and put his hand on her leg and up her body to her breast. Resident 2 stated the next morning she was in her doorway and told resident 1 to stay away and resident 1 shook his fist at her. Resident 2 stated she had warned him that if he came in her room again she would [NAME] him. Resident 2 stated she was very worried he would enter her room and try to do something with he [TRUNCATED]

Based on interview and record review it was determined, for 3 of 6 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Specifically, allegations of abuse were not thoroughly investigated and staff did not prevent further abuse after a male resident entered female resident rooms without their permission. One female resident was touched by the male resident during the night and another female residents expressed to staff she would use [NAME] the male resident if he entered her room again. The female resident later maced the male resident when he tried to enter her room. This resulted in the finding of harm for two residents. Resident identifiers: 1, 2 and 3. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery, hemiplegia and hemiparesis, dysarthria and dysphagia follow cerebral infarction, and sexual dysfunction not due to a substance or known physiological condition. Resident 1's medical record was reviewed on [DATE]. A Pre-Admission Screening Applicant/Resident Review (PASRR) dated [DATE] revealed that resident 1 had hypersexual behaviors. The comment and notes section revealed New medication started on [DATE] for hypersexuality. Resident 1 was screened out for a level II because the diagnosis was not considered to be a serious mental illness. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 1 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS further revealed resident 1 was not steady but able to stabilized without human assistance when moving from seated to standing, walking, turning around and facing the opposite direction while walking and transferring from surface to surface. A care plan dated [DATE] and edited on [DATE] revealed behavioral symptoms because resident 1 made sexually inappropriate comments/actions toward staff and others. The goal was that resident 1 would not exhibit inappropriate comments/actions. An approach dated [DATE] revealed Remind [resident 1] that his comments can make others uncomfortable, but do not alienate him. Two approaches with start dates of [DATE] revealed to Let resident know those types of comments are unwelcome, and to please stop. Make sure he is being appropriate around other residents. Praise resident for appropriate behaviors and [Resident 1] stated he will go to his room if he has an urge. An approach dated [DATE] was one on one supervision related to an incident on [DATE]. A care plan dated [DATE] with a created date of [DATE] revealed that resident 1 had behavioral symptoms of making other residents feel unsafe by entering their rooms. The goal was to make other residents in the building feel safer and the approach was one on one care in place. Resident 1's progress notes were reviewed and revealed the following: a. On [DATE] at 10:30 AM, Resident found in another residents room showing her his penis. SS reached out to his daughter [name removed], she sats [sic] that he has been a very sexual person his whole life. She is unsure what to do at this time. She states that she will come in and speak to him. SS has contacted police, they are on the way. Daughter is planning on coming by as well, she is questioning his mental state at this point and would like us to send him out for a psyche [psychological] eval [evaluation]. She states that he has been trying to leave the facility, and since his stroke she feels that he is not in his normal mental state. b. On [DATE] at 10:47 AM, Resident is on 1:1 care right now. c. On [DATE] at 7:09 PM and was edited by the nurse on [DATE] at 10:34 AM revealed, Resident has been inappropriate all shift. Asking staff if 'anyone wants to hook up and if we can find someone to hook up with him he will be in room [ROOM NUMBER]'. Educated [resident 1] about inappropriate comments and behaviors. Staff will continue to monitor, documented, and educated [resident 1] on this behavior. No falls or injuries this shift. d. On [DATE] at 9:39 PM and was edited by the nurse on [DATE] at 12:27 PM revealed, .Pt has been making inappropriate comments this shift. LN [Licensed Nurse] educated resident on making inappropriate comments. He verbalized understanding . e. On [DATE] at 8:19 AM, Nurse went to patients room in 501 to administer medications to patient. Patient reports that [resident 1] was in here [sic] room pulling her covers off while she was asleep. Resident in 501 states she yelled 'get out of my room.' Nurse told patient in 501 she will talk to [resident 1] about the issue. After leaving 501 room, patient in 503 opened her door and reports that [resident 1] was in her room trying to mover [sic] her bedside table. Patient states she yelled at him to get out. Nurse told patient in 503 she will talk to patient. Administrator, DON, and MD notified. f. On [DATE] at 7:17 AM, recorded as a late entry on [DATE] at 7:17 AM by the NP revealed, .Had pepper spray to eyes earlier today. He is resolved with eye wash. He continues to be inappropriate with other staff and residents requesting sex. g. On [DATE] at 9:27 AM, LN was notified by another LN that resident was outside a room at the end of the hall with what appears to be orange colored substance on his glasses. LN went to assess and immediately started choking from something in the air. A nearby CNA informed LN that a [sic] this patient had attempted to enter the patients room uninvited and was sprayed with something. LN immediately knocked on the door and asked the patient what the substance was and was told it was pepper spray. This LN and another LN took him back to his room and started washing his face and eyes with saline. Patient recovered quickly. LN notified DON and administrator of event. The patient down the hall then called police. MD and daughter has been notified of event. Order to monitor for any side effects from pepper spray in the eyes for 3 days. Order carried out. h. On [DATE] at 10:29 AM, SS called residents daughter and asked about a discharge plan, she is comfortable with her dad discharging home to her house today. Resident is a threat to other residents safety and well being here [name of facility]. i. On [DATE] at 10:36 AM, the physician documented I was informed that [resident 1] entered a female patient's room uninvited and unwelcome. She warned him not to enter. The police were called and he is being charged with a misdemeanor trespassing. DHS [Department of Health Services], the ombudsman, and APS [Adult Protective Services] were also notified. It is my professional opinion that [resident 1] poses a threat to the patients at our facility and should be removed ASAP [as soon as possible]. j. On [DATE] at 11:08 AM, Resident is currently on 1:1 supervision. k. On [DATE] at 1:58 PM, SS has been working with daughter and his Utah Case management team, if he leaves today he will lose his New Choice Waiver. His daughter has teenage daughters, so him discharging to his daughters is not ideal. I then called mobile crisis unit and spoke to [name removed], they could not help either. l. On [DATE] at 3:09 PM, SS and business office went down to issue resident discharge notice. he signed it and understood. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, hypo-osmolality and hyponatremia, chronic pain, fibromyalgia, and personal history of a transient ischemic attack. Resident 3's medical record was reviewed on [DATE]. Resident 3's progress notes revealed the following entries: a. On [DATE] at 1:45 PM, Patient arrived via stretcher . Oriented to place, time, place [sic] and situation. Patient can't hear on the right ear and able to on the left ear. Patient has on hearing aide with case and charger .Patient states she only lays on left side because it hurts her to lay on her right side and on her back . b. On [DATE] at 5:03 PM, Type of MDS Assessment: Admit.She has adequate hearing in right ear. She is deaf in lef [Sic] ear and has hearing aides. She has clear speech. She is understood and she understands others. Her cognition is intact aeb [as evidenced by] BIMS score of ,d+[DATE] .Pt requires extensive assist of staff for most ADLs . c. On [DATE] at 8:29 AM, Residents discharge was pushed out to the 10th due to Covid +, however resident wants to leave the [DATE] as originally planned. SS reached out to [name of assisted living], they are fine with taking her Covid + . d. On [DATE] at 6:31 PM, Resident discharged today. e. On [DATE] at 3:20 PM, DON and SS went to [name of assisted living] where [resident 3] discharged to from facility to follow up with resident's report of male resident entering room on [DATE] and pulling down covers while resident was sleeping. [Resident 3] reported to DON and SS that while [resident 3] was in bed facing window a male resident in wheelchair stroked her back twice. On the first time she could not see anyone after turning head to look back after the second time she turned around to the other side facing the door and saw male resident in wheelchair next to bed who proceeded to touch her leg inappropriately and up to her breast. She then yelled for him to get out of her room and resident left. Resident did not report extent of abuse to nurse on Saturday before discharging. [Local police department] was called to report abuse and SS is reporting to state agency. It should be noted that there was a no note regarding the incident on [DATE] in resident 3's medical record but there was a note in resident 1's medical record. 3. Resident 2 was admitted to the facility on [DATE] with diagnoses which included infection following a procedure, sepsis, fusion of spine, diabetes mellitus, generalized anxiety disorder and depression. Resident 2's medical record was reviewed on [DATE]. Resident 2's progress notes revealed the following entries: a. On [DATE] at 8:30 AM, .Patient is alert and oriented to person, place, time and situation. Hear [sic] adequate ob [sic] both sides no hearing aides. Has glasses. b. On [DATE] at 3:27 PM, Type of MDS Assessment: Admit .Her cognition is intact aeb BIMS score of ,d+[DATE] . c. On [DATE] at 8:45 AM, SS reached out to [name of behavioral health company] to follow up on referral for a psyche eval, [name removed] was going to come and complete it last Friday, however she has been very ill. [Name removed] responded to me this morning stating that she is not a provider for [resident 2's] insurance, and said that it may be best to refer her somewhere when she discharges. In the meantime, SS has received no reports of resident having any behaviors in the past week or so. She seems to have settled in, and spends a lot of time working on the puzzle in the dining area. d. On [DATE] at 12:09 AM, .Rapid COVID test done, with positive results . e. On [DATE] at 8:19 AM, recorded as late entry on [DATE] at 12:24 PM, LN went in to administer morning medications and asked resident how she was feeling about the situation. Resident stated she was angry that it happened. LN notified resident that the other patient would have a 1:1 supervision aide and she stated she felt better about that. Resident said she just wanted to go back to sleep. f. On [DATE] at 10:53 AM, LN was notified of an incident involving another resident this morning. LN went in to talk to this resident about what happened. Resident stated that another resident opened her door and tried to come in her room so she sprayed him with pepper spray. She stated she was fearful of what he might do so she called the police. LN assured resident that we will do all we can to prevent the other resident from going into her room. g. On [DATE] at 2:46 PM, recorded as a late entry on [DATE] at 6:56 PM, SS went to speak with resident in regards to the incident that happened this morning. SS asked resident how she was feeling, she started telling me that nobody cares about how she is feeling. I reassured resident that I care, and that's why I am here. I asked her if she feels safe and secure, she stated that she hasn't felt safe or secure since she arrived. I asked what I could do to help her feel safe, and her response was 'nothing could be done or it would be done already'. I offered her a counseling referral and she argued with me about how she would be able to do it, said she did not have correct technology for virtual visits . h. On [DATE] at 11:12 AM, Spoke with daughter [name removed] about how we could help [resident 2] feel safe in our facility, daughter stated she feels the best option is to have resident transferred to another facility. Ensured daughter and resident that we are taking every step to ensure resident feels safe, multiple options were refused by resident, SS working on finding facility that resident will approve. i. On [DATE] at 1:38 PM, UM [Unit Manager] went to check in with patient on how she was feeling after yesterdays events. Expressed that we want to make sure that she feels safe here and address any emotional concerns she may have at this time. Her reply was 'I'm fine, I'm fine.' . j. On [DATE] at 6:10 AM, Referral to LCSW [Licensed Clinical Social Worker] sent, SS will assist resident with choosing a counseling place today. k. On [DATE] at 2:16 PM, Due to recent events it was discovered that residents daughter had brought her in pepper spray because resident reported to daughter that she did not feel safe. However, resident and daughter failed to report that pepper spray was [NAME] [sic] in, or that [resident 2] felt unsafe during her stay. SS had been in [resident 2's] room over the past couple of weeks, and she had not said anything to me. Staff have not reported to myself or any other management that resident has not felt safe. It should be noted that there was a no note regarding the incident on [DATE] in resident 2's medical record but there was a note in resident 1's medical record. l. On [DATE] at 1:33 PM, Patient discharged home today. A review of the facility reported incidents to the State Survey Agency revealed the facility reported on [DATE] at 10:39 AM, the following incident. The initial report revealed on [DATE] with no time indicated, resident 1 tried to enter resident 2's room. The report revealed resident 2 told him no and sprayed him with pepper spray. The follow-up investigation report revealed that resident 1 was interviewed. [Resident 1] admitts [sic] to atempting [sic] to enter [resident 2's] room where she warned him and told him to leave. When he did not leave [resident 2] sprayed him. Through the day [resident 1] was on a one on one with staff and did not report or display any psychological harm or disstress [sic] as a result. According to the summary of interviews, [Resident 2] was interviewed. [Resident 2] stated she warned [resident 1] not to go into her room when [resident 1] did not leave she sprayed him with pepper spray. This was done is [sic] self defense. [Resident 1] reports that her daughter brought in the pepper spray and the daughter verified she did bring in the pepper spray. Staff were not notified that pepper spray was brought into the facility. The Summary of interviews with other residents who have had contact with the alleged perpetrator revealed During the course of this investigation another allegation came to light. It was reported by [resident 2] that a recently discharged resident [resident 3] told [resident 2] that [resident 1] had entered [resident 3's] room and touched her inappropiately [sic]. This was reported as a separate allegation. The conclusion was that the allegation was verified, It is verified that [resident 2] did spray [resident 1] in the face with a pepper spray like substance, but it was done out of self defense. The form further revealed that abuse training and in-service with staff sine [sic] incident. A review of the facility reported incident to the State Survey Agency revealed on [DATE] at 4:59 PM, the following incident occurred. The initial report revealed that on [DATE] at an unknown time resident 3 reported that resident 1 had allegedly entered her room and pulled her covers off. The follow-up investigation report revealed [Resident 3] accused [resident 1] of touching her inappropriately. [Resident 3] says that she feels safe and secure in her new home . The form further revealed [Resident 1] confirms that he was in [resident 3's] room, and that she was 'teasing him.' He confirms that he did touch her, and that he won't do it again. The allegation was verified The allegation of innapropriate [sic] touching was verified as evidenced by [resident 1] admitting to the action. The form further revealed that resident 1 was given a discharge notice but then passed away. Resident 3 was offered counseling services but felt safe in her new home. The systemic actions were Reviewed and provided abuse inservice. The facility provided abuse training and reporting with staff signatures from [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. There was no specific education information provided. It should be noted that resident 1 had a progress note on [DATE] regarding resident 1 going in and out of resident 2 and 3's room. There was no invesitgation until [DATE] after resident 1 had been maced. On [DATE] at 2:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 1 was alert and oriented to person, place, time and sometimes situation. RN 1 stated resident 1 did have times of confusion. RN 1 stated resident 1 was provided one on one supervision for being inappropriate with female staff. RN 1 stated resident 2 resided in room [ROOM NUMBER] and resident 3 resided in room [ROOM NUMBER]. RN 1 stated the first time she heard about any interactions, was on [DATE] when resident 2 told her that a man in an orange hat came into her room and moved her bedside table in the middle of the night. RN 1 stated resident 2 told her if he entered her room again she had [NAME]. RN 1 stated that resident 2 told her that her daughter brought her the [NAME]. RN 1 stated she reported what resident 2 had told her to the DON and Administrator (ADM). RN 1 stated that happened on [DATE]. RN 1 stated resident 3 had told her that someone entered her room and tugged on her blanket in the middle of the night and she nudged him with her leg. RN 1 stated when she reported to the DON, she thought resident 1 was provided with one on one supervision after that incident but could not remember. RN 1 provided a text message sent to the DON on [DATE] with the nurses note from resident 1's medical record. The text message further revealed This is my note about [resident 1]. This was this morning. And awhile ago when I was discharging 501, I hear 503 [resident 2] yelling 'get out of here! I will [NAME] [sic] you if you come near my door or come in my room and call the cops after' While she was yelling at him, [resident 1] was holding his fist at her! I told [resident 1] to leave and while telling him to leave, [resident 3] 501 tells family members that, that was the guy I told was in my room this morning. Family member started to tell me you guys can't have him going into peoples room and that he shouldn't be here. Told them we are dealing with the issue. On [DATE] at 4:42 PM, a phone interview was conducted with RN 2. RN 2 stated resident 1 went into other resident rooms. RN 2 stated resident 1 lost his cell phone and went into everyone's room looking for it. RN 2 stated around [DATE] several residents told resident 1 to get out of their rooms. RN 2 stated resident 2 was aware that resident 1 was entering resident rooms. RN 2 stated she was working the morning that resident 1 was maced by resident 2. RN 2 stated he opened resident 2's door and she was ready and sprayed resident 1 in the doorway. RN 2 stated prior to resident 1 being maced resident 2 had complained that he had gone into her room because the information had been passed onto her in report by other nurses. RN 2 stated resident 1 was maced between 6:00 AM and 6:45 AM. On [DATE] at 2:42 PM, an interview was conducted with the Resident Advocate (RA) and the DON. The RA stated resident 1 had some behaviors/incidents. The RA stated resident 1 went into female rooms. The RA stated that he had entered 3 different female resident rooms including resident 2 and resident 3. The RA stated resident 1 exposed himself to a female resident in [DATE]. The RA stated that resident 1 attempted to touch the female residents when he went into their rooms. The RA stated resident 2 and resident 3 were in rooms next to each other. The RA stated they found out resident 1 had entered resident 3's room and touched her from resident 2. The RA stated resident 1 entered resident 3's room and touched her leg or back and pulled the blankets off. The DON stated that she remembered the pepper spray happened on Monday [DATE] before their 9:00 AM meeting. The DON stated that the Saturday ([DATE]) before, Registered Nurse (RN) 1 reached out to her about resident 2 having [NAME] and was going to [NAME] resident 1 if he entered her room. The DON stated she was not sure why resident 2 needed [NAME]. The DON stated she instructed RN 1 to report it to the Administrator (ADM) who was the abuse coordinator. The DON stated resident 1 was moved to his own room and his behaviors calmed down a lot. The DON stated then his behaviors started again and he was put on one on one supervision. The DON stated resident 1 was placed on one on one on [DATE] after he exposed himself to a resident and did not come off of one one one supervision until he went to the hospital on [DATE]. The DON was asked how resident 1 had been maced if he was provided one on one supervision. The DON stated if it was during shift change, a CNA might be late and the nurses should have kept an eye on him. The DON stated she did not know how long resident 1 was without a one on one on [DATE]. The DON stated after resident 1 was maced, staff washed his eyes out and one on one supervision was continued. The RA stated she talked to resident 2 on [DATE] and resident 2 reported that resident 1 tried to go in and touch her beside table and she threw him out. The RA stated that resident 2 stated resident 1 tried to enter her room on [DATE] and told resident 1 she would pepper spray him if he entered her room again. The RA stated that resident 1 had been removed from one on one supervision at one point from the ADM. The DON stated there should have been a physician's order for residents to receive one on one supervision. The DON stated according to resident 1's medical record he received one one one supervision from [DATE] until [DATE]. The DON stated resident 1's daughter reported that resident 1 had always been a sexual person. The DON stated that resident 1 had an increase in his medication Paxil on [DATE] because of hypersexual behaviors. On [DATE] at 3:55 PM, an interview was conducted with the ADM. The ADM stated he was the facility abuse coordinator. The ADM stated resident 1 had issues and was provided one on one supervision until his behavior improved and was taken off. The ADM stated there was another incident and resident 1 was put back on one on one supervision. The ADM stated resident 1's daughter informed staff that resident 1 had a history of being sexually inappropriate. The ADM stated he was notified that resident 1 tried to go into resident 2's room but resident 2 did not say anything prior to spraying resident 1 with [NAME]. The ADM stated police came to the facility and did not press charges against resident 2 because resident 1 was in her doorway, and she acted in self defense. The ADM stated after resident 1 was maced he was provided one on one supervision. The ADM stated that resident 2 told staff that resident 1 entered resident 3's room prior. The ADM stated he was not notified that resident 2 had [NAME] or that resident 1 had entered other residents' rooms prior to [DATE]. The ADM stated even if he had been notified that resident 2 had [NAME], he would not have completed an abuse investigation but would probably have talked to resident 2 regarding why she needed it. On [DATE] at 12:28 PM, a follow up interview was conducted with the ADM. The ADM stated he was not aware of any events on [DATE] with resident 1 or that resident 2 had [NAME]. The ADM stated he was out to eat for his wife's birthday on [DATE]. The ADM stated staff were probably not bugging him because of that. The ADM stated the DON did not know how to fill out the abuse reporting to the State Survey Agency. The ADM stated that the Social Service Director had completed abuse reporting and investigating in the past but he had taken that over so he was aware of issues in the facility. The ADM stated he looked back at his text messages and his tiger texts on [DATE] and there were no notification from RN 1 or the DON. On [DATE] at 2:33 PM, a phone interview was conducted with resident 2. Resident 2 stated that a few days after she was admitted , resident 1 came up to her in the dining room and asked her to have sex with him. Resident 2 stated she complained resident 1 was going in and out of her room for 2 weeks straight. Resident 2 stated he either entered her room or was knocking on the door between midnight and 2:00 AM most nights. Resident 2 stated he molested the resident in the room next to her who was resident 3. Resident 2 stated the nurses knew he was in and out of rooms. Resident 2 stated resident 3 told her that resident 1 entered resident 3's room in the middle of the night and put his hand on her leg and up her body to her breast. Resident 2 stated the next morning she was in her doorway and told resident 1 to stay away and resident 1 shook his fist at her. Resident 2 stated she had warned him that if he came in her room again she would [NAME] him. Resident 2 stated she was very worried he would enter her room and try to do something with her and she would hurt her back trying to get him away. Resident 2 stated she had recently had back surgery. Resident 2 stated she was concerned he would get into her bed when she was not awake. Resident 2 stated she slept during the day and had a note on her door to not disturb because that was the only time she could get rest. Resident 2 stated another resident reported to her that when the resident was at lunch, resident 1 went into her room, got naked, and was in her bed. Resident 2 stated she became a light sleeper and a couple of times he caught her sleeping, she woke up and told him to get out. Resident 2 stated that staff did not care and would come ask her if she was okay and she responded by saying I'm fine, I'm fine because they did not do anything. Resident 2 stated she asked to talk to a therapist and was told she was not there long term, so she could not have counseling. Resident 2 stated she told her daughter about resident 1 coming in her room, so her daughter brought her [NAME] to protect herself. Resident 2 stated resident 1 was in her doorway, opened her door and she sprayed him with [NAME] on [DATE] and called the police. On [DATE] at 3:13 PM, a phone interview was conducted with resident 3. Resident 3 stated she was at the facilty for about a month. Resident 3 stated there was a guy who went around in his wheelchair through the hallway. Resident 3 stated the last morning she was there at about 7:00 AM, after the nurse brought her medications in, she felt someone behind her scratching at her back. Resident 3 stated she asked what was going on and there was no response. Resident 3 stated she was unable to turn in bed or sleep on the right side because of back surgery. Resident 3 stated she had to sleep with her back to the door. Resident 3 stated she felt the scratching on her back again with a rub touch with the finger. Resident 3 stated she turned a little more and saw a man in a wheelchair behind her. Resident 3 stated he touched her leg and ran his hand all the way up to her breast. Resident 3 stated there was a lot of COVID-19 in the facility, so she yelled that she had COVID and he was going to get sick. Resident 3 stated he went to the doorway and just sat there and looked at her so she yelled it again. Resident 3 stated she told the nurse she had been assaulted and the nurse responded that was not the first time he was in another resident's rooms. Resident 3 stated he talked to the neighbor, who was resident 2, and the same man had come into her room and scared her. Resident 3 stated resident 2 was so terrified of him coming in again, she was sleeping during the day and her daughter brought in pepper spray. Resident 3 stated she discharged from the facility on [DATE]. Resident 3 stated when she was leaving the facility, resident 1 was physically being stopped by staff because he was trying to get into her room. Resident 3 stated that staff took him to another area of the facility. Resident 3 stated she did not have hearing in one ear and had a hearing aide for the other ear but it was broken. Resident 3 stated she was so scared because of the assault, staff at her assisted living installed a loud doorbell. Resident 3 stated that the Social Worker and DON came to her assisted living to get a statement about what happened. Resident 3 stated her and resident 2 were back away from the main hall and we were more accessible for this guy to enter their rooms. Resident 3 stated resident 1 had not entered her room previously. Resident 3 stated that detectives from the local police department came to talk to her and informed her that resident 1 had died . The facility's Abuse, Neglect and Exploitation Policy with a reviewed/revised date of [DATE] and implemented on [DATE] revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also including the deprivation by an individual, including a care taker, of foods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. .'Sexual Abuse' is non-consensual sexual contact of any type with resident. V. Investigation on Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. V [TRUNCATED]

