Every finding on record at San Rafael Health and Rehabilitation

Based on observation, interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse for 2 (Resident #35 and Resident #38) of 3 residents reviewed for abuse. Specifically, on 11/26/2023, RN #6 yelled in Resident #38's face, shook the resident, and insisted the resident allow staff to transfer the resident back to bed. Staff who witnessed the abuse did not immediately report the incident to administration, which resulted in a delay in initiating an investigation and implementing protective measures to prevent further abuse. As a result, RN #6 continued working in the facility and was involved in another incident of abuse toward Resident #38 on 11/26/2023. The facility's investigation of the incidents did not include interviews with other residents to determine if they had witnessed abuse or may have also been abused by RN #6 and did not include skin assessments to determine if other residents had bruises or other injuries that may have been attributed to abuse. Additionally, on 03/20/2024, the facility reported an allegation of resident-to-resident abuse for Resident #35. The facility's investigation did not include obtaining a copy of the sheriff's office report and a witness statement from the nurse assigned to the resident's care at the time the alleged incident occurred. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, F610 S483.12(c)(2) ? (4) Alleged Violations-Investigate/Prevent/Correct at a scope and severity of J. The IJ began on the night shift on 11/24/2023, when RN #6 forcibly transferred Resident #38 from a recliner to bed against the resident's will. The certified nurse aides (CNAs) who witnessed the transfer did not immediately report the incident despite feeling they had witnessed verbal and physical abuse, which allowed RN #6 to continue working with access to the resident. As a result of this, RN #6 was involved in a second incident, in which he grabbed Resident #38, shaking the resident by the arms and shirt collar before the resident agreed to allow the CNAs to transfer them back to the bed from their recliner. Once the facility was made aware of the incidents, they did not complete a thorough investigation, to include documenting any interviews completed with the staff involved and interviewing all residents and staff who could have had information regarding the incidents or about RN #6's treatment of residents. Additionally, the facility did not conduct skin assessments of other residents who received care from RN #6 to determine if there were any bruises or other injuries that may have been a result of abuse. On 11/13/2024 at 5:26 PM, the Administrator was informed of the IJ situation and provided a completed IJ template. A removal plan was requested. The removal plan was accepted by the State Survey Agency (SSA) on 11/15/2024 at 4:37 PM. The IJ was removed on 11/15/2024 at 6:50 PM after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance remained at the lower scope and severity of D, no actual harm with the potential for more than minimal harm. Findings included: A facility policy titled, Policy and Procedure for Prohibiting Abuse, dated 02/2017, revealed, Administrator or designee will investigate incidents and administrator will be responsible for reporting initial allegations and the results of the investigations to proper authorities. The policy also specified, 3. The administration will initiate the investigation process by immediately interviewing staff and residents who have any knowledge of the allegation. According to the policy, 5. Investigation including documentation of all interviews will be completed within 5 working days, and 8. After the investigation is complete and within no more than 5 working days, the administrator will document a summary of findings and report those findings to all agencies which were initially notified. 1. An Admission Record revealed the facility admitted Resident #38 on 11/01/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right side paralysis and weakness following a stroke), muscle wasting and atrophy, difficulty walking, and anxiety disorder. Per the Admission Record, the facility discharged the resident on 08/06/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had physical and verbal behavioral symptoms directed toward others that significantly interfered with the resident's care and put others at significant risk for physical injury and disrupted the care and living environment of others. The MDS revealed that the resident rejected care one to three days during the assessment look-back period and was always incontinent of bladder and bowel. A DLBC [Division of Licensing and Background] - Form 358: Facility Reported Incidents document revealed that on 11/28/2023 at 2:30 PM, the Administrator reported allegations of Physical Abuse and Mental/Verbal Abuse of Resident #38 by RN #6. The document revealed CNAs, including CNAs #2, #8, #9, and #10, became aware of the incident on 11/24/2023 in the Early Morning and notified administration on 11/28/2023 at 2:00 PM. The document revealed the CNAs were trying to put the resident into bed from the resident's recliner, and when the resident did not want to go to bed, RN #6 went into Resident #38's room, yelled in the resident's face that the resident needed to get into bed, grabbed the resident's arms and wrist, and shook the resident. Per the document, RN #6 gave the resident a choice to let the CNAs put them in bed or RN #6 would do it, then counted down from five. The document indicated RN #6 then grabbed the resident by their arms and legs and moved the resident to their bed. The document indicated Resident #38 told RN #6 to stop hurting them. The facility's investigation documents included an undated, handwritten statement provided to the facility by CNA #2, an undated, handwritten statement provided to the facility by CNA #8, and an undated, typed statement provided to the facility by CNA #10, all of which contained a description of RN #6 being verbally and physically abusive to Resident #38. CNA #10's statement indicated she and CNA #2 did not know what to do in the situation because they both had to work with RN #6 for the remainder of the night, and CNA #10 and CNA #9 were also scheduled to work with RN #6 over the following two days. The typed statement revealed, We [CNA #10 and CNA #2] both decided that we were going to write a report, but we weren't going to turn it in till the next week when [RN #6] wasn't working. CNA #10's statement also included details of a second incident that occurred on 11/26/2023, in which CNA #10 was attempting to change Resident #38's brief while CNA #9 was providing care for the resident's roommate. According to the statement, CNA #10 realized Resident #38 had a large bowel movement and that she needed to transfer the resident to bed for incontinence care. The statement indicated Resident #38 refused to allow CNA #10 and CNA #9 to use a mechanical lift to transfer the resident to bed. According to the statement, the CNAs also asked CNA #8 to assist with the transfer, but they were unable, so they notified RN #6. The statement indicated that when RN #6 entered the resident's room, he said I'm here now and you know what that means. The statement indicated that the RN's comment scared the resident and when the resident became upset, RN #6 got even more angry and grabbed the resident's arms like he did the other day (11/24/2023) and started kinda [kind of] shaking the resident. Per the statement, the resident repeatedly said RN #6 was hurting them and to stop. The statement indicated she and CNA #8 did not discuss this incident, but with what happened the other day, she knew she needed to include this encounter in her report. A Follow-Up Investigation Report, dated as submitted to the State on 12/04/2023, included a section for the facility to document a summary of interviews with other residents who may have had contact with the alleged perpetrator. This section indicated, No interviews with other residents occurred. The report indicated that Resident #38 was interviewed and denied being abused. The report revealed the facility unsubstantiated the abuse allegation. The facility's investigation did not include interviews with any other residents regarding their experiences with RN #6 or any skin assessments to determine if there were any bruises or other injuries that may have been attributed to physical abuse. During an interview on 10/16/2024 at 11:22 AM, the Administrator stated the information he had provided to the survey team was pretty much all the information he had for the investigation. He stated he did not maintain any documentation regarding the incident and just input the information into the reports he sent to the state survey agency. He stated that he could see that by not having the documents, it did not look like a full investigation. He stated, If it wasn't documented, it didn't happen. During an interview on 10/16/2024 at 1:33 PM, the Administrator stated he did not have any more information to provide. During an interview on 10/18/2024 at 9:42 AM, the Director of Nursing (DON) stated that when completing an investigation, someone should interview everyone who was involved in an incident, including nurses. She stated she did not interview all the aides who worked the night of the incident. She stated that they tried to investigate the details and find out if it was validated or not. She stated that according to the resident, the incident was a not big issue and there was nothing to worry about. The DON stated she did not feel they did a thorough investigation into the incident. She stated that they did not interview any other residents to see if they had issues with RN #6. She stated that staff did complete skin checks on a daily basis, but there was nothing officially completed for this incident. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated that aside from the above referenced written statements, he did not document any interviews as a part of the investigation. During a telephone interview on 11/11/2024 at 3:25 PM, CNA #2 said the incident involving Resident #38 and RN #6 had occurred approximately a year prior, so she could not recall the exact details. CNA #2 stated the incident she witnessed was observed by herself, CNA #9, and CNA #10. According to CNA #2, a second incident was witnessed by CNA #8 on another day, and a few days later, when CNA #2 and CNA #8 were both working, they wrote the statements they provided to the facility. During a telephone interview on 11/11/2024 at 4:06 PM, CNA #10 stated she wrote her statement after witnessing the second incident. CNA #10 indicated she could no longer recall all the details, but she recalled that she and CNA #2 were trying to provide incontinence care to the resident, and the resident refused. According to CNA #10, RN #6 came in and grabbed the resident's hands, and the resident told the nurse to stop because it hurt. CNA #10 said RN #6 grabbed the resident's hand and leg and tossed the resident into bed. During a follow-up telephone interview on 11/14/2024 at 1:59 PM, CNA #10 said she considered both incidents she witnessed to be abuse because Resident #38 did not want RN #6 to move them, but RN #6 did not care what the resident wanted. CNA #10 further stated the facility had only questioned her about one of the two incidents she reported. During a telephone interview on 11/11/2024 at 1:18 PM, CNA #8 stated on the night in question, she, CNA #2, and RN #6 went into Resident #38's room. According to CNA #8, RN #6 went over and started yelling at the resident, grabbed the resident's shirt, and kind of shook and yelled at the resident. CNA #8 could not recall exactly what RN #6 said to the resident but indicated RN #6 was being very aggressive with the resident. CNA #8 said Resident #38 looked scared during the incident. CNA #8 said that following this incident, CNA #2 told her about another incident CNA #2 had witnessed, so CNA #2 and CNA #8 both wrote the statements they later provided to the facility. CNA #8 said she had never seen RN #6 act this way with other residents and described the incident as shocking. During a follow-up telephone interview on 11/14/2024 at 12:11 PM, CNA #8 clarified that there was one incident involving CNAs #8, #9, and #10, RN #6, and Resident #38, and there was a separate incident that CNA #2 was involved in on a different day. CNA #8 said she considered the incident she witnessed to be physical abuse due to the way RN #6 grabbed Resident #38's shirt and shook the resident. During an interview on 10/17/2024 at 9:41 AM, RN #6 said there was a time when he did pick Resident #38 up and put the resident in bed. According to RN #6, Resident #38 was agitated when RN #6 went into their room. RN #6 said the resident was seated in their recliner with their brief still on and their pants pulled halfway down. RN #6 said fecal matter was coming out of the resident's brief. Per RN #6, he put his arm underneath the resident's left arm and told the resident he could not leave them like that. According to RN #6, Resident #38 required two people for transfers and could not support their weight, so RN #6 had to hold the resident's legs in an awkward position. RN #6 said the resident's recliner was positioned against the bed, and the resident was precariously positioned on the recliner, so he lifted the resident, which caused his own shoulder to pop; however, RN #6 stated it felt as though the resident was lying on the ground and felt like he had to heave the resident up on the bed. During an interview with the DON on 11/12/2024 at 9:30 AM, the DON confirmed she had received the statements from CNAs #2, #8, and #10; however, the DON stated she was only aware of one incident involving Resident #38. During an interview on 11/12/2024 at 10:49 AM, the Administrator stated he was only aware of one incident between RN #6 and Resident #38. He was not aware of any other incidents. During a follow-up interview on 11/12/2024 at 3:13 PM, the Administrator read over the statements provided to the facility by CNAs #2, #8, and #10. The Administrator said he obviously forgot there were multiple incidents reported because it had been almost a year. He confirmed that per the statements, multiple incidents were reported and based on the statements, it sounded bad. During an interview on 11/12/2024 at 4:01 PM, the DON stated she would have interviewed about the second incident if she had realized there were two incidents. She did not document her interviews with the aides anywhere. As far as how they came up with their determination of unsubstantiated, she stated they interviewed RN #6 and suspended him and talked to the aides a little bit. She stated, The resident was the priority and if [the resident] tells me [they are] fine, then I assume [they are] okay. During a telephone interview on 11/13/2024 at 12:12 PM, the Chief Executive Officer (CEO), stated if an alleged perpetrator (AP) was a staff member, they should be suspended and not allowed in the building until the conclusion of the investigation. He stated when conducting the investigation, the