Every finding on record at Rosemont Health & Rehab Center, LLC

Based on staff and resident interview, clinical record review, review of facility documents, the facility staff failed to administer physician ordered medications for 1 of 7 residents (Resident #1), in the survey sample. The findings included: Resident #1 was admitted to the facility 2/16/22 and readmitted on [DATE]. The resident's diagnoses include Diabetes Mellitus without complications and Depression Unspecified. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. In section GG (Functional Abilities Goal) the resident was coded as requiring supervision with eating, requiring partial or moderate assistance with oral hygiene, requiring substantial/maximal assistance with toileting/hygiene, dependent with showering/bathing. According to the Medication Administration Record (MAR) Resident #1 had a scheduled eye appointment on 9/19/23. The MAR listed a chart code of #13 which indicated that Resident #1 was absent from home and didn't receive his morning medications or treatment on 9/19/23 at 9:00 AM. The following medications were not administered on 9/19/23 at 9:00 AM: Baclofen Tablet 5 MG Give 1 tablet by mouth one time a day for spasms. Cetirizine HCl Tablet 10 MG Give 1 tablet by mouth one time a day for allergic rhinitis. Bacitracin External Ointment 500 UNIT/GM (Bacitracin (Topical) Apply to scalp topically two times a day for sores to scalp. Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day for hypertension. Combigan Solution 0.2-0.5 % (Brimonidine Tartrate- Timolol) Instill 1 drop in both eyes two times a day for eye care. Eliquis Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT prevention. Fluticasone Propionate Suspension 50 MCG/ACT 2 spray in both nostrils two times a day for allergies. Metformin HCl Tablet 500 MG Give 1 tablet by mouth two times a day for Diabetes Mellitus (DMII). Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times a day for pain. Voltaren External Gel 1 % (Diclofenac Sodium (Topical) Apply to bilateral knees topically two times a day for pain. Gabapentin Oral Capsule (Gabapentin) Give 400 mg by mouth three times a day for neuropathy. On 3/27/24 an interview was conducted with Licensed Practical Nurse (LPN) #2 at approximately 2:45 PM. LPN #2 said that she is not aware of the resident not getting medications nor a lunch tray but said that Resident #1 did get nauseated and was vomiting at his appointment on 9/19/23. LPN #2 also said that the resident will get lightheaded when sitting up in the wheel chair. LPN #2 also mentioned that he should have received his lunch tray but the family usually orders food out. He came back from his appointment with fried chicken. According to the MAR/TAR and medical records LPN #2 was his nurse on 9/19/23 On 3/27/24 at approximately 3:30 PM., The DON was asked for a medication audit record to ensure the time the medications were given on 9/19/23. On 3/28/24 at approximately 9:30 AM., an interview was conducted with Resident #1 concerning his eye appointment on 9/19/23. Resident #1 mentioned that on 9/19/23 he did not receive his breakfast or morning medications because the staff was running late on getting him ready for his eye appointment. Resident #1 also stated that the staff is now checking his blood sugars and providing meals when he returns from appointments. On 3/28/24 at approximately 10:10 AM., an interview was conducted with the unit manager LPN #1 concerning missed medications and treatment. LPN #1 said that she's not sure if the resident received his medications on 9/19/23. On 3/28/24 at approximately 1:40 PM., an interview was conducted with the Medical Director concerning missed treatments. The Medical Director said that the Skin prep is used to dry the area out on the residents skin. On 3/29/24 at approximately 3:39 PM, a final interview was conducted remotely with the Administrator, Director of Nursing, and Regional Nurse Consultant. The DON said she would look into it (missed medications). A medication audit record was requested for the second time to ensure if medications were given to Resident on 9/19/23 when he returned from his appointment. The DON was not able to provide the audit record to validate medications were administered. No further information was given from the DON concerning the missed medications prior to survey exit.

Based on family interviews, staff interviews and a clinical record review, the facility staff failed to provide the required supervision for 1 resident (Resident #1) which resulted in an unwitnessed fall that caused facial contusion and a closed displaced phalanx (fracture) of the left ring finger, which constituted harm at past non-compliance. The findings included: Resident #1 was originally admitted to the facility 5/22/2015 and was current resident in the facility. Resident #1's diagnoses included a stroke with left hemiparesis and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/24/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing and locomotion, extensive assistance of one person with bed mobility, transfers, walking, personal hygiene, dressing, and toileting and supervision after set-up with eating. A nurse's note date 4/27/23 read, the resident fell out of her wheel chair while outside and hit the right side of her face. The resident was transported to the hospital and diagnosed with a contusion to her face and a closed displaced phalanx (fracture) of the left ring finger. A splint was applied and an order to follow up with an orthopedist or hand surgery specialist. The resident's care plan with a revision date of 5/5/23 had a problem which read, (name of resident) is at risk for falls. A fall mat is in place for safety. The resident had falls 6/18/21 and 4/27/23. The goal read, minimize risks for falls/minimize injuries related to falls through 6/22/23. The interventions included, Ensure resident not outside unsupervised. Implement preventative fall interventions/devices. Fall mat at bedside for safety. Maintain needed items within reach. Offer assistance with toileting during care opportunities. An interview was conducted with Resident #1's daughter by telephone on 6/7/23 at approximately 9:14 a.m. The daughter elaborated on her mother being left in a wheel chair outside unsupervised, and falling from the wheel chair onto the driveway. An interview was also conducted with daughter #2 on 6/7/23 at 9:40 a.m., she talked about the fall outside while the resident was unsupervised as well of the injuries sustained. On 6/7/23 at approximately 2:20 p.m., an interview was conducted with certified nursing assistant (CNA) #1. CNA #1 stated Resident #1 attends the PACE program one day each week, she feeds herself well, is totally incontinent of her bladder and bowels, can self propel her wheel chair some days short distances and when she is in bed her bed is kept in the lowest position. An interview was conducted with CNA #2 on 6/7/23 at approximately 2:55 p.m. CNA #2 stated she had been employed with the facility for about three months. She also stated Resident #1 asked her to take her outside and she took her outside and left her for she had to return to her unit to care for other residents. CNA #2 stated since the fall of Resident #2 she has been educated to notify the nurse prior to allowing a resident to go outside and she has been re-inserviced on the facility's fall prevention program. An interview was conducted with the Front Desk Receptionist (FDR) on 6/8/23 at 2:45 p.m. The FDR stated on 4/27/23 at approximately 2:00 p.m., she observed a resident was on the ground near the bench in the parking lot with the wheel chair she was sitting in nearby. The FDR also stated another resident was observed nearby but there was not any staff present. She stated she immediately came into the facility and called for help and nursing staff responded to her call. The FDR stated the PACE transporter did not leave her outside for they always bring the resident inside the building. An interview was conducted with CNA #3 on 6/8/23 at 10:55 a.m. CNA #2 stated if a resident desires to go out to smoke, it is required that they sign out in the book at the nurse's station and notify the nurse on duty. If the resident is independent, they may go out unassisted but if they are not independent a staff member must stay outside with the resident. CNA #3 stated also all staff are to monitor residents for fall potentials. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 6/8/23 at 11:25 a.m. LPN #1 stated all staff are to identify fall risk and hazards, spills, positioning/sloughing, in the chair keeping personal possession nearby, toileting, and rounding frequently to know where abouts of the resident. All residents who had experienced falls since 4/27/23 were reviewed during the survey. There was one resident who should utilize a wheel chair for locomotion who fell walking without a wheel chair. A lack of supervision wasn't identified as the root cause. Eighteen additional falls were also reviewed, but lack of supervision was not identified as a root cause Date of Corrective action plan, 4/28/23. The facility developed a five-point plan secondary to Resident #1's fall with facial bruising a left ring finger fracture. 1. The facility determined based on Resident #1's cognition she should have been supervised while outside. 2. The facility completed a 100 percent review of all falls in the facility for the previous 30 days to determine like-residents (residents with a BIMS score below 12), had prior unwitnessed falls outside and a 100 percent of environmental conditions was completed there were no environmental hazards outside. 3. One hundred (100) percent education for all nurses by the Director of Nursing and Staff Development Coordinator to educate on resident supervision while outside and Resident with BIMS under 12 to require visual observation while outside of the community front doors. 4. The Administrator, Director of Nursing and Staff Development Coordinator to complete weekly audits 5 times per week for 5 weeks that include environmental observations, staff interviews regarding the education above and resident interviews. All Quality Assurance and Performance Improvement (QAPI) finding will be forwarded to the QAPI committee. 5. Corrective action was completed on 5/4/23. On 6/8/23 at approximately 1:40 p.m., the above allegations were shared with the Administrator, Director of Nursing and two corporate consultants. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no concerns were voiced. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-689.

Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed to convey within 30 days after the resident's discharge from the facility the resident's funds, and a final accounting of those funds, to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded as rarely to never capable of making her needs known. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, toileting, personal hygiene and dressing, and total care of one person with eating and bathing. In section H (Bladder and Bowel) the resident was coded as requiring the use of an indwelling catheter and always incontinent of her bowels. An interview was conducted with the Resident Representative on 11/17/22 at approximately 10:13 a.m. The Resident Representative stated she hadn't received the monies from her sister's personal fund account which the facility had held since her discharge 6/30/22. An interview was conducted with the Business Officer Manager (BOM) on 11/17/22 at approximately 11:30 a.m. The BOM stated she thought she had sent a request for Resident #121's funds to be conveyed to the Resident and/or Representative but after reviewing the records she recognized she had only froze the account. The BOM presented a document at approximately 4:10 p.m. which indicated a request was sent to the financial department to have $3,556.51 sent to the Resident Representative. On 11/17/22 at approximately 2:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced. COMPLAINT DEFICIENCY

Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed the facility staff failed to ensure the resident's personal funds which exceeded $100.00 were kept in an interest bearing account until it was distributed to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded as rarely to never capable of making her needs known. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, toileting, personal hygiene and dressing, and total care of one person with eating and bathing. In section H (Bladder and Bowel) the resident was coded as requiring the use of an indwelling catheter and always incontinent of her bowels. An interview was conducted with the Resident Representative on 11/17/22 at approximately 10:13 a.m. The Resident Representative stated she hadn't received the monies from her sister's personal fund account which the facility had held since her discharge 6/30/22. An interview was conducted with the Business Officer Manager (BOM) on 11/17/22 at approximately 11:30 a.m. The BOM stated she thought she had sent a request for Resident #121's funds to be conveyed to the Resident and/or Representative but after reviewing the records she recognized she had only froze the account. The BOM presented a document at approximately 4:10 p.m. which indicated a request was sent to the financial department to have $3,556.51 sent to the Resident Representative. No interest accrued on the monies in the Resident's account because it had been frozen. The facility policy titled Resident Personal Funds Management with a revision date of 4/9/21 read the the facility will deposit in excess of $50.00 in an interest-bearing account (at a rate of return equal to or above the rate at local banking institutions) account insured by FDIC that is separate from any Facility operating account. All interest earned will be credited to the Resident account. On 11/17/22 at approximately 2:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced. COMPLAINT DEFICIENCY

Based on resident interview, staff interviews and clinical record review, the facility staff failed to ensure 1 out of 3 residents (Resident #118) in the survey sample received the services needed to meet their dental needs. The findings included: The facility staff failed to follow-up with a dental visit recommended by the dentist on 07/31/22 for Resident #118. Diagnosis for Resident #118 included but not limited to Type II Diabetes. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 10/20/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. The MDS coded Resident #118 supervision with setup help only with eating. Under section L0200 (Dental) coded Resident #118 being without mouth or facial pain, discomfort, or difficulty with chewing. An interview was conducted with Resident #118 on 11/15/22 at approximately 12:15 p.m. He stated he was seen by the dentist about 3-4 months ago and should have had a follow up appointment which never happened. He stated he needs dentures but his teeth on the bottom are rotten down to the gumline. The resident also stated no one at the facility had spoken to him regarding his dental issues related to having his teeth pulled or receiving dentures. The resident denies dental pain or discomfort currently. A review of Resident #118 clinical record revealed a dental note dated 07/31/22 that stated the staff reported Resident #118 needed to be seen for multiple mandibular fractured (broken) teeth. All the fractured teeth are at the bottom gumline. The note included Resident #118 voiced difficulty eating and would like to have dentures. The note also stated the resident was advised that he (dentist) does not make dentures for the facility and will need to locate a Medicaid provider who will do teeth extractions and fabricate complete dentures. On 11/16/22 at approximately 3:25 p.m., an interview was conducted with the Business of Manager (BOM). She stated she was not aware the dentist office had put Resident #1's progress note inside his bill until 09/21/22. She said she notified the nursing staff on 09/21/22 that there were dental notes in the some of the resident's charts. She stated she did not tell anyone that Resident #118 had a dental note from his dental visit on 07/31/22. She stated she took ownership of her mistake. A debriefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 11/17/22 at approximately 4:15 p.m., who were informed of the above findings. No further information was provided prior to exit. The facility's policy titled Dental Services revised on 08/11/20. It is the facility policy that the facility will assist in obtaining routine and 24-hour emergency dental care/services to meet the needs of each resident. -Procedure: -Dental services are available to meet the resident's needs. -Failure of a dentist to provide follow-up services will result in the facility's right to use its Consult Dentist to provide the resident's dental needs. -The Director of Nursing, or his/her designee, or any clinical staff member is responsible for notifying Social Services of a resident's need for dental services. -If the referral cannot be made within 3 days, the facility will document what was done to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that lead to the delay. COMPLAINT DEFICIENCY

Based on closed record review, complaint investigation, and family and staff interviews, the facility staff failed to ensure one resident (Resident #297), in the survey sample of 46 residents, was free from sexual assault which resulted in harm. The findings included: Resident #297 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In the most recent Minimum Data Set (MDS) dated [DATE], it was coded that this resident had a BIMS score of 3 out of a possible score of 15 which indicated severe impairment in the cognitive skills necessary for daily decision-making. Resident #297 required extensive assistance for bed mobility and was dependent on staff for transfers, dressing, grooming, eating, toileting and bathing. A Care Plan dated 06/07/21 indicated: Focus- Altered or at risk for altered behaviors and/or mood due to acute confusion. Goal- resident will display a positive affect. Interventions- Ensure the resident feels safe in her environment. Resident History: The perpetrator, Resident #145 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the resident's most recent MDS with ARD of 6/11/21, the resident's BIMS was a 13 in a possible score of 15 which indicated intact cognition with the necessary skills needed for daily decision-making. The resident did not trigger for wandering or other behaviors. The resident required extensive assistance for bed mobility, transfers, dressing, toileting, and hygiene. He was independent in eating. The resident used a wheelchair for mobility. Resident #145 was on the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Sex offender's database did not have him listed as an offender. A nursing note dated 8/24/21 at 05:10 a.m. indicated, While CNA was (sic) doing there 2 hour rounding the CNA a (sic) patient in Resident #297 room with her gown up and brief slid to the side. Immediately removed the other party involved to his room and did a thorough head to toe assessment on patient. Resident #297 had scant light pink blood on chuck that was under her but no physical trauma to the vagina that (writer) was able to see externally. Authorities were made aware and all responsible parties were notified. A Facility Incident/Accident Report (FRI) dated 08/24/21 at (14:02) indicated, Incident Description: On August 24, 2021, at 5:10 a.m., Resident #145 was spotted in Resident #297 room. CNA #4 cracked door and saw Resident #145 with his hands down Resident #297 brief. Resident #145 was immediately separated and put in his room. A staff member was put outside his room to watch him. Former LPN #9 agency nurse immediately called the police. The police showed up around 8:00 a.m. Police officers questioned both residents. Resident #297 was sent to the hospital. At 9:00 am. Police Officer detective showed up and interviewed Resident #145. She left after interviewing Resident #145 at facility to speak with Resident #297 family at the hospital. Immediate Action Taken-Description: Resident separated, Police called. Resident sent to hospital. Resident #145 arrested from facility. Interviews started and skin assessments started. Immediate discharge given to resident. Injuries Observed at Time of Incident: No injuries observed at time of incident. A Local Police Incident Report dated 08/24/21 at 09:22 AM indicated: Last Known Secure: 08/24/21 at 05:00 AM At Found: 08/24/21 at 7:06 AM Crime: 1: Sexual Battery Weapons/Tools - 1. (Hands, ETC.) The FRI indicated: Two Police Officers arrived at approximately 0800. They interviewed both residents. Resident #297's family member had already arrived at the Center. The FRI indicated: A Detective interviewed Resident #145 and also went to local hospital to meet with Resident #297's and her family. During this initial police investigation, Resident #145 remained on 1:1 observation with staff. The FRI indicated: Nursing Supervisor reports going to Resident #145 after providing care for Resident #297. Nursing Supervisor reports asking Resident #145 what did you do. Nursing Supervisor reports he answered I am sorry and I touched her. The FRI indicated : At approximately 0930 Officer called center and said to continue to secure Resident #145, and that they would be out to arrest him. Local Police arrived at 1330 and removed him from center. During a phone interview on 9/20/22 at 6:11 a.m. with CNA #4, she stated during her shift rounds on 8/24/21, she noticed Resident #297 door was open which she usually keeps closed at night. CNA #4 stated she went into the room and observed Resident #145 with his hand in Resident #297's brief. CNA #4 stated she asked Resident #145 to leave the room. CNA #4 stated she called for the (former ADON Staff #7) who was working during the shift. CNA #4 was asked if Resident #145 was a wanderer. CNA #4 stated, No. CNA #4 was asked if Resident #4 had been caught in Resident #297 room before and she stated, No. CNA #4 was asked if Resident #145 had been seen in other female resident rooms and she stated, No. A Review of a written statement given by the former Assistant Director of Nursing (ADON) #7 dated 8/24/21 indicated: At 5:10 called to room [ROOM NUMBER] by CNA #4. On arrival to Resident #247 room where Resident #145 (Perpetrator) was in his wheelchair facing the door saying 'I'm sorry.' Observed Resident #247 laying on her back with her gown up around her neck exposing her breast, abdomen, and legs. Her diaper was opened on the right side. Her eyes were open and she was following our movements around the bed. We [name of former agency LPN #9 and former ADON#7] examined Resident #247 for any injuries. None were noted. There was a smear of blood on the disposable pad beneath her. Our exam did not reveal any bleeding. [Name of CNA #4] bathed and dressed Resident #247. [Name of former ADON #7] checked her 15 minutes later and she was resting comfortably with eyes closed. Excerpts from the above-written statement of former ADON Staff #7 included .Went into Resident #145's room and asked him what he was doing and he stated, 'I was in someone's room but I don't know why.' Asked what he was doing in the room with Resident #297 and he stated, 'I don't know.' You do know what you were doing in there; he shook his head yes. Tell me what you did, and he said 'I touched her.' I asked him where he touched her and he said 'down there' pointing to his groin. He again stated he was sorry. The statement indicated that on 8/24/21 at 5:40 a.m., the former ADON staff #7 called Resident #297's daughter and explained the incident to her. She said she would be at the facility in a little while. After the incident, Resident #145 (perpetrator) remained in his room in the bed for the remainder of the shift. During a phone interview on 9/21/22 at 3:59 p.m., former ADON Staff #7 stated CNA #4 called her to Resident #297's room and reported that Resident #145 was observed with his hands inside Resident 297's brief. After removing Resident #145 from the room, the Former ADON Staff #7 stated she asked CNA #4 to clean Resident #297 up. She stated she called the Administrator, DON, Family, and physician. An aide was assigned to watch Resident #145 and sit outside of his room. Former ADON Staff #7 was asked to describe Resident #145. She stated he was usually up near the nursing station during the day. He was not a wanderer nor had he had behaviors of seeking out female residents. During a phone interview on 9/22/22 at 10:13 a.m., the former DON Staff #8 stated she received a call from the Former ADON Staff #7 regarding CNA #4 observing Resident #145 in Resident #297 room with his hands in the brief of Resident #297. The Former DON Staff #8 stated she arrived around 5:30 a.m. the family arrived around 6:30 am. She stated Agency staff LPN #9 called the police, but she was not sure what time the police were called. She said the police arrived around 8:00 a.m. Former DON Staff #8 was asked to describe Resident #145. She stated she did not know much about the resident. She said she had only been working at the facility for about two weeks and was not aware of him going into other resident rooms. A written statement given by agency staff LPN #7 indicated: To Whom It May Concern (writer Agency Staff LPN #7 name) worked on 8/24/21 when it was reported to her that one of the patients had been sexually assaulted by another resident. A thorough head-to-toe exam was performed and noticed scant light pink blood on chux under Resident #297. The male who was involved was immediately removed and asked what happened and he admitted to putting his hands up Resident #297's vagina. All parties were notified. During an interview on 9/22/22 at 4:59 p.m. with agency Staff LPN #7, she stated Resident #297 was assessed after the sexual assault was reported by CNA #4. She said a scant amount of blood was on her brief. The family was notified, the Administrator was notified, and the physician was notified. She said the family came and the rest of the resident's daughters arrived and asked that 911 be called. The Agency Staff LPN Other #7 was asked to describe Resident #145. She stated she did not know the resident, it was her first time at the facility. During a phone interview on 9/22/22 at 4:35 p.m., former Administrator #10 was asked to describe Resident #145. He stated, as far as he knew, the resident was not a wanderer. He would come to the nursing station and talk with the staff. A sex registry background check did not indicate he had committed any previous acts of sexual assault. The former Administrator #10 stated, all parties were notified and a follow-up FRI report was submitted to the State survey and certification agency. During a phone interview on 9/20/22 at 11:39 a.m., Resident #297's daughter stated she received a call from the facility after 5:00 am on 8/24/21 and when she arrived at the facility, her mother had been cleaned up and given a bath. She asked the former ADON #7 to call 911 and send her mother to the hospital. The resident's daughter stated, after her sisters arrived they went to the hospital and were met there later on by the police. She stated her mother was not able to talk or call out for help nor was she able to defend herself against any type of assault. A facility policy for Abuse, Neglect, and Exploitation dated 5/6/21 indicated: Sexual abuse -includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. Complaint Deficiency