Based on interview and record review, it was determined, the facility did not ensure each resident received adequate supervision and services to prevent accidents. Specifically, for 1 out of 34 sampled residents, one resident sustained a skin tear to his face after falling off the bed during wound care. Resident identifier: 75. Findings include: Resident 75 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, [CONDITION(S)] of vertebra, sacral and sacrococcygeal region, stage 4 pressure ulcer, acute [CONDITION(S)], contracture of muscle (multiple sites), dependence on respiratory (ventilatory) status, [CONDITION(S)] status, severe protein-calorie malnutrition, need for assistance with personal care, bed confinement status, and cognitive communication deficit. Resident 75's medical records were reviewed on 5/18/22. A quarterly Minimum Data Set assessment dated [DATE], revealed that resident 75 required total dependence with two plus persons physical assistance for bed mobility. A review of resident 75's physician's orders revealed the following wound care orders: a. L (Left) hip wound tx (treatment): Cleanse with NS (normal saline) or wound spray. Apply collagen to wound bed, cover with regular alginate . Cover with bordered foam dressing. Daily and PRN (as needed). Order initiated on 5/12/22. b. R (Right) hip wound tx: Cleanse with NS or wound spray. Apply medical grade honey to wound bed. cover with foam dressing. Daily and PRN. Order initiated on 5/5/22. c. R upper back inferior wound tx: cleanse with NS or wound spray. Apply medical grade honey. Cover with foam dressing. Daily and PRN. Order initiated on 5/17/22. d. R upper back superior wound tx: Cleanse with NS or wound spray. Apply medical grade honey. Cover with foam dressing. Daily and PRN. Order initiated on 5/17/22. e. Sacrum wound vac (vacuum): Clean with NS or wound spray. Oil emulsion to exposed bone. Pack undermining with collagen powder, and apply collagen powder to wound bed . Change vac 3 times week, Tu (Tuesday), Th (Thursday), Sat (Saturday) and PRN. Order initiated on 5/17/22. A progress note dated 4/21/22, written by Nurse Practitioner (NP) 1 and signed by the Wound Care Nurse (WCN) revealed that resident 75, has severe contractures and remains in the fetal position and is very stiff. An Event report created on 5/17/22, revealed that resident 75 had a witnessed fall during wound care treatment. The following was located within the Event Details. a. A progress note dated 5/17/22 at 2:21 PM, revealed that resident 75 had sustained a fall during wound care. The progress note read, During wound care, resident [75] was on his side, as wound nurse turned ¾ turn to reach for a sponge, resident [75] slipped off the bed, and onto the floor, bed in low position. He [resident 75] received a skin tear to his R lateral face, near his eye. Steri strips put in place. Resident [75] examined from head to toe with no other issues noted .MD (Medical Director), DON (Director of Nursing), floor nurse, and family notified . b. A progress note dated 5/17/22 at 11:41 PM, revealed, patient assessed often. Patient has no decline from fall . right eye has steri strips intact. c. A progress note dated 5/18/22 at 4:10 PM, revealed, continue to monitor [resident 75] after recent witnessed fall no changes from baseline or change in LOC (level of consciousness). [Resident 75] is contracted and very frail. On 5/19/22 at 9:05 AM, an interview was conducted with the WCN. The WCN stated that resident 75 was unable to move by himself, and he always required at least two people during his cares. The WCN stated that resident 75 was severely contracted in a fetal position. The WCN stated that she and NP 1 were conducting a dressing change for resident 75's wounds, located on his backside. The WCN stated that she and NP 1 were holding resident 75 on his side, and as the WCN took a hand off resident 75 to reach for gauze, resident 75 slid off the bed and onto the floor. On 5/19/22 at 9:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1 and CNA 2. CNA 1 stated that resident 75 required at least two people for all of resident 75's care. CNA 2 stated that resident 75 could not move at all by himself and required two or more people to keep him safe during cares. On 5/23/22 at 1:00 PM, an interview was conducted with NP 1. NP 1 stated she was conducting wound care with the WCN on the day resident 75 fell on [DATE]. NP 1 stated that she and the WCN were on opposite sides of resident 75's bed, with resident 75's backside facing NP 1. Resident 75's front side was facing the WCN. NP 1 stated that resident 75 was positioned on his side, and resident 75 was, closer to the left side of the bed, with the bed being in the lowest position. NP 1 stated that resident 75 was being held up by herself and the WCN. NP 1 stated that she was attempting to write the date on the new bandages for resident 75's backside wounds, and at the same time the WCN took a hand off resident 75 to reach for gauze. NP 1 stated that once the WCN took her hand off resident 75, he slid off the bed and onto the floor. NP 1 stated that once resident 75 slid off the bed, the WCN and NP 1 got resident 75 back into the bed, conducted neurological checks, assessed resident 75's head, and started vital signs. NP 1 stated that usually there were three people in the room during wound care, however NP 1 stated they did not think it was unreasonable to have two people in the room for resident 75's wound care. NP 1 stated wound care for resident 75 had been done with two people in the past.

Based on observation, interview and record review it was determined for 1 of 6 sampled residents that the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice. Specifically, a resident had a delay in treatment after sustaining a fracture from a fall which resulted in the resident experiencing uncontrolled pain. The deficient practice identified for resident 3 for the delay in treatment after a change in condition was found to have occurred at a harm level. Resident identifier: 3. Findings include: HARM Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/5/18 resident 3's medical record was reviewed. Review of the nursing progress notes revealed the following; a. On 5/12/18 at 10:30 PM, the note stated, Resident was found on the floor by her bed. She said that she was walking to turn the lights off and she tripped and fell to her knees and then to her left side where she landed on her left shoulder. Resident then layed (sic) on her back anck (sic) called for help. Residents VS (vital signs) were all in normal range. She complained of some pain to her left shoulder. Her daughter was notified. Morning nurse will monitor and proceed if any further action needs to be taken. Incedent (sic) report filled out and turned in. It should be noted that the physician was not notified of the resident's fall and complaints of pain. b. On 5/13/18 at 7:38 PM, the note stated, ., c/o (complained of) left arm pain, given [MEDICATION NAME] (scheduled dose) and [MEDICATION NAME] as prescribed with some relief, will get xray on left arm tonight c. On 5/14/18 at 10:37 AM, the note stated, Received report from a.m. RN (registered nurse) that Resident had fallen the night before. She was LOA (leave of absence) with daughter for Mother's Day. Daughter brought her back early because she was in so much pain from her fall. Pain meds were given and (L) arm/shoulder assessed. Resident was guarding her left elbow and stated that her arm hurt. Sent order to (name of imaging company) for X-ray of left (L) Humerus and (L) elbow. Called to confirm the order. Was told by (name of imaging company) they no longer do X-rays of the Humerus because Medicare doesn't pay for it. Ordered X-ray of the (L) shoulder. Results as follows: .nondisplaced [MEDICAL CONDITION] neck .Called (daughter) to inform her of the X-ray results and that Resident would be sent to the hospital for treatment .Resident returned to facility two hours later. No surgery was necessary and (L) shoulder was stabilized with a sling .Daughter gave RN a Rx (prescription) for [MEDICATION NAME] 10 mg (milligram) -325 mg oral tablets .(doctors name), DON (Director of Nursing), and family notified. d. On 5/14/18 at 9:02 PM the note stated, c/o right shoulder pain, given [MEDICATION NAME] as prescribed with good relief Review of the incident report revealed that the fall occurred on 5/12/18 at 10:30 PM. The report documented the fall as unwitnessed and that pain was present and a [MEDICAL CONDITION] shoulder was suspected. The report documented that the physician assistant (PA) and resident's daughter were notified on 5/15/18, however no time was documented. Review of the radiology report on 5/13/18 at 8:53 PM revealed an impression of a [MEDICAL CONDITION] neck. The medical director was informed of the results on 5/13/18 at 10:40 PM. Review of the physician orders revealed the following; a. Tylenol 1000 mg by mouth three times a day as needed (PRN) for pain. The order was initiated on 4/5/17. b. [MEDICATION NAME] 10/325 mg, give 1 tablet by mouth every 6 hours as needed for pain. The order was initiated on 5/14/18. Review of the Medication Administration Record [REDACTED] a. On 5/13/18 at 8:35 PM Tylenol 1000 mg was administered for pain with a numeric pain score of 8 (on a scale of 0 to 10). No documentation could be found for a follow up pain score for the medication effectiveness. It should be noted that the PRN pain medication was not administered until 22 hours after the fall occurred. b. On 5/14/18 at 8:18 AM Tylenol 1000 mg was administered. No documentation could be found for a pain score pre and post medication administration. c. On 5/14/18 at 9:00 PM [MEDICATION NAME] 10/325 mg was administered. The pain score was documented as a 6 out of 10 prior to the medication administration. No documentation could be found of a follow up post pain score for effectiveness. Review of the facility policy and procedures on Client Care - Pain Management revealed that Residents will be assessed by a licensed nurse for pain .with a change in condition. Additionally, they will be assessed for any persistent or worsening pain. The policy further stated, (name of facility) believes that the relief of pain is an important part of our resident's care and staff will respond as quickly as possible to reports of pain. The policy states that documentation of all PRN pain medications must include the following on the MAR: location, type of pain, education, sedation scale, side effects, rater, pain scale, and Non-Pharmacologic interventions. Additionally, Documentation of physician notification of the resident's non-response to pain medication and any changes in the pain medication regimen shall be noted on the nursing notes. On 6/5/18 at 9:45 AM, an interview was conducted with resident 3. Resident 3 stated she was going to have surgery on her left shoulder today but it was canceled due to blood work. Resident 3 stated that she fractured her left shoulder the day before Mother's Day at around 10:00 PM. The resident stated that she was walking from the bed to a chair to obtain a blanket when her foot got caught up on the oxygen tubing and she fell . Resident 3 stated the pain was horrible and that she cried all night, I was in so much pain. Resident 3 stated her daughter came to the facility the next day, on Mother's Day, and requested to see the X-ray after the fall. Resident 3 stated that the facility informed her daughter that an x-ray hadn't been done yet and the daughter then demanded they do an x-ray. Resident 3 stated that she was then transferred to the hospital that night. Resident 3 stated she was given Tylenol after the fall as that was the only pain medication that was ordered, and that it was not effective. Resident 3 stated again, the pain was horrible. Resident 3 stated she informed the nurse that the Tylenol took the edge off, but it didn't take the pain away. Resident 3 stated that the hospital medical doctor (MD) ordered [MEDICATION NAME] and it took the pain completely away. Resident 3 stated the [MEDICATION NAME] was ordered every 6 hours and that the pain would wake her up at night when more pain medication was due. Resident 3 stated that the [MEDICATION NAME] was covering her pain now. On 6/5/18 at 12:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated his expectation of nursing staff was to assess a change in condition and to notify the DON, family, and MD. The DON further stated that I would have expected the nurse to notify the doctor, it appears she did not. The DON stated that on the incident report the nurse documented pain present and a suspected [MEDICAL CONDITION] shoulder. The DON further stated that he would have expected the nurse to notify the MD and get an order for [REDACTED]. Yes, I would have expected to call the doctor sooner. The DON stated that his expectation would be to address the resident's pain with medication or non-pharmacological interventions, but was unable to identify where this information would be documented. The DON confirmed that the resident didn't receive any PRN pain medication until 5/13/18 at 8:35 PM when the Tylenol was administered for an 8/10 pain score. The DON also stated, we can always send them out to get an x-ray done at the clinic or hospital or figure out what the resident wants to do. The DON stated that he would have expected the nursing staff to complete a pre and post pain score for medication administration. The DON reported that the incident was reported in morning meeting on the Monday following the incident, but that there was no documentation of this. The DON stated, I can remember the incident and them talking about her being in pain and the views of the x-ray and that it showed a fracture and she was going to be sent out. She was scheduled for surgery but she can't have it yet because of blood work. The DON stated that notification should happen immediately. I wasn't aware of the delay in treatment. I did hear that she was crying out all night in the morning meeting on Monday. Then I asked about the x-ray and that's when she got scheduled to go out and look at it further.

Based on observation, interview, and record review it was determined that the facility failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, it was determined that the facility did not provide sufficient nursing staff to meet the resident's needs in the areas of answering resident call lights in a timely manner, assisting the residents with their meals, and assistance with toileting. Resident identifiers: 41, 44, 46, 72, 207, 208, and 209. Findings include: 1. A resident council group meeting was held with residents on 12/11/17 at approximately 10:15 AM. Eight residents and one family member attended the meeting. Residents indicated that Certified Nurse Aide (CNA) staffing had affected their care in the following ways: a. Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 41 stated that average wait time for call lights to be answered depended on what CNA was on shift but most often it was a 30 minute wait. b. Resident 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 46 stated that the facility staff did not answer call lights in a timely manner and that the average call light was answered between 30 to 60 minutes. Resident 46 stated that there were times when her bottom was sore from sitting on the toilet for so long waiting for an aide to assist her. c. Resident 72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 72 stated that the facility staff did not answer call lights in a timely manner and that the average call light was answered between 30 to 60 minutes. Residents 72 stated that he has had to sit on the toilet for long periods of time before a CNA answered the bathroom call light. Resident 72's family member also stated that she has had concerns with call lights not being answered promptly and had brought it to the attention of staff on numerous occasions. 2. On 12/11/17, a review of resident council minutes from (MONTH) (YEAR) through (MONTH) (YEAR) was performed. The resident council minutes revealed the following: a. For the month of (MONTH) (YEAR), under section Review of Old Business/Concerns: old business reviewed and approved stated - #1 Not all the time it depends who is on Call lights b. For the month of (MONTH) (YEAR), under section Discussion of New Business stated - Nursing: are call lights being answered in a timely manner? #1 - No - -everyone stated they are a little slow right now. c. For the month of (MONTH) (YEAR), under section Review of Old Business/Concerns: old business reviewed and approved with 4 carry over's stated - #1call lights are slow - - inconsistent - depends on who is on. d. For the month of (MONTH) (YEAR), under section Discussion of New Business stated - Nursing: are lights being answered in a timely manner? #11 at meals the food is served but they run off and if you need it cut up or anything else it is hard to get help. e. For the month of (MONTH) (YEAR), under section Review of Old Business/Concerns: old business reviewed and approved with 4 carry over's stated - #1call lights are slow - - inconsistent - depends on who is on. f. For the month of (MONTH) (YEAR), under section Discussion of New Business stated - Nursing: are lights being answered in a timely manner? See old business #1. g. For the month of (MONTH) (YEAR), under section Discussion of New Business stated - Nursing: are call lights being answered in a timely manner? #1- It depends on who is on .up to a 30 minute wait. 3. Resident 208 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/5/17 at 8:00 AM, an interview was conducted with resident 208. Resident 208 stated that there was not enough staff to assist residents and that she would wait at least 15 minutes for the CNAs (Certified Nursing Assistants) to answer her call light. Resident 208 stated that she had just pushed the call light about 20 minutes ago and the CNA had come in and turned off the call light and told her that they would return. Resident 208 stated that she was still waiting for the CNA to return because she needed to go to the bathroom. Resident 208 stated that it was common for the CNA staff to turn off the light and tell her that they would be back, and not return. Resident 208 stated that because of the lack of assistance to the bathroom, she had had an episode of incontinence of bowel and bladder. Resident 208 stated, but only one time. 4. Resident 207 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/5/17 at 8:20 AM, an interview was conducted with resident 207. Resident 207 stated that there was not enough staff, that it took them 15 minutes or longer to answer his call light. 5. Resident 209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/5/17 at 9:55 AM, an interview was conducted with resident 209. Resident 209 stated that I need to go to the bathroom really bad, can you help me? Resident 209 stated that her call light had been on for about 20 minutes. Occupational Therapy stepped into resident 209's room, turned off the call light and assisted resident 209 to the bathroom. On 12/5/17 at 10:30 AM, an interview was again conducted with resident 209. Resident 209 stated that it was not uncommon for her call light to go unanswered for 20 minutes or longer. Resident 209 stated that the facility are short on staff. Resident 209 stated that she had taken to calling on her light about 20 minutes early, as she was trying to anticipate needing to go to the bathroom, just so that staff would be there when she needed to go. 6. Resident 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of resident 44 from 12/4/17 - 12/7/17 revealed that resident 44 had bilateral contractures of his hands and knees. No observations were made of resident 44 having a splint device or brace to his hands or knees. Resident 44 was observed to lie in bed. No observations were made of resident 44 being up and being placed in his specialized wheel chair. On 12/12/17, resident 44's medical record was reviewed. Review of the medical record revealed a Significant change Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 44 as having a functional limitation in range of motion in the upper and lower extremities on both sides and that resident 44 was receiving Restorative Therapy for passive range of motion and splint or brace assistance. Review of resident 44's care plan revealed no care plan for the Restorative Therapy program or for the splint or brace assistance. Review of the medical record revealed two Restorative Therapy Referral forms. Facility staff documented the following on the referral form dated 11/14/16: Instructions: Hand hygiene to B (bilateral) hands, palm protectors and hand rolls donned up to 8 hrs (hours) daily as tolerated secondary to contracture management. Facility staff documented the following on the referral form dated 6/2/17: PROM (passive range of motion) to UE (upper extremities) and LE (lower extremities) . Brace Program: B knee braces 4-6 hours (per) day as tolerated. Review of the physician orders [REDACTED]. On 12/12/17, the Minimum Data Set Coordinator (MDSC) was interviewed. The MDSC stated that she was responsible for overseeing the Restorative Nurse Aide Program. The MDSC stated that she just recently began overseeing the program. The MDSC stated that resident 44 was not listed on the program previously. The MDSC stated that she had just added resident 44 to the program the week of 12/11/17. On 12/12/17 at 1:22 PM, Restorative Nursing Aide (RNA) 2 was interviewed. RNA 2 stated that she was unaware of resident 44 having an RNA program. RNA 2 stated that she had not done range of motion with resident 44 nor had she applied the braces to his knees or the splints to his hands. RNA 2 stated that she had been doing the RNA program for about three weeks and that she was not told that resident 44 was supposed to have an RNA program. On 12/11/17, the Physical Therapy Director (PTD) was interviewed. The PTD stated that he did not know why resident 44 was not receiving the RNA program that had been developed for him. The PTD stated that, in addition to the braces and splints, the staff should have been getting resident 44 up in his chair daily. The PTD stated that resident 44 getting into his chair daily would help resident 44 with the contracture management and would assist with resident 44 receiving range of motion. On 12/12/17 at 8:50 AM, Certified Nursing Assistant (CNA) 22 was interviewed. CNA 22 stated that the staff had not gotten resident 44 up and into his chair the week of 12/4/17 because there was not enough staff to get him up. CNA 22 stated that if the shower aide called in sick then the CNAs on the floor would need to do their own showers of residents and then the staff would not have time to get resident 44 up and into his chair. Staff Interviews 1. On 12/12/17 at 12:06 PM, an interview was conducted with CNA 2. CNA 2 stated that the facility did not have enough staff. CNA 2 stated that she always felt rushed and was always running from one room to another. CNA 2 stated that she never had enough time to complete tasks adequately and that I don't have time to spend the quality time with the residents that they need. CNA 2 stated that all residents should be toileted every two hours and as needed and that their call light should be answered as soon as it comes on so that residents can get to the bathroom timely. 2. On 12/12/17 at 12:15 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 208 was always continent of bowel and bladder and that the only way for resident 208 to remain continent of bowel and bladder was to get resident 208 to the bathroom in a timely manner. CNA 3 stated that all resident call lights should be answered as soon as they come on and that CNA's should not turn off the call light and tell the resident they will come back. 3. On 12/12/17 at approximately 1:30 PM, an interview with CNA 9 was conducted. CNA 9 stated that there were frequent times when she felt rushed while doing her job. CNA 9 stated that residents sometimes required more assistance depending on their acuity. CNA 9 stated she was unable to take breaks quite frequently because of the workload. (Cross refer to F-550, F-677, F-688, F-692, F-791)