staff should interview any potential witnesses, anyone who was in the area who may have seen or heard anything, including any witnesses. He indicated there should be an assessment of the resident to ensure there were no injuries and that assessment should be documented. He stated if it was determined through investigation that there were any other residents who were potentially involved, they would interview them. He had in the past asked alert and oriented residents if they had had any issues with staff and how they had been treated, without giving the name of the staff person to protect them. He stated any staff who were involved or who were identified during the course of the investigation should also be interviewed. He stated he felt like the Administrator should have had better documentation of the investigation into the allegations and felt the Administrator had done a lot more than what he documented. He stated he knew the Administrator interviewed more people than what he documented. The facility submitted a removal plan that was accepted by the state survey agency on 11/15/2024 at 4:44 PM. The removal plan indicated the following: 1. Training was started on 11/14/2024 at 12:00 PM. Training will be provided by Chief Operating Officer (COO) to Administrator, the Director of Nursing (DON), and Assistant Director of Nursing (ADON) on how to recognize abuse, the types of abuse, when to report abuse, and who to report the abuse to, as well as how to conduct a proper and thorough investigation, to include statements from residents, statements from staff involved, as well as interview other staff and residents. The facility has also established an abuse committee, that includes Administrator, DON, ADON, RA [Resident Advocate], and COO or CEO for the Management Company to assure the correct outcome of the reported incidence. The abuse committee will be part of our regularly scheduled QAPI [Quality Assurance and Performance Improvement] meetings where we will discuss any issues that may have come up and determine the appropriate actions. The training was completed on 11/14/2024. The CEO from the management company started training 11/14/2024 with individuals and in small groups of all other employees on the abuse policy and procedures, reporting, and investigations prior to them working on their next shift 11/15/2024. 2. The full investigation of alleged incidents regarding Registered Nurse (RN) #6 from November 2023 will be performed with COO, CEO and the Administrator as part of Administrator training. The investigation started 11/14/2024 and will be completed by 11/15/2024. All residents were interviewed in this process by RA. With the COO, CEO, Administrator and DON, additional interviews are being done in connection with the incident back in November 2023. During this investigation, RN #6 has been suspended pending the findings of the investigation. - The COO met with the Administrator, DON, ADON, and RA and trained them on abuse training to include staff interviews and resident interviews and to create an abuse committee, that includes Administrator, DON, ADON, RA, and COO to meet together to review the evidence and interviews to come to the right conclusion. This was completed 11/14/2024. - The COO for the management company provided 1:1 and training with DON, ADON, Administrator, and RA on proper investigation processes, to include resident interviews and staff interviews, which included a resident interview form and staff interview form. This was completed on 11/14/2024. - Having trained the DON and ADON on proper staff interviews, along with the Administrator, the COO then directed the DON and ADON to conduct all staff interviews and give the staff the opportunity to express any concerns they may have related to proper treatment of residents. The CEO, in training, also asked all staff if they had any concerns with the treatment of patients. This was completed 11/15/2024. 3. The Medical Director was notified on 11/14/2024 at 4:15 PM about the immediate jeopardy and was updated about the current removal plan. MD was in agreement to proceed with removal plan. 4. The ad hoc Quality Assurance and Performance Improvement (QAPI) meeting is scheduled for 11/15/2024. Discussed in the QAPI meeting were abuse policy and procedures, Utah Healthcare Association abuse training from September 2022, investigation training. CEO, DON, ADON, RA, and Administrator were present. 5. CEO and COO will be reviewing incidents from November 2023 regarding RN #6 through the survey process and future investigations, making sure that the investigation was done properly, and all documentation and interviews are done. Will review the findings from the committee and sign off on investigations after they are completed. Will be reviewed 11/15/2024 before 12:00 PM. The immediacy of the IJ was removed on 11/15/2024, 4:37 PM. On 11/15/2024, the survey team conducted on-site verification to confirm the facility had implemented the above written removal plan, as follows: 1. The team was able to verify that the Administrator, DON, ADON, and the RA received training on abuse investigations, including conducting interviews as part of the investigation. This was verified by conducting interviews with these staff members and reviewing training documentation provided by the facility. Staff In-Service sheets revealed facility staff members received copies of and were educated on the facility's abuse policies, including recognizing the signs and symptoms of abuse/neglect, immediate reporting, investigations, and protection measures. Interviews were conducted with 14 staff, including dietary staff, housekeeping staff, laundry staff, two Licensed Practical Nurses (LPNs), one RN, the ADON, DON, RA, and Administrator, to verify they had received and understood the in-service materials. Per the inservice records, the facility was able to in-service all staff except for two, who were out of the state/country. The plan to in-service these staff was to provide the in-service prior to their next scheduled shifts. Neither staff were on the schedule until after the end of the month. 2. The survey team reviewed the facility's investigation into the allegations of abuse from November 2023. The facility's investigation revealed the facility interviewed all 41 residents residing in the facility at the time of the current survey, interviewed all staff involved in the November 2023 incidents, and interviewed other staff who may have had knowledge of the incidents. Per the facility's Abuse Committee minutes, dated 11/14/2024, the facility was unable to substantiate abuse had occurred after completing their investigation. The team was able to verify that the Administrator, DON, ADON, and the RA received training on abuse investigations, including conducting interviews as part of the investigation. This was verified by conducting interviews with these staff members and reviewing training documentation provided by the facility. 3. During a telephone interview on 11/15/2024 at 5:53 PM, the Medical Director confirmed the facility notified them on 11/14/2024 of the IJ findings and updated them on the removal plan. 4. QAPI- Abuse Prevention, Reporting & Investigation Sub-Committee minutes, dated 11/15/2024 at 3:15 PM, revealed the facility's QAPI committee met on 11/15/2024 to discuss abuse policy and procedures and the outcome of the facility's investigation into the 11/2023 incidents. According to the minutes, the facility did not substantiate abuse related to the 11/2023 incidents. 5. The survey team reviewed the facility's investigation into the allegations of abuse from November 2023. The facility's investigation revealed the facility interviewed all 41 residents residing in the facility at the time of the current survey, interviewed all staff involved in the November 2023 incidents, and interviewed other staff who may have had knowledge of the incidents. 40141 2. An Admission Record indicated that the facility admitted Resident #35 on 10/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, seizures, bipolar disorder, and anxiety disorder. A quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2024, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had disorganized thinking that fluctuated. Resident #35's care plan included a focus area initiated on 10/23/2023, that indicated the resident had impaired cognitive function or impaired thought processes related to dementia. An intervention directed staff to monitor, document, and report any changes in cognitive function (initiated 10/23/2023). The care plan also revealed a focus area initiated on 07/08/2024, that indicated the resident had a low cognitive level and had difficulties with recall and orientation. An Admission Record indicated that the facility admitted Resident #36 on 02/16/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of dementia. An admission MDS, with an ARD of 02/26/2024, revealed Resident #36 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #36's care plan included a focus area initiated on 05/23/2024, that indicated the resident had a behavior of being possessive of some of the residents. Interventions directed staff to intervene as necessary to protect the rights and safety of others and to redirect the resident from residents of whom they were possessive (initiated 05/23/2024). Resident #36's Progress Notes revealed a Behavior Note, dated 03/19/2024 at 8:52 PM and electronically signed by Registered Nurse (RN) #17, that revealed Certified Nurse Aide (CNA) #11 reported that Resident #36 was rude to her when she went to get Resident #35's clothes for a bath. The note indicated that CNA #11 reported that Resident #36 had shown aggression toward Resident #35 and the CNA. Resident #36's Progress Notes revealed a Behavior Note, dated 03/19/2024 at 9:39 PM and electronically signed by Registered Nurse (RN) #17, that revealed that earlier in the shift, CNA #11 entered Resident #35 and Resident #36's room to assist Resident #35 with a shower. The note indicated that Resident #36 indicated that they were in charge of Resident #35 and that they (Resident #36) were not going to let Resident #35 go with the CNA. Per the note, CNA #11 informed Resident #36 that Resident #35 could make their own decisions. The note indicated that Resident #36 got up and tried to block the door, but CNA #11 was able to exit the room. A DLBC [Division of Licensing and Background]-358 Facility reported incidents document, revealed the facility reported Sexual Abuse, Mental/Verbal Abuse to the state survey agency on 03/20/2024 at 11:00 AM. According to the report, on 03/19/2024 on the evening shift, CNA #11 went to get Resident #35 for a bath. Resident #36 blocked CNA #11 from taking Resident #35, grabbed and shook CNA #11, and told her that they (Resident #36) were in charge of Resident #35. The document indicated that Resident #36 stated that CNA #11 could not take Resident #35 to the shower and tried to lock CNA #11 out of the room. Per the document, a nurse relocated Resident #35 to another part of the facility to get them away from Resident #36. The document indicated that Resident #35 told the nurse in the morning that Resident #36 had tried to force Resident #35 to have sex. The document indicated that administration was notified of the incident on 03/20/2024 in the Early Morning by RN #17. A Follow-Up Investigation Report, submitted to the state survey agency on 03/26/2024, revealed that the sheriff's office interviewed Resident #35 and indicated they did not feel like the situation needed any further investigation because Resident #35 stated that nothing happened. The Follow-Up Investigation Report did not include an interview or statement from RN #17. The investigation provided by the facility did not include a copy of the sheriff's office report or a statement from RN #17. A handwritten statement, dated 03/26/2024 and signed by CNA #11, indicated that the CNA had walked into Resident #35 and Resident #36's room to help Resident #35 with a shower and Resident #36 became upset. The statement indicated that Resident #36 tried to stop them from leaving the room and became agitated. Per the statement, CNA #11 was able to remove herself from the room and reported the incident to RN #17. The statement indicated while giving Resident #35 a shower, Resident #35 reported that they were scared of Resident #36, and revealed that Resident #36 had demanded they (Resident #35) have sex with them (Resident #36). The statement indicated that CNA #11 reported to RN #17 what Resident #35 had said to her after the shower, and Resident #35 was moved to another room. During a telephone interview on 10/16/2024 at 6:35 PM, CNA #11 stated that on the night of the incident, she was walking with Resident #35 in the room to get ready to go get a shower when Resident #36 got angry, stood up, and started walking toward Resident #35. CNA #11 stated that Resident #36 had started shaking her, then after a minute or two, the resident calmed down and the CNA and Resident #35 left the room. CNA #11 indicated there were times that Resident #35 liked Resident #36 and then times when Resident #35 said they hated Resident #36. CNA #11 stated that Resident #36 tried to have sex with Resident #35 but Resident #35 refused. CNA #11 stated that she was not aware of any sexual activity that occurred, and that Resident #35 told the CNA that they had never had sex. CNA #11 stated that she reported the incident to RN #17 that night. During an interview on 10/18/2024 at 9:35 AM, the Director of Nursing (DON) stated that CNA #11 was getting Resident #35 for a shower and Resident #36 became anxious and told CNA #11 that she could not take Resident #35 for a shower. The DON stated that Resident #36 would not let CNA #11 leave, and when she was able to leave, she reported the incident to the nurse. The DON stated that the incident happened after 6:00 PM. The DON stated that whoever received the allegation would initiate a report, then give that to the Administrator and he would notify the state survey agency. She stated that Resident #35 reported that Resident #36 tried to force them to have sex. The DON stated that the investigation was not thorough and stated that they should have a copy of the sheriff office's report to keep with the facility's documentation. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated that the incident between Resident #35 and Resident #36 occurred on 03/19/2024, and Resident #35 was moved to another room. He stated that it was brought to their attention later that Resident #35 stated that Resident #36 tried having sex with them (Resident #35). The Administrator stated that staff spoke with Resident #35, who denied anything happened. The Administrator stated that a sheriff's deputy interviewed the resident and determined that nothing happened. He stated that he did not have a copy of the sheriff's office report but that he should. He stated that not everything was in the facility's investigation, to include the sheriff's office report and nurse witness statements. He stated that he expected a more thorough investigation and to have evidence of what the facility had done.