Based on a closed record review, complaint investigation, family and staff interviews, the facility staff failed to preserve evidence following an incident of sexual abuse for one resident (Resident #297) in the survey sample of 46 residents. The findings included: Resident #297 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In the most recent Minimum Data Set (MDS) dated [DATE], it was noted this resident had a BIMS score of 3 which indicated the resident was severely impaired in the skills needed for daily decision-making. Resident #297 required extensive assistance for bed mobility and was dependent on staff for transfers, dressing, grooming, eating, toileting and bathing. A Care Plan dated 06/07/21 indicated: Focus- Altered or at risk for altered behaviors and/or mood due to acute confusion. Goal- resident will display a positive affect. Interventions- Ensure the resident feels safe in her environment. The perpetrator, Resident #145 was admitted on [DATE]. He had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the resident's most recent MDS with ARD of 6/11/21, the resident's BIMS was a 13 which indicated he was cognitively intact with the skills for daily decision-making. He did not trigger for wandering or other behaviors. The resident required extensive assistance for bed mobility, transfers, dressing, toileting, and hygiene. He was independent in eating. The resident was coded to use a wheelchair for mobility. Resident #145 was on the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Sex offender's database does not have him listed as an offender. A nursing note dated 8/26/21 -Late Entry - Indicated: Late Entry for the incident on 8/24/21 at 5:10 am: Male resident was immediately removed from residents room when he was found in her room, by a CNA (certified nursing assistant), with his hands between her legs. He was escorted to his room where he went to bed and remained on 1:1 surveillance. Patient did not appear to be upset. She was lying in bed with her eyes open and following (sic) writers (movements). Physical exam was completed, No bruising noted and no scratches or other signs of injury noted to back, buttocks or vaginal area. There was no discharge or drainage noted from vaginal area. Breast appeared to be untouched and had no s/s of any bruising, scratches etc. There was a smear of blood located on her diaper however the exam did not reveal any signs of trauma or blood visible at time of exam. Patient did not voice any discomfort nor pain with words or facial expressions. She was given a bed bath, gown changed and bedding changed. She was resting comfortably in bed with eyes closed when her family arrived. A Review of a written statement given by the former Assistant Director of Nursing (ADON) #7 dated 8/24/21 indicated: At 5:10 called to room [ROOM NUMBER] by CNA #4. On arrival to Resident #247 room where Resident #145 (Perpetrator) was in his wheelchair facing the door saying 'I'm sorry.' Observed Resident #247 laying on her back with her gown up around her neck exposing her breast, abdomen, and legs. Her diaper was opened on the right side. Her eyes were open and she was following our movements around the bed. We [former agency LPN #9 and former ADON#7] examined Resident #247 for any injuries. None were noted. There was a smear of blood on the disposable pad beneath her. Our exam did not reveal any bleeding. [Name of CNA #4] bathed and dressed Resident #247. [Name of former ADON #7] checked her 15 minutes later and she was resting comfortably with eyes closed. During a phone interview on 9/21/22 at 3:59 p.m., former ADON#7 stated that CNA #4 cleaned up Resident #247 up at her request. She said the bed was messy and her diaper was changed. The former ADON #7 stated, she had the assigned CNA #4 to wash Resident #247's peri area, put on a new diaper and a clean gown, change the linen, and change her blanket. She stated during the interview that she instructed staff to make sure to clean Resident #247 up before law enforcement was contacted and before Resident #247 was transferred to the emergency room for examination. She was asked if this incident was investigated as a sexual assault and she stated, Yes. She was also asked if she had sexual abuse training and responded that she had, but her personal training folder did not have evidence of abuse training or what to do in cases of suspected sexual assault. During the above interview, former ADON #7 was asked if Resident #145 (Perpetrator) was examined for potential evidence to which she said she did not know. She was asked bathing or clean the resident, and washing linens and or clothing before the resident had been examined would impede the investigation, and responded that she messed up. The former ADON #7 was also asked if the bed linens, diapers, are gowns were preserved for evidence and responded, No, the disposable items were discarded and the linens were sent to laundry to be washed. During a phone interview on 9/20/22 at 6:11 a.m., the assigned CNA #4 stated she was instructed by former ADON#7 to clean up Resident #247, give her a bed bath to include the peri-area, change her brief and place the resident in a clean gown. CNA#4 also said she was also instructed to change the resident's bed linens. During a phone interview on 9/20/22 at 11:39 a.m., Resident #247's daughter stated she received a call from the facility after 5:00 a.m. on 8/24/21. When she arrived at the facility, her mother had been cleaned up and given a bath. She asked the former ADON #7 to call 911 and send her mother to the hospital. A facility Abuse policy dated 5/26/21 indicated: Sexual abuse- Includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. Protection of Resident: In Allegations of Sexual Abuse every effort will be made to preserve evidence on both the resident and the perpetrator. Resident and perpetrator: a. Will not be bathed or cleaned b. Will not receive incontinence care c. The Incontinence brief will not be changed e. No oral care will be provided f. Both resident and perpetrator will be evaluated in the ER. g. Linens will be bagged and provided as evidence if applicable h. Police to be notified. Complaint Deficiency

Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed to convey within 30 days after the resident's discharge from the facility the resident's funds, and a final accounting of those funds, to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded as rarely to never capable of making her needs known. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, toileting, personal hygiene and dressing, and total care of one person with eating and bathing. In section H (Bladder and Bowel) the resident was coded as requiring the use of an indwelling catheter and always incontinent of her bowels. An interview was conducted with the Resident Representative on 11/17/22 at approximately 10:13 a.m. The Resident Representative stated she hadn't received the monies from her sister's personal fund account which the facility had held since her discharge 6/30/22. An interview was conducted with the Business Officer Manager (BOM) on 11/17/22 at approximately 11:30 a.m. The BOM stated she thought she had sent a request for Resident #121's funds to be conveyed to the Resident and/or Representative but after reviewing the records she recognized she had only froze the account. The BOM presented a document at approximately 4:10 p.m. which indicated a request was sent to the financial department to have $3,556.51 sent to the Resident Representative. On 11/17/22 at approximately 2:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced.