Based on observation, interview, and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not monitor and reassess a resident after the resident experienced a change in condition thus causing the resident to experience an episode of autonomic dysreflexia. Resident identifier: 61. HARM Findings include: Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/4/17, resident 61 was observed to be in her room, lying in bed. Resident 61 was observed to be lethargic. No observations were made of resident 61 getting up and into her wheel chair during the day on 12/4/17. On 12/4/17, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 61 did not feel well and that the doctor had been notified. On 12/5/17, the following observations were made: RN 1 was observed to be in resident 61's room with Certified Nursing Assistant (CNA) 3 assisting RN 1. RN 1 was observed to be setting up supplies to place a foley catheter into resident 61. When the surveyor asked if she could watch the care being provided, RN 1 stated that resident 61, Is in Autonomic Dysreflexia and this is an emergency situation! On 12/5/17, resident 61's medical record was reviewed. Review of the medical record revealed the following entries: a. 10/11/17 19:26 (7:26 PM): Late Entry: Received a call for the ER (emergency room ) nurse at (name of local acute care hospital) at 0815 (8:15 AM) stating that patient was stable and ready to return to hunter hollow to resume cares. Patient was sent to ER for severe hypertension. Nurse at the ER reported that they performed a bladder scan and noted 900 ml (milliliters) of fluid retained in her bladder; the bladder was emptied and VS (Vital Signs) returned to normal: . b. 10/12/17 10:02 AM: pt (patient) is here for a Gun shot wound to the neck, quidrplegia (sic) autonoic (sic) dysreflexia. c. 10/12/17 18:23 (6:23 PM): please flush superpubic (sic) catheter daily and prn (as needed) to prevent catheter occlusion. d. 12/3/17 23:59 (11:59 PM): Resident alert and oriented x 4 , lethargic, . incontinent of bowel. suprapubic cath (catheter) redness around, draining yellow clear urine, dressing change, . breakdown to buttock dressing intact . Resident on Ventilator at Noc (night), VS WNL (within Normal Limits),[MEDICAL CONDITION] care manage by RT (Respiratory Therapist). Call light within reach. e. 12/4/17 20:03 (8:03 PM): Patient has appeared to have increased lethargy recently. Today patient had no desire to get out of bed and requested to sleep after her medications have been given. Upon following up on her and offering her some options for her day and personal cares she continued to request to sleep. CNA notified RN on shift change that patient had no urinary output but has since been repositioned. Entered room to evaluate down drain bag which had scanty amount of urine and is abnormal for the patient. Flushed foley catheter in which RN unable to flush, but able to aspirate. Urine varying in color and turbidity. General color is dark yellow. Able to aspirate approximately 240 cc (cubic centimeters) from suprapubic cath, but difficulty remained with flushing and was sluggish. Patient states she had not had any meals today and has had poor oral fluid intake. Pt. has scheduled apt. (appointment) to have suprapubic cath. RN concerned that her new order of clonezepam (sic) is too strong and causing symptoms as well as dehydration. While dressing wound on patient's buttock today she experienced some respiratory distress. RT to lavage, suction and RN assisting with AMBU bag. Pt. improved with interventions. O2 (oxygen saturation) 98%. Tolerating the ventilator and respiratory status and overall stability was obtained. BP (blood pressure): 96/53. Notified NP (Nurse Practitioner) of concerns with decline in condition. T.O. (Telephone Order) CBC (Complete Blood Count), BMP (Basic Metabolic Panel) STAT (immediately). 2.) Start 0.9% NS (normal saline) IV (intravenous) 500 ml (at) 100 ml/hr (milliliters per hour) x 1. 3.) Flush suprapubic cath BID (twice daily). 4.) Straight cath if able to insert and if necessary for [MEDICAL CONDITION]. 5.) Push oral fluids. 6.) Change clonezepam (sic) to 0.25 mg (milligrams) PO (by mouth) Q8 (every 8) hours prn. 7.) Hold sedating medications until pt. returns to baseline. f. 12/5/17 15:24 (3:24 PM): Late Entry. At 1000 (10:00 AM) the RT reported to RN that patient was very diaphoretic. Entered the room in which patient's arms had dropplets (sic) of sweat and chest of her shirt was saturated in sweat. Patient c/o (complains of) feeling cold. Blood pressure reading 205/92, and bladder was visibly distended and palpable. Inserted a 18F (french) foley catheter with down drain and secured to left leg as her suprapubic catheter is not patent and b/p reading is critically high. CNA to assist with positioning and at bedside to assist RN. Output after insertion was 400 cc (cubic centimeter). Blood pressures began stabilizing to patient's norm: 150/83, then 112/72. Flow of output controlled with binding of tubing as to not cause a sudden drop in blood pressure. Notified NP. N.O. (New Order) 1.) Suprapubic catheter to be changed in physician office only. 2.) Implement foley catheter care Q (every) shift. 3.) Send Urine for UA (urinalysis) with C&S (culture and sensitivity) if indicated. Total output at approximately 1300-1400 pm (2:00 - 3:00 PM) was 900 b/p 117/63 and symptoms have stabilized. No documentation could be found to show that facility staff implemented the orders received on 12/4/17. No documentation could be found to show that facility staff continued to assess resident 61's change in condition identified on 12/4/17. Review of resident 61's care plan revealed a care plan for Urinary Incont (incontinence) Indwelling Cath dated 11/28/17. Facility staff documented the following Outcomes in regards to the identified concern: (Resident 61) has a suprapubic catheter r/t (related to) [MEDICAL CONDITION] bladder and (Resident 61) will have no untreated s/s (sign or symptoms) of complication r/t suprapubic. Facility staff documented the following interventions to help resident 61 achieve the listed outcomes: Eval (evaluate) for Symptoms of UTI (urinary tract infection), promote hydration, proper cleansing. Add Indwelling Urinary Catheter to Problem List, Support Skin Care, Catheter Care Needs While Promoting Indep (independence). Check for physician [DIAGNOSES REDACTED]., Anchor Drainage Tube of Foley to Prevent Tension. No documentation could be found to show that facility staff had developed a plan of care regarding resident 61's autonomic dysreflexia and interventions for treatment of [REDACTED]. On 12/6/17 at 8:42 AM, RN 1 was interviewed. RN 1 stated that the Night Shift Nurse should have documented whether or not she completed the telephone orders received on 12/4/17. RN 1 further stated that the Night Shift Nurse should have documented that she had monitored resident 61 and continued to reassess resident 61 through the night. RN 1 stated that she was unaware of what happened through the night prior to the Autonomic dysreflexia episode on 12/5/17. On 12/11/17, the facility Director of Nursing (DON) was interviewed. The DON stated that the Night Shift Nurse should have documented that she had implemented the physician's orders [REDACTED]. The DON confirmed that without the documentation she (the DON) had no idea what happened with resident 61 throughout the night of 12/4/17. Facility staff were unable to find a policy and procedure in regards to a change in condition and what staff should do if a resident experienced a change in condition.

Based on interview, observation and record review it was determined that the facility failed to maintain a Quality Assessment and Assurance Committee that developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, deficient practices identified during the survey regarding Resident Rights, Quality of Care, Nutrition, Sufficient Staffing, Dental Services and Administration were found to have occurred at a Harm level. Resident identifiers: 34, 61, and 208. Findings include: 1. The facility Quality Assessment and Assurance Committee did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, one resident who was dependent on staff for toileting, did not have the call light answered timely which resulted in an incontinence episode of bowel and bladder. The findings were determined to have occurred at a harm level. Resident identifier: 208. (Cross refer to F550) 2. The facility Quality Assessment and Assurance Committee did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not monitor and reassess a resident after the resident experienced a change in condition thus causing the resident to experience an episode of autonomic dysreflexia. The deficient practice identified for resident 61 was found to have occurred at a harm level. Resident identifier: 61. (Cross refer to F684) 3. The facility Quality Assessment and Assurance Committee did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, residents who had experienced a significant weight loss were not evaluated by the facility Registered Dietitian (RD). Additionally, facility staff were not assisting the residents with eating nor were they implementing the correct interventions suggested by the RD. The deficient practice identified for residents 34 and 61 was found to have occurred at a Harm level. Resident identifiers: 34 and 61. (Cross refer to F692) 4. The facility Quality Assessment and Assurance Committee failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents not being toileted timely, residents being assessed after a change in condition, and residents not receiving the proper diet or assistance with eating thus sustaining a significant weight loss. The deficient practice identified for residents 34, 61, and 208 was found to have occurred at a Harm Level. Resident identifiers: 34, 61, and 208. (Cross refer to F550, F684, and F692) 5. The facility Quality Assessment and Assurance Committee failed to ensure that a resident with lost or damaged dentures was referred promptly for dental services. Additionally, when the referral did not occur within 3 days, the facility did not provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services. Specifically, a resident with broken dentures did not receive dental services to fix/replace her dentures. Subsequently, the resident was prescribed a pureed diet due to her inability to masticate a regular diet texture. The resident experienced a 17.2 % loss of her total body weight within 99 days of being admitted to the facility. Additionally, the resident did not receive assistance with eating nor the correct physician prescribed diet. The deficient practice identified for resident 34 was found to have occurred at a Harm level. Resident identifier: 34. (Cross refer to F791) 6. The facility Quality Assessment and Assurance Committee failed to maintain an Administration that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F835) It should be noted that deficient practice was identified in the following areas during the facility's recertification survey in (YEAR): F-580, F-607, F-641, F-656, F-657, F-677, F-684, F-725, F-761, and F-880. The deficient practices identified, for the above mentioned areas, during the current recertification survey were the same areas of concern identified on the last recertification survey.

Based on observation, record review and interview it was determined that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, deficient practices identified during the survey regarding Resident Rights, Quality of Care, Nutrition, Sufficient Staffing, Dental Services and Quality Assurance and Performance Improvement were found to have occurred at a Harm level. Resident identifiers: 34, 61, and 208. Findings include: 1. The facility Administration did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, one resident who was dependent on staff for toileting, did not have the call light answered timely which resulted in an incontinence episode of bowel and bladder. The findings were determined to have occurred at a harm level. Resident identifier: 208. (Cross refer to F550) 2. The facility Administration did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not monitor and reassess a resident after the resident experienced a change in condition thus causing the resident to experience an episode of autonomic dysreflexia. The deficient practice identified for resident 61 was found to have occurred at a harm level. Resident identifier: 61. (Cross refer to F684) 3. The facility Administration did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, residents who had experienced a significant weight loss were not evaluated by the facility Registered Dietitian (RD). Additionally, facility staff were not assisting the residents with eating nor were they implementing the correct interventions suggested by the RD. The deficient practice identified for residents 34 and 61 was found to have occurred at a Harm level. Resident identifiers: 34 and 61. (Cross refer to F692) 4. The facility Administration failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents not being toileted timely, residents not being assessed after a change in condition, and residents not receiving the proper diet or assistance with eating thus sustaining a significant weight loss. The deficient practice identified for residents 34, 61, and 208 was found to have occurred at a Harm Level. Resident identifiers: 34, 61, and 208. (Cross refer to F550, F684, and F692) 5. The facility Administration failed to ensure that a resident with lost or damaged dentures was referred promptly for dental services. Additionally, when the referral did not occur within 3 days, the facility did not provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services. Specifically, a resident with broken dentures did not receive dental services to fix/replace her dentures. Subsequently, the resident was prescribed a pureed diet due to her inability to masticate a regular diet texture. The resident experienced a 17.2 % loss of her total body weight within 99 days of being admitted to the facility. Additionally, the resident did not receive assistance with eating nor the correct physician prescribed diet. The deficient practice identified for resident 34 was found to have occurred at a Harm level. Resident identifier: 34. (Cross refer to F791) 6. The facility administration failed to maintain a Quality Assessment and Assurance Committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F867) It should be noted that deficient practice was identified in the following areas during the facility's recertification survey in (YEAR): F-580, F-607, F-641, F-656, F-657, F-677, F-684, F-725, F-761, and F-880. The deficient practices identified, for the above mentioned areas, during the current recertification survey were the same areas of concern identified on the last recertification survey.