Based on interview, record review, and facility document and policy review, the facility failed to ensure staff immediately reported allegations of abuse for 3 (Residents #38, #35 and #3) of 4 residents reviewed for abuse. Specifically, on 11/24/2024, certified nurse aides (CNAs) witnessed an incident involving Registered Nurse (RN) #6 and Resident #38 in which RN #6 aggressively transferred Resident #38 against their will; however, the CNAs who witnessed the transfer did not immediately report that they considered what they witnessed to be abusive, which allowed RN #6 to continue working with access to the resident. Subsequently, the CNAs witnessed a second incident on 11/26/2023 in which RN #6 grabbed Resident #38 and shook the resident to convince the resident to allow staff to transfer them back to their bed for care. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.12(c)(1) Reporting of Alleged Violations, F609, at a scope and severity of J. The IJ began on the nightshift on 11/24/2023 when RN #6 aggressively transferred Resident #38 from a recliner to the bed without consent from the resident, and the CNAs did not immediately report what they witnessed. Subsequently on 11/26/2024, CNAs again witnessed RN #6 grab Resident #38 and shake the resident to convince the resident to allow staff to transfer them back to their bed for care. The CNAs did not report either incident to facility management until 11/28/2023. On 11/13/2024 at 5:26 PM, the Administrator was informed of the IJ situation and provided a completed IJ template. A removal plan was requested. The removal plan was accepted by the State Survey Agency (SSA) on 11/15/2024 at 4:44 PM. The IJ was removed on 11/15/2024 at 6:50 PM after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance remained at the lower scope and severity of D, no actual harm with the potential for more than minimal harm. Additional findings were identified related to Resident #35 and Resident #3. Specifically, on the evening of 03/19/2024 after being notified of an allegation of potential resident-to resident sexual abuse involving Resident #35, RN #17 failed to immediately notify management of the allegation, and as a result, the facility did not submit an initial report to the SSA until 03/20/2024 at 11:00 AM. In addition, staff members aware of an allegation that Resident #3 was verbally abused by RN #6 failed to immediately report the allegation to management on 10/11/2024. Also, once management was informed of the allegation of abuse on 10/14/2024, the facility failed to report the allegation to the SSA within two hours. Findings included: A facility policy titled, Policy and Procedure for Prohibiting Abuse, dated 02/2017, revealed, It is the policy of this facility to provide person-centered care by promoting the well-being of its residents in a safe and supportive environment. The facility prohibits any abuse. Our residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat a resident's symptoms. The section of the policy titled, Reporting Protocol revealed, 1. Any person who suspects that abuse, neglect or misappropriation of property may have occurred, will immediately report the alleged violation to the facility administration and/or advocacy agencies according to the law. 2. The Administration will immediately notify Adult Protective Services or local law enforcement authority, the local long term care Ombudsman and State Survey and Certification for all allegations of abuse, neglect or exploitation. 1. An Admission Record revealed the facility admitted Resident #38 on 11/01/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle wasting and atrophy, difficulty walking, and anxiety disorder. Per the Admission Record, the facility discharged the resident on 08/06/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had physical and verbal behavioral symptoms directed towards others that significantly interfered with the resident's care and put others at significant risk for physical injury and disrupted the care and living environment of others. The MDS revealed the resident rejected care one to three days during the assessment look-back period. The MDS revealed that the resident had a functional limitation in range of motion on one side of their upper and lower extremities. Per the MDS, the resident required partial to moderate assistance from staff with upper body dressing and required substantial/maximal assistance with lower body dressing and toileting hygiene. The MDS indicated the resident was always incontinent of bladder and bowel. A DLBC [Division of Licensing and Background] - Form 358: Facility Reported Incidents document revealed that on 11/28/2023 at 2:30 PM, the Administrator reported allegations of Physical Abuse and Mental/Verbal Abuse of Resident #38 by RN #6. The document revealed CNAs, including CNAs #2, #8, #9, and #10, became aware of the incident on 11/24/2023 in the Early Morning and notified administration on 11/28/2023 at 2:00 PM. The document revealed the CNAs were trying to put the resident into bed from the resident's recliner, and when the resident did not want to go to bed, RN #6 went into Resident #38's room, yelled in the resident's face that the resident needed to get into bed, grabbed the resident's arms and wrist, and shook the resident. Per the document, RN #6 gave the resident a choice to let the CNAs put them in bed or RN #6 would do it, then counted down from five. The document indicated RN #6 then grabbed the resident by their arms and legs and moved the resident to their bed. The document indicated Resident #38 told RN #6 to stop hurting them. Statements provided by the facility, written by CNAs #2, #8, and #10, detailed allegations regarding incidents that allegedly occurred on 11/24/2023, 11/26/2023, and 11/28/2023. The details of the CNA witness statements were as follows: An undated, handwritten statement provided to the facility by CNA #2 revealed that on 11/24/2023, RN #6 asked that she and CNA #10 attempt to get Resident #38 into bed. The statement indicated that when the resident refused, RN #6 demanded the resident get into bed. According to the statement, Resident #38 kept saying they were fine in their chair and did not want to get into bed, but RN #6 grabbed the resident by their shirt and told the resident they had to, no matter what. The statement indicated that the resident crossed their arms in an attempt to get away from RN #6, telling the nurse to get away from them and that RN #6 was hurting them. The statement indicated RN #6 grabbled the resident by the wrist angrily. Per the statement, after about 20 minutes of the RN and the resident going back and forth, RN #6 told the resident they had five seconds to decide if the CNAs or if he (RN #6) was going to get the resident into bed. The statement indicated that RN #6 then held up five fingers, counted down, then grabbed the resident by the wrist and ankle and pushed the resident on the bed so aggressively that it moved the whole bed. An undated, typed statement provided to the facility by CNA #10 revealed that on 11/24/2024 RN #6 instructed her and CNA #2 to let him know if Resident #38 refused to allow the CNAs to transfer them. The statement indicated the resident refused to get in bed twice, so the CNAs notified RN #6. The statement indicated RN #6 went into the resident's room and told the resident to Get in the [expletive] bed. The statement indicated the resident kept refusing, and RN #6 grabbed the resident by the top of their shirt and shook them, telling the resident, You need to get in your bed or you'll [you will] die sitting in this chair. Per the statement, the resident still refused and told RN #6, You should just leave me alone, but RN #6 grabbed both of the resident's arms while they were crossed against the resident's chest and shook the resident. Resident #38 said, You're [You are] hurting me. Per the statement, CNA #10 and CNA #2 looked at each other and were unsure what to do, while RN #6 continued talking to the resident about a risk verses benefit form that the resident could sign in a few days to allow the resident to stay in bed all the time. Per the statement, Resident #38 responded and said, I want to leave this place, and Let me die. The statement indicated RN #6 then grabbed the resident by an arm and a leg and threw the resident onto the bed, and the resident almost fell off the bed in the process. Per the statement, RN #6 shoved the bed over very aggressively and grabbed the resident again and pulled them, then shoved the bed back against the wall. Per the statement, the resident stated, That big guy is a monster. According to the statement, CNA #10 and CNA #2 did not know what to do in the situation because they both had to work with RN #6 for the remainder of the night, and CNA #10 and CNA #9 had to also work with RN #6 over the following two days. The typed statement revealed, We [CNA #10 and CNA #2] both decided that we were going to write a report, but we weren't [were not] going to turn it in till [until] the next week when [RN #6] wasn't [was not] working. The report further indicated that following the incident, RN #6 stopped CNA #10 and CNA #2 in the hallway to tell them he did not want any of that to happen; he just did not want anyone to die on his watch, as though he was just trying to justify the whole situation. In addition, the statement indicated CNA #10 and CNA #2 also spoke with CNA #9 to see what she felt about it, but it seemed to them that CNA #9 kept on justifying that what he did was okay. The typed statement from CNA #10 also included details of a second incident that occurred on 11/26/2023. Per the statement, on 11/26/2023, CNA #10 was attempting to change Resident #38's brief while CNA #9 was providing care for the resident's roommate; however, CNA #10 realized Resident #38 had a large bowel movement and needed to transfer to their bed for incontinence care. The statement indicated Resident #38 refused to allow CNA #10 and CNA #9 to use a mechanical lift to transfer the resident to bed. According to the statement, the CNAs also asked CNA #8 to assist with the transfer, but they were unable, so they notified RN #6. The statement indicated that when RN #6 entered the resident's room, he said I'm here now and you know what that means. The statement indicated that the RN's comment scared the resident and when the resident became upset, RN #6 got even more angry and grabbed the resident's arms like he did the other day (11/24/2023) and started kinda [kind of] shaking the resident. Per the statement, the resident repeatedly said RN #6 was hurting them and to stop. The statement indicated she and CNA #8 did not discuss this incident, but with what happened the other day, she knew she needed to include this encounter in her report. An undated, handwritten statement provided to the facility by CNA #8 indicated that on 11/28/2023, she, CNA #10, and CNA #9 were attempting to change Resident #38's brief but the resident refused, and RN #6 was notified. According to the statement, RN #6 got in [the resident's] face and yelled at the resident. The statement indicated RN #6 told the resident they were going to place the resident into a mechanical lift without asking. Per the statement, RN #6 was shaking the resident's arms, and the resident kept repeating, Ow. During an interview on 10/17/2024 at 8:56 AM, CNA #2 stated she had never experienced a situation like she did in 11/2023 and did not know what to do. CNA #2 said she had the Director of Nursing's (DON's) number but did not know why she did not call the DON about the incident. During a follow-up telephone interview on 11/11/2024 at 3:25 PM, after reading the statement provided to the facility by CNA #2 regarding the alleged incident on 11/24/2023, CNA #2 confirmed she had written the statement and indicated the date and details of the incident were accurate to the best of her knowledge. CNA #2 said the incident occurred approximately a year prior, so she could not recall the exact details. CNA #2 stated the incident she witnessed was observed by herself, CNA #9, and CNA #10. According to CNA #2, a second incident was witnessed by CNA #8 on another day, and a few days later, when CNA #2 and CNA #8 were both working, they wrote the statements they provided to the facility. CNA #2 said that she and CNA #8 