Based on resident interview, staff interviews and clinical record review, the facility staff failed to follow professional standards of nursing practices for 1 out of 40 residents (Resident #51) in the survey sample. The findings included: The facility staff failed to obtained daily weights per physician orders for Resident #51. Resident #51 was admitted to the facility on [DATE]. Diagnosis for Resident #51 included but are not limited to Congestive Heart Failure (CHF). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/12/22 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #51 total dependence of one with toilet use, personal hygiene and bathing, extensive assistance of one with bed mobility, transfer and dressing and supervision with eating with Activities of Daily Living (ADL) care. Resident #51's person-centered care plan initiated on 11/25/20 identified the resident with a diagnoses of CHF. The goal set for the resident by the staff is the resident's body weight will remain within normal limits through the next review date of 11/02/22. Some of the interventions/approaches the staff would use to accomplish this goal is to monitor weights per routine and as needed and to notify the physician of any abnormalities. An interview was conducted with Resident #51 on 09/18/22 at approximately 5:37 p.m. He stated his heart doctor gave orders for the nurses to check his weight every day but it's not being done. A review of Physician Order Summary (POS) revealed an order written by the cardiologist to obtain and monitor Resident #51's weights daily starting on 8/30/22 daily at 6:00 a.m. A review of Resident's #51's Treatment Administration Record (TAR) for September 2022 indicated the following missing weights: 09/02 through 09/06 and 09/16 through 09/19/22. A phone call was placed to LPN #1 on 09/21/22 at approximately 11:10 a.m. The LPN was assigned to obtain Resident #51's weight on 09/02/22, 09/16/22 and 09/19/22 at 6:00 a.m. A message was left, the LPN never returned the call. An interview was conducted with the Director of Nursing (DON) on 09/22/22 at approximately 9:35 a.m. The DON said she expect for the nurses to obtained weights as ordered by the physician. She stated if the resident refuse to be weighed, the resident is to be educated on the importance of being weighed and if they still refuse then the refusal is documented in the resident's clinical record and the physician is to be notified. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Weights revised on 02/01/20. It is the policy of the facility that obtaining accurate weights is vital for the nutritional assessment of each resident and can be used as a basis for medical and nutritional intervention. Nursing is responsible for the determination of each individual's weight. Definitions: -Congestive Heart Failure means that your heart can't pump enough oxygen-rich blood to meet your body's needs. Heart failure doesn't mean that your heart has stopped or is about to stop beating. But without enough blood flow, your organs may not work well, which can cause serious problems (https://medlineplus.gov).

Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed to convey within 30 days after the resident's discharge from the facility the resident's funds, and a final accounting of those funds, to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded as rarely to never capable of making her needs known. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, toileting, personal hygiene and dressing, and total care of one person with eating and bathing. In section H (Bladder and Bowel) the resident was coded as requiring the use of an indwelling catheter and always incontinent of her bowels. An interview was conducted with the Resident Representative on 11/17/22 at approximately 10:13 a.m. The Resident Representative stated she hadn't received the monies from her sister's personal fund account which the facility had held since her discharge 6/30/22. An interview was conducted with the Business Officer Manager (BOM) on 11/17/22 at approximately 11:30 a.m. The BOM stated she thought she had sent a request for Resident #121's funds to be conveyed to the Resident and/or Representative but after reviewing the records she recognized she had only froze the account. The BOM presented a document at approximately 4:10 p.m. which indicated a request was sent to the financial department to have $3,556.51 sent to the Resident Representative. On 11/17/22 at approximately 2:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced.

Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed the facility staff failed to ensure the resident's personal funds which exceeded $100.00 were kept in an interest bearing account until it was distributed to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded as rarely to never capable of making her needs known. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, toileting, personal hygiene and dressing, and total care of one person with eating and bathing. In section H (Bladder and Bowel) the resident was coded as requiring the use of an indwelling catheter and always incontinent of her bowels. An interview was conducted with the Resident Representative on 11/17/22 at approximately 10:13 a.m. The Resident Representative stated she hadn't received the monies from her sister's personal fund account which the facility had held since her discharge 6/30/22. An interview was conducted with the Business Officer Manager (BOM) on 11/17/22 at approximately 11:30 a.m. The BOM stated she thought she had sent a request for Resident #121's funds to be conveyed to the Resident and/or Representative but after reviewing the records she recognized she had only froze the account. The BOM presented a document at approximately 4:10 p.m. which indicated a request was sent to the financial department to have $3,556.51 sent to the Resident Representative. No interest accrued on the monies in the Resident's account because it had been frozen. The facility policy titled Resident Personal Funds Management with a revision date of 4/9/21 read the the facility will deposit in excess of $50.00 in an interest-bearing account (at a rate of return equal to or above the rate at local banking institutions) account insured by FDIC that is separate from any Facility operating account. All interest earned will be credited to the Resident account. On 11/17/22 at approximately 2:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced.

Based on staff interview and clinical record review, the facility staff failed to include anticoagulation in the comprehensive care plan, for 1 of 40 resident (Resident #32), in the survey sample. The findings included: The facility staff failed to develop a care plan for Resident #32 who was receiving an anticoagulant medication (Coumadin). Resident #32 was originally admitted to the nursing facility on 09/25/21. Diagnosis for included but are not limited to Atrial Fibrillation (A-Fib). The current Minimum Data Set (MDS) a significant change assessment with an Assessment Reference Date (ARD) of 07/13/22 coded Resident #32 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The residents MDS was coded for the usage of anticoagulant. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an anticoagulant for 6 days. The review of Resident 32's comprehensive care plan did not include a care plan for the use of an anticoagulant. The current physician order dated 09/16/22 read to give Coumadin (anticoagulant) 5 mg by mouth in the evening every Tues, Thurs, Fri, Sun and Coumadin 4 mg by mouth in the evening every Mon, Wed and Sat related to A-Fib. An interview was conducted with both MDS Coordinator's on 09/21/22 at approximately 9:06 a.m. She stated if a resident is on Coumadin therapy, there should be an anticoagulation care plan. On the same day, at approximately 1:00 p.m., the MDS Coordinator stated, Resident #32 did not have an anticoagulant care plan but one has been created. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings; no further information was provided prior to exit. Definitions: -Atrial Fibrillation is the most common type of arrhythmia. An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. (Source: www.Nhlbl.nih.gov).

Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed the facility staff failed to ensure the resident's personal funds which exceeded $100.00 were kept in an interest bearing account until it was distributed to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded as rarely to never capable of making her needs known. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, toileting, personal hygiene and dressing, and total care of one person with eating and bathing. In section H (Bladder and Bowel) the resident was coded as requiring the use of an indwelling catheter and always incontinent of her bowels. An interview was conducted with the Resident Representative on 11/17/22 at approximately 10:13 a.m. The Resident Representative stated she hadn't received the monies from her sister's personal fund account which the facility had held since her discharge 6/30/22. An interview was conducted with the Business Officer Manager (BOM) on 11/17/22 at approximately 11:30 a.m. The BOM stated she thought she had sent a request for Resident #121's funds to be conveyed to the Resident and/or Representative but after reviewing the records she recognized she had only froze the account. The BOM presented a document at approximately 4:10 p.m. which indicated a request was sent to the financial department to have $3,556.51 sent to the Resident Representative. No interest accrued on the monies in the Resident's account because it had been frozen. The facility policy titled Resident Personal Funds Management with a revision date of 4/9/21 read the the facility will deposit in excess of $50.00 in an interest-bearing account (at a rate of return equal to or above the rate at local banking institutions) account insured by FDIC that is separate from any Facility operating account. All interest earned will be credited to the Resident account. On 11/17/22 at approximately 2:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced.