Based on observation, interview and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that a resident with lost or damaged dentures was referred promptly for dental services. Additionally, when the referral did not occur within 3 days, the facility did not provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services. Specifically, a resident with broken dentures did not receive dental services to fix/replace her dentures. Subsequently, the resident was prescribed a pureed diet due to her inability to masticate a regular diet texture. The resident experienced a 17.2 % loss of her total body weight within 99 days of being admitted to the facility. Additionally, the resident did not receive assistance with eating nor the correct physician prescribed diet. Resident identifier: 34. HARM Findings include: 1. Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/5/17 at approximately 8:20 AM, resident 34 was interviewed. Resident 34 stated that she was missing her dentures because the top denture was broken. Resident 34 stated that it was difficult for her to eat without her dentures. Resident 34 stated that she did not like the diet she was receiving. Resident 34 stated that she did not like the texture of the food served. Resident 34 further stated that she did not like the Boost as it was too sweet. Resident 34 stated that if she had her dentures, she would eat a steak and salad. Resident 34 stated that the facility was not helping her to get her dentures fixed, They don't care if I have my dentures, they won't help me get them fixed! Observations of resident 34 revealed the following: a. 12/4/17: Breakfast meal: At 9:30 AM, facility staff were observed to remove resident 34's tray from her room. Resident 34 had not consumed any food on the tray. No observations were made of facility staff assisting resident 34 prior to the removal of her tray. No observations were made of facility staff offering resident 34 an alternative food item since she had not consumed her breakfast. Observations of the meal ticket, on resident 34's tray, revealed resident 34 was served a Regular Mechanical Soft, Regular Portion diet. Facility staff had documented Boost every Meal under the supplements section of the meal ticket. b. 12/5/17: Breakfast meal: At approximately 8:45 AM, resident 34 was observed to be lying in bed with her meal tray positioned above her on a bed side table. Resident 34 was observed to be lying at a 30 degree angle. Resident 34 stated that she could not see her food. Resident 34 stated that she was legally blind. Resident 34 stated that the staff would usually cut up her eggs and then leave. No observations were made of facility staff cutting up resident 34's eggs. No observations were made of facility staff assisting resident 34 with her meal. At 9:30 AM, Certified Nursing Assistant (CNA) 20 was observed to enter resident 34's room. CNA 20 was observed to remove resident 34's breakfast tray and raise the head of resident 34's bed. Resident 34 was observed to be lying at a 75 degree angle. CNA 20 was observed to take the Boost off of resident 34's tray and take the Boost back into resident 34. CNA 20 stated, Boost is what will help her out now! No observations were made of CNA 20 offering an alternative food item. Observations of the meal tray revealed that resident 34 had consumed none of her breakfast meal. On 12/5/17 at 10:48 AM, observations of the Boost given to resident 34 at 9:30 AM revealed that resident 34 had consumed none of the Boost supplement. c. 12/5/17: Lunch meal: Observations revealed that resident 34 was served a soft bean taco and ice cream with chocolate sauce. Resident 34 was observed to be lying at a 30 degree angle with her meal tray above her on a bedside table. Resident 34 stated that she could not see the food that was on her plate. Resident 34 stated that she was legally blind. Resident 34 stated that none of the staff had explained to her what she had been served. Resident 34 stated that the food felt like some sort of burrito. Resident 34 stated that she did not like the food served. Resident 34 asked the surveyor if she could assist her with the meal. At approximately 1:20 PM, facility staff were observed to remove resident 34's lunch tray. Observations revealed that resident 34 had consumed none of the meal served nor had resident 34 consumed any of the Boost supplement given to her at 9:30 AM. No observations were made of facility staff assisting resident 34 with her meal. No observations were made of facility staff offering resident 34 an alternative food item. d. 12/6/17: Lunch meal: Observations revealed that facility staff placed resident 34's lunch tray on her bedside table and then left the room. Resident 34 was observed to be lying at a 30 degree angle, sleeping. No observations were made of facility staff waking resident 34 to let her know that her lunch had arrived. At approximately 1:30 PM, facility staff were observed to remove resident 34's lunch tray. Resident 34 had slept through the meal and therefore and not consumed any of the meal. The Boost supplement from the morning meal remained on resident 34's bedside table, unopened. No observations were made of facility staff assisting resident 34 with the noon meal. No observations were made of facility staff offering resident 34 an alternative food item. It should be noted that from 12/4/17 - 12/6/17, four meals, no observations were made of resident 34 consuming any food. Observations of resident 34's meal ticket on 12/4/17 - 12/6/17 revealed that resident 34 was served a Regular Mechanical Soft Regular portion diet with Boost supplement at every meal. On 12/6/17, resident 34 was re-interviewed. Resident 34 stated that staff had never offered an alternative if she did not consume the meal served. Resident 34 stated that if she had her dentures, she would be eating, lots of salad. Resident 34 stated that she wished she could have a steak as she did not like the texture of the food served. Resident 34 stated that the facility served the same thing over and over again. On 12/7/17, the facility Meal Intake Detail Report was reviewed. According to the report, facility staff documented that on 12/4/17, resident 34 consumed 50 % of her breakfast meal and that she had refused the breakfast alternate. On 12/6/17, facility staff documented that resident 34 consumed 75 % of her lunch meal. No documentation could be found for the breakfast and lunch meal on 12/5/17. On 12/6/17 resident 34's medical record was reviewed. Review of the medical record revealed an Admission Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 34 as requiring extensive assistance with a 1 person physical assist with eating, having broken or loose fitting full or partial dentures and that resident 34 was receiving a mechanically altered, therapeutic diet. Additionally, Dental Care and Activities of Daily Living (ADLs) were triggered on the Care Area Assessment and facility staff indicated that the areas would be care planned. Review of a Quarterly MDS assessment dated [DATE] revealed that facility staff assessed resident 34 as requiring limited assistance with a one person physical assist with eating. Review of resident 34's care plan revealed the following: a. Dental care plan dated 8/31/17. The Outcomes listed on the Care Plan included: Dental Care to meet needs, Average Meal Consumption per day, (Resident 34) has broken top denture plate and missing teeth on the bottom, and (Resident 34) will tolerate her diet with no unaddressed pain. The Interventions listed to help resident 34 achieve the stated outcomes were: Evaluate for oral pain source, Refer (Resident 34) to dental professional as appropriate for her dental needs, and Assist (Resident 34) with oral care as needed to prevent possible oral cavity problems. b. Nutrition care plan dated 9/11/17. The Outcomes listed for the nutrition care plan included: Average meal consumption per day, compare most recent weight against admission weight, Weight change per month, Intakes leaving < (less than) 25 % (at) meals, Therapeutic/Altered consistency diet, BMI (Body Mass Index) less than 18.5, (Resident 34) will have no significant weight change i.e. > (greater than) 2 % X 1 wk (week), > 5 % X 1 mo (month), > 7.5 % X 3 mo, > 10 % X 6 mo, (Resident 34) will have moist mucous membrane and no tenting of skin TNR (Through Next Review), and (Resident 34) will have skin remain intact. The Interventions listed to help resident 34 achieve the stated outcomes were: Will monitor weights, intakes, labs and skin integrity. Discuss in NAR (Nutrition At Risk) as needed, Diet, supplements, medications as ordered, and SNP (Special Nutritional Program). c. ADL Function/Rehab dated 8/31/17. The Outcomes listed for the ADL care plan included: Functions at Optimal Level with ADLs, Personal Hygiene, (Resident 34) requires ext (extensive) assist w/ (with) bed mobility, transfer, dressing, eating, toilet, hygiene, bath r/t (related to) fracture, (Resident 34) will perform toileting tasks independently by discharge, (Resident 34) will walk 50' (feet) independently, with assistive devices if necessary, by discharge. The Interventions listed to help resident 34 achieve the stated outcomes were: Provide assistance to Support Level of Need, Encourage (Resident 34) to utilize assistive devices for function, safety, and independence, Provide PT/OT (Physical Therapy/Occupational Therapy) per orders to increase strength and mobility for safe discharge, and Add Self Care Deficit to Problem List. Review of the facility documented weights revealed the following weights: a. 8/25/17: 103.2 lbs (pounds) b. 9/5/17: 98.2 lbs c. 9/12/17: 97.1 lbs d. 9/26/17: 96.9 lbs e. 10/9/17: 93.7 lbs f. 10/17/17: 92.8 lbs g. 10/24/17: 95.6 lbs h. 10/30/17: 97.2 lbs i. 11/14/17: 91.4 lbs j. 12/7/17: 85.4 lbs Review of the weights revealed that resident 34 had experienced a 10.07 % loss of her total body weight from 8/25/17 - 10/17/17 (53 days), an 11.4 % loss of her total body weight from 8/25/17 - 11/14/17 (81 days) and 17.2 % of her total body weight since admission (8/25/17 - 12/7/17). Review of the physician's orders [REDACTED]. It should be noted that observations of resident 34's diet card or meal ticket on 12/4/17 - 12/7/17 revealed that resident 34 was receiving a Regular Mechanical Soft Regular Portion diet. Review of Progress Notes revealed the following Admission Note: admitted this 91 y/o (year old) female to room [ROOM NUMBER].Resident is legally blind. Has eyeglasses on but son says it does not really do anything. She needs help with her meals. She has broken dentures on the upper part and has missing teeth on the bottom. Review of the medical record revealed a SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 8/22/17. According to the SLP evaluation, resident 34's Oral Peripheral Exam revealed that, Dentures (Dentures are broken down the middle. Pt (patient) reports that they have been broken for some time and that it makes chewing and swallowing difficult). The SLP documented under the Clinical Impressions portion of the evaluation that, Pt struggled with the oral mastication phase of swallowing. Adaptation (changing diet to puree) will alleviate all dysphagia symptoms. Additionally, the SLP documented the following recommendations: Diet Recs (recommendations) - Solids = Puree Consistencies, Diet Recs - Liquids = Thin liquids, Supervision for Oral Intake = Occasional supervision and To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions upright posture during meals. Review of the Dietary Progress Notes revealed the following entries: a. 8/28/17: New Admit. 91 y.o. female. Dx (diagnosis) of Fx (fracture), Aneurysm, Weakness, [MEDICAL CONDITIONS](hypertension). Admit weight 103.2, 96 % IWR (Ideal Weight Range), BMI 17.7. underweight for height. Intakes averaging 48 % Puree Heart Healthy Diet. Skin has surgical wound to R (right) shoulder. Visceral protein store depletion likely d/t (due to) an acute condition, inflammation. Spoke with SLP, reports patient not eating well. Will rec (recommend) Boost TID (three times daily) to meal tray, Medpass 120 mL (milliliters) BID (twice daily), MVI w/ MIN (multi-vitamin with mineral) 1 tablet PO (by mouth) daily. Res (resident) is self directed with food choices. Continue P[NAME] (plan of care) and monitor labs, weight, intakes and skin integrity. Make additional recommendations as needed. b. 8/29/17: RD Note: Concur with above assessment for 91 y.o underweight for height Female with Dx of Fx, Aneurysm, Weakness, [MEDICAL CONDITION], HTN, with R shoulder fracture. BMI 17.7. Diet: Puree Heart Healthy, appropriate. Intakes not meeting needs. Will rec Boost TID to meal tray (it is the practice to provide supplements with meals), Medpass 120 mL BID, MVI w/ MIN with help to prevent additional weight loss. Continue to monitor with follow-up as needed. c. 9/1/17: Weight was reviewed, no significant change att (at this time). Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. d. 9/6/17: Addendum on 9/11/17 - RD reviewed wt (weight) note. Rec: SNP, CP[NAME] (continue plan of care. CTM (Continue to monitor). 9/6/17 Note. Res weight is 98.2, down 4.8 % X 1 week. Intakes averaging 43 % M/S (Mechanical Soft) Heart Healthy diet, Boost TID to meal tray, Medpass 120 mL BID, MVI w/ MIN. Will monitor x 1 week and make additional recommendations as needed. Discuss in NAR. Res is self directed with food choices. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. It should be noted that resident 34 was switched to a Mechanical Soft diet from the recommended Puree without an additional evaluation from the SLP to determine safety with the Mechanical Soft Diet. e. 9/15/17: Weight was reviewed, no significant change att. Continue P[NAME] and monitor labs, weights, intakes, and skin integrity. Make additional recommendations as needed. f. 9/22/17: Weight was reviewed, no significant change att. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. g. 9/29/17: Weight was reviewed, no significant change att. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. It should be noted that on 9/29/17, resident 34 had experienced a 6.1 % loss of her total body weight since admission. h. 10/6/17: Weight was reviewed, no significant change att. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. i. 10/11/17: Addendum on 10/17/17 - RD reviewed weight note. Concur with DT (Diet Tech) note and recommendations are appropriate at this time. 9/6/17 Note. Res weight is 98.2, down 4.8 % x 1 week. Intakes averaging 43 % M/S SNP Diet, Medpass 60 mL BID, MVI w/ MIN: Aware res does not like Boost and it was D/C'd (discontinued). Patient was on a higher amount of Medpass but wasn't drinking all of it so it was decreased. Have spoken with res a few times, aware she has only a few teeth on the bottom and has broken her dentures and is unable to get new ones fit att. Patient has refused Puree texture and was upgraded to M/S texture but continue to have difficulty chewing d/t missing teeth. Have put res on list to see house dentist to look at getting new dentures. Discuss in NAR. Res is self directed with food choices. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. No documentation could be found to show that resident 34 was receiving an increased amount of Medpass. No documentation could be found to show that the Boost was discontinued due to resident 34 not liking the Boost. According to resident 34's meal ticket and observations, resident 34 was still receiving the Boost on 12/4/17 - 12/7/17. No documentation could be found to show that resident 34 was seen by the house dentist. j. 10/20/17: Weight was reviewed, no significant change att. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. It should be noted that on 10/20/17, resident 34 had lost 5.49 % of her total body weight since 9/5/17 and resident 34 had lost 10.07 % of her total body weight since admission (53 days). k. 10/24/17: Res weight is 95.6 # (lbs), up 3 % x 1 week, UBWR (usual body weight remains) 93-98 # x 6 weeks. Intakes averaging 50 % of a Regular M/S Diet, Medpass 60 mL BID (accepting 75% per MAR ((Medication Administration Record)) summary), MVI w/ MIN. Will not discuss in NAR. Res is self directed with food choices. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. It should be noted that no documentation could be found recommending that resident 34's SNP diet be discontinued. No documentation could be found recommending that the Medpass be decreased to 60 mL BID. l. 11/7/17: Res refused weight this week. Continue P[NAME] and monitor labs, weights, intakes and skin integrity. Make additional recommendations as needed. Review of physician progress notes [REDACTED]. She developed a coccyx PU (pressure ulcer). Coccyx - 1 cm (centimeter) diam (diameter) partial thickness erosion, 0.1 depth, clean, granulating, periwound OK. St. (stage) II PU, clean, Barrier cream. No documentation could be found to show that resident 34 was weighed between 11/7/17 - 12/7/17. On 12/7/17, the surveyor had to request that facility staff obtain a current weight on resident 34. No documentation could be found to show that facility staff had obtained any current laboratory values for the facility RD to evaluate. No documentation could be found to show that the facility RD had made recommendations for current laboratory values to be drawn. No documentation could be found to show that the RD evaluated resident 34 after the significant weight loss nor after resident 34 developed the stage II pressure ulcer. Resident 34 experienced a 6.9 % total loss of her body weight from 9/5/17 - 11/14/17 and an 11.4 % total loss of her body weight from 8/25/17 - 11/14/17 (81 days). On 12/7/17 at approximately 1:30 PM, the facility Dietary Manager (DM) was interviewed. The DM stated that he did not deal with the clinical side of residents and their nutritional needs. The DM stated that he only ran the kitchen. The DM confirmed that resident 34 should have been seen by the RD after her weight, on 11/14/17, of 91 pounds. On 12/7/17, the DM was observed to call the facility RD and obtain orders for resident 34 to have an SNP diet and receive Medpass. It should be noted that resident 34 already had orders in place for the interventions or orders obtained by the DM on 12/7/17. On 12/7/17 at approximately 2:00 PM, the facility Director of Nursing (DON) and Corporate Nurse were interviewed. The DON stated that the facility had switched dental providers in the beginning of (MONTH) and that resident 34 was scheduled to see the dentist the week of 12/11/17. No documentation could be found to show that resident 34 was scheduled to see the dentist the week of 12/11/17. (Cross refer to F-677, F-692, F-806, and F-808)

Based on observation and interview, it was determined, for 2 of 25 sample residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, one resident, who was dependent upon staff for toileting, did not have the call light answered timely which resulted in an incontinence episode of bowel and bladder; one resident was transported multiple times through the facility in a hospital gown and bare feet; and Certified Nursing Assistants (CNAs) were observed standing to feed residents. Resident identifiers: 49 and 208. HARM Findings include: 1. Resident 208 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/5/17 at 8:00 AM, an interview was conducted with resident 208. Resident 208 stated that there were not enough staff to assist residents and that she would wait, at least 15 minutes for the CNAs (Certified Nursing Assistants) to answer her call light. Resident 208 stated that she had just pushed the call light about 20 minutes ago and a facility CNA had come in and turned off the call light and told her that they would return. Resident 208 stated that she was still waiting for the CNA to return because she needed to go to the bathroom. Resident 208 stated that it was common for the CNA staff to turn off the light saying that they would be back, and not return. Resident 208 stated that because of the lack of assistance to the bathroom, she had experienced an episode of incontinence of bowel and bladder. Resident 208 stated, but only one time. On 12/12/17 resident 208's medical record was reviewed. A nurse's note dated 12/4/17 at 15:37 (3:37 PM), revealed, Care Plan Considerations/MDS (Minimum Data Set) with ARD (Assessment Reference Date) 11/28/17 (Resident 208) is alert and oriented x (times) 3-4 She requires extensive assistance with bed mobility, transfers, dressing, toileting, and bathing The MDS assessment dated [DATE] for resident 208 revealed that resident 208 required extensive 2 person assistance with transfers and toileting. The care plan dated 12/4/17 for resident 208 revealed that resident 208 had an ADL (Activities of Daily Living) care plan. The outcomes listed on the care plan included the following: a. Functions at Optimal Level with ADLs. b. (Resident 208) gets 1-2 person assist with transfer, bed mobility, dressing, toilet, hygiene, bath, r/t (related to) fracture. c. (Resident 208) will be taken seriously and have her ADL needs met daily while maintaining her independence. The Interventions on the ADL Care Plan included the following: a. Provide Assistance to support level of need. On 12/12/17 at 12:06 PM, an interview was conducted with CNA 2. CNA 2 stated that the facility did not have enough staff. CNA 2 stated that she always felt rushed and was always running from one room to another. CNA 2 stated that she never had enough time to complete tasks adequately and that I don't have time to spend the quality time with the residents that they need. CNA 2 stated that all residents should be toileted every two hours and as needed and that their call light should be answered as soon as it comes on so that residents can get to the bathroom timely. On 12/12/17 at 12:15 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 208 was always continent of bowel and bladder and that the only way for resident 208 to remain continent of bowel and bladder was to get resident 208 to the bathroom in a timely manner. CNA 3 stated that all resident call lights should be answered as soon as they come on and that CNAs should not turn off the call light and tell the resident they will come back. CNA 3 confirmed that resident 208 was dependent on facility staff to transfer to the wheelchair and to take her to the bathroom. CNA 3 stated that resident 208's incontinence episode makes me sad. Potential for Harm: 2. Resident 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/4/17 at 8:45 AM, an observation was made of resident 49 in the facility dining room. Resident 49 was observed to have on a hospital gown. Resident 49 was observed to have bare feet. On 12/5/17 at 12:30 PM, an observation was made of resident 49 in the facility dining room. Resident 49 was observed to have on a hospital gown. Resident 49 was observed to have bare feet. On 12/6/17 at 2:00 PM, an observation was made of resident 49 sitting in the 200 hallway. Resident 49 was observed to have on a hospital gown. Resident 49 was observed to have bare feet. On 12/7/17 at 9:40 AM, an observation was made of resident 49 sitting in the 200 hallway. Resident 49 was observed to have on a hospital gown. Resident 49 was observed to be wearing green socks. On 12/11/17 at 12:30 PM, an observation was made of resident 49 sitting in the facility dining room. Resident 49 was observed to have on a hospital gown. Resident 49 was observed to be wearing green socks. On 12/12/17 at 12:15 PM, an observation was made of resident 49 sitting in the facility dining room. Resident 49 was observed to have on a hospital gown. Resident 49 was observed to be wearing green socks. On 12/11/17 at 9:30 AM, an interview was conducted with CNA 7. CNA 7 stated that CNAs were unable to get resident 49 dressed as resident 49 has no clothes. CNA 7 stated that the staff had found a pair of socks, for resident 49, to wear last week. On 12/12/17 at 1:20 PM, an interview was conducted with the facility Social Service Worker (SSW). The facility SSW stated that she had not talked with resident 49's son about getting clothing because I have been reamed so many times by resident 49's son that communication has broken down and I don't call him. The facility SSW stated we can get her socks but that the facility did not have access to resident 49's money to get her any clothing. 3. On 12/4/17 at 8:33 AM, an observation was made in the assisted area of the facility dining room. CNA 8 was observed to walk around the second dining table of four seated residents. CNA 8 was observed to give one bite of food to each resident as she continued to walk around the table. On 12/4/17 during the noon meal, and on 12/6/17 during the breakfast and noon meal, CNA 8 was observed to be feeding residents in the Assisted Dining area of the Dining Room. CNA 8 was observed to assist one resident with a bite of food and then walk over to another resident at the same table and then give that resident a bite of food. The table was observed to have four residents sitting at the table receiving assistance from CNA 8. Each resident received assistance with one bite of food at a time before CNA 8 was observed to walk over to the next resident. No observations were made of CNA 8 sitting down and assisting just one resident, at a time, with their meal. On 12/6/17 during the noon meal, CNA 8 was interviewed. CNA 8 stated that the facility did not have enough staff to allow the CNAs to sit down and assist just one resident at a time. CNA 8 stated that in order for the residents to be able to eat at the same time, she (CNA 8) needed to walk around the table and stand while assisting the residents. (Cross refer to F 677 and F 725)