slid their statements under the DON's door. During a telephone interview on 11/11/2024 at 4:06 PM, after reading the statement provided to the facility by CNA #10 regarding the alleged incidents on 11/24/2023 and 11/26/2023, CNA #10 confirmed she had written the statement and indicated the dates of the incidents referenced in her statement were accurate. CNA #10 said she wrote the statement after witnessing the second incident. CNA #10 said she could no longer recall all the details, but she recalled that she and CNA #2 were trying to provide incontinence care to the resident, and the resident refused. According to CNA #10, RN #6 came in and grabbed the resident's hands, and the resident told the nurse to stop because it hurt. CNA #10 said RN #6 grabbed the resident's hand and leg and tossed the resident into bed. CNA #10 said she thought they had reported the incidents a few days later when they were not scheduled to work with RN #6. According to CNA #10, she was not trained on how to report abuse and did not know how to report abuse until after the incidents with Resident #38 and RN #6. During a telephone interview on 11/11/2024 at 1:18 PM, after reading the statement provided to the facility by CNA #8 regarding the alleged incident on 11/28/2023, CNA #8 confirmed she had written the statement but indicated the date of 11/28/2023 was not correct because RN #6 did not work that day. CNA #8 stated the incident she described occurred over the weekend, either on Saturday (11/25/2023) or Sunday (11/26/2023). CNA #8 said, aside from the date, the details of what she wrote in her statement were accurate. CNA #8 stated on the night in question, she, CNA #2, and RN #6 went into Resident #38's room. According to CNA #8, RN #6 went over and started yelling at the resident, grabbed the resident's shirt, and kind of shook and yelled at the resident. CNA #8 could not recall exactly what RN #6 said to the resident but indicated RN #6 was being very aggressive with the resident. CNA #8 said Resident #38 looked scared during the incident. CNA #8 said that following this incident, CNA #2 told her about another incident CNA #2 had witnessed, so CNA #2 and CNA #8 both wrote the statements they later provided to the facility. CNA #8 said she and CNA #2 slid their statements under the DON's door, and she thought they discussed the incidents with the DON the following week. During an interview on 10/18/2024 at 9:42 AM, the DON stated allegation of abuse should be reported immediately. The DON said if the alleged abuser was a nurse, the CNAs had her number and could call her. During a follow-up interview on 11/12/2024 at 9:30 AM, the DON said she learned of the alleged incidents involving RN #6 and Resident #38 when she found the statements provided by the CNAs on Tuesday morning (11/28/2023). According to the DON, once she became aware, she immediately notified the Administrator. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated that he reported abuse allegations to the SSA. He stated that any allegations of abuse should be reported within two hours. He stated that CNAs should be reporting to their nurse, then the nurse would report to the manager. The Administrator stated that if a CNA witnessed what they felt was abuse by the charge nurse, they should immediately report it to their manager. The Administrator said the CNAs should have immediately reported the incident on the night they saw it, but he thought they did not report it until a few days later. During an interview on 11/12/2024 at 10:49 AM, the Administrator confirmed the CNAs had not reported the incidents involving Resident #38 and RN #6 until 11/28/2023. The Administrator said staff should always report any allegations of abuse so the facility could take any necessary steps to protects the residents and so the facility could investigate to determine if abuse occurred. The facility submitted a removal plan that was accepted by the SSA on 11/15/2024 at 4:44 PM. The removal plan indicated the following: 1. Training was initiated on 11/14/2024 at 12:00 PM. The training was provided by Chief Operating Officer (COO) to the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) on how to recognize abuse, the types of abuse, when to report abuse, and who to report the abuse to, as well as how to conduct a proper and thorough investigation, to include statements from residents, statements from staff involved, as well as interview other staff and residents. We also established an abuse committee that includes Administrator, DON, ADON, RA, and someone from the corporate office to determine the correct outcome of the reported incidence. The abuse committee will be part of our regularly scheduled quality assurance and performance improvement (QAPI) meetings. We will discuss any issues that may have come up and determine appropriate corrective actions. Training was completed 11/14/2024. The CEO from the management company started training 11/14/24 with individuals, and small groups, with all other employees on company abuse policy and procedures, the importance of reporting immediately any suspected abuse, to report any suspected abuse to the Administrator. All staff are required to have this training prior to working their next shift beginning 11/15/2024. 2. The Chief Executive Officer (CEO) will communicate via face to face, via Zoom, or Facetime to all staff members currently employed by the facility on proper identification of abuse and immediately reporting of all suspected abuse. Documentation will be completed on day of training. Each staff will receive a copy of the abuse policy and will be required to sign they have received the training from the corporate officer prior to coming on shift. All staff will be made aware of where to find the Administrator's and DON's numbers which are located behind the nurses' station, so they will be able to contact them if an incident needs to be reported. Training will start 11/14/2024 and will be completed 11/15/2024. 3. Three of the four employees that had knowledge and reported late, no longer work at the facility. Certified Nurse Aide (CNA) #10's term date was 4/23/2024, CNA #8 Term date was 2/11/2024, and CNA #9 term date was 5/6/2024. CNA #2 is currently working at the facility and is getting 1:1 training about the abuse policy, when to report the abuse, and who to report the abuse to by the CEO prior to their shift on 11/15/2024. 4. The ad hoc Quality Assurance and Performance Improvement (QAPI) is scheduled for 11/15/2024. Discussed in the QAPI meeting were abuse policy and procedures, Utah Healthcare Association abuse training from September 2022, investigation training. The investigation process currently ongoing related to one suspended employee. The CEO, DON, ADON, RA, and Administrator were present. 5. Training will be done with all new staff in 1:1 or small group orientation and all agency personnel before they start work on any shifts. The Human Resources department, Administrator or DON will provide training on the abuse policy and procedures. 6. The Medical Director was notified of the immediate jeopardy on 11/14/2024 at 4:15 PM. The MD was also updated with the current removal plan for the immediate jeopardy. The MD was in agreement to proceed with the removal plan. 7. All staff will have the opportunity to report any incidents or concerns related to patient safety in 1:1 interviews with DON, ADON, or Administrator. Further opportunity has been provided by CEO of the corporate office through the abuse training conducted 1:1 and in small groups training as well as via facetime and zoom trainings. The immediacy of the IJ was removed on 11/15/2024, 4:37 PM. On 11/15/2024, the surveyor team conducted on-site verification to confirm the facility had implemented the above written removal plan, as follows: 1. The team was able to verify that the Administrator, DON, ADON, and the RA received training on abuse investigations, including conducting interviews as part of the investigation. This was verified by conducting interviews with these staff members and reviewing training documentation provided by the facility. Staff In-Service sheets revealed facility staff members received copies of and were educated on the facility's abuse policies, including recognizing the signs and symptoms of abuse/neglect, immediate reporting, investigations, and protection measures. Interviews were conducted with 14 staff, including dietary staff, housekeeping staff, laundry staff, two Licensed Practical Nurses (LPNs), one RN, the ADON, DON, RA, and Administrator, to verify they had received and understood the in-service materials. Per the inservice records, the facility was able to in-service all staff except for two, who were out of the state/country. The plan to in-service these staff was to provide the in-service prior to their next scheduled shifts. Neither staff were on the schedule until after the end of the month. Abuse Committee minutes, dated 11/14/2024, reveled the facility established an abuse committee that consisted of the Administrator, DON, ADON, RA, and a member of corporate staff. 2. Staff In-Service sheets revealed facility staff members received copies of and were educated on the facility's abuse policies, including recognizing the signs and symptoms of abuse/neglect, immediate reporting, investigations, and protection measures. Interviews were conducted with 14 staff, including dietary staff, housekeeping staff, laundry staff, two Licensed Practical Nurses (LPNs), one RN, the ADON, DON, RA, and Administrator, to verify they had received and understood the in-service materials. Per the inservice records, the facility was able to in-service all staff except for two, who were out of the state/country. The plan to in-service these staff was to provide the in-service prior to their next scheduled shifts. Neither staff were on the schedule until after the end of the month. 3. Staff In-Service sheets revealed CNA #2 received copies of and was educated on the facility's abuse policies, including recognizing the signs and symptoms of abuse/neglect and immediate reporting. CNAs #8, #9, and #10's personnel files were reviewed to verify they were no longer employed by the facility. 4. QAPI- Abuse Prevention, Reporting & Investigation Sub-Committee minutes, dated 11/15/2024 at 3:15 PM, revealed the facility's QAPI committee, including the CEO, Administrator, DON, ADON, and RA, met on 11/15/2024 to discuss abuse policy and procedures and the outcome of the facility's investigation into the 11/2023 incidents. 5. Staff In-Service sheets revealed facility staff members received copies of and were educated on the facility's abuse policies, including recognizing the signs and symptoms of abuse/neglect, immediate reporting, investigations, and protection measures. Interviews were conducted with 14 staff, including dietary staff, housekeeping staff, laundry staff, two Licensed Practical Nurses (LPNs), one RN, the ADON, DON, RA, and Administrator, to verify they had received and understood the in-service materials. Per the inservice records, the facility was able to in-service all staff except for two, who were out of the state/country. The plan to in-service these staff was to provide the in-service prior to their next scheduled shifts. Neither staff were on the schedule until after the end of the month. 6. During a telephone interview on 11/15/2024 at 5:53 PM, the Medical Director confirmed the facility notified them on 11/14/2024 of the IJ findings and updated them on the removal plan. 7. Staff Investigation Report Forms revealed the facility conducted staff interviews to determine if any staff had knowledge of any other potential abuse. 