Based on observations, staff interviews, and clinical record review, the facility staff failed to ensure a resident received the application of his right hand splint as ordered by the physician to prevent further decrease in range of motion for 1 of 40 residents, (Resident #35), in the survey sample. The findings included: Resident #35 was originally admitted to the facility 07/14/22. Diagnosis for Resident #35 included but are not limited to Cerebral Infarction (stroke) with right hemiparesis (weakness or inability to move one side of the body). Resident #35's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 07/14/22 coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. In section G (Physical limitation in Range of Motion) the resident was coded for limitation one side to both upper and lower extremity. Resident #35's person-centered care plan initiated on 11/13/20 identified the resident requires the use of a splint/brace to right palm to delay or avoid loss of independence. The goal set for the resident by the staff is the resident will have no further loss of function to extremity through next review of 10/12/22. Some of the interventions/approaches the staff would use to accomplish this goal is to provide education to the resident why splint/brace is necessary for care and follow on/off schedule for brace/splint. A review of Resident #35's Treatment Administration Record (TAR) for September 2022 revealed an order with a start date of 12/15/20 to apply right palm guard on for 8 hours maximum, apply in the morning (6 a.m.) and remove per schedule (2:00 p.m.) On 09/19/22 at approximately 9:52 a.m., Resident #35 was observed lying in bed with his right hand on top of the covers. Resident #35's right hand/fingers were contracted. Sitting on top of the night stand was a hand splint. On the same day at approximately 11:54 a.m., Resident #35 was observed in the hallway without the hand splint on. On 09/20/22 at approximately 9:52 a.m., Resident #35 observed lying in bed with hand splint sitting on the night stand. On the same day at approximately 11:51 a.m., hand splint remain on night stand. On 09/21/22 at approximately 9:48 a.m., Resident #35 observed lying in bed with hand splint sitting on the night stand. The Director of Rehab was interviewed on 09/21/22 at approximately 9:48 a.m., who stated Resident #35's splint was instituted on 08/08/22. She stated the resident is to wear the right hand splint for 8 hours then remove. She said the nurses are responsible for apply the splint to prevent further contracture to his right hand. An interview was conducted with License Practical Nurse (LPN) #6 on 09/21/22 at approximately 10:31 a.m. She stated that the LPN clearly signed off she had applied the hand splint when she did not on 09/20/22 and 09/21/22 at 6:00 a.m. When asked if she removed Resident #35's hand splint at 2:00 p.m., as ordered by the physician, she replied I can't remember. She stated she attempted to apply Resident #35's splint around 9:00 a.m., but he refused. She stated she forgot to document the refusal in the residents' clinical record. A phone call was placed to LPN #1 on 09/21/22 at approximately 11:10 a.m. The LPN was assigned to apply Resident #35's right hand splint on 09/19/22 and 09/20/22 at 6:00 a.m. A message was left, the LPN never returned the call. On 09/22/22 at approximately 9:54 a.m., an interview was conducted with the Director of Nursing who stated she expected for the nurses to apply Resident #35's right hand splint as ordered by the physician. She said if the resident refuses to wear the splint, the nurses are to document the refusal in the resident's clinical record and notify the physician. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Splint Issuance revised on 03/11/22. It is the facility's policy that splints shall be issued or fabricated with a provider's order and therapist must evaluate patient to determine need for splint, fit and issuance. -Procedure: Client will be instructed in wearing schedule, precautions a splint care. The splint schedule will be communicated to the multidisciplinary team and documented in the care plan. A splint check will be performed to determine patient satisfaction and adequate splint fit and splint function.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to afford two residents (R#62 and R#38) in the survey sample the opportunity to participate in the care planning process. The findings included: Resident #62 was originally admitted to the facility 04/25/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 08/18/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #62 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) of the MDS the resident was coded as requiring total dependence of two persons with bed mobility, toileting and bathing. Requires total dependence of one person with dressing and personal hygiene. Requires supervision with set-up help only with eating. The Care Plan read: FOCUS: Resident #62 is long term placement at the facility related to hands with ADL's Goals: FOCUS: Resident will express need and acceptance of placement through next review Date Initiated: 12/15/2020 Created on: Target Date: 10/27/2022 INTERVENTIONS: Encourage family and/or responsible party to assist with adjustment by bringing in items from home that the resident enjoys Date Initiated: 12/15/2020 Created. On 09/19/22 at approximately 11:44 AM., an interview was conducted with Resident #62. He could not recall receiving a recent invitation for a care plan meeting. He stated, They never tell me anything. Resident #62 also said that he attended [CONDITION(S)] three days a week every Tuesday, Thursday and Saturday. On 9/19/22 at approximately 5:30 PM., an interview was conducted with the SW (Social Worker) concerning Care Plan meetings and invitations. She said that Resident #62's brother attended the meetings and would usually fill him in when he returned from [CONDITION(S)]. A review of the quarterly Care Plan Conference Summary dated 3/08/22 (Tuesday) revealed that Resident #62 did not attend the meeting due to him being at [CONDITION(S)] but his Resident Representative (RP) was in attendance. A review of the quarterly Care Plan Conference Summary dated 6/08/22 (Thursday) did not indicate if Resident #62 was present but did indicated the RP was in attendance. On 9/22/22 at approximately 2:00 PM an interview was conducted with LPN (MDS, Coordinator) #1 concerning Resident #62. She said that the social worker has to notify the family and resident about care plan meetings. She said that his next scheduled Care Plan meeting was scheduled for 11/28/22 which fell on a Wednesday. On 9/22/22 at approximately 3:10 PM., a pre-exit was with the DON (Director of Nursing) and Corporate staff member #1 and Corporate staff member #2. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. 2. The facility staff failed to invite Resident #38 to attend their person-centered care plan meeting. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 07/20/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. An interview was conducted with Resident #38 on 09/19/22 at approximately 10:34 a.m., who stated he is never been invited to attend a care plan meeting nor given a care plan invitation letter. An interview was conducted with the MDS Coordinator #1 on 09/22/22 at approximately 10:17 a.m. She stated she provides the Social Worker (SW) with the care plan date but the SW will invite the resident to attend their care plan meeting. She stated Resident #38 should have been invited to attend his care plan meetings on 02/28/22, 04/18/22 and 07/20/22. An interview was conducted with the SW on 09/21/22 at 2:53 p.m. She stated she was not able to locate where Resident #38 was ever invited to attend his care plan meeting on the days mentioned above. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Comprehensive Care Planning revised on 07/19/19. It is the facility policy that the interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. -Procedure read in part: L. The facility designee is responsible for preparing and updating a list of those residents scheduled for each conference. The list is generated ten (10) days prior to each meeting. M. The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting. The letter of requested participation (original) is presented to the resident at least five (5) days prior to the date of conference. A copy of the letter is maintained for reference.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure 2 of 40 residents in the survey sample, (Resident #32 and 81) were given the opportunity to formulate an advance directive. The findings included: 1. The facility staff failed to ensure Resident #32 was given the opportunity to formulate an Advance Directive. Resident #32 was originally admitted to the nursing facility on 09/25/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS) a significant change assessment with an Assessment Reference Date (ARD) of 07/13/22 coded Resident #32 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. Resident #32's person-centered care plan created on 09/27/21 with a revision date of 07/11/2022 identified the resident has an advance directive as a full code. The goal set for the resident by the staff is to follow the residents' wishes. Some of the interventions to manager goal include but not limited to review advanced directives with resident/family periodically and involve the Physician/Nurse Practitioner (NP) in advanced directives conversations. A review of the clinical record revealed that there was no advance directive for Resident #32. Review of Resident #32's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Admission Director on 09/21/22 at approximately 1:35 p.m. He stated he was not responsible for advance directives. He said he would ask the resident or their representative on admission if they have an advance directive and if they do, it's forwarded to the Social Worker (SW). He stated if the resident did not have an advance directive then the social worker is informed. An interview was conducted with the SW on 09/21/22 at 2:53 p.m., who stated, she guess she was responsible for ensuring Resident #32 had an advance directive. When asked if Resident #32 was given the opportunity to formulate an advance directive, she stated, No. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings. No further information was provided prior to exit. Definitions: [CONDITION(S)] is a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people (https://www.webmd.com). -Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/ 5.htm). -Heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs (https://medlineplus.gov/druginfo/meds/a 2.html). The facility's policy titled Your Path Advance Care Planning Meeting Protocol revised on 09/01/15. It is the policy of this facility to ensure Your path - Advance Care Planning is conducted upon each patient's admission to the facility. The Your Path - Advancing Care Planning meeting will be completed within 5 days of admission, prior to completing and/or updating dating the plan of care. 2. The facility staff failed to ensure Resident #81 was given the opportunity to formulate an Advance Directive. Resident #81 was originally admitted to the nursing facility on 04/12/22. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS) an admission assessment with an Assessment Reference Date (ARD) of 08/31/22 coded Resident #81 with as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #81 cognitive abilities for daily decision making were moderately impaired. A review of the clinical record revealed that there was no advance directive for Resident #81. On 9/22/22 at approximately 1:10 PM ., an interview was conducted with Corporate staff member #2 concerning advanced directives. She said that no advance directive was completed. On 9/22/22 at approximately 3:10 PM., a pre-exit was held with the DON (Director of Nursing) and Corporate staff member #1 and Corporate staff member #2. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 4 residents (Resident #39 and #64) in the survey sample. The findings included: 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #39 who was discharged from skilled services with Medicare days remaining. Resident #39 was admitted to the nursing facility on 07/14/22. Diagnosis for Resident #39 included but are not limited to Congestive Heart Failure (CHF) and COVID-19. The Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) date of 09/18/22 coded Resident #39 a 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated moderate cognitive impairment. Review of the SNF Beneficiary Notification provided by the facility was noted that Resident #39 was not issued a SNF ABN letter. Resident #39 started Medicare Part A stay on 07/14/22 and the last covered day was on 07/27/22. Resident #39 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #39 had only used 13 days of her Medicare Part A services with 87 days remaining. Resident #39 should have been issued a SNF ABN letter. An interview was conducted with the Social Worker on 09/21/22 at approximately 2:53 p.m. She stated Resident #39 should have been issued an ABN letter but could not locate where the ABN letter was ever issued. 2. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #64 who was discharged from skilled services with Medicare days remaining. Resident #64 was admitted to the nursing facility on 08/18/22. Diagnosis for Resident #64 included but not limited to Congestive Heart Failure and Stage III kidney disease. Resident #64's Minimum Data Set (MDS) an admission assessment with an Assessment Reference Date (ARD) date of 08/24/22 coded Resident #64 a 07 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated severe cognitive impairment. Resident #64 started Medicare Part A stay on 08/18/22 and the last covered day was on 09/01/22. Resident #64 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #64 had only used 13 days of her Medicare Part A services with 87 days remaining. Resident #64 should have been issued a SNF ABN letter. An interview was conducted with the Social Worker on 09/21/22 at approximately 2:53 p.m. She stated Resident #64 should have been issued an ABN letter but could not locate where the ABN letter was ever issued. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Medicare Cut Letter revised on 01/29/21. It is the policy of this facility to assure all rights receive timely and appropriate notification of Medicare non-coverage for services in accordance with State and Federal guidelines.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to send a care plan to include their goals when discharged and admitted to the hospital for 1 of 46 residents (Resident #50), in the survey sample. The findings included; The facility staff failed to send a copy of Resident #50's care plan to include their goals when discharged and admitted to the hospital on 09/04/22. Resident #50 was originally admitted to the nursing facility on 10/22/21. Diagnosis for Resident #50 included but are not limited to Cerebrovascular accident (stroke) with left hemiparesis (weakness or inability to move one side of the body). Resident #50's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 08/03/22 coded a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. A review of Resident #50's quarterly MDS assessment on 08/03/22, under Section G (Functional Status) was coded requiring extensive assistance of one with bathing and supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene for Activities of Daily Living (ADL) care. The Discharge MDS assessments was dated for 09/04/22 - discharge return anticipated. Resident #50 was readmitted to the nursing facility on 09/07/22. The nursing note dated 09/04/22 at approximately 11:22 p.m., revealed Resident #50 noted with constant chest pain. A new order was given to send Resident #50 to the emergency room (ER) for evaluation and treatment. A phone call was placed to License Practical Nurse (LPN) #1 on 09/21/22 at approximately 11:10 a.m. The LPN sent Resident #50 to the hospital on 09/04/22 at 11:22 p.m. A message was left, the LPN never returned the call. An interview was conducted with LPN #2 on 09/21/22 at approximately 5:00 p.m. She said when a resident is discharged to the hospital, a copy of the resident's care plan is to be sent with them along with other required documents. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings. No further information was provided prior to exit. The facility provided a document titled Discharge/Transfer Documentation Check List guide for Nursing and Social Services read in part: when transferring a resident to the emergency room (ER), home, or another facility; the facility must send their entire comprehensive care plan.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to send a notice to a representative of the Ombudsman office for 1 of 46 residents (Resident #77), in the survey sample. The findings included: The facility staff failed to send a notice to a representative of the Ombudsman office for Resident #77's discharge to the hospital. Resident #77 was admitted to the facility on [DATE]. Diagnoses for this resident included COPD, sepsis, CVA, dysphagia and hypotension. A review of the clinical records indicated this resident was admitted to the hospital on 06/24/22. Resident #77 was observed in bed with his eyes closed during the survey at 9:33 a.m. on 09/19/22. Resident #77 was also observed observed in bed watching television at 2:15 p.m. on 09/19/22. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having a BIMS score of 1. This resident was assessed as total care in the areas of Activities of Daily Living. A Care Plan dated 8/30/22 indicated: Focus- Resident at increased risk for malnutrition due to recurrent hospitalization s. Goals- Enteral feeding/supplements to support normal lab levels. Interventions-monitor resident for sign and symptoms of dehydration such as poor skin turgor, cracked lips, thirst, fever, abnormal labs. A hospital admission history and physical assessment plan indicated Resident #77 was admitted to the hospital on 06/24/22. During an interview at 1: 38 p.m. on 9/22/22 the Social Service Director stated she had not submitted a notice of transfer to the Ombudsman office regarding Resident #77's admission to the hospital on 06/24/22.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to send a copy of the facility's bed hold policy for 1 of 46 residents (Resident #50), in the survey sample. The findings included: The facility staff failed to provide Resident #50 or resident's representative a copy of the bed hold policy when discharged and admitted to the hospital on 09/04/22. Resident #50 was originally admitted to the nursing facility on 10/22/21. Diagnosis for Resident #50 included but are not limited to Cerebrovascular accident (stroke) with left hemiparesis (weakness or inability to move one side of the body). Resident #50's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 08/03/22 coded a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. A review of Resident #50's quarterly MDS assessment on 08/03/22, under Section G (Functional Status) was coded requiring extensive assistance of one with bathing and supervision with bed mobility, transfer, dressing, eating, toilet use and personal hygiene for Activities of Daily Living (ADL) care. The Discharge MDS assessments was dated for 09/04/22 - discharge return anticipated. Resident #50 was readmitted to the nursing facility on 09/07/22. The nursing note dated 09/04/22 at approximately 11:22 p.m., revealed Resident #50 noted with constant chest pain. A new order was given to send Resident #50 to the emergency room (ER) for evaluation and treatment. A phone call was placed to License Practical Nurse (LPN) #1 on 09/21/22 at approximately 11:10 a.m. The LPN sent Resident #50 to the hospital on 09/04/22 at 11:22 p.m. A message was left, the LPN never returned the call. An interview was conducted with LPN #2 on 09/21/22 at approximately 5:00 p.m. She said when a resident is discharged to the hospital, a copy of the bed hold policy is to be sent with them along with other required documents. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Bed Hold Letter Policy revised on 09/26/20. It is the policy of this facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter.