Based on observation, interview, and record review it was determined that the facility failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents being injured due to falls and a resident not receiving pain medication timely. (Residents 40, 71, 136, and 138). Resident identifiers: 40, 71, 99, 113 136, 138, and 211. Findings include: 1. Resident 136 was admitted to the facility on [DATE], 3/9/16, 5/13/16, and most recently 10/24/16 with [DIAGNOSES REDACTED]. On 11/30/16 at approximately 10:55 AM, resident 136 was observed to be sitting up in bed rubbing her left leg. Resident 136 was observed to be rocking back and forth. Resident 136 stated that she was in pain and had just received her pain medication. Resident 136 answered the state surveyors questions very abruptly and stated that she was very uncomfortable. On 11/30/16 resident 136's medical record was reviewed. Review of the physician's orders [REDACTED]. a. 11/14/16: [MEDICATION NAME] 2.5 mg (milligrams) BID (twice daily). On 11/30/16 at 10:30 AM, Registered Nurse (RN) 10 was observed to be administering medications. RN 10 stated that she was still administering morning medications to residents. According to the form provided to state surveys, upon entrance, morning medications or twice daily medications were to be administered at 8:00 AM and then again at 8:00 PM. Review of the Medication Administration Record [REDACTED]. The medication was ordered to be given at 8:00 AM. (Note: Resident 136's [MEDICATION NAME] was administered 2 hours and 42 minutes later than the scheduled time.) On 11/30/16 at 12:30 PM, resident 136 was re-interviewed. Resident 136 stated that the pain medication had helped her and that she was feeling much better. Resident 136 was observed to be sitting up in bed at the time of the interview, consuming her lunch. Resident 136 appeared to be calm and was pleasant when answering questions. 2. Resident 113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/30/16, a continuous five hour observation was made of resident 113. From 6:00 AM until 11:15 AM, no observations were made of facility staff toileting resident 113 or providing incontinence care. On 11/29/16, resident 113's medical record was reviewed. Review of the medical record revealed an Annual Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 113 as being frequently incontinent of both bowel and bladder with no toileting program in place. Review of the care plan revealed a care plan titled [MEDICAL CONDITION] dated 2/9/16. The following Outcomes were listed on the care plan: Skin Integrity General, Resident at risk for bowel and bladder complications r/t (related to) impaired mobility and incontinence, Resident will have BM (bowel movement) at least q3days (every three days), and no s/s (signs or symptoms) of UTI (urinary tract infection) this quarter, and Resident will have no skin breakdown this quarter. Facility staff initiated the following Interventions to help resident 113 achieve the stated outcomes: Evaluate Vital Signs, Output, Sx (symptoms) of UTI, Voiding Pain, Note urine Color, Clarity, Amount, Odor, Evaluate Meds (medications) for Potential Side Effect of Incontinence, Promote Optimal Fluid and Nutrition Intake Constipation or stool volume in rectum can cause increase in urinary frequency, Prevent Constipation to Decrease Urinary Incontinence, Provide Peri Care, and Consult with Physician for Variations in Evaluation Findings. No documentation could be found on the care plan in regards to how frequently facility staff should have been providing incontinence care. On 11/30/16, RN 1 was interviewed. RN 1 stated that facility Certified Nursing Assistants (CNAs) should have been providing incontinence care to residents every two hours and as needed. On 11/30/16, CNA 7 was interviewed. CNA 7 stated that facility staff had learned, in orientation, that residents should have incontinence care provided every two hours. On 11/30/16, the facility Director of Nursing (DON) was interviewed. The DON stated that facility staff should have been providing incontinence care to residents every two hours and as needed. 3. Residents 71, 136, and 138 sustained significant injuries with falls and resident 40 was transferred incorrectly by staff thus sustaining a significant injury. On 12/1/16 at approximately 8:00 AM, Registered Nurse (RN) 4 and CNA 12 were interviewed. Both RN 4 and CNA 12 stated that they did not feel that the facility had enough staff to be able to respond to the tab and pressure alarms, implemented for residents who had experienced falls, during the busy times of the day. The busy times of the day, according to RN 4 and CNA 12, were 6:00 AM until 8:30 AM, after breakfast until 12:00 PM, and after lunch until dinner. RN 4 stated that all staff were in rooms and trying to get residents up in the morning and that staff did not always hear the alarms. (Note: The times in which staff were not busy were the times when residents were down in the dining room eating meals.) 4. Resident 138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/28/16 at 1:46 PM, an interview was conducted with resident 138. Resident 138 stated that there was not enough staff for the facility. Resident 138 stated that sometimes they take a long time to answer my call light. Sometimes when they don't answer, I fall back to sleep. Resident 138 stated that she would wait approximately 20 minutes for her call light to be answered and would take herself to the bathroom if they did not answer her call light. On 11/29/16 resident 138's medical record was reviewed. Incident reports for resident 138 revealed the following: a. Fall on 11/7/15. @ 11AM, CNA found pt lying on the floor. Pt told the nurse she lost her balance after using the bathroom and hit her head on the floor. Noted hematoma at the back of her head. c/o pain. Give PRN [MEDICATION NAME] 5/325 mg for pain w (with)/ effect (sic). Applied ice pack to site. Neurocheck was initiated. Will continue to monitor. b. Fall on 11/30/15. CNA found resident lying on the floor in her room next to her bed. Some water had been spilled on the floor. Resident stated she wanted to go to the bathroom and fell . Her walker was nearby. Resident stated she did not hit her head Neuro check was done - grips equal, oriented x 3, PERRLA. No apparent injuries at this time. c. Fall on 10/16/16 with a goose egg to head. Resident finished using restroom and was headed back to bed when she fell to floor. Her R knee cap hurts to the touch. She has a big goose egg on the left side of her forehead. no other complaints at this time. 5. Resident 71 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/28/16 at 2:37 PM, a family interview was conducted with resident 71's daughter. Resident 71's daughter stated that there was not enough staff to meet her mother's needs and that it would take 15 minutes to an hour to answer the call light. Resident 71's daughter stated, I went last week to get some help at the desk to get my mom back in bed. The lady at the desk told me that 'I could come and help, but, you need to go and push the call light to get her aide in there.' I said to her 'so you can't help? or this is not your patient?' The lady stated again that 'I could come and help but you need to go and push the call light for her aide.' Then the lady told me that 'It will take them time to get to your mom.' On 11/30/16 resident 71's medical record was reviewed. A nurse's note dated 4/11/16 at 16:11 (4:11 PM) revealed that Resident was found sitting on the floor in the bathroom. Full body assessment done. Complained of upper back pain. She verbalized that she hit her back on the shower chair. ROM (Range of Motion) within patient limits. PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation). Not in distress. (Daughter) present. ADON (Assistant Director of Nursing, and PA notified. Reminded to use call light when needing help. Will continue to monitor A nurse's note dated 9/1/16 at 1:57 AM revealed that Pt was trying to get up to go to the bathroom when she slid off her bed onto the floor. Pt was not wearing any socks or shoes. Pt told the caregiver when she tried to stand up the ground was slippery and she slid onto her buttocks. Nothing noted on the floor. Pt's feet were dry and caused her to slide. Pt assessed on the floor. Good ROM in bilateral arms and legs. No c/o (complaints of) pain noted. Pt assisted up and into her bed. Pt reassessed while in bed. Good ROM in bilateral arms and legs. No c/o pain noted. Pt is noted to have a 1/2 inch x 1/2 inch 'L' shaped skin tear to her L (left) forearm with a hematoma. Pt stated she got the skin tear from her bed frame. Skin tear to L forearm cleansed with NS (Normal Saline), steri strips applied. ABX (Antibiotic) ointment applied. No bleeding noted. Left skin tear OTA (open to air). May cover PRN (as needed) Skid grip socks put on Pt. Talked with Pt and educated her to call for any assistance. Pt showed understanding. Pt no longer needed to go to the restroom. Assisted Pt in changing her brief. Pt resting in bed. Call light in reach. MD and DON notified. Will endorse with AM nurse to notify family. Continue with current plan of care. A nurse's note dated 10/3/16 at 14:53 (2:53 PM) revealed that Found on the floor by the laundry lady. She was positioned on her back with her feet under her bed and her head under the other bed. She was trying to transfer herself from her wheelchair to her bed. Bed was in low position. Bedside mat in place. Wheelchair was nearby. Patient alert and oriented to self. Grips equal and strong bilaterally. Able to follow all directions and commands. She denies hitting her head Family was notified and aware. (Physician) was informed. WCM (Will continue monitoring). A nurse's note dated 10/8/16 at 21:48 (9:48 PM) revealed that Patient verbalized to the nurse 'she slid off on her wheelchair and sat down on the floor.' Patient was trying to reach the bathroom. She was trying to hold againts (sic) the wall so she won't fall and she got skin tear on her right arm Cleanse site with NS, pat dry and cover with steri-strips WCM. 6. Resident 99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/29/16 at 9:39 AM an interview was conducted with resident 99. Resident 99 stated that there was not enough staff. Resident 99 stated that she had to wait up to 20 minutes for help when I call on my light. 7. On 12/1/16 at 8:26 AM, resident 211 was observed to activate his call light. Facility staff were not observed to answer resident 211's call light until 8:35 AM. (Cross refer F-309, F-312, and F-323)

Based on observation, interview, and record review it was determined, for 5 of 45 sample residents, that the facility did not ensure that residents received adequate supervision and assistance devices to prevent accidents. Specifically, facility staff did not implement interventions to prevent residents from falling and sustaining significant injuries (Residents 71, 136, and 138). One resident was transferred incorrectly and sustained significant injuries to her legs that required sutures (Resident 40). Additionally, interventions that were implemented to prevent falls were not being utilized by facility staff nor did the facility have adequate staff to implement interventions effectively. The deficient practice identified for residents 40, 71, 136, and 138 was found to have occurred at a Harm Level, indicating a Sub Standard Level of Care. The deficient practice identified for resident 105 was found to have occurred at a potential for harm and will not be included in the Sub Standard Level of Care. Resident identifiers: 40, 71, 105, 136, and 138. Findings include: Harm: 1. Resident 136 was admitted to the facility on [DATE], 3/9/16, 5/13/16, and most recently 10/24/16 with [DIAGNOSES REDACTED]. On 11/30/16 resident 136's medical record was reviewed. Review of the medical record revealed that resident 136 was originally admitted to the facility on [DATE] after experiencing a fall at an Assisted Living Facility and sustaining pelvic and facial fractures. Review of facility Incident reports and Progress Notes revealed the following incidents and entries: First Fall with injury: a. Progress Note: 11/12/15: . Pt (patient) is still a fall risk and is impulsive and continues to try to get up and walk around in her room without anyone being there. Therapy continues to remind her to use her call light. b. Progress Note: 11/12/15: Safety strategies were discussed with therapies and family during the care conference. Staff will be rearranging her bed to be against the wall and remove the floor pads. Pt. will have a pressure pad alarm placed on her mattress. c. Progress Note: 11/26/15: . She is a fall risk and has personal alarm on at all times. d. Progress Note: 11/30/15: . Pt is fall risk and has fall precautions in place, but pt doesn't follow the fall precautions, Pt is educated about the importance of the fall precautions, she seems to understand but then doesn't follow, requires redirection, call light and fluids are in reach, wctm (will continue to monitor). e. Progress Note: 12/1/15: Pt is A (alert) and O x3 (oriented times three), is able to verbalize her needs and concerns when asked, . Pt is a fall risk and is on fall precaution, pt doesn't (sic) follow her fall precautions. Pt needs redirection and reeducation. (Note: No documentation could be found to show what the fall precautions were for resident 136 at the time the above entries were made.) f. Incident Report: 12/3/15: Time of Incident: 1:40 AM, Exact Location of Incident: Inside Patient's room, Describe Incident: At around 1:40 AM, NOD (nurse on duty) heard somebody saing (sic) 'Oh No!' repeatedly. NOD tried to check patient's room because it was already closed (it stays open). NOD found pt on the floor lying down on her left side. Pt. received a skin tear on her L (left) arm and a bump on her left occiput (occipital)) area. Initial V/S (vital signs) taken, WNL (within normal limits). Resident is placed on neuro (neurological) checks and VS check. C/O (complains of) pain from her L occiput, Ice pack placed on the affected area. Encouraged pt to press call light if she needs to do her ADLs (Activities of Daily Living). DON (Director of Nursing) Follow Up: Monitor through resolution. (Note: Facility staff did not make a Progress Note entry to accompany the above fall. Additionally, no documentation could be found to show what interventions were being utilized at the time of the fall. No documentation could be found to show if resident 136's Personal Alarm was alarming at the time of the fall.) g. Progress Note: 12/4/15: Patient alert and oriented X 4. Patient assisted with moving to room 105B today without issues. Patient's behavior is appropriate for the transition. h. Incident Report: 12/5/15: Time of Incident: 2230 (10:30 PM), Exact Location of Incident: Pt. room, Describe Incident: (at) 2230 pt. found lying on the floor close to the bathroom door. Pt. got a skin tear on her left knee below the knee and on her left shoulder. Pt. doesn't remember what exactly happen. Neuro check was initiated. Initial V/S BP (blood pressure) 177/91, P (pulse) 93, R (respirations) 16, T (temperature) = 96.0, O2 (oxygen) sat (saturation) 96 % on 2 Liters. Pt. assisted back to her wheelchair and clean her wound (with) NS (normal saline) and cover (with) dressing. Notified (Name) ((Grandson in law)) and (name) ((PA)) (Physician's Assistant). Will continue to monitor. DON Follow up: monitor per protocol. Progress Note: 12/5/15: (at) 2230 Pt. found lying on the floor close to the bathroom door. Pt. got a skin tear on her left knee, below the knee and on her left shoulder. Pt. doesn't remember what exactly happen. Neurocheck was initiated. Initial V/S BP: 177/91, P=93, T=96, O2Sat=96% on 2 Liters. Assisted pt. back to her wheelchair and clean her wound w/ (with) NS and cover w/ dressing. Notified (name) ((Grandson in law)) and (name) ((PA)). Will continue to monitor. (Note: No documentation could be found to show what interventions were being utilized at the time of the fall. No documentation could be found to show if resident 136's Personal Alarm was alarming at the time of the fall.) i. Progress Note: 12/7/15: . Pt. is fall risk. She has a tab alarm and pressure alarm for safety. j. Progress Note: 12/12/15: No fall at this time. Sleeping in bed w/ tab alarm and bed in low position. Pt. has pressure alarm for safety awareness. k. Incident Report: 3/5/16: Time of Incident: 1940 (7:40 PM), Exact Location of Incident: Resident Room, Describe Incident: (at) approximately 1940, Resident found sitting on the floor w/ her back against her closet. Resident verbalized 'I tripped!' Resident left leg is swelling on the left mid thigh w/ external rotation. She cannot move her L leg. She rate her pain level out of 10/10. Can wigle (sic) her toes but can't flexed or extend her left leg. Call (name of PA) at 0740PM and notified son (name) from (State). Son request to send her out to ER (emergency room ) for further evaluation. Resident was transported via (name of ambulance company) in a stretcher. DON Follow up: admitted to hospital L femur fx (fracture). Progress Note: 3/5/16: At approximately 1940 resident found sitting on the floor w/ her back againts (sic) her closet. Resident verbalized 'I Triped (sic)'. Resident Left leg is swelling on the Left midthigh with external rotation. She cannot move her Left leg. She rate her pain level out of 10/10. Can wigle (sic) her toes but cant (sic) flexed or extend her Left Leg. Call (name of PA) right after fell (sic) 7:40 and Notified her Son (name) from (State) and her said thru (through) the phone to send her mom (sic) to the ER. Try to call her Grandaughter (sic) ((name)) left a message then she call back around 2100 (9:00 PM). PRN (as needed) Tramadol 100 mg (milligrams) was given at 1940. (name of ambulance) arrived (at) the facility (at) 2000 (8:00 PM). (Note: No documentation could be found to show what interventions were being utilized at the time of the fall. No documentation could be found to show if resident 136's Personal Alarm was alarming at the time of the fall.) Review of the Hospital History and Physical dated 3/6/16 revealed that resident 136 sustained a displaced and angulated intertrochanteric fracture of the left proximal femur. Review of resident 136's care plan revealed a Falls care plan dated 3/7/16. Facility staff listed the following Outcomes on the care plan: Will be Free From Injury Post fall, Description of Fall Activity, Additional Intervention to Prevent Future Fall, Resident will be free from falls TNR (Through Next Review). Facility staff implemented the following interventions to help resident 136 achieve the stated goals: Morse Fall Risk Standard Precautions, Bed in low position if unattended, call light with in reach, mobility support items available, non-slip foot wear, personal items with in reach, sensory aid items with in reach, traffic path in room free of clutter, wheels locked with transfers., 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, and Evaluate Routine and Patterns to Assist at Times Needed. (Note: The above care plan was dated for two days after resident 136 was discharged from the facility. The care plan did not have dates as to when the interventions were put into place. Resident 136's bed being placed against the wall on 11/12/15 was not listed as an intervention nor was the pressure pad placed on the mattress listed. The personal alarm implemented on 11/26/15 was not listed as an intervention.) 2nd Fall with Injury: Resident 136 was readmitted to the facility on [DATE] after having an open reduction internal fixation completed for the displaced and angulated intertrochanteric fracture of the left proximal femur sustained on 3/5/16. a. Incident Report: 3/14/16: Time of Incident: 1:30 PM, Exact Location of Incident: On her floor, on her mat (sic). She was sitting on her bottom., Describe Incident: Resident was calling out, 'help.' Went to her room with aides. Resident was sitting on the floor on the mat (sic) next to the window. She said she was trying to get up and was holding on to the table and window ledge. There are no apparent injuries. Resident denies pain. DON Follow Up: monitor per protocol (no) injuries. Progress Note: 3/14/16: Resident was yelling 'help'. She was found sitting on the floor on the mat (sic) next to her bed. She said she was trying to get up and was trying to hold on her (sic) table and window ledge to keep from falling. There are no apparent injuries. Resident denies pain. (Note: No documentation could be found to show what interventions were being utilized at the time of the fall except for a fall matt.) b. Progress Note: 3/16/16: .Resident was F.O.F (found on floor) on Monday the 14th. She is having a lot pain in left hip with some swelling. xray ordered which showed no acute finding. Will continue to monitor pain of hip. Notify surgeon if needed. c. Progress Note: 3/16/16: .Pt had fall on Monday and left hip has become more swollen, notified (name) PA and ordered STAT (immediate) x-ray which came back normal, will ice area and continue with normal ADLs. Pt has been agitated today, yelling out for help, gave PRN pain medication which seemed to help a little but pt was still trying to climb out of bed. Tab alarm is in place and working. d. Incident Report: 3/24/16: Time of Incident: 0330 (3:30 AM), Exact Location of Incident: Bed Room, Describe Incident: Res (resident) was found laying on her bedside mat (sic). Pt stated she was getting up to go to the Doctors. Pt assessed on the bed side mat (sic). Hematoma noted to forehead. good ROM (range of motion) in Bil (bilateral) arms and legs. Pt assisted up to bed. bed low to the ground. Pt. holding her tab alarm. Pt. re-assessed. golf ball size hematoma to forehead. (no) other inj. (injuries) noted. ice applied. neuro check within normal limits. DON Follow Up: monitor through resolution, neuro checks WNL. Progress Note: 3/24/16: Pt was found laying on her bedside mat (sic) on the floor. Pt stated she was trying to get up to go to the Doctors. Pt assessed by RN (Registered Nurse). Good ROM in Bilateral arms and legs. pt noted to have a hematoma to the (L) side of her forehead. PERRLA (pupils equal round reactive to light and accommodation). Equal hand grips. Pt assisted to her bed and assessed again. No other injuries noted. Good ROM in bilateral arms and legs. Pt was holding her tab alarm when found. Hematoma to the (L) side of her forehead is the size of a golf ball. Ice applied to hematoma. Pt had no c/o pain at present time. Neuro checks within normal limits. e. Incident Report: 3/28/16: Time of Incident: 1815 (6:15 PM), Exact Location of Incident: Bathroom, Describe Incident: (at) 1815, resident found lying on the floor V/S taken BP - 151/98, P - 88, T - 96.7, R - 20, O2 Sat = 96 % on 2 Liters. Assess from head to toe. No injury was noted. Bruising from previous fall. Pt. alert and confused. Denies pain and discomfort. Assisted pt. back to wheel chair. Will continue to monitor. DON Follow Up: monitor per protocol, staying close to nurse during med pass as possible. Progress Note: 3/28/16: Approximately around 1815, Resident found lying on the floor in the Bathroom area. V/S was taken BP=151/98, P=88, T=96.7, R=20, O2Sat=96% on 2 Liters. Assess from Head to Toe. No injury noted. Bruising from previous fall. Assisted pt. back to her wheel chair, close to the nurses station. Will continue to monitor. (Note: No documentation could be found to show what interventions were being utilized at the time of the fall.) f. Progress Note: 3/29/16: . Call light is within reach but patient has to be reminded constantly to use call light. Pt is fall risk, bed is low to ground, bed alarm in place and working. g. Incident Report: 4/5/16: Time of Incident: 1738 (5:38 PM), Exact Location of Incident: Public restroom on 300, Describe Incident: found pt in RestRoom on floor. she said she needed to use Restroom. Pt has no aditional (sic) pain she said she's fine. DON Follow Up: spoke (with) staff (and) resident, fell to a seated position (No) head involvement. Progress Note: 4/5/16: pt had fall will continue to monitor. (Note: No documentation could be found to show what interventions were being utilized at the time of the fall. No documentation could be found to show if resident 136's Personal Alarm or Tab Alarm were alarming at the time of the fall.) h. Incident Report: 4/8/16: Time of Incident: 0830 (8:30 AM), Exact Location of Incident: Room, Describe Incident: CNA (Certified Nursing Assistant) heard her calling for help. Found her under bedside table. Says she hit back of head. Examined and there was small goose egg. Helped her get up and started neuro checks, gave tylenol for headache. DON Follow Up: Neuro checks WNL, continue to monitor for AMS (acute mental symptoms). No Progress note was found to accompany the above incident report. (Note: No documentation could be found to show what interventions were being utilized at the time of the fall. No documentation could be found to show if resident 136's Personal Alarm or Tab Alarm were alarming at the time of the fall.) i. Incident Report: 4/26/16: Time of Incident: 1130 (11:30 AM), Exact Location of Incident: 103, Describe Incident: Pt went into room and fell on floor. I found pt. on floor. pt stated she hit her head. Pt had no pain. DON Follow Up: neuro checks WNL, continue all safety precautions monitor for AMS. Incident Report: 4/26/16: Time of Incident: 1400 (2:00 PM), Exact Location of Incident: Room 103, Describe Incident: found pt on floor was lying on mat (sic). pt said she slid out of bed. DON Follow Up: monitor per protocol, (no) injuries, offered to take to activity resident declined. Progress Note: 4/26/16: pt. had multiple incidents today. 2 falls, pt swatted at cna, CNA blocked and a skin tear occurred., pt. is being monitored for falls. (Note: On the first incident report, the DON Follow up indicated that resident 136's neuro checks were with in normal limits. The staff member filling out the incident report did not indicate that neuro checks had been initiated. On the second incident report, the DON Follow up indicated that resident 136 was offered to be taken to an activity. The staff member filling out the incident report did not indicate that staff offered to take resident 136 to an activity. Additionally, no documentation could be found to show if resident 136's Personal Alarm or Tab Alarm were alarming at the time of the falls.) j. Incident Report: 5/2/16: Time of Incident: 12:00 PM, Exact Location of Incident: Bathroom, Describe Incident: Found on floor by CNA. Bathroom light was on when CNA went to answer light she found pt on the floor, on her back. She stated that she hit her head and R (right) elbow. Noted small skin tear R - elbow. No other injuries. DON, PA notified. Grandaughter (sic) (name) notified via voicemail, (telephone number). DON Follow Up: neuro check WNL, monitor skin tear, bed, chair, and tab alarm in place and working. Progress Note: 5/2/16: Resident has had a fall today at 1200 PM. Resident had light for help in bathroom, when CNA answered light she found resident on floor, laying on her back. Assessment, VS and neuro check done and then resident was assisted back to wheelchair. Resident stated that she hit her head and R - elbow. Skin tear noted on R - elbow, no other injuries noted. PA (name), DON, granddaughter (name) notified ((via voicemail)), Pressure, tab alarm, floor mat, call light in place. (Note: The DON follow up indicated that the bed, chair and tab alarm were in place and working. The staff filling out the incident report did not document that the tab or chair alarm were alarming when the staff went to answer the call light.) k. Incident Report: 5/9/16: Time of Incident: 1900 (7:00 PM), Exact Location of Incident: Pt. room, Describe Incident: (at) approximately about 1900, CNA heard pt. fall on the ground. Assisted pt. and initiated V/S BP 105/66, P=81, R=18, T=97.4, O2 Sat=95 2.5 Liters. Pt. c/o of (sic) pain and unable to move left leg. give PRN pain medication and order STAT x-ray on upper left extremities. DON Follow Up: admitted to hospital L femur fx. Progress Notes: 1. 5/9/16 21:49 (9:49 PM): Approximately around 1900 CNA heard pt. fell (sic) on the ground, assisted pt and initiated V/S BP=105/66, P=81, T=97.4, O2sat=95% on 2.5 Liters. Pt c/o of pain and unable to move left leg. Give PRN pain medication & (and) order STAT x-ray on upper left extremities. Notify MD and call (name) ((granddaughter)) left message. 2. 5/10/16 7:54 AM: (Name of Medical Imaging company) Interpretation: Findings: There is a new oblique fracture midshaft of the femur with up to 10 mm (millimeters) separation of the major fragments. Medullary rod remains in place. Lucency around distal tip of the medullary rod and small focus of cortical breakthrough anteriorly here which appears chronic. Developing heterotopic [DIAGNOSES REDACTED]s surround the fragmented proximal femur particularly medially. No other fracture seen. Impression: New oblique fracture midshaft of the femur. Left leg was stabilized and resident was sent via wheelchair by RMC-HH (Rocky Mountain Care - Home Health) transportation to (name of local acute care hospital) - West ER (emergency room ). Granddaughter, (name), notified. She said she is a teacher and cannot leave to accopmany (sic) her grandmother to the hospital. She would like a call with updates on her grandmother's condition. Note with request included with packet sent to hospital. Review of the Readmission Note, by the facility Medical Director, for resident 136 dated 5/13/16 revealed the following: 5/9/2016 - Hospital Discharge - I spoke with he (sic) nurse caring for (resident 136) last evening. She advised me that (resident 136) had fallen was in severe pain. Complaining of pain in her leg. I ordered a STAT X-ray, I did not get the results back until around 0500 (5:00 AM) this morning. (Resident 136) sustained a mid shaft fracture of the femur. I asked that she be sent to the hospital for further evaluation and treatment. Review of the radiology report in the medical record revealed that the facility received the x-ray results, via fax, on 5/9/16 at 7:58 PM. Review of resident 136's care plan revealed a Falls care plan dated 5/11/16. Facility staff listed the following Outcomes on the care plan: Will be Free From Injury Post fall, Description of Fall Activity, Additional Intervention to Prevent Future Fall, Resident at risk from fallas (sic) due to recent history of falls, and Resident will not have a fall with injuries. Facility staff implemented the following interventions to help resident 136 achieve the stated goals: Morse Fall Risk Standard Precautions, Bed in low position if unattended, call light with in reach, mobility support items available, non-slip foot wear, personal items with in reach, sensory aid items with in reach, traffic path in room free of clutter, wheels locked with transfers., Eval (evaluate) for Orthostatic Hypotension, Slower Position Transition, Ensure glasses Worn and Lighting Optimal, Consult Physician for PT or OT, 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 and Resident Specific Intervention. (Note: The above care plan was dated for one day after resident 136 was discharged from the facility. The care plan did not have dates as to when the interventions were put into place. The care plan only consisted of two new interventions (Evaluating for Orthostatic hypotension, Slower Position Change and Ensuring glasses are worn and Lighting was Optimal. Once again, the care plan did not contain the Tab Alarm or Personal Alarm nor the alarm to the bed and chair.) 3rd Fall with Injury: Resident 136 was readmitted to the facility on [DATE] after having an open reduction internal fixation completed for the new oblique fracture midshaft of the femur sustained on 5/9/16. a. Incident Report: 5/28/16: Time of Incident: 1700 (5:00 PM), Exact Location of Incident: Pt. room, Describe Incident: (at) 1700 pt. found sitting on the floor mat. She verbalized 'I was lying down in my bed and I slid off the bed (sic). No Injuries noted. Help resident back to bed. Notify family (name) ((Granddaughter) and (name) ((PA). WCM (will continue to monitor). DON Follow Up: monitor per protocol. Progress Note: 5/29/16: (at) 1700 Pt. found sitting on the floormat, She verbalized 'I was lying down in my bed and I slid off the bed (sic). No injuries noted. Help resident back to bed. Notify family (name) ((Granddaughter)) and (name) ((PA)). (Note: No documentation could be found to show if resident 136's Personal Alarm, Tab Alarm or bed alarm were alarming at the time of the fall.) b. Incident Report: 6/9/16: Time of Incident: 11:20 AM, Exact Location of Incident: 103 b Bathroom, Describe Incident: Pt stated 'She fell while using the Bathroom.' I found pt in the doorway saying help. DON Follow Up: Intervention added: observe/check on resident frequently to avoid future falls. Progress Note: 6/9/16: Pt had a fall was walking into bathroom and fell , pt has a tab alarm, no changes in care plan. (Note: No documentation could be found to show if resident 136's Personal Alarm, Tab Alarm or bed alarm were alarming at the time of the fall.) c. Incident Report: 6/21/16: Time of Incident: 6:10 AM, Exact Location of Incident: In her room next to her bed, Describe Incident: CNA reported resident was on the fall mat on the floor next to her bed. She had disconnected her bed alarm and said she wanted to get up. Bed was in low position. Resident denied pain and assessment revealed no apparent injuries at this time. Report given to AM shift RN and will continue to monitor. DON Follow Up: No injuries, monitor per protocol. Progress Note: 6/21/16: CNA found resident on the fall mat next to her bed at 06:10 AM. Bed was in low position. Resident stated she disconnected her bed alarm because she wanted to get up. Resident denied pain and assessment revealed no apparent injuries at this time. d. Incident Report: 6/26/16: Time of Incident: 06:30 AM, Exact Location of Incident: Pt. Bathroom, Describe Incident: (at) 0630 AM, Pt. fell backward when she stood up to use the toilet. Resident said she slipped because her socks were slippery. Aide witnessed fall. No bruising or injury at this time. WCM. DON Follow Up: provided no-skid socks, resident reminded to use call light and ask for help if she is alone, encourage to wear the slipper socks. Progress Note: 6/26/16: (at) 0630 AM, Pt. fell backward when she stood up to use the toilet. Resident said she slipped because her socks where (sic) slippery. Aide witnessed fall. No bruising or injury at this time. (Note: No documentation could be found to show if resident 136's Personal Alarm, Tab Alarm or bed alarm were alarming at the time of the fall. Additionally, the DON Follow Up indicated that the facility would provide no-skid socks. According to resident 136's care plans from her previous admissions, that particular intervention was put into place in March 2016.) e. Incident Report: 6/28/16: Time of Incident: 1845 (6:45 PM), Exact Location of Incident: Public Restroom 300 hall, Describe Incident: found pt on floor in 300 hall public restroom. pt had hematoma on right arm. Behavior has been same. DON Follow Up: monitor through resolution. No Progress Note could be found for the above mentioned incident. (Note: No documentation could be found to show if resident 136's Personal Alarm, or Tab Alarm were alarming at the time of the fall.) f. Incident Report: 7/1/16: Time of Incident: 1945 (7:45 PM), Exact Location of Incident: Public Restroom, Describe Incident: Patient alert and oriented X 1, locked herself in the public restroom, fell , w/c (wheel chair) alarm 'alarmed' after opening the restroom door, Patient found sitting on the floor near to her wc 'stated i want to go home.' she was carrying a pant, jacket, (and) t-shirt in her w/c, denies pain, had scratches on left side back, redness. 2 staff transferred patient from the floor to the w/c. DON Follow Up: monitor through resolution. Progress Note: 7/1/16: Patient alert and oriented x1 locked herself in the public restroom, fell , w/c alarm 'alarmed' after opening the restroom door. patient found sitting on the floor near to her w/c stated: 'I want to go home' she was carring (sic) a pant, jacket and t-shirt in her w/c, denies pain, had redness, sratches (sic) on left side back. 2 staff transferred (sic) patient from the floor to the w/c. g. Incident Reports: 1. 7/7/16: Time of Incident: blank, Exact Location of Incident: 103b, Describe Incident: pt tried to toilet herself with out asking for help and fell found pt on floor in bathroom. DON Follow Up: (no) injury, resident removed tab alarm, replaced to middle of back, resident reminded to ask for assistance. 2. 7/7/16: Time of Incident: blank, Exact Location of Incident: 103, Describe Incident: Pt. was reaching for tissue and slid out of bed. DON Follow Up: Kleenex within reach, added wedge for positioning and therapy eval wc for proper seat height. Progress Note: 7/7/16: a wedge was placed under pts bed sheets to help pt not slide out of bed. A leg pad was placed under leg to help with positioning to keep heel elevated, wheel chair was tilted back to help pt maintain proper posture. (Note: The DON Follow Up indicated that resident 136 had removed the tab alarm. Facility staff did not document that the resident had removed the tab alarm on the incident report nor in the Progress note. Additionally, facility staff did not document in the Progress note to placed the tab alarm to the middle of resident 136's back.) h. Incident Report: 8/2/16: Time of Incident: 1700 (5:00 PM), Exact Location of Incident: Bathroom, Describe Incident: Pt. slid to floor w (with) assistance by CNA, assist to floor. DON Follow Up: assess staff attendance in bathroom. Progress Note: 8/2/16: pt was about to fall, CNA grabbed pt and helped to her (sic) the floor with out injury. Pt slid to floor while CNA was holding her to the ground (sic). (Note: No documentation could be found to show an assessment of staff attendance in the bathroom was completed.) i. Incident Report: 8/17/16: Time of Incident: 1800 (6:00 PM), Exact Location of Incident: Pts. room by pts bed, Describe Incident: Pt fall in her room by bedside yelling 'help' and found on floor mat. Pt said try to get up by herself from w/c to bed after dinner then out of balance and fall. No injury. DON Follow Up: assist to bed after dinner. Progress Note: 8/17/16: Pt fall around 1755 (5:55 PM) in her room by bedside. CNA walk by and hear Pt yelling 'help.' Pt is found sit on floor's mat (sic) by bedside. assit (sic) Pt back to bed by 2 persons transfer (at) this time. Pt is alert and oriented * 4 (times 4), Pt states 'try to get up to bed myself .' .bed alarm applied. (Note: No documentation could be found to show if resident 136's Personal Alarm, or Tab Alarm were alarming at the time of the fall.) j. Incident Report: 9/7/16: Time of Incident: 1500 (3:00 PM), Exact Location of Incident: Pts room by bed, Describe Incident: CNA walk by hallway and saw pt on floor (mat). had BM all over pts cloth (clothes) and mat. Pt denies pain. no injuries. DON Follow Up: Education of safety awareness. Progress Note: 9/7/16: around 1500 pm CNA reported, found pt sit on floor by pt's bed, had accident bowel movement all over floor and cloth. Pt need 2 person assist to clean and transfer to bed, denies pian (sic) or discomfort (at) this time. no injure (sic) noted. personal alarm applied. (Note: No documentation could be found to show if resident 136's Personal Alarm, Tab Alarm or bed alarm were alarming at the time of the fall.) k. Incident Report: 10/14/16: Time of Incident: 1630 (4:30 PM), Exact Location of Incident: 103A, Describe Incident: Pt yelled and found pt sit on floor by bed. States try to get up from bed to get w/c then slide down. R knee hit on floor slight redness no skin tear. (name of Medical Director) went in to check pt. ice pack applied. DON Follow Up: monitor through resolution, continue to keep in line of sight. Progress Note: 10/14/16: around 4:30 pm found pt sit on floor by bed, Pt stated ' .I just want to go to get w/c .' and stated Lt (left) knee down, slightly redness noted. (name of Medical Director) notified and go into pts room assess Pt. ice pack applied. no new ordered (at) this time. (Note: No documentation could be found to show if resident 136's Personal Alarm, Tab Alarm or bed alarm were alarming at the time of the fall.) l. Incident Report: 10/15/16: Time of Incident: 1020 (10:20 AM), Exact Location of Incident: Bathroom, Describe Incident: Around 1020 AM, Pt found sitting on the floor next to the toilet. Pt was trying to get - up in her wheel chair without assistance and fell . She denies hitting her head. Assessed patient, No injury noted. Assisted pt back to bed w/ tab alarm and bed in low position DON Follow Up: non slip pad to WC added. Progress Note: 10/15/16: Around 1020 AM, Pt found sitting on the floor next to the toilet. Pt was trying to get - up in her