40141 2. An Admission Record indicated that the facility admitted Resident #35 on 10/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, seizures, bipolar disorder, and anxiety disorder. A quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2024, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had disorganized thinking that fluctuated. An Admission Record indicated that the facility admitted Resident #36 on 02/16/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of dementia. An admission MDS, with an ARD of 02/26/2024, revealed Resident #36 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #36's Progress Notes revealed a Behavior Note, dated 03/19/2024 at 8:52 PM and electronically signed by Registered Nurse (RN) #17, that revealed Certified Nurse Aide (CNA) #11 reported that Resident #36 was rude to her when she went to get Resident #35's clothes for a bath. The note indicated that CNA #11 reported that Resident #36 had shown aggression toward Resident #35 and the CNA. Resident #36's Progress Notes revealed a Behavior Note, dated 03/19/2024 at 9:39 PM and electronically signed by RN #17, that revealed that earlier in the shift, CNA #11 entered Resident #35 and Resident #36's room to assist Resident #35 with a shower. The note indicated that Resident #36 indicated that they were in charge of Resident #35 and that they (Resident #36) was not going to let Resident #35 go with the CNA. Per the note, CNA #11 informed Resident #36 that Resident #35 could make their own decisions. The note indicated that Resident #36 got up and tried to block the door, but CNA #11 was able to exit the room. A DLBC [Division of Licensing and Background]-358 Facility reported incidents document, revealed the facility reported Sexual Abuse, Mental/Verbal Abuse to the state survey agency on 03/20/2024 at 11:00 AM, indicating that on 03/19/2024 on the evening shift, CNA #11 went to get Resident #35 for a bath. The document revealed that Resident #36 blocked CNA #11 from taking Resident #35, grabbed and shook CNA #11, and told her that they (Resident #36) were in charge of Resident #35. The document indicated that Resident #36 stated that CNA #11 could not take Resident #35 to the shower and tried to lock CNA #11 out of the room. Per the document, a nurse relocated Resident #35 to another part of the facility to get them away from Resident #36. The document indicated that Resident #35 told the nurse in the morning that Resident #36 had tried to force Resident #35 to have sex. The document indicated that administration was notified of the incident on 03/20/2024 in the Early Morning by RN #17. A handwritten statement, dated 03/26/2024 and signed by CNA #11, indicated that the CNA had walked into Resident #35 and Resident #36's room to help Resident #35 with a shower and Resident #36 became upset. The statement indicated that Resident #36 tried to stop them from leaving the room and became agitated. Per the statement, CNA #11 was able to remove herself from the room and reported the incident to RN #17. The statement indicated while giving Resident #35 a shower, Resident #35 reported that they were scared of Resident #36, and revealed that Resident #36 had demanded they (Resident #35) have sex with them (Resident #36). The statement indicated that CNA #11 reported to RN #17 what Resident #35 had said to her after the shower, and Resident #35 was moved to another room. During a telephone interview on 10/16/2024 at 6:35 PM, CNA #11 stated that on the night of the incident, she was walking with Resident #35 in the room to get ready to go get a shower when Resident #36 got angry, stood up, and started walking toward Resident #35. CNA #11 stated that Resident #36 had started shaking her, then after a minute or two, the resident calmed down and the CNA and Resident #35 left the room. CNA #11 indicated there were times that Resident #35 liked Resident #36 and then times when Resident #35 said they hated Resident #36. CNA #11 stated that Resident #36 tried to have sex with Resident #35 but Resident #35 refused. CNA #11 stated that she was not aware of any sexual activity that occurred, and that Resident #35 told the CNA that they had never had sex. CNA #11 stated that she reported the incident to RN #17 that night. During a telephone interview on 10/17/2024 at 11:34 AM, RN #17 stated that she did not receive a report of Resident #36 trying to force Resident #35 to have sex. RN #17 stated that she was not at the facility when the incident occurred. During an interview on 10/18/2024 at 9:35 AM, the Director of Nursing (DON) stated that CNA #11 was getting Resident #35 for a shower and Resident #36 became anxious and told CNA #11 that she could not take Resident #35 for a shower. The DON stated that Resident #36 would not let CNA #11 leave, and when she was able to leave, she reported the incident to the nurse. The DON stated that the incident happened after 6:00 PM. The DON stated that whoever received the allegation would initiate a report, then give that to the Administrator and he would notify the state survey agency. She stated that Resident #35 reported that Resident #36 tried to force them to have sex. The DON stated the allegation should have been reported to the state survey agency the night of the incident. The DON stated that the report revealed that RN #17 was the nurse that night and administration was not notified until the following morning. The DON stated that the incident was reported to the state survey agency at 11:00 AM the following day and was not reported in the required timeframe. The DON stated it should have been reported immediately to administration and the Administrator should have come in to start the investigation. The DON stated she expected reporting of abuse to be done immediately. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated that the incident between Resident #35 and Resident #36 occurred on 03/19/2024, and Resident #35 was moved to another room. He stated that it was brought to their attention later that Resident #35 stated that Resident #36 tried having sex with them (Resident #35). The Administrator stated that the state survey agency should have been notified within two hours and stated that it did not look like the allegation had been reported timely, as it was reported at 11:00 AM the following day. 22445 3. An Admission Record revealed the facility admitted Resident #3 on 03/11/2020 and most recently on 06/29/2024. According to the Admission Record, the resident had a medical history that included unspecified bipolar disorder, panic disorder, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (paralysis on the left side of the body following a stroke). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #3 had a Brief Interview for [TRUNCATED]

Based on observation, interview, record review, and facility document and policy review, the facility failed to protect Resident #38's right to be free from verbal and physical abuse perpetrated by Registered Nurse (RN) #6. This deficient practice affected 1 (Resident #38) of 4 sampled residents reviewed for abuse. Specifically, on 11/24/2023, RN #6 ; however, the CNA. On 11/26/2023, RN #6 yelled in Resident #38's face, shook the resident, and insisted the resident allow staff to transfer the resident back to bed. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F600, at a scope and severity of J. The IJ began during the nightshift on 11/24/2023 when RN #6 aggressively transferred Resident #38 from the recliner to the bed without consent from the resident. The certified nurse aides (CNAs) who witnessed the transfer did not immediately report what happened after they witnessed what they considered to be abusive, which allowed RN #6 to continue working with access to the resident. Subsequently, the CNAs witnessed a second incident on 11/26/2023 in which RN #6 grabbed Resident #38 and shook the resident to convince the resident to allow staff to transfer them back to their bed for care. On 11/13/2024 at 5:26 PM, the Administrator was informed of the IJ situation and provided a completed IJ template. A removal plan was requested. The removal plan was accepted by the State Survey Agency (SSA) on 11/15/2024 at 4:44 PM. The IJ was removed on 11/15/2024 at 6:50 PM after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance remained at a lower scope and severity of D, no actual harm with the potential for more than minimal harm. Findings included: A facility policy titled, Policy and Procedure for Prohibiting Abuse, dated 02/2017, revealed, It is the policy of this facility to provide person-centered care by promoting the well-being of its residents in a safe and supportive environment. The facility prohibits any abuse. Our residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat a resident's symptoms. The policy indicated, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy defined verbal abuse as the use of oral, written, or gestural language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance and indicated, Physical abuse includes hitting, slapping, pinching and kicking and controlling behavior through corporal punishment and, Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation including doing so on social media. An Admission Record revealed the facility admitted Resident #38 on 11/01/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle wasting and atrophy, difficulty walking, and anxiety disorder. Per the Admission Record, the facility discharged the resident on 08/06/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had physical and verbal behavioral symptoms directed towards others that significantly interfered with the resident's care and put others at significant risk for physical injury and disrupted the care and living environment of others. The MDS revealed the resident rejected care one to three days during the assessment look-back period. The MDS revealed that the resident had a functional limitation in range of motion on one side of their upper and lower extremities. Per the MDS, the resident required partial to moderate assistance from staff with upper body dressing and required substantial/maximal assistance with lower body dressing and toileting hygiene. The MDS indicated the resident was always incontinent of bladder and bowel. A DLBC [Division of Licensing and Background] - Form 358: Facility Reported Incidents document revealed that on 11/28/2023 at 2:30 PM, the Administrator reported allegations of Physical Abuse and Mental/Verbal Abuse of Resident #38 by RN #6. The document revealed CNAs, including CNAs #2, #8, #9, and #10, became aware of the incident on 11/24/2023 in the Early Morning and notified administration on 11/28/2023 at 2:00 PM. The document revealed the CNAs were trying to put the resident into bed from the resident's recliner, and when the resident did not want to go to bed, RN #6 went into Resident #38's room, yelled in the resident's face that the resident needed to get into bed, grabbed the resident's arms and wrist, and shook the resident. Per the document, RN #6 gave the resident a choice to let the CNAs put them in bed or RN #6 would do it, then counted down from five. The document indicated RN #6 then grabbed the resident by their arms and legs and moved the resident to their bed. The document indicated Resident #38 told RN #6 to stop hurting them. The DLBC- Form 358: Facility Reported Incidents document included only information related to an alleged incident on 11/24/2023; however, statements provided by the facility, written by CNAs #2, #8, and #10, detailed allegations regarding incidents that allegedly occurred on 11/24/2023, 11/26/2023, and 11/28/2023. The facility had no documentation of a statement provided by CNA #9. The details of the CNA witness statements were as follows: An undated, handwritten statement provided to the facility by CNA #2 revealed that on 11/24/2023, RN #6 asked that she and CNA #10 attempt to get Resident #38 into bed. The statement indicated that when the resident refused, RN #6 demanded the resident get into bed. According to the statement, Resident #38 kept saying they were fine in their chair and did not want to get into bed, but RN #6 grabbed the resident by their shirt and told the resident they had to, no matter what. The statement indicated that the resident crossed their arms in an attempt to get away from RN #6, telling the nurse to get away from them and that RN #6 was hurting them. The statement indicated RN #6 grabbled the resident by the wrist angrily. Per the statement, after about 20 minutes of the RN and the resident going back and forth, RN #6 told the resident they had five seconds to decide if the CNAs or if he (RN #6) was going to get the resident into bed. The statement indicated that RN #6 then held up five fingers, counted down, then grabbed the resident by the wrist and ankle and pushed the resident on the bed so aggressively that it moved the whole bed. An undated, typed statement provided to the facility by CNA #10 revealed that