Based on a clinical record review, resident interview, staff interviews, facility document review and during the course of a complaint investigation the facility failed to ensure 1 of 3 residents (Resident #1) in the survey sample was free from an avoidable fall from the bed during the provision of incontinent care that required an emergency room evaluation and hospital admission of a subsequent impacted left femur fracture, resulting in harm, Resident #1. The facility staff failed to ensure extensive two person staff assist was provided during incontinent care to Resident #1 on 12/16/21. As a result, Resident #1 fell out of the bed and onto the floor. The resident sustained an impacted left femur fracture requiring hospitalization . The findings included: Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to spastic [CONDITION(S)] of the left side and left femur neck fracture. Resident #1's most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 7/28/22. The resident's Brief Interview for Mental Status (BIMS) was coded as an 8 out of a possible 15, indicating the resident was moderately cognitively intact and capable of some daily decision making. Under Section G Function Status, Resident #1 is coded as requiring total dependence 2 person physical assist for toileting. Resident #1's MDS with an ARD of 9/28/21 was also reviewed. The Brief Interview for Mental Status was coded as a 12 out of 15 indicating the resident was cognitively intact and capable of daily decision making. Under Section G Function Status, Resident #1 was coded as requiring total dependence 2 person physical assist for toileting. Resident #1's Fall Risk assessment dated [DATE] was reviewed and indicated the resident was a high fall risk with a score of 14. Resident #1's Comprehensive Care Plan last revised 8/3/22 was reviewed and is documented as follows: .Focus: Resident has self-care deficit. Two person assist for toilet use. Date Initiated: 9/28/21 . Resident #1's Progress Notes for 12/16/21 were reviewed and revealed that at 4:30 a.m. the Certified Nursing Assistant (CNA) was providing incontinent care to the Resident #1 while in bed. The CNA turned the resident to the right side and she rolled over onto the floor. Upon assessment Resident #1 complained of left hip and left arm pain of an 8 out of 10 on the pain scale. Stat x-rays were obtained which identified an impacted left femur fracture and the resident was sent to the emergency room and admitted to the hospital that same day. Resident #1's Hospital Discharge Summary dated 12/19/21 was reviewed. The Hospital Discharge Summary indicated that the Resident #1 stated she was getting changed by the nurse at the facility and she rolled off the bed. The Resident was admitted with an impacted left femur fracture. On 8/9/22 at approximately 11:30 a.m. an interview was conducted with Resident #1 regarding her fall and fractured hip on 12/16/21. Resident #1 stated that the CNA was providing incontinent care that morning by herself and when she rolled her over she fell right out of the bed on to the floor and broke her hip. On 8/10/22 at 8:25 a.m. a phone interview was conducted with CNA #2 regarding Resident #1's fall on 12/16/21. CNA #2 told the surveyor that she went in the change Resident #1 around 4:30 a.m. and that the resident was very contracted in both of her legs. CNA #2 stated that she pulled Resident #1 towards her with the sheet and rolled her over on her right side and that the resident was moving all over the bed. CNA #2 said she reached back to grab some wipes from the bedside table and the resident stated to slide off the bed. The CNA also stated that she tried to hold on to the resident and was able to ease her head to the ground but from the waist down she had already hit the floor. CNA #1 stated that she was not aware that Resident #1 required 2 person assist for toileting but looking back now she should have had another person helping her. On 8/10/22 at 8:50 a.m. a phone interview was conducted with Licensed Practical Nurse (LPN) #2 regarding Resident #1's fall on 12/16/21. LPN #2 stated she was passing medications down the hall and that CNA #2 came out into the hall hollering for her to come to Resident #1's room. LPN #2 stated that when she walked into the room Resident #1 was on the floor beside the bed and complaining of pain. LPN #2 also said that CNA #2 told her that she was changing the resident and when she rolled her over the resident fell out of the bed. On 8/11/22 at 10:38 a.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #1's fall from her bed on 12/16/21. The DON stated that CNA #2 did not have another staff member assisting her while providing incontinent care to Resident #1 on 12/16/21, which resulted in the resident falling out of the bed and fracturing her hip. The DON also stated Resident #1 was harmed because she fell and fractured her hip and that she did not receive the 2 person assist that she was care planned for. The facility policy titled Fall Prevention and Management Policy last revised 12/9/19 was reviewed and is documented as follows: .Policy: If risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated . .Procedure: Individualized interventions will be implemented based on the assessment and care planned accordingly . On 8/11/22 a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Clinical Services where the above information was shared. Upon entrance the facility provided a Quality Assessment and Performance Improvement Action Plan with a start date of 12/16/21. The allegation of compliance date was 2/7/22. The facility is requesting past non-compliance. The plan stated the facility failed to follow fall protocols, ensure fall interventions were followed and CNA's were competent in the handling of residents. The facility reviewed all falls from the previous 30 days to ensure all falls interventions and care plans were updated. The facility provided education to all licensed nurses (agency included) on the fall policy and protocols, interventions and updating the care plan. The facility staff was also educated and competencies were completed with CNA's on the proper transfer and handling of residents. The DON/designee is to audit fall process in the clinical meeting daily for appropriate interventions and care plan updates 5 times a week for 6 weeks. Facility audits were reviewed with no issues identified. Facility nursing staff were interviewed on all units and verbalized training on the above stated issues and how they will respond hence forth. The facility conducted a QAPI (Quality Assurance and Performance Improvement) meeting on 12/20/21 with all required attendees present. During the survey no current residents were identified in the sample with the above deficient practice. After the facility's Quality Assessment and Performance Improvement Action Plan, training documents and audits were reviewed it was determined that the facility was in compliance as of 8/10/22. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on observation, resident interview, staff interview, clinical record review, and a review of facility documents, the facility's staff failed to provide effective pain management for one resident diagnosed with post surgical foot repair for one of eight residents (Resident #8), in a closed record survey sample. The findings included: Resident #8 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnosis for Resident #8 included but not limited Post Traumatic Stress Disorder, Depression, Diabetes Mellitus and Other Orthopedic Conditions. The current Minimum Data Set (MDS), a discharged assessment with an Assessment Reference Date (ARD) of 12/24/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15 indicating resident is cognitively intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with locomotion on and off the unit, dressing, toilet use and personal hygiene. Requiring the supervision of one person with transfers and requires set-up help only with eating. In section M (Skin Conditions) the resident was coded under Other Problems part (E) coded resident as having a surgical wound. M1200-Skin and Ulcer Treatments part (F) coded resident as needing Surgical Wound Care. In section J (Health Conditions) J0100-Pain Management (B) coded resident as receiving prn pain medications. (C) Receive non-medication intervention for pain. J0400- Pain frequency coded the resident as needing pain medication frequently. A review of the careplan reads: Focus: The resident has pain r/t flat foot repair. Created on 12/24/2020. Goals: The resident will display a decrease in behaviors of inadequate pain control through the review date. The resident will not have discomfort related to side effects of analgesia through the review date. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Created on 12/24/20. Interventions: Administer analgesia/medications per orders. assess/record/report to Nurse resident complaints of pain or requests for pain treatment. Identify and record previous pain history and management of that pain and impact on function per routine. Created on 12/24/20. A review of Resident #8's physician order summary reads: Percocet Tablet 10-325 MG (oxycodone-acetaminophen). Give 2 tablets by mouth every 4 hours as needed for pain. Order Date: 12/19/20. Start Date: 12/19/20. Hydromorphone HCI tablet 2 MG give 0.5 by mouth every 3 hours as needed for pain. Order Date: 12/20/20. Start Date 12/20/20. Ibuprofen Tablet 800 MG give 1 tablet by mouth every 6 hours as needed for pain. A review of the MAR (Medication Administration Record) reveals the following: Resident #8 received Hydromorphone HCI tablet 2 mg give 0.5 tablet every 3 hours as needed for pain on the following dates/times: 12/20/20 at 6:46 AM. (pain level 7) (effective). 12/20/20 at 3:04 PM (Pain level 9) (Effective)., 12/23/20 at 1:20 PM (Pain level 7) (effective) and on 12/24/20 at 11:47 AM (Pain level is 9) (Ineffective). Resident was administered Percocet tablets 10-325 mg 2 tabs as needed for pain on the following dates: 12/20/20 4:46 PM (Pain level 8) (Effective). 12/21/20 administered at 3:01 AM (Pain level 6) (Effective)., administered at 9:28 AM (pain level 8) (Effective) and administered at 6:14 PM (Pain level 8) (Effective).12/22/20 administered at 9:07 AM (pain level 5) (Effective) and administered at 4:11 PM (Pain level 9) (Effective). 12/23/20 administered at 4:02 PM (Pain Level is 10) (Effective). 12/24/21 Administered medication at 9:30 AM (pain level 8) (Ineffective) Administered medication at 2:13 PM (Pain Level 8). Ibuprofen 800 mg tablet was administered on 12/24/20 at 5:00 AM (Pain level 3) (Ineffective) and 11:48 AM (Pain level 9) (Drug refused). A review of progress notes revealed the following: According to the admissions note Resident #8 arrived to the facility via stretcher by medical transport on 12/19/20 at 18:41 (6:41 PM) from a local hospital. Reason for Admission: S/P (Status Post) Right foot surgery/Surgical incision to right lateral foot. The Resident's pain level was 7 on arrival to the facility. On 12/20/2020 at 00:59 (12:59 AM) Nursing Note Text: 10:30 This nurse (LPN #5, Licensed Practical Nurse) came to the patient's room, pt (patient) was agitated and complaining about her medication. This nurse explained to the pt that the pharmacy is already processing her narcotic medications and we are just waiting on the code to get her medications. Pt became more agitated and wanted to leave. This nurse explained the patient's rights and the discharge AMA. Pt refused to sign the AMA and left the facility at 2326 (11:26 PM). Pt came back at 2340 and wanted to get her discharge summary from the hospital. This nurse together with LPN #3, and CNA #2 came out the building and tried to calm the patient down and explained the facility protocol. At 0010 (12:10 AM) resident was back to her bed. Resident is now resting. According to the progress notes Resident #8 had pain (pain level 7) issues on arrival to the facility on [DATE] at 6:41 PM until she received her as needed dilaudid/hydromorphone 2 mg 0.5 tablets on 12/20/20 at 6:43 AM. An interview was conducted with Resident #8 on 4/14/21 at approximately, 12:40 PM concerning her pain issues while residing at the facility. She stated, I'm Forty-four years old and alert. I didn't get all of my medications until three days later. I was in a lot of pain when I got there. I didn't get my pain medication until the next morning. I kept trying to leave the facility because I was in pain and didn't feel right being in there. An interview was conducted on 4/15/21 at 7:50 PM with LPN (Licensed Practical Nurse) #3 concerning Resident #8's medications. She stated, When she came here she was not happy because we didn't come to her ASAP (as soon as possible) as she got here right at shift change. She wanted to go AMA (Against Medical Advice) on admission. We couldn't tend to her right away. She requested that nurse, LPN (Licensed Practical Nurse) #6 not help her. I didn't have any issues. She was very particular about her medications. She was knowledgeable about her medications. She was alert and oriented. I only had her that one time. On 4/16/21 at approximately 12:22 PM an interview was conducted with LPN #5 concerning Resident #8's pain medications. She stated, I admitted her. When I received a hospital report she was wanting her pain medications. The nurse at the hospital called and said. We asked if they had a prescription with them. The nurse said she was going to medicate her. I did her assessment. I asked her if she received pain med. She said yes. I saw a prescription in her folder. I faxed it three times. The pharmacy kept saying they didn't receive it. I needed to wait for the code in the STAT box. I got the code around 12 midnight before I left. I gave her dilaudid 1/2 tab at 12 midnight. She was angry. That was the only pill she had. The night nurse was there (LPN #3) She gave her the 6 am meds. We don't have Percocet anymore in the lock box. There's a problem with the fax. I was explaining to her about the meds. She (Resident #8) thought the pharmacy was located inside of here already. When she left the hospital she only had paper work. She was very agitated. Since she came around 7:00 PM it (medication) usually comes around 4:00 am (pharmacy). That's why we have to get medications from the stat box. I called the physician earlier to verify all of the meds. We cannot open the narcotic box until we get the pharmacy code. I called them and they gave me the code and it opened automatically. The resident received meds. The Omnicare issues are related to the fax. They will keep saying they didn't receive it (the fax). I made a copy of my fax and gave them to the former DON (Director of Nursing). When we had the other company we had no issues. She received medications at hospital around 5 PM before being sent here. Since the new company took over we have issues in delay of getting code to the narcotic box due to the fax. A review of the Omnicare Request document for Removal of Schedule II-V (2-5) Medications from the Emergency Supply (ER lock box). Reads: Dilaudid 2 mg po (by mouth) 1 tablet. Quantity Requested: 0.5 mg. Time: 11:45 PM. Prescriber: Facility doctor. Faxed three times on 12/20/20 with the following times listed: 12:01 AM, 12:50:15 AM and 1:40:31 AM. The Pharmacy Response section on the authorization reads: Quantity: 1(one) Reads: (given at 0030). Dated 12/20/20. Time: illegible. Reads: code given to LPN #5 at 12:24 AM. According to the Physician's order summary dated 12/19/20 Resident #8 was scheduled to receive as needed Percocet 10-325 mg (Oxycodone-Acetaminophen) 2 tablets every 4 hours for pain. LPN #5 stated that the emergency lock boxes no longer have percocets inside. On 4/16/20 at 1:26 PM an interview was conducted with the Pharmacy Manager at Omnicare concerning the request for removal of scheduled medications and emergency locked box. She stated, the medication was given at 12:30 AM on 12/20/20. The dilaudid is kept in the box but not the Percocet. There was a pull from the STAT box at 12:30 Midnight. She got the code at Midnight and pulled the medication from the narcotic box. You really can't tell when she opened the box or gave it. The only paper trail is when they fax over the request and when we fax it back. So we usually call each other so no one will get hold of the four digit code. The Pharmacy system failed. There could be situations where their fax machines may not be working or our lines are down. They are required to fax all hard scripts and schedule IV (5) orders. The back-up pharmacy would have been the CVS Pharmacy. They were not opened. They (facility staff) could have called in or the doctor could have called if there were issues. The surveyor asked Pharmacist if she could explain how the ER (Emergency Box) code system works). She stated, There's an electronic pad that requires a code because the DEA (Drug Enforcement Administration) is very strict. They fax a hard script and removal form gives the facility permission to take morphine out for the resident. Giving her the code doesn't mean she went to the box right then. On 4/27/21 at 3:17 PM spoke to the Omnicare Pharmacy Account Manager concerning Pharmacy Response section on the Request for Removal of Schedule 2-5 medications from the Emergency Supply. The Pharmacy Account Manager verified under the Pharmacy Response section the authorization number was correct. The quantity 1 (one) was correct but stated that there are no hand written responses beside the quantity as listed on the copy the said surveyor received via email from the facility. (Reads: given at 0030 in manual print). The time was written as 12:18 AM per Pharmacy Account Manager. The facility's policy on Pain Management and Pain Protocol Date Reviewed and Revised on May 21, 2015. Effective May 27, 2011. It is the policy of this facility to ensure any resident that is admitted to the facility is assessed for pain and or the potential for pain in order for the resident to obtain or maintain his or her highest practicable level of physical, mental and psychological well being in accordance with the comprehensive assessment and plan of care. Procedure: A pain evaluation will occur on admission to the facility. The resident will be reassessed for pain at regular intervals. On 04/16/21 at approximately 3:52 p.m., the above findings were shared with the Administrator and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. COMPLAINT DEFICIENCY