Based on interview, observation and record review it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, one area of deficient practice was identified to have occurred at a Substandard Quality of Care Level with Harm and deficient practice which resulted in Harm was identified in an additional three areas. The deficient practice identified for residents 40, 71, 136, and 138 was found to have occurred at a Harm Level. Resident identifiers: 40, 71, 136, and 138. Findings include: 1. The facility administration failed to ensure that residents received adequate supervision and assistive devices to prevent accidents. This failure resulted in a finding of Harm for four residents. Resident identifiers: 40, 71, 136, and 138. (Cross refer to F-323) 2. The facility administration failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents being injured due to falls and a resident not receiving pain medication timely. (Residents 40, 71, 136, and 138). (Cross refer to F-309 and F-353) 3. The facility administration failed to maintain a Quality Assessment and Assurance Committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F-520) On 11/28/16, the facility Administrator was interviewed during an Entrance conference. The facility Administrator stated that he was unaware that the Final Rule regarding new regulations had taken effect on 11/28/16. The Administrator stated that the corporation had a great education team and he was sure that they are on top of the new regulations and what we need to do.

Based on observation, interview, and medical record review it was determined, for 5 of 45 sample residents, that residents were not free of significant medication errors. Specifically, facility staff did not administer a resident's (resident 136) prescribed pain medication timely resulting in the resident having significant pain. Additionally, residents did not receive medications, including insulin, at the scheduled time. The deficient practice identified in regards to resident 136 will be cited at Harm. The deficient practice identified for residents 105, 110, 118, and 234 will be cited at a potential for harm and will not be included in the Harm. Resident identifiers: 105, 110, 118, 136, and 234. Findings include: 1. Resident 136 was admitted to the facility on [DATE], 3/9/16, 5/13/16, and most recently 10/24/16 with [DIAGNOSES REDACTED]. On 11/30/16 at approximately 10:55 AM, resident 136 was observed to be sitting up in bed rubbing her left leg. Resident 136 was observed to be rocking back and forth. Resident 136 stated that she was in pain and had just received her pain medication. Resident 136 answered the state surveyor's questions very abruptly and stated that she was very uncomfortable. On 11/30/16 resident 136's medical record was reviewed. Review of the medical record revealed that resident 136 was admitted on to hospice services on 10/25/16. Review of the physician's orders [REDACTED]. a. 11/14/16: [MEDICATION NAME] 2.5 mg (milligrams) BID (twice daily). b. 11/21/16: [MEDICATION NAME] 15 mg 1/2 tablet PO (by mouth) Q (every) 6 (hours) PRN (as needed) for pain. Review of the Progress Notes revealed the following entries: a. 11/15/16: . was very pleasant (sic) today with new med (medication) change of [MEDICATION NAME] bid. pt (patient) was not aggressive or verbally aggressive(sic) today. b. 11/30/16: .Medication change was helping her for pain. On 11/30/16 at 10:30 AM, Registered Nurse (RN) 10 was observed to be administering medications. RN 10 stated that she was still administering morning medications to residents. According to the form provided to state surveys, upon entrance, morning medications or twice daily medications were to be administered at 8:00 AM and then again at 8:00 PM. Review of the Medication Administration Record [REDACTED]. The medication was ordered to be given at 8:00 AM. (Note: Resident 136's [MEDICATION NAME] was administered 2 hours and 42 minutes later than the scheduled time.) On 11/30/16 at 12:30 PM, resident 136 was re-interviewed. Resident 136 stated that the pain medication had helped her and that she was feeling much better. Resident 136 was observed to be sitting up in bed at the time of the interview, consuming her lunch. Resident 136 appeared to be calm and was pleasant when answering questions. 2. Resident 110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/30/16, resident 110's medical record was reviewed. Resident 110's physician's orders [REDACTED]. Additionally, resident 110 had an order for [REDACTED]. Resident 110's November MAR indicated [REDACTED] a. 11/25/16: 12:18 PM BS (Blood Sugar) not done, equipment not available. No [MEDICATION NAME] R administered. (NOTE: Facility staff documented a BS and the administration of the [MEDICATION NAME] R Insulin for Resident 110 on 11/25/16 at 12:30 AM. No documentation could be found to show that the equipment and medication were unavailable 12 hours prior to the above documentation.) b. 11/26/16: 12:00 AM BS 94 Not given, too lwo (sic) c. 11/26/16: 4:23 PM BS 74 Not given (Note: No documentation could be found in the physician's orders [REDACTED].) d. 11/26/16: 9:02 PM [MEDICATION NAME] 46 units given (NOTE: The [MEDICATION NAME] was administered six hours and 2 minutes after it was scheduled to be administered.) e. 11/27/16: 4:07 AM BS not available 4 units [MEDICATION NAME] R administered. (NOTE: Resident 110's [MEDICATION NAME] R Insulin was administered approximately four hours and 7 minutes after it was scheduled to be administered.) f. 11/27/16: 7:03 AM BS 213 4 units [MEDICATION NAME] R administered. (NOTE: According to the documentation, facility staff administered the [MEDICATION NAME] R Insulin, to resident 110, three hours after the last administration of Insulin.) g. 11/27/16: 4:50 PM: [MEDICATION NAME] 46 units given (NOTE: The [MEDICATION NAME] was administered 1 hour and 50 minutes after it was scheduled to be administered.) h. 11/29/16: 5:13 PM: [MEDICATION NAME] 46 units given (NOTE: The [MEDICATION NAME] was administered two hours and 13 minutes after it was scheduled to be administered.) i. 11/29/16: 7:46 PM BS not available 4 units [MEDICATION NAME] R administered. (NOTE: Resident 110's [MEDICATION NAME] R Insulin was administered approximately three hours and 46 minutes after it was scheduled to be administered.) j. 11/30/16: 11:10 AM BS 284 4 units [MEDICATION NAME] R administered. (NOTE: Resident 110's [MEDICATION NAME] R Insulin was administered approximately three hours and 46 minutes after it was scheduled to be administered.) k. 11/30/16: 4:00 PM BS not available No [MEDICATION NAME] R administered. (NOTE: No documentation could be located in the medical record to show that resident 110's BS was monitored or that the [MEDICATION NAME] R Insulin had been administered.) On 11/30/16 at 1:10 PM, an interview was conducted with RN (Registered Nurse) 10. RN 10 stated that she did not know why the [MEDICATION NAME] R Insulin had not been administered at times. RN 10 stated that she did not know why the [MEDICATION NAME] R Insulin had been given at 4:07 AM rather than at 12:00 AM, as scheduled. On 11/30/16 at 3:10 PM, an interview was conducted with the facility DON (Director of Nursing). The facility DON stated that she did not know why the [MEDICATION NAME] R Insulin was not given on some days, why the physician was not notified that the [MEDICATION NAME] R Insulin was not given, nor why the insulin was administered more than 4 hours late. 3. Resident 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/1/16 a review of resident 105's medical record was completed. Resident 105's physician orders [REDACTED]. a. [MEDICATION NAME] 7 units, twice daily (BID) b. Humalog sliding scale, four times daily before meals and at hour of sleep, notify physician for blood sugars over 500 Resident 105's MAR for October 2016 and November 2016 were reviewed and revealed that resident 105's 8:00 PM dose of [MEDICATION NAME] was either held or given late on the following incidences: a. 10/3/16 given at 12:53 AM on 10/4/16, comments: Flexible Med (medication) pass. b. 10/6/16 held, comments: due to blood sugar of 112. c. 10/9/16 held, comments: due to low blood sugar. d. 10/17/16 given at 4:18 AM on 10/18/16, comments: Flexible Med Pass. e. 10/18/16 given at 4:24 AM on 10/19/16, comments: Flexible Med Pass. f. 10/24/16 given at 3:49 AM on 10/25/15, comments: Flexible Med Pass. g. 10/27/16 given at 11:43 AM on 10/27/16, comments: Flexible Med Pass. h. 10/29/16 given at 4:26 AM on 10/30/16, comments: Flexible Med Pass. i. 11/1/16 held, comments: held due to low blood sugar 79. j. 11/7/16 held, comments: not given blood sugar 113 at 9:02 PM. k. 11/8/16 held, comments: not given blood sugar 50 at 8:08 PM. l. 11/9/16 held, comments: not given blood sugar 72 at 8:37 PM. m. 11/13/16 held, comments: not given blood sugar 106 at 8:17 PM. n. 11/18/16 given at 4:23 AM on 11/19/16, comments: Flexible Med Pass. o. 11/201/6 held, comments: not given blood sugar too low at 10:29 PM. p. 11/21/16 held, comments: not given blood sugar 76 at 9:01 PM. q. 11/22/16 held, comments: not given blood sugar 88 at 8:34 PM. r. 11/23/16 held, comments: blood sugar 109. Insulin held at 9:06 PM. s. 11/24/16 given at 11:29 PM on 11/24/16, comments: Flexible Med Pass. t. 11/25/16 given at 5:49 AM on 11/26/16, comments: Flexible Med Pass. u. 11/27/16 held, comments: not given blood sugar 56. Food given. No insulin given at 8:03 PM. No documentation could be found in resident 105's medical record to show that the physician was notified when the insulin was held. No documentation could be found to show that the physician had ordered for resident 105's insulin to be held. On 11/30/16 at 7:34 AM, RN 1 was interviewed. RN 1 stated that she would report a low blood sugar to the physician so the physician would know if the insulin needed to be adjusted. RN 1 stated that occasionally, a long term insulin, like [MEDICATION NAME], may need to be adjusted but in most cases the physician preferred long term insulins to be given as ordered. RN 1 stated that if a resident's blood sugars were to bottom out then the physician should have been be notified before it was determined to hold a long term insulin. RN 1 stated that she (RN 1) would notify the physician and hold the insulin until she received a response from the physician. RN 1 stated that the facility had a kiosk to notify the physician and that facility staff could also reach the physician by phone. RN 1 stated that she would document communication with the physician in the progress notes and/or the comments on the MAR. RN 1 stated the flexible medication pass meant that medications could be given an hour before or after the scheduled time. On 11/30/16 at 7:41 AM, RN 2 was interviewed. RN 2 stated that long term insulins would not typically be held unless the blood sugar was really low, like below 60. RN 2 stated that before a long term insulin was held the blood sugar would be reported to the physician. RN 2 stated that communication with the physician should have been documented in the medical record. RN 2 stated that typically she would document medications given in the MAR indicated [REDACTED]. On 11/30/16 at 9:07 AM, a follow up interview was conducted with RN 2. RN 2 stated that resident 105's blood sugars were very dynamic and needed to be checked often. RN 2 stated that she was not aware of incidences when resident 105's [MEDICATION NAME] had been held but stated resident 105 had a history of [REDACTED]. On 11/30/16 at 9:10 AM, the Director of Nursing (DON) was interviewed. The DON stated that the flexible medication pass meant that medications could be given an hour before or after the scheduled time The DON stated that she would have to check on the medications documented as given late. The DON stated she would look for notification of the physician for the held insulins. On 12/1/16 at 9:42 AM, the DON confirmed that the physician was not notified of the low blood sugars and there was no order from the physician to hold the [MEDICATION NAME]. The DON stated that the nurse who administered the late insulin doses reported giving the insulin on time but charting it late. The DON did not know why the nurse did not document that the insulin was given at an earlier time. 4. Resident 118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/1/16 a review of resident 118's medical record was completed. Resident 118's physician orders [REDACTED]. Resident 118's MAR for October 2016 and November 2016 were reviewed and revealed that resident 118's 10:00 PM dose of [MEDICATION NAME] was held without a physician's orders [REDACTED]. a. 10/3/16 given at 12:14 AM, comments: Flexible Med Pass. b. 10/7/16, comments: not given: blood sugar 112 at 9:11 PM. c. 10/17/16 given at 4:13 AM on 10/18/16, comments: Flexible Med Pass. d. 10/18/16 given at 4:18 AM on 10/19/16, comments: Flexible Med Pass. e. 10/24/16, comments: not given too low at 3:45 AM. f. 10/27/16 given at 11:50 PM on 10/27/16, comments: Flexible Med Pass. g. 10/29/16 given at 4:13 AM on 10/30/16, comments: Flexible Med Pass. h. 11/24/16 given at 11:34 PM on 11/24/16, comments: Flexible Med Pass. i. 11/25/16 given at 5:49 AM on 11/26/16, comments: Flexible Med Pass. j. 11/29/16, comments: not given: blood sugar 115 at 9:45 PM. No documentation could be found in resident 118's medical record to show that the physician was notified when the insulin was held. No documentation could be found to show that the physician had ordered for resident 118's insulin to be held. On 12/1/16 at 9:42 AM, the DON confirmed that the physician was not notified of the held insulin doses. The DON stated that the nurse who administered the late insulin doses reported giving the insulin on time but charting it late. The DON did not know why the nurse did not document that the insulin was given at an earlier time. 5. Resident 234 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/1/16 a review of resident 234's medical record was completed. Resident 234's physician orders [REDACTED]. Resident 234's MAR for November 2016 was reviewed and revealed that resident 234's 8:00 PM dose of [MEDICATION NAME] was given late on the following incidences: a. 11/23/16 given at 10:50 PM, comments: Flexible Med Pass. b. 11/24/16 given at 11:10 PM, comments: Flexible Med Pass. c. 11/30/16 given at 11:41 PM, comments: Flexible med pass. On 12/1/16 at 9:42 AM, the DON stated that the nurse who administered the late insulin doses reported giving the insulin on time but charting it late. The DON did not know why the nurse did not document that the insulin was given at an earlier time.