on 11/24/2024 RN #6 instructed her and CNA #2 to let him know if Resident #38 refused to allow the CNAs to transfer them. The statement indicated the resident refused to get in bed twice, so the CNAs notified RN #6. The statement indicated RN #6 went into the resident's room and told the resident to Get in the [expletive] bed. The statement indicated the resident kept refusing, and RN #6 grabbed the resident by the top of their shirt and shook them, telling the resident, You need to get in your bed or you'll [you will] die sitting in this chair. Per the statement, the resident still refused and told RN #6, You should just leave me alone, but RN #6 grabbed both of the resident's arms while they were crossed against the resident's chest and shook the resident. Resident #38 said, You're [You are] hurting me. Per the statement, CNA #10 and CNA #2 looked at each other and were unsure what to do, while RN #6 continued talking to the resident about a risk versus benefit form that the resident could sign in a few days to allow the resident to stay in bed all the time. Per the statement, Resident #38 responded and said, I want to leave this place, and Let me die. The statement indicated RN #6 then grabbed the resident by an arm and a leg and threw the resident onto the bed, and the resident almost fell off the bed in the process. Per the statement, RN #6 shoved the bed over very aggressively and grabbed the resident again and pulled them, then shoved the bed back against the wall. Per the statement, the resident stated, That big guy is a monster. According to the statement, CNA #10 and CNA #2 did not know what to do in the situation because they both had to work with RN #6 for the remainder of the night, and CNA #10 and CNA #9 had to also work with RN #6 over the following two days. The typed statement revealed, We [CNA #10 and CNA #2] both decided that we were going to write a report, but we weren't [were not] going to turn it in till [until] the next week when [RN #6] wasn't [was not] working. The report further indicated that following the incident, RN #6 stopped CNA #10 and CNA #2 in the hallway to tell them he did not want any of that to happen; he just did not want anyone to die on his watch, as though he was just trying to justify the whole situation. In addition, the statement indicated CNA #10 and CNA #2 also spoke with CNA #9 to see what she felt about it, but it seemed to them that CNA #9 kept on justifying that what he did was okay. The typed statement from CNA #10 also included details of a second incident that occurred on 11/26/2023. Per the statement, on 11/26/2023, CNA #10 was attempting to change Resident #38's brief while CNA #9 was providing care for the resident's roommate; however, CNA #10 realized Resident #38 had a large bowel movement and needed to transfer to their bed for incontinence care. The statement indicated Resident #38 refused to allow CNA #10 and CNA #9 to use a mechanical lift to transfer the resident to bed. According to the statement, the CNAs also asked CNA #8 to assist with the transfer, but they were unable, so they notified RN #6. The statement indicated that when RN #6 entered the resident's room, he said I'm here now and you know what that means. The statement indicated that the RN's comment scared the resident and when the resident became upset, RN #6 got even more angry and grabbed the resident's arms like he did the other day (11/24/2023) and started kinda [kind of] shaking the resident. Per the statement, the resident repeatedly said RN #6 was hurting them and to stop. The statement indicated she and CNA #8 did not discuss this incident, but with what happened the other day, she knew she needed to include this encounter in her report. An undated, handwritten statement provided to the facility by CNA #8 indicated that on 11/28/2023, she, CNA #10, and CNA #9 were attempting to change Resident #38's brief but the resident refused, and RN #6 was notified. According to the statement, RN #6 got in [the resident's] face and yelled at the resident. The statement indicated RN #6 told the resident they were going to place the resident into a mechanical lift without asking. Per the statement, RN #6 was shaking the resident's arms, and the resident kept repeating, Ow. Review of timecards for CNAs #2, #8, #9, and #10 and RN #6 revealed CNAs #2, #9, and #10 and RN #6 worked together during the nightshift on 11/24/2023 at the time of the first incident, and CNAs #8, #9, and #10 and RN #6 worked together during the nightshift on 11/26/2023. During a telephone interview on 11/11/2024 at 3:25 PM, after reading the statement provided to the facility by CNA #2 regarding the alleged incident on 11/24/2023, CNA #2 confirmed she had written the statement and indicated the date and details of the incident were accurate to the best of her knowledge. CNA #2 said the incident occurred approximately a year prior, so she could not recall the exact details. CNA #2 stated the incident she witnessed was observed by herself, CNA #9, and CNA #10. According to CNA #2, a second incident was witnessed by CNA #8 on another day, and a few days later, when CNA #2 and CNA #8 were both working, they wrote the statements they provided to the facility. During a follow-up telephone interview on 11/14/2024 at 3:56 PM, CNA #2 said she considered the incident she witnessed as physical abuse because of the way RN #6 moved Resident #38, despite the resident not wanting to move. During a telephone interview on 11/11/2024 at 4:06 PM, after reading the statement provided to the facility by CNA #10 regarding the alleged incidents on 11/24/2023 and 11/26/2023, CNA #10 confirmed she had written the statement and indicated the dates of the incidents referenced in her statement were accurate. CNA #10 said she wrote the statement after witnessing the second incident. CNA #10 said she could no longer recall all the details, but she recalled that she and CNA #2 were trying to provide incontinence care to the resident, and the resident refused. According to CNA #10, RN #6 came in and grabbed the resident's hands, and the resident told the nurse to stop because it hurt. CNA #10 said RN #6 grabbed the resident's hand and leg and tossed the resident into bed. During a follow-up telephone interview on 11/14/2024 at 1:59 PM, CNA #10 said she considered both incidents she witnessed as abuse because Resident #38 did not want RN #6 to move them, but RN #6 did not care what the resident wanted. CNA #10 further stated the facility had only questioned her about one of the two incidents she reported. During a telephone interview on 11/11/2024 at 1:18 PM, after reading the statement provided to the facility by CNA #8 regarding the alleged incident on 11/28/2023, CNA #8 confirmed she had written the statement but indicated the date of 11/28/2023 was not correct because RN #6 did not work that day. CNA #8 stated the incident she described occurred over the weekend, either on Saturday (11/25/2023) or Sunday (11/26/2023). CNA #8 said, aside from the date, the details of what she wrote in her statement were accurate. CNA #8 stated on the night in question, she, CNA #2, and RN #6 went into Resident #38's room. According to CNA #8, RN #6 went over and started yelling at the resident, grabbed the resident's shirt, and kind of shook and yelled at the resident. CNA #8 could not recall exactly what RN #6 said to the resident but indicated RN #6 was being very aggressive with the resident. CNA #8 said Resident #38 looked scared during the incident. CNA #8 said that following this incident, CNA #2 told her about another incident CNA #2 had witnessed, so CNA #2 and CNA #8 both wrote the statements they later provided to the facility. CNA #8 said she had never seen RN #6 act this way with other residents and described the incident as shocking. During a follow-up telephone interview on 11/14/2024 at 12:11 PM, CNA #8 clarified that there was one incident involving CNAs #8, #9, and #10, RN #6, and Resident #38, and there was a separate incident that CNA #2 was involved in on a different day. CNA #8 said she considered the incident she witnessed as physical abuse due to the way RN #6 grabbed Resident #38's shirt and shook the resident. During an interview on 10/17/2024 at 9:41 AM, RN #6 said there was a time when he did pick Resident #38 up and put the resident in bed. According to RN #6, Resident #38 was agitated when RN #6 went into their room. RN #6 said the resident was seated in their recliner with their brief still on and their pants pulled halfway down. RN #6 said fecal matter was coming out of the resident's brief. Per RN #6, he put his arm underneath the resident's left arm and told the resident he could not leave them like that. According to RN #6, Resident #38 required two people for transfers and could not support their weight, so RN #6 had to hold the resident's legs in an awkward position. RN #6 said the resident's recliner was positioned against the bed, and the resident was precariously positioned on the recliner, so he lifted the resident, which caused his shoulder to pop; however, RN #6 stated it felt as though the resident was lying on the ground and felt like he had to heave the resident up on the bed. During an interview with the DON on 11/12/2024 at 9:30 AM, the DON confirmed she had received the statements from CNAs #2, #8, and #10; however, the DON stated she was only aware of one incident involving Resident #38. During a follow-up interview on 11/12/2024 at 4:01 PM, the DON stated that after reading the statements from CNA #2, #8, and #10 again, it sounded as though there were two separate incidents. The DON said that according to the statements, the dates were matching up, except for the one dated 11/28/2023, which she assumed was probably a wrong date because RN #6 did not work that day. During an interview on 11/12/2024 at 10:49 AM, the Administrator stated he was only aware of one incident between RN #6 and Resident #38. He was not aware of any other incidents. During a follow-up interview on 11/12/2024 at 3:13 PM, the Administrator read over the statements provided to the facility by CNAs #2, #8, and #10. The Administrator said he obviously forgot there were multiple incidents reported because it had been almost a year. He confirmed that per the statements, multiple incidents were reported and based on the statements, it sounded bad. The facility submitted a removal plan that was accepted by the SSA on 11/15/2024 at 4:44 PM. The removal plan indicated the following: 1. Per facility policy, Registered Nurse (RN) #6 was suspended immediately at 11:00 AM on 11/14/2024, pending the outcome of the investigation into the alleged incidents dated November of 2023. 2. With the help of the Corporate Officer, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Resident Advocate (RA), the Administrator will reinvestigate alleged abuse incidents from November 2023. The investigation of the incident dated November 2023 started on 11/14/2024 and will be completed by 11/18/2024 or before. The November 2023 incident is being investigated by the CEO, Administrator and DON. All residents were interviewed through this process by RA, ADON and /or DON, additional interviews are being conducted in connection with the incident in November 2023. During this investigation RN #6 has been suspended pending the findings of the investigation. - The Chief Operating Officer (COO) met with the Administrator and DON and trained them on abuse investigation to include staff interviews and resident interviews and to create an abuse committee that includes Administrator, DON, ADON, RA, and COO to meet and review the evidence and interviews to come to the right conclusion. The abuse committee will be part of our regular quality assurance and performance improvement (QAPI) meetings where we will discuss any issues that may have come up and determine the correct actions. The training was provided by the COO to the DON, ADON, and RA on 11/14/2024. - The COO Provided 1:1 training with DON, ADON, Administrator, and Resident Advocate (RA) on proper investigation, to include resident interviews and staff interviews. The training included a resident interview form and staff interview form. This was completed on 11/14/2024. - The Corporate Officer conducting the investigation, having trained the RA, and instructed the RA to conduct all resident interviews. Having trained the DON and ADON on proper staff interviews along with the Administrator, the Corporate Officer directed the DON and ADON to conduct interviews of all staff interviews and provide an opportunity to express any concerns related to treatment of residents. Training and in-service are being given to all staff members by the CEO on abuse and proper and timely abuse reporting. The CEO, in training, is asking all staff if they have any concerns with the treatment of patients. Training of Administrator, DON, ADON, and RA completed 11/14/2024. 