Based on observation, staff interviews, clinical record review and facility document review the facility staff failed to implement an assistive device to prevent an avoidable accident during a transfer that resulted in a fracture for one of 21 residents in the survey sample, Resident #12. The facility staff failed to implement a (Hoyer) mechanical lift device to transfer Resident #21 from the bed to a wheelchair per the resident's identified needs and plan of care. On 10/12/16 during a pivot transfer the resident's leg gave out and the resident sustained [REDACTED]. Hoyer lifts, or mechanical lifts, are devices used to transfer heavy or completely dependent patients. The lifts are designed to protect both patient and worker from injury during transfer. The findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a significant change with an assessment reference date of 10/24/16 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the residents cognition was intact. The resident required assistance of two staff for bed mobility and transfers and had limited range of motion to the lower extremities. The resident was coded as having a fall with a major injury. Review of the comprehensive plan of care dated 6/24/16 identified two problems related to falls as follows: 1. The resident was at risk for falls related to weakness, impaired mobility, incontinence, history of falls, non-ambulatory, flaccid left sided hemiparesis. The goal was that the resident would demonstrate the ability to transfer without a fall related injury. Two interventions listed were to remind the resident to call for assistance before moving from bed-to-chair and from chair-to-bed, and use Hoyer lift for transfer. 2. Patient (resident) has a history of refusing mechanical lift. The goal was that the patient will use the Hoyer lift for transfers. Interventions listed was for the staff to educate the patient (resident) on safety and importance of Hoyer lift for transfers and to transfer using Hoyer lift with two person assist for all transfers. An initial Facility Reported Incident (FRI) was faxed to the State Survey Agency on 10/12/16 of an unusual occurrence involving Resident #12. The FRI indicated the resident was transferred by a CNA (Certified Nurse Aide) without the use of a mechanical lift. Upon transfer from the bed to the wheelchair the CNA heard a pop from the residents left shoulder and immediately notified a nursing staff. An X-ray was obtained and showed a sub-acute left humerus fracture (long bone in the arm or forelimb that runs from the shoulder to the elbow). The FRI summary report of the facility's internal investigation and conclusion was reviewed. The resident had requested to sit on her wheelchair. The resident told the CNA, help me stand on my good leg so I can Pivot to the chair because I hate the lift. The CNA performed the transfer manually instead of the mechanical lift, that resulted in a fracture. On 1/18/16 at 10:40 a.m., the CNA (certified nurse aide #2) was interviewed. The CNA stated the resident had requested to be transferred from the bed to the wheelchair. The resident had refused the lift stating, She doesn't like to use the machine at all .she has a fear of the lift . The CNA stated she had taken care of the resident previously and was aware that if the resident refused to use the mechanical lift she was to report this to the charge nurse first. The charge nurse would then come to the room and educate the resident about the need to use the mechanical lift, at times the residents daughter would also be called to speak with the resident. The CNA stated during the pivot transfer she had placed her arms around the resident like a bear hug, the resident lost balance, the residents left arm went up, and then she heard a pop. The CNA stated she immediately left the room to get a nurse after placing the resident in the wheelchair. The CNA was questioned if she had access to a gait belt to be used during resident transferred, she stated, Yes, they are kept in the staff lounge. The CNA was asked if she used the gait belt for the transfer of Resident #12, she stated, No. The CNA stated, I had pivoted her before without using a gait belt. A gait belt is a device used to transfer people from one position to another, from one thing to another or while ambulating people that have problems with balance. For example, you would use a gait belt to move a patient from a standing position to a wheelchair. On 1/18/17 at 2:27 p.m., the staff development coordinator (SDC) was interviewed. The SDC stated, I was coming down the hallway and saw the CNA, she looked as if she was in need of someone .she looked upset and distressed. She asked me if I could come and take a look at the resident .I immediately looked at the resident's shoulder .the resident stated she was okay. The SDC left to get the unit manager. On 1/18/17 at 2:40 p.m., the Bayside unit manager was interviewed. The unit manager stated, I was called to the room by (name of SDC), we both went to the resident's room and assessed the resident .her shoulder looked swollen . The unit manager stated, the CNA took matters into her own hands .the resident wanted to be transferred .the CNA shouldn't have transferred the resident .during the pivot her legs got weak .it was done incorrectly .she did cause harm. The resident refused to go to the emergency room for evaluation. An x-ray was done at the facility and evidenced a fracture to the proximal humerus. The resident was prescribed Percocet 325 milligrams 2 tablets every 4 hours as needed for pain, a left arm sling was placed on the resident and an orthopedic appointment was made, On 1/17/16 at 2:30 p.m., the resident was observed sitting up in the wheelchair at the bedside. A sensor alarm was attached to the back of the wheelchair to alert staff if the resident attempted to get up unassisted. The resident stated she has lower leg pain on and off, and denied any other pain at this time. The resident stated she gets up out of bed with a lift. During the survey days residents were observed to be transferred according to their plan of care. In response to the inappropriate transfer the facility developed a corrective action plan as follows: 1. The resident refused to go to the emergency room . X-rays were obtained. An orthopedic appointment was scheduled. The interdisciplinary team reviewed the resident's plan of care with revisions developed and implemented to address the resident's individualized needs to include pain management regiment and therapy evaluation for transfer needs. 2. Identification of all residents requiring a mechanical lift who have the potential to be affected. 3. The SDC/Designee will provide education to the nursing staff and new nursing staff regarding standards of practice for performing resident transfers. Education will include validation of skills competency for the nursing staff regarding the operation of the mechanical lift by October 25, 2016. The nursing staff will perform resident transfers in accordance with the resident's plan of care and the established standards. 4. The DON (Director of Nursing)/ Designee will review 100% of the medical records of resident's that require the utilization of a mechanical lift for transfer assistance to validate implementation of appropriate measures per the residents' plan of care. The Clinical Managers will conduct staff observations of 10% of resident to validate adherence to the plan of care during transfers for four weeks then monthly for three months. Findings will be reported to the QAPI (Quality Assurance Performance Improvement) Committee for further review and recommendations. 5. Date of completion October 25, 2016. The facility met the criteria for past non-compliance for F-323 with a corrective action date of 10/25/16. The above findings was shared with the Administrator, the acting Director of Nursing and the Director of Clinical Services during a pre-exit meeting conducted on 1/19/17 at 4:20 p.m. The administrator stated there have not been any falls since 10/25/16 related to the failure to use a mechanical lift.