Based on interview, observation and record review it was determined that the facility failed to maintain a Quality Assessment and Assurance Committee that developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, one area of deficient practice was identified to have occurred at a Substandard Quality of Care Level with Harm and deficient practice which resulted in Harm was identified in an additional three areas. The deficient practice identified for residents 40, 71, 136, and 138 was found to have occurred at a Harm Level. Resident identifiers: 40, 71, 136, and 138. Findings include: 1. The facility Quality Assessment and Assurance Committee failed to ensure that residents received adequate supervision and assistive devices to prevent accidents. This failure resulted in a finding of Harm for four residents. Resident identifiers: 40, 71, 136, and 138. (Cross refer to F-323) 2. The facility Quality Assessment and Assurance Committee failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, staffing levels, education, monitoring, and interventions were at an inadequate level to meet the needs of the residents within the facility, resulting in residents being injured due to falls and a resident not receiving pain medication timely. (Residents 40, 71, 136, and 138). (Cross refer to F-309 and F-353) 3. The facility Quality Assessment and Assurance Committee failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (Cross refer to F-490) On 12/1/16, the facility Director of Nursing (DON) and Corporate Nurse (CN) were interviewed. The DON and CN stated that they had identified that the facility had a concern with falls and significant injuries and had been working on a plan to correct the issue. On 11/28/16, the facility Administrator was interviewed during an Entrance conference. The facility Administrator stated that he was unaware that the Final Rule regarding new regulations had taken effect on 11/28/16. The Administrator stated that the corporation had a great education team and he was sure that they are on top of the new regulations and what we need to do. On 12/1/16, the facility Administrator stated that the facility Medical Director had not been very active at the facility while the facility had employed a Physician's Assistant. The Administrator stated that since the Physician's Assistant had been let go, the Medical Director was taking a more active role.

Based on observation, interview, and record review it was determined, for 4 of 45 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, facility staff did not administer a resident's physician ordered pain medication timely, thus causing the resident to experience significant pain and facility staff waited approximately 10 hours before notifying the physician regarding an X-ray that showed the resident had experienced a fractured femur. The delay in the administration of prescribed pain medication and the delay in notifying the physician regarding a significant injury (Resident 136) will be cited at Harm. Additionally, facility staff were not coordinating care with [MEDICAL TREATMENT] and hospice providers and facility staff kept a resident on isolation precautions unnecessarily. (Residents 94, 157 and 228). The deficient practice identified for residents 94, 157, and 228 will not be included in the Harm but will be cited at a potential for Harm. Resident identifiers: 94, 136, 157, and 228. Findings include: 1. Resident 136 was admitted to the facility on [DATE], 3/9/16, 5/13/16, and most recently 10/24/16 with [DIAGNOSES REDACTED]. A. On 11/30/16 at approximately 10:55 AM, resident 136 was observed to be sitting up in bed rubbing her left leg. Resident 136 was observed to be rocking back and forth. Resident 136 stated that she was in pain and had just received her pain medication. Resident 136 answered the state surveyors questions very abruptly and stated that she was very uncomfortable. On 11/30/16 resident 136's medical record was reviewed. Review of the medical record revealed that resident 136 was admitted on to hospice services on 10/25/16. Review of the physician's orders [REDACTED]. a. 11/14/16: [MEDICATION NAME] 2.5 mg (milligrams) BID (twice daily). b. 11/21/16: [MEDICATION NAME] 15 mg 1/2 tablet PO (by mouth) Q (every) 6 (hours) PRN (as needed) for pain. Review of the Progress Notes revealed the following entries: a. 11/15/16: . was very pleasant (sic) today with new med (medication) change of [MEDICATION NAME] bid. pt (patient) was not aggressive or verbally aggressive(sic) today. b. 11/30/16: .Medication change was helping her for pain. Review of resident 136's care plan revealed a care plan for End of Life dated 11/29/16. The following outcomes were documented on the care plan: Effective pain mgmt (management), Emotional support, End of Life, Pain Present, Resident has decreased appetite, weight loss, weakness, and was admitted to (name of hospice company) hospice. The following interventions were initiated to help resident 136 achieve the stated outcomes: Evaluate for Signs of Pain during care and intervene, . Provide Comfort measures for Pain and Anxiety, . No documentation could be found to show that facility staff had developed a more specific care plan to address resident 136's pain. The above mentioned interventions were the only interventions in regards to resident 136's pain. Review of the Medication Administration Record [REDACTED]. The medication was ordered to be given at 8:00 AM. (Note: Resident 136's [MEDICATION NAME] was administered 2 hours and 42 minutes later than the scheduled time.) On 11/30/16 at 12:30 PM, resident 136 was re-interviewed. Resident 136 stated that the pain medication had helped her and that she was feeling much better. Resident 136 was observed to be sitting up in bed at the time of the interview, consuming her lunch. Resident 136 appeared to be calm and was pleasant when answering questions. B. Review of facility incident reports revealed the following incident report dated 5/9/16 at 1900 (7:00 PM): Type of Injury: Left leg unable to move. Describe Incident: (at) approximately about 1900, CNA (Certified Nursing Assistant) heard pt. (patient) fall on the ground. Assisted pt. and initiated V/S (vital signs) BP (blood pressure) 105/66, P (pulse) = 81, T (temperature) = 97.4 O2 (oxygen) sat (saturation) = 95, 2.5 Liters. Pt. c/o (complains of) of pain and unable to move left leg. give prn (as needed) pain medication (and) order STAT (immediate) x-ray on upper extremities (sic). According to the incident report, facility staff documented that the facility Physician's Assistant (PA) was notified of the fall at 20:41 (8:41 PM). Review of the Progress Notes revealed the following entries: a. 5/9/16 21:49 (9:49 PM): Approximately around 1900 CNA heard pt. fell (sic) on the ground, assisted pt and initiated V/S BP=105/66, P=81, T=97.4, O 2 sat=95% on 2.5 Liters. Pt c/o of pain and unable to move left leg. Give PRN pain medication & (and) order STAT x-ray on upper left extremities (sic). Notify MD (Medical Doctor) and call (name) ((granddaughter)) left message. b. 5/10/16 7:54 AM: (Name of Medical Imaging company) Interpretation: Findings: There is a new oblique fracture midshaft of the femur with up to 10 mm (millimeters) separation of the major fragments. Medullary rod remains in place. Lucency around distal tip of the medullary rod and small focus of cortical breakthrough anteriorly here which appears chronic. Developing heterotopic [DIAGNOSES REDACTED]s surround the fragmented proximal femur particularly medially. No other fracture seen. Impression: New oblique fracture midshaft of the femur. Left leg was stabilized and resident was sent via wheelchair by RMC-HH (Rocky Mountain Care - Home Health) transportation to (name of local acute care hospital) - West ER (emergency room ). Granddaughter, (name), notified. She said she is a teacher and cannot leave to accopmany (sic) her grandmother to the hospital. She would like a call with updates on her grandmother's condition. Note with request included with packet sent to hospital. Review of the Readmission Note, by the facility Medical Director, for resident 136 dated 5/13/16 revealed the following: 5/9/2016 - Hospital Discharge - I spoke with he (sic) nurse caring for (resident 136) last evening. She advised me that (resident 136) had fallen was in severe pain. Complaining of pain in her leg. I ordered a STAT X-ray, I did not get the results back until around 0500 (5:00 AM) this morning. (Resident 136) sustained a mid shaft [MEDICAL CONDITION]. I asked that she be sent to the hospital for further evaluation and treatment. Review of the radiology report in the medical record revealed that the facility received the x-ray results, via fax, on 5/9/16 at 7:58 PM. On 12/1/16 at 1:05 PM, the Medical Imaging company, that performed the STAT X-ray for resident 136 on 5/9/16, was interviewed. The Medical Imaging company confirmed that they had faxed the X-ray results for resident 136 to the facility on [DATE] at 7:57 PM. (Note: Facility staff waited approximately 10 hours before notifying the physician regarding resident 136's fractured femur. Additionally, according to the incident report, facility staff waited an hour and 41 minutes before notifying the facility PA about resident 136's fall.) (Note: Prior to the above documented fall, it should be noted that resident 136 had experienced 11 prior falls with one of the falls resulting in a displaced and angulated intertrochanteric [MEDICAL CONDITION] proximal femur.) 2. Resident 228 was admitted to the facility on [DATE] with diagnose which included acute pain, bacterial infection, constipation, anxiety, encounter for palliative care, necrotizing fascitis, osteo[DIAGNOSES REDACTED], septic shock, multiple pressure ulcers, [MEDICAL CONDITIONS], Tibia (TIB)/ Fibula (FIB) fracture, and history of [MEDICAL CONDITION]. On 12/1/16, resident 228's medical record was reviewed. Admission nursing progress notes revealed that resident 228 was admitted to the facility from a hospital with an order for [REDACTED].>A care plan dated 11/9/16 for resident 228 revealed the following: Problems: End of Life treatments and procedure. Intervention: Hospice to provide nursing care two times per week, CNA (Certified Nursing Assistant) care 3 times per week and social service worker (SSW) evaluation once per month/as needed (PRN). The Hospice admission records revealed that resident 228 was to be seen by the hospice aide 3 times per week. On 12/1/16, the facility hospice records were reviewed. According to the facility, resident 228 was seen by the hospice aide on the following dates: a. 11/5/16 - regular visit. No documentation could be found to show that resident 228 was seen three times weekly by the Hospice aide. On 12/1/16, the facility provided additional visit notes from the Hospice Company. (Note: The facility provided the additional notes after contacting the Hospice company and having the Hospice company fax over the additional visit notes.) The Hospice Company was able to provide documentation for the following visits by the Hospice aide: a. 11/7/16 b. 11/9/16 c. 11/11/16 d. 11/16/16 e. 11/18/16 f. 11/21/16 g. 11/28/16 No documentation could be provided, by the facility, for visits that should have occurred on 11/14/16, 11/23/16 and 11/25/16. Review of the medical record revealed the facility had visit notes, for resident 228, from the Hospice Registered Nurse (RN) for the following dates: a. 11/04/16- admission b. 11/06/16-regular visit c. 11/07/16-regular visit No documentation could be found to show that the Hospice RN had visited resident 228 since the documented 11/7/16 regular visit note. No documentation could be located in the medical record to show that the hospice SSW had evaluated resident 228. On 12/1/16 at 7:52 AM, RN 4 was interviewed. RN 4 stated that the facility's own company provided the hospice care for resident 228 and that all of the RN, CNA and SSW Hospice visit notes should have been located in the facility's electronic medical record. 3. Resident 157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/29/16 resident 157's medical record was reviewed. Review of the medical record revealed that upon admission to the facility, resident 157 had a physician's orders [REDACTED]. According to the order, resident 157 should have received the last dose of antibiotic on 11/16/16. On 11/28/16 at 8:15 AM, resident 157 was observed to be on isolation precautions. On 11/30/16 at 9:25 AM, Licensed Practical Nurse (LPN) 2 was interviewed. LPN 2 stated that resident 157 was on isolation precautions for [MEDICAL CONDITION] On 11/30/16 at 9:35 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that she did not recall why resident 157 was on isolation precautions. On 11/30/16 at 9:45 AM, CNA 3 was interviewed. CNA 3 stated that resident 157 was on isolation precautions for [MEDICAL CONDITION]. On 12/1/16 at 8:15 AM, RN 9 was interviewed. RN 9 stated that resident 157 was on isolation precautions for [MEDICAL CONDITION]. RN 9 stated that resident 157 continued to be symptomatic for the [MEDICAL CONDITION] by continuing to have loose stools. On 12/1/16 at 8:20 AM, CNA 3 was re-interviewed. CNA 3 stated that resident 157 had had small amounts of diarrhea once daily for three days that week. On 12/1/16 at 8:27 AM, the facility Medical Director (MD) was interviewed. The MD stated that when a resident was treated for [REDACTED]. The MD stated that because resident 157 was receiving an antibiotic that could cause the resident to have loose stools then an order would be written to have the facility collect three separate stool cultures to rule out if the resident continued to have [MEDICAL CONDITION]. The MD confirmed that she had not ordered the stool cultures for resident 157 even though resident 157 had completed the antibiotic course almost two weeks prior. The MD stated that she would order the stool cultures for resident 157 to determine if the isolation precautions should be lifted. Note: Resident 157 remained on isolation precautions approximately two weeks longer than necessary due to the MD not ordering for stool cultures to be obtained and tested for [MEDICAL CONDITION]. 4. Resident 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/29/16 at 2:00 PM, RN 3 was interviewed. RN 3 stated that when a resident went out of the facility to [MEDICAL TREATMENT], the facility sent a Referral to Physicians and Clinics Form with the resident. RN 3 stated that when a resident returned from the [MEDICAL TREATMENT] appointment, the form was then given to the Medical Records department to be scanned into the Powerchart system. On 11/29/16, resident 94's medical record was reviewed. Review of the physician's orders [REDACTED]. Review of the medical record revealed [MEDICAL TREATMENT] communication forms for resident 94 up to and including 11/2/16. No documentation with [MEDICAL TREATMENT] could be found in the electronic medical record after 11/2/16. On 11/29/16 at 2:15 PM, the Medical Records Director (MRD) was interviewed. The MRD stated that she had the Referral to Physicians and Clinics Form, for resident 94, for 11/16/16, 11/21/16, and 11/28/16. The MRD stated that she was unable to locate any additional Referral to Physicians and Clinics Forms for resident 94. On 11/30/16 at 2:00 PM, the facility Director of Nursing (DON) was interviewed. The DON stated that a Referral to Physicians and Clinics form should accompany the resident every time the resident went to a [MEDICAL TREATMENT] appointment. The DON further stated that most of the time the form was sent with the resident. According to the physician's orders [REDACTED]. No documentation could be found to show that facility staff sent a Referral to Physicians and Clinics Form with resident 94 on the above mentioned dates. On 11/30/16 at 1:00 PM, a local [MEDICAL TREATMENT] Center employee (DE) was interviewed. The DE stated that the facility had called the [MEDICAL TREATMENT] center twenty minutes prior to request resident 94's records for the month of November. The DE stated that the facility did not always send a Referral to Physicians and Clinics Form with resident 94. The DE stated that resident 94 had refused [MEDICAL TREATMENT] services three times in the month of November (11/7/16, 11/14/16, and 11/18/16). No documentation could be found to show that facility staff had developed a care plan for resident 94 in regards to resident 94 requiring [MEDICAL TREATMENT] services three times weekly. No documentation could be found to show that resident 94 had refused [MEDICAL TREATMENT] services in the month of November.

Based on interview and record review the facility did not ensure the environment remained free of accidents or provide devices to prevent accidents. Specifically the facility failed to provide foot rests for 1 of 5 sampled residents, which resulted in the resident sustaining a fracture to her left tibia. Resident identifier 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record for resident 1 was reviewed on 12/15/14. The admission Minimum Data Set Assessment that was completed on 7/31/14 was reviewed. The facility staff assessed resident 1 as requiring total assistance with a two person physical assist with transfers and total assistance with one person physical assist with locomotion on and off the unit. The facility staff documented that resident 1 had limited range of motion to the lower extremities. On 9/5/14, a facility staff member documented on the "Resident Care Card" for resident 1 with "...NOTES: Please use footrest on wc (wheelchair) at all times..." Review of the incident report completed by Licensed Practical Nurse (LPN) 1 on 11/6/14, revealed that resident 1 was complaining of pain to her left knee and proximal areas. LPN 1 documented that the incident occurred on 11/3/14 at 7:30 AM. . A nursing note dated 11/3/14 at 1:36 PM documented "examined resident right (sic) knee and area of fib (fibula)/tib (tibia) with swelling and bruises. ..." (Note: The injury to resident 1's left knee.) On 11/3/14, resident 1's primary care physician (PCP) wrote an order to obtain an x-ray to resident 1's "left knee Fibula/Tibia to rule out fracture." Review of the x-ray results revealed that resident 1 sustained an "acute fracture of the left proximal tibia with mild displacement and angulation." A nursing note, dated 11/4/14 at 10:41 AM, revealed that a facility staff member documented, "(resident 1's) LLE (lower left extremity) had a portable tib fib left 2 view x-ray performed on 11/3/14 for bruising,edema, pain in knee impression states: acute fracture of left Proximal tibia with mild displacement and angulation. Intact left knee arthroplasty. Osteoporosis is present. MD (name redacted) notified. V.O. (Verbal Order) urgently send patient to orthopedic for consult r/t (related to) fracture (fx) left tibia. ...Inquired of patient regarding incident in which she was unable to recall any details. (CNA (Certified Nursing Assistant) 1 and CNA 2) state that during a two person transfer yesterday morning 11/3/14 the patient had complaints of pain with transfer, they state that was (sic) incapable of lifting the affected leg, and state that a cold compress was placed by the nurse who was notified of the change. CNA's today state that yesterday before going home the knee was swollen. ..." On 12/15/14 at 2:30 PM, an interview was conducted with LPN 1 who was working at the time resident 1's knee was injured. LPN 1 stated that resident 1 had contractures to her feet. LPN 1 stated that two CNA's had assisted resident 1 out of bed and into her wheelchair. The CNA's then propelled resident 1 to the dining room. LPN 1 stated that resident 1 was unable to to use her feet to propel herself in the wheelchair. LPN 1 further stated that resident 1's wheelchair should have had foot rests in place. LPN 1 stated that she did not remember if CNA 1 or CNA 2 told her that resident 1 sustained an injury but that resident 1 was complaining of pain in her left lower extremity. LPN 1 stated that she instructed CNA 1 and CNA 2 to lay resident 1 down in bed. LPN 1 stated that an ice pack was placed on the left knee and that resident 1 was medicated for pain. LPN 1 stated that resident 1's physician ordered an x-ray to be completed. On 12/15/14 at 2:15 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated she received the x-ray report on 11/4/14. The ADON stated she and the SSW (Social Services Worker) started an investigation to determine how resident 1 sustained a fracture. On 12/16/14 at 10:00 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 1 was a two person total assist with transfers. CNA 1 stated that on the morning of 11/3/14, resident 1 was in her wheelchair and CNA 2 was pushing the resident 1 to the dining room. CNA 1 stated that resident 1's wheelchair did not have foot rests on it. CNA 1 stated he was at the side of the wheelchair and told resident 1 to pick her feet up. CNA 1 stated resident 1 was unable to lift her feet and so he stopped CNA 2 from pushing the wheelchair. CNA 2 stated that resident 1's feet were pulled backwards underneath the wheelchair. CNA 1 stated that he later found some foot rests and placed them on resident 1's wheelchair. CNA 1 stated that resident 1 complained of pain after breakfast. CNA 1 stated that LPN 1 was notified and that he was instructed to lay resident 1 down and to apply a cold compress to her left knee. CNA 1 stated that he did not notice any bruising or swelling to the left knee. CNA 2's written statement of the incident was reviewed. CNA 2 documented that the incident occurred on 11/3/14 at 7:30 AM. CNA 2 documented, "(CNA 1) and I went to resident 1's room to get her dressed and into her wheelchair. At the time when she was in her wheelchair she complained about pain in her left leg. CNA 2 stated that he and CNA 1 then told LPN 1 and LPN 1 said to lay resident 1 down to put ice on it and keep her in bed. CNA 2 stated that it was the next day that resident 1's knee was swollen". On 12/16/14 at 3:15 PM, an interview was conducted with the DON. The DON stated that resident 1 required foot rests on her wheelchair at all times.

Based on interview, observation, and record review it was determined, for 1 of 50 sample residents, that the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels. Specifically, a resident experienced a 20 pound (lbs) weight loss over a two month period with no dietary interventions. Resident identifier: 123. Findings include: Resident 123 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/29/12 resident 123's medical record was reviewed. Review of the medical record revealed that resident 123 was discharged to the local hospital on [DATE]. Review of the Hospital History and Physical dated 9/1/12 revealed that upon admission to the hospital, resident 123's Hematocrit (HCT) was 11.5 % (percent) and resident 123's [MEDICATION NAME] (ALB) was 2.5 G/DL (Grams per Deciliter). The Hospital Discharge Summary revealed that resident 123 was diagnosed at the local hospital with normocytic [MEDICAL CONDITION] and received 4 units of packed red blood cells while at the hospital. (Note: A normal [MEDICATION NAME] ranges from 3.5 - 5.0 G/DL and a normal female HCT ranges from 35.0 - 49.0 percent). A review of facility weight report, printed on 11/26/12, revealed the following weights for resident 123: a. 9/4/12: 146 lbs b. 9/11/12: 146 lbs c. 11/15/12: 126.6 lbs On 11/29/12 at 10:00 AM, the facility Director of Nursing (DON) was interviewed. The DON was asked if the facility had any additional weights for resident 123. The DON stated that all of resident 123's weights were documented in the computer except the weights obtained for the week of 11/26/12. On 11/29/12 at approximately 1:00 PM, the facility DON reported that she had found additional weights for resident 123 and the weights were now documented in the computer. On 11/29/12 at 1:30 PM, the electronic medical record "Vital Signs Report" was reviewed for additional weights. The following weights were now documented in the electronic medical record: a. 9/4/12: 146 lbs (According to the documentation, the weight was entered into the medical record on 9/6/12 at 7:18 AM by a facility Certified Nursing Assistant (CNA)). b. 9/11/12: 146 lbs (According to the documentation, the weight was entered into the medical record on 9/11/12 at 11:51 AM by a facility CNA). c. 10/8/12: 140 lbs (According to the documentation, the weight was entered into the medical record on 11/29/12 at 11:09 AM by the facility DON). This was a six pound weight loss in one month and 4.1% loss of resident 123's total body weight. d. 11/15/12: 127 lbs (According to the documentation, the weight was entered into the medical record on 11/15/12 by a facility CNA). This was a 13 pound weight loss in one month and 7.9% loss of resident 123's total body weight. Additionally, this was a loss of 13% of resident 123's total body weight in a two month time frame. e. 11/20/12: 130 lbs (According to the documentation, the weight was entered into the medical record on 11/29/12 at 11:12 AM by the facility DON). f. 11/28/12: 132 lbs (According to the documentation, the weight was entered into the medical record on 11/29/12 at 11:12 AM by the facility DON). On 11/29/12 at approximately 1:30 PM, state surveyors requested that facility staff weigh resident 123. Observations of a facility staff member weighing resident 123 revealed her weight to be 129.6. The facility staff member that weighed resident 123 in the presence of the surveyor reported that he was the staff member that had obtained resident 123's weights previously. (Note: A resident is considered to have experienced a significant weight loss when the resident loses 5% of their total body weight in a month, 7.5% of their total body weight in 3 months, or 10% of their total body weight in 6 months.) Review of the "Dietary Communication" slips revealed the following orders for resident 123: a. 9/3/12: "Mechanical Soft, Nectar Thick Liquids." b. 9/10/12: "Mech (Mechanical) SNP (Special Nutritional Program) / Nectar thick, Mighty shake (with) meals." c. 9/11/12: "SNP - Mighty shakes each meal." No other dietary orders or communication slips could be located in resident 123's medical record. Review of the facility Nurse's Notes and all other "General" notes in the electronic medical record revealed no entries concerning resident 123's significant weight loss. On 11/29/12, resident 123's meal consumption percentage for the last 30 days was reviewed. Review of the report revealed that facility staff did not separately document how much Mighty Shake resident 123 was consuming. Facility staff documented a percentage of food consumed and then how much fluid resident 123 consumed, but did not differentiate between fluids such as water, juice, or Mighty Shake. On 11/26/12, 11/27/12 and 11/29/12, resident 123 was observed during the breakfast meal. Resident 123 was observed to drink two 8 ounce glasses of liquid with thickener placed in the glass prior to being served her meal. On 11/26/12 and 11/27/12, resident 123 was observed to be served her breakfast meal after she had consumed two 8 ounce glasses of liquid. No observations were made of resident 123 receiving a Mighty Shake with her breakfast meal on 11/26/12 and 11/27/12. On 11/29/12, resident 123 was observed to be served a Mighty Shake when she was served her breakfast meal. Review of the Dietary Progress Notes revealed the following entries: a. "7/10/12: . . . " b. "9/10/12: Monthly wt (weight) is 146, (up) 6.6% x (times) 1 m (month). po (by mouth) intake (approximately) 63%. Diet is NTL (nectar thick liquids), puree (with) 2.0 (nutritional supplement) 120 ml (milliliters) BID (twice daily). Skin is WD&I (warm dry and intact). Labs 9/1/12: indicate (decreased) HCT, (decreased) Hgb (Hemoglobin), (increased) Gluc (glucose), (increased) BUN (blood, urea, nitrogen), (and) (decreased) ALB 2.5. Will rec. (recommend) adding SNP to diet (and) Mighty shakes (with) meals RT (related to) (decreased) ALB. CTM (continue to monitor) (and) re-eval (evaluate)." c. "11/27/12: Wt. is 126, (down) 9% X 3 M, (down) 13.7% X 6 M. po intake (approximately) 65%. Diet is SNP, M/S (mechanical soft), NTL (with) Mighty shake TID (three times daily). Skin is WD&I. Labs 11/5/12 indicate (decreased) Hgb, (decreased) HCT. Will rec. adding snacks TID RT continuous wt. (decline). CTM (and) re-eval." (It should be noted that the above entries were made by a Dietary Technician (DT) and not a Registered Dietitian nor were the above entries co-signed by a Registered Dietitian. Additionally, the DT did not evaluate resident 123 after she experienced a six pound weight loss between September and October and it took and additional 12 days for the DT to evaluate resident 123 after she experienced a 13% loss of total body weight in a two month period.) d. "11/27/12: Concur (with) DT (Diet Tech) eval (and) rec (recommendations). SNP diet provides add (additional) 1000 cal (calories) (and) 40 g (grams) Pro (protein). Mighty Shake TID provides 600 cal (and) 21 g Pro. (Increased) Pro snack added recently. Rsd (resident) is self directed (with) food choices. Current intake should meet est (estimated) needs. Eschar (Left) heel noted no new breakdown. (Increased) Pro needs RT healing (and) at risk. New est needs calculated. No new rec att (at this time). Will monitor." The above entry was made by the facility Registered Dietitian. It should be noted that the Diet Tech did not mention resident 123's skin breakdown in her charting nor that the snacks were supposed to be increased protein snacks. In addition, review of resident 123's admission orders [REDACTED]. Review of resident 123's Laboratory values revealed facility staff had not obtained any recent [MEDICATION NAME] or Protein levels for resident 123. On 11/29/12 at 1:35 PM, Certified Nursing Assistant (CNA) 13 was interviewed. CNA 13 stated that the Restorative Aides obtained the resident weights. CNA 13 stated that she created the sheet of which residents needed to be weighed and then gave the sheet to the Restorative Aides. CNA 13 stated that the DON was the person who told her which residents to include on the weekly weight sheet. CNA 13 further stated that she received the information of who to put on weekly weights after the skin and weight meeting. CNA 13 stated that she examined the resident weights every Monday or Tuesday with the Assistant Director of Nursing (ADON) and if a resident experienced either a three pound gain or loss the facility staff would obtain another weight. On 11/29/12 at 1:10 PM, the facility DON and ADON were interviewed. The DON stated that the facility was unable to locate their skin and weight notes in the electronic medical record. The DON stated that she was unable to access that part of the medical record. The DON stated that there was a tab in the electronic medical record titled Nutrition at Risk (NAR). The DON further stated that she had placed notes in the electronic medical record under the NAR section concerning resident 123. The DON stated that she had discontinued resident 123's weekly weights back in September due to resident 123's weight being "stable." The DON stated that she had started weekly weights for resident 123 two weeks ago. When asked about the new dietary intervention of snacks ordered on [DATE], the DON stated that every resident received a snack. The DON further stated that if snacks were ordered, the resident was offered the same snacks that the other residents were offered in the facility including those without the dietary intervention of snacks. The DON stated that the health shakes given to residents were recorded on the meal percentage form as part of the fluids consumed and not as part of the meal. The DON stated that the health shakes were not recorded separately. On 11/29/12 at 1:15 PM, the ADON stated the facility just started doing the NAR meeting weekly. The ADON stated that the facility was previously doing the NAR meeting monthly. The ADON stated that she was unable to locate the order to have resident 123's weekly weights discontinued. The ADON further stated that she was unable to find the facility policy regarding weights. The ADON stated that the facility practice was to weigh residents monthly except for the Medicare residents who were weighed weekly. The ADON further stated that all other residents were weighed monthly except by physicians order. On 11/29/12 at 1:20 PM, the Corporate Minimum Data Set nurse stated that he had contaced the electronic medical record company and was told that the electronic medical record program did not have a NAR section. On 11/29/12 at 1:55 PM, the facility Registered Dietitian (RD) was interviewed. The RD stated that the DT received the information of a resident's weight change from the Restorative Nurse. The RD stated that she would expect to be notified within three days if a resident experienced a significant weight change. The RD stated that she and the DT are one and the same and if the facility notified the DT of a weight change it was like notifying her. The RD stated that the DT was in the facility Monday through Friday every week. The RD stated that if a resident experienced a significant weight loss that either her or the DT would do an assessment. The RD stated that if she recommended for a resident to have snacks as a dietary intervention that the resident should be receiving something specific to the resident over and above the snacks offered to the other residents. The RD stated that she did not write the orders for her recommendations but gave the recommendation to the DON or ADON to be taken to the kitchen and followed up on. When asked how the kitchen would know what type of snack to provide if the recommendation was for snacks, the RD replied, "Not sure how the kitchen would know what snack to give." When asked how the RD would know, based on the facility's tracking method of meal and fluid consumption, how much of the fluid consumption is health shake, the RD replied, "That is a good question." The RD stated that she was not notified of the weight loss concerning resident 123. The RD further stated that her recommendations would have changed had she been notified. The RD stated that it was a problem that resident 123 had lost weight and that she (the RD) had not been notified.

Based on interview and record review it was determined, for 1 of 50 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the hospice nurse had written an order for [REDACTED]. Facility staff did not contact the hospice nurse regarding the [MEDICATION NAME] order, therefore not coordinating care. Resident identifier: 123. Findings include: Resident 123 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/29/12 resident 123's medical record was reviewed. Review of the medical record revealed that resident 123 was discharged to the local hospital on [DATE]. Review of the Hospital History and Physical dated 9/1/12 revealed that upon admission to the hospital, resident 123's Hematocrit (HCT) was 11.5 and resident 123 had been receiving [MEDICATION NAME] 3.5 mg (milligrams) QHS (every hour of sleep). The Hospital Discharge Summary revealed that resident 123 was diagnosed at the local hospital with normocytic [MEDICAL CONDITION] and received 4 units of packed red blood cells. In addition, upon discharge from the hospital, resident 123 was no longer receiving [MEDICATION NAME]. (It should be noted that a normal female HCT ranges from 35.0 - 49.0 percent.) Review of resident 123's physician orders [REDACTED]. 1. "9/10/12: 1300 (1:00 PM) D/C (Discontinue) [MEDICATION NAME] et (and) all PT/INR ([MEDICATION NAME]/International Ratio) checks." (Order written by hospice nurse.) 2. "9/13/12: INR - 1.0 PT: 9.8 DC [MEDICATION NAME] order, Start [MEDICATION NAME] 5 mg po (by mouth) QHS, Recheck in 3 days." (Order written by facility staff nurse.) 3. "9/23/12: PT 43.4 INR 4.3 Hold [MEDICATION NAME] x (for) 1 day and then decrease to 4 mg QHS. Check PT/INR in 4 days." (Order written by facility staff nurse.) 4. "9/24/12: INR - 3.3 PT - 32.7 Continue [MEDICATION NAME] dose. Recheck on 10/1/12." (Order written by facility staff nurse.) 5. "10/1/12: INR = 4.5 PT = 44.6 Hold [MEDICATION NAME] x 2 days, recheck and restart (if therapeutic) : [MEDICATION NAME] 3-5 mg po Q day." (Order written by facility staff nurse.) 6. "10/3/12: INR = 4.3 Hold [MEDICATION NAME] x 2 days, recheck INR on Friday (10/5/12)." (Order written by facility staff nurse.) 7. "10/5/12: D/C [MEDICATION NAME]. Do Not start again r/t (related to) intolerance to pt. (patient)." (Order written by hospice nurse.) Review of the facility Laboratory values revealed the following values: 1. 9/6/12: Resident 123's HCT was 40.6. 2. 9/13/12: Resident 123's HCT was 28.7. (Note: This was the same day the [MEDICATION NAME] was restarted by facility staff.) 3. 10/1/12: Resident 123's HCT was 26.3. Review of the Hospice IDT (Interdisciplinary Team) Plan of Care Update dated 10/8/12 revealed the following note: "Patient is a [AGE] year old female who continues to decline AEB: (as evidenced by) Pt. has Left heel decubitis ulcer with min (minimal) draingage (sic) and appears to be resolving. Left LE (lower extremity), [MEDICAL CONDITION] has resolved. Hospice nurse per MD (Medical Doctor) orders DC [MEDICATION NAME] on 9/10/12 r/t pt. HX (history) of decreasing HCT and a small bleed somewhere. Staff on 9/13/12 DC'd my [MEDICATION NAME] order and restarted [MEDICATION NAME] and family not aware of [MEDICATION NAME] restarted. INR on 10/1/12 was 4.6 and on 10/3/12 was 4.0. CNA (Certified Nursing Assistant) reported large hematoma in Pt's (patients) private area and spreading to groin and inner thigh. [MEDICATION NAME] was DC'd again and hospice SN (Nurse) verifying orders q (every) visit to make sure not started again. . . . " No documentation could be found to show facility staff measured or assessed resident 123's hematoma. On 11/29/12 at 10:00 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that resident 123 had two doctors, the facility Medical Director and the hospice doctor. The DON stated that if facility staff received orders from the facility Medical Director, the facility staff should have contacted the hospice nurse. The DON further stated that the facility staff contact the hospice nurse so the hospice nurse can coordinate care with the hospice doctor. The DON stated that when the hospice nurse was notified of an order from the facility Medical Director, she was to check with the hospice doctor to ensure that it was an order he wanted as well. On 11/29/12 at 1:05 PM, Registered Nurse (RN) 2 was interviewed. RN 2 confirmed that resident 123 had two physicians. RN 2 stated that if facility staff received an order from the facility Medical Director that the staff nurse was to call the hospice nurse and notify the hospice nurse of the order. RN 2 further stated that the hospice nurse would then inform the hospice doctor of the order so the care would be coordinated. On 11/30/12 at 1:30 PM, resident 123's hospice nurse was interviewed via the telephone. The hospice nurse stated that she was "livid" that facility staff had restarted the [MEDICATION NAME] for resident 123 after she had discontinued the medication. The hospice nurse stated that the facility staff had never contacted her regarding restarting the [MEDICATION NAME]. The hospice nurse stated that the [MEDICATION NAME] should have "never" been restarted due to resident 123's history of the blood transfusion and the [MEDICAL CONDITION]. The hospice nurse stated that when she questioned facility staff as to why the [MEDICATION NAME] had been restarted, none of the facility staff members knew why the [MEDICATION NAME] had been restarted. The hospice nurse stated before she discovered that resident 123 had been restarted on the [MEDICATION NAME], she had been trying to figure out why resident 123 was declining so rapidly.