3. After training by Corporate Officer on 11/14/2024 to RA on proper interview questions on an abuse incident, the RA went with the Minimum Data Set (MDS) Coordinator and conducted all interviews with residents. RA conducted all interviews and MDS Coordinator went as a witness to all interviews. Residents that are not able to communicate were assessed to make sure there was no concerns of abuse. Based on interviews with all residents, there was no evidence of abuse of other residents found. All reported they feel safe and know who to report to if abuse occurred. 4. Findings of the November 2023 incident will be reported to the survey team and the state survey and certification agency and the appropriate actions will be taken to either substantiate or unsubstantiate whether abuse occurred. 5. The Chief Executive Officer (CEO) will communicate face to face to each staff member on proper identification of abuse and reporting of abuse timely. Each staff will receive a copy of the abuse policy and will be required to sign they have received the training from the CEO prior to coming on shift. All staff will be made aware of where to find the Administrator and DON's phone numbers, which are located behind the nurses' station, so they will be able to contact them if an incident needs to be reported. Training will start 11/14/2024 and will be completed 11/15/2024 or prior to a staff member working their next scheduled shift. 6. The ad hoc quality assurance and performance improvement (QAPI) meeting is scheduled for 11/15/2024. Discussed in the QAPI meeting were abuse policy and procedures, Utah Healthcare Association abuse training from September 2022, investigation training. Investigation and findings of the November 2023 incident. The CEO, DON, ADON, RA, and Administrator are present. 7. The Medical Director was notified on 11/14/2024 at 4:15 PM about the immediate jeopardy and was updated about the current removal plan. MD was in agreement to proceed with removal plan. The immediacy of the IJ was removed on 11/15/2024, 4:37 PM. On 11/15/2024, the survey team conducted on-site verification to confirm the facility had implemented the above written removal plan, as follows: 1. During an interview on 11/15/2024 at 5:51 PM, the Administrator and CEO stated RN #6 was provided disciplinary action over the phone, since he was unable to come to the facility due to an illness. They also reported RN #6 was notified he was suspended pending the outcome of the facility's investigation into the 11/2023 incidents. 2. The survey team reviewed the facility's investigation into the allegations of abuse from November 2023. The facility's investigation revealed the facility interviewed all 41 residents residing in the facility at the time of the current survey, interviewed all staff involved in the November 2023 incidents, and interviewed other staff who may have had knowledge of the incidents. Per the facility's Abuse Committee minutes, dated 11/14/2024, the facility was unable to substantiate abuse had occurred after completing their investigation. The team was able to verify that the Administrator, DON, ADON, and the RA received training on abuse investigations, including conducting interviews as part of the investigation. This was verified by conducting interviews with these staff members and reviewing training documentation provided by the facility. Staff In-Service sheets revealed facility staff members received copies of and were educated on the facility's abuse policies, including recognizing the signs and symptoms of abuse/neglect, immediate reporting, investigations, and protection measures. Interviews were conducted with 14 staff, including dietary staff, housekeeping staff, laundry staff, two Licensed Practical Nurses (LPNs), one RN, the ADON, DON, RA, and Administrator, to verify they had received and understood the in-service materials. Per the inservice records, the facility was able to in-service all staff except for two, who were out of the state/country. The plan to in-service these staff was to provide the in-service prior to their next scheduled shifts. Neither staff were on the schedule until after the end of the month. 3. The survey team reviewed the facility's investigation into the allegations of abuse from November 2023. The facility's investigation revealed the facility interviewed all 41 residents residing in the facility at the time of the current survey. 4. The survey team reviewed the facility's investigation into the allegations of abuse from November 2023. The facility's investigation revealed the facility interviewed all 41 residents residing in the facility at the time of the current survey, interviewed all staff involved in the November 2023 incidents, and interviewed other staff who may have had knowledge of the incidents. Per the facility's Abuse Committee minutes, dated 11/14/2024, the facility was unable to substantiate abuse had occurred after completing their investigation. 5. Staff In-Service sheets revealed facility staff members received copies of and were educated on the facility's abuse policies, including recognizing the signs and symptoms of abuse/neglect, immediate reporting, investigations, and protection measures. Interviews were conducted with 14 staff, including dietary staff, housekeeping staff, laundry staff, two Licensed Practical Nurses (LPNs), one RN, the ADON, DON, RA, and Administrator, to verify they had received and understood the in-service materials. Per the inservice records, the facility was able to in-service all staff except for two, who were out of the state/country. The plan to in-service these staff was to provide the in-service prior to their next scheduled shifts. Neither staff were on the schedule until after the end of the month. 6. QAPI- Abuse Prevention, Reporting & Investigation Sub-Committee minutes, dated 11/15/2024 at 3:15 PM, revealed the facility's QAPI committee met on 11/15/2024 to discuss abuse policy and procedures and the outcome of the facility's investigation into the 11/2023 incidents. According to the minutes, the facility did not substantiate abuse related to the 11/2023 incidents. 7. During a telephone interview on 11/15/2024 at 5:53 PM, the Medical Director confirmed the facility notified them on 11/14/2024 of the IJ findings and updated them on the removal plan.

Based on observation, interview, facility document review, and facility policy review, the facility failed to put interventions in place to prevent future falls for 2 (Resident #35 and Resident #27) of 2 residents reviewed for falls. The failure resulted in Resident #35 sustaining falls on 11/04/2023 which resulted in a laceration to the resident's head, 12/19/2023, 02/23/2024 which resulted in a right clavicle fracture, 05/21/2024 which resulted in an abrasion to their left knee, 07/12/2024, 07/22/2024 which resulted in swelling to the face and an abrasion on the nose, 07/27/2024, and 08/06/2024 with no evidence the facility initiated interventions after the falls to prevent future falls. Additionally, the facility failed to complete wandering assessments, ensure a resident was safe from eloping from the facility, and failed to investigate to find the root cause of an elopement for 1 (Resident #190) of 3 residents reviewed for elopement; and failed to ensure they assessed for resident safety before leaving medications at a resident's bedside for 1 (Resident #4) of 1 resident reviewed for accident hazards. Findings included: 1. A facility policy titled, Falls-Clinical Protocol, revised 09/2012, indicated, 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. The policy also indicated that based on assessment, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. An Admission Record indicated the facility admitted Resident #35 on 10/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, seizures, bipolar disorder, and anxiety disorder. A quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 07/16/2024, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had disorganized thinking that fluctuated, had no limitation in range of motion, and did not use mobility devices. The MDS indicated the resident was independent with rolling left and right in bed and required supervision to move from sitting to lying or standing. Resident #35's care plan, included a diagnosis area initiated on 10/23/2023, that indicated the resident was at very high risk for falls with fractures related to seizure disorder, osteoarthritis, and confusion. A risk management form, dated 11/04/2023 at 7:30 PM, indicated Resident #35 fell in the common area when they got up from a recliner. The form revealed the resident hit their head on the floor, causing a 4-centimeter laceration. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. Resident #35's Progress Notes, dated 12/19/2023 at 9:14 AM, indicated Resident #35 was found sitting on the floor next to their bed and had spilled their juice on the floor next to them. The notes revealed the resident had no injury. The Progress Notes and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 02/23/2024 at 1:30 PM, indicated Resident #35 was found on the floor next to their bed. The form revealed the fall resulted in a right clavicle fracture that required a sling, and an orthopedic doctor follow-up. The form revealed no evidence there were interventions initiated related to this fall. Resident #35's care plan was updated to include details about the fall; however, the care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 05/21/2024 at 8:45 PM, indicated Resident #35 tripped as they were coming in from outside. The form revealed the resident stated they tripped on their boot or slipper. The form revealed the resident had an abrasion to their left knee that measured 2 centimeters by 1 centimeter. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 07/12/2024 at 8:00 PM, indicated Resident #35 was found sitting on the floor in their room. The form revealed the resident stated they did not know what happened. The form revealed the resident had no injury. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 07/22/2024 at 7:24 PM, indicated Resident #35 fell outside and reported they had possibly had a seizure. The form revealed the resident had swelling to the face and an abrasion on the nose. The form revealed no evidence there were interventions initiated related to this fall. Resident #35's care plan was updated to include details about the fall; however, the care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 07/27/2024 at 9:50 PM, indicated Resident #35 fell in their room and had no injuries. The form revealed the resident was placed in the common area for monitoring. The form revealed the resident had no injury. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 08/06/2024 at 12:15 AM, indicated Resident #35 fell in their room next to the bed. The form revealed the resident had no injury. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. During an interview on 10/17/2024 at 9:12 AM, the Director of Nursing (DON) stated she expected fall interventions to be put in place to help potentially prevent falls. The DON stated that for Resident #35's fall on 07/27/2024 the risk management form indicated there was poor lighting in the room, so the intervention was for the bathroom light to remain on for lighting. The DON stated, however, the intervention for the bathroom light to remain on for lighting was not documented in the resident's progress notes or on the resident's care plan. The DON stated there was a lack of fall interventions. During an interview on 10/16/2024 at 1:47 PM, Certified Nursing Aide (CNA) #1 stated the nurses completed the fall investigations. CNA #1 stated the nurses, and the DON implemented fall interventions. During an interview on 10/16/2024 at 2:16 PM, Registered Nurse (RN) #12 stated when a resident fell , the nurses completed a risk management form in the computer that tracked the falls. RN #12 stated the nurses were responsible for updating the care plan with new interventions. RN #12 stated the MDS Coordinator also checked the care plan for interventions. During an interview on 10/16/2024 at 2:26 PM, RN #4 stated when a fall occurred the nurses were to write an incident note and then complete a risk management form that tracked falls. RN #4 stated the nurse had to review the care plan to implement more personalized interventions. During an interview on 10/17/2024 at 9:42 AM, RN #6 stated the nurse on duty and management were responsible for completing fall investigations. RN #6 stated the nurse on duty would implement an intervention and then update the care plan after a fall. During a telephone interview on 10/17/2024 at 11:34 AM, RN #17 stated the nurses completed a risk management form for a fall, and then document a nurses note. RN #17 stated the DON and the Administrator went through the risk management forms to determine interventions. During an interview on 10/17/2024 at 12:08 PM, the MDS Coordinator stated the care plan was completed after the MDS assessment. The MDS Coordinator stated other staff also updated care plans, and the nurses would update fall care plans, as the fall happened. During an interview on 10/18/2024 at 9:35 AM, the DON reviewed falls for Resident #35 for 07/12/2024 and 05/21/2024 and stated she did not see any interventions for the falls. The DON stated the forms should have been completed better. The DON stated that staff knew Resident #35 was a frequent faller who had seizures and maybe just thought falls were a common occurrence. The DON stated she read through the incident reports but did not review the care plan to make sure interventions were placed. The DON stated the nurses were responsible for investigating the root cause of a fall and to put new interventions in place. The DON stated she expected the nurses to look for a root cause, to place an intervention, and let the CNAs know the intervention. The DON stated she expected for everybody to follow through to keep the residents safe and that it was documented. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated the nurses should investigate, put in a risk assessment and then implement interventions for a fall. The Administrator stated he and the DON were responsible for reviewing falls in morning meetings and in Quality Assurance Performance Improvement meetings. The Administrator stated they tried to determine what caused the fall. The Administrator stated he had not looked to ensure an intervention was in place. The Administrator stated that fall investigations and interventions were to protect the resident. The Administrator stated he expected staff to document everything and to look deeper into the incident to put things in place to best protect Resident #35. 2. A facility policy titled, Self-Administration of Medications, revised 02/2021, indicated, 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy also specified, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. An Admission Record indicated the facility admitted Resident #4 on 10/03/2019. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #4's Order Summary Report, with active orders as of 10/15/2024, contained an order dated 12/20/2019 for fluticasone propionate suspension 50 micrograms (mcg) /(per) actuation (act) with instructions to give two spays in each nostril two times a day for nasal congestion. The Order Summary Report also contained an order dated 10/08/2021 for albuterol sulfate hydrofluoroalkane (HFA) with instructions for two puffs inhaled orally every four hours as needed for wheezing related to COPD and asthma. The Order Summary Report contained an order dated 02/16/2022 for Spiriva Respimat Aerosol Solution 2.5 mcg/act with instructions to inhale two puffs in the morning for COPD. Resident #4's care plan did not address respiratory issues or the need for respiratory medications specifically the albuterol sulfate HFA inhaler. During an observation on 10/14/2024 at 10:05 AM, Resident #4 was in their room with a Spiriva inhaler, albuterol inhaler, and fluticasone nasal spray on the overbed table. Resident #4 stated the nurse would bring their pills in, they would take them and then the nurse left the two inhalers and the nose spray. Resident #4 stated the albuterol inhaler was their emergency inhaler. During an observation on 10/15/2024 at 8:57 AM, Resident #4 was in their room, sitting in a recliner drinking with the fluticasone nasal spray and albuterol inhaler on the overbed table. During an interview on 10/16/2024 at 8:29 AM, Registered Nurse (RN) #12 stated medications were not left in the resident rooms. RN #12 stated residents were not allowed to self-administer medications. RN #12 stated Resident #4 was approved by the Director of Nursing (DON) and the physician for the albuterol to be in the room but not the nasal spray. RN #12 stated Resident #4 informed the nurse when he used the inhaler because if the resident was short of breath, they called us to the room, and we would cue Resident #4 to use the albuterol inhaler. RN #12 stated she was not aware of a self-administration assessment form. During an interview on 10/16/2024 at 8:40 AM, RN #4 stated medications were not left in resident rooms. RN #4 stated Resident #4 was allowed to keep the rescue inhaler (albuterol sulfate) at bedside. RN #4 stated she observed the resident administering the medication, but they wanted to keep the inhaler. RN #4 stated she did not know if the resident had been assessed to self-administer the inhaler. RN #4 stated the resident was good about letting staff know if they needed the inhaler. During an interview on 10/17/2024 at 8:42 AM, the DON stated the facility did not document Resident #4's medication self-administration assessment anywhere. The DON stated she expected for a resident's medication self-administration assessment to be conducted and documented. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated residents were not allowed to keep medications in their room unless it was deemed safe to do so. 49044 3. A facility policy titled, Wandering and Elopements, dated 2001, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The section titled Policy Interpretation and Implementation included 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An Admission Record revealed the facility admitted Resident #190 on 08/04/2023. According to the Admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease; insomnia; dementia in other diseases classified elsewhere, unspecified severity, with agitation; and bipolar disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2023, revealed Resident #190 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident wandered daily during the assessment period. The MDS revealed the resident's wandering put the resident at significant risk of getting to a potentially dangerous place. The MDS revealed the resident required supervision with locomotion on and off the unit. Resident #190's undated Baseline Care Plan revealed that the resident was at risk for elopement. Resident #190's Care Plan included a diagnosis area, initiated on 08/22/2023, that indicated the resident was an elopement risk and wandered related to a history of attempts to leave the facility unattended and wandering aimlessly. The Admission Record and MDS revealed an admitted [DATE]; in contrast, an admission summary Progress Notes identified an admitted [DATE]. Resident #190's admission summary Progress Notes, dated 08/05/2023 at 1:43 PM, revealed Registered Nurse (RN) #5 documented that the resident arrived with family and had diagnoses of Alzheimer's disease, dementia, and insomnia. The notes revealed the family seemed in a hurry and did not stay long, although the nurse did go over the paperwork with them. The notes revealed the resident was extremely forgetful and confused as to why they were in the facility. The note revealed, per the family, the resident had dementia for a while and had been living with another family member until they could no longer take care of the resident. The notes revealed the family reported that there had been multiple incidents when the resident left the house and no one could find them, and the police would get involved. The notes revealed the family reported they took the resident to the hospital, where they assessed and referred the resident for long-term care. A DLBC [Division of Licensing and Background Checks] - Form 358: Facility Reported Incidents, sent to the State Agency on 08/05/2023 at 9:25 PM, revealed that, on 08/05/2023 at 7:15 PM, Resident #190 eloped from the facility. The form revealed the facility provided a detailed account of the incident, which included the Resident is new to the facility and has dementia. Family needed more help with [the resident] because [the resident] wanders and was becoming more than family could handle. Resident came into a new environment and was wanting to leave because it was unfamiliar to [the resident]. [The resident] was wondering the building trying to get out and staff was trying to help [the resident] fill [sic] welcome and safe. Multiple calls were placed to residents [family] to help calm [the resident]. Resident then went out back door where the alarmed [sic] sounded. By the time staff got there resident had already made it out of the building and resident was not in sight when staff when [sic] out doors [sic]. Staff looked around the inside and outside of the building and resident could not be found. Sheriff's office was called and [Administrator] was called. Deputy found resident down the road at a house close by the facility. Resident was taken back to the facility where they were able to help [the resident] back into the building gaining [the resident's] trust. Resident is happy and relaxed currently in the building after talking with [Administrator] and resident's [family]. The DLBC - Form 358: Facility Reported Incidents revealed Resident #190 eloped from the facility on 08/05/2023 at 7:15 PM through a back door where the alarm sounded; in contrast, behavior Progress Notes revealed the resident eloped on 08/06/2024 at 4:00 PM through an emergency exit in the kitchen. Resident #190's behavior Progress Notes, dated 08/06/2023 at 4:00 PM, revealed RN #6 documented that, at approximately 4:00 PM, Resident #190 left the security of the facility through an emergency exit in the kitchen. The notes revealed the sheriff's office was called within five minutes of the resident's absence, and the resident was soon located and brought back to the facility by a sheriff's deputy. The notes revealed the resident was agitated at that time but was able to be calmed. The notes revealed a facility aide was able to sit with the resident, one-on-one, and for a period of time, noting this intervention offered improvement to the resident's mood and disposition. The notes revealed that, at approximately 8:00 PM, the resident was highly agitated and attempted to leave the facility for a second time. The notes revealed multiple aides were involved with reorienting the resident and encouraging them to remain calm. The notes revealed the resident became belligerent and yelled profanities at staff. The notes revealed the resident was also aggressive toward the aides, pushing them out of the way of the direction the resident was traveling. The notes revealed that, at approximately 9:00 PM, with direction from facility management, facility staff was able to reason with the resident and the resident agreed to take bedtime medications and after a period of an hour retired for the evening. The admission summary Progress Notes, dated 08/05/2023 at 1:43 PM, revealed the family reported that there had been multiple incidents when the resident left the house and no one could find them, and the police would get involved; in contrast, the DLBC - HS FORM 359: Follow-Up Investigation Report revealed the facility indicated that, at the time the resident was admitted , the only information provided was a diagnosis of dementia and that the resident wandered, with no indication that there was a risk of elopement at that time. A DLBC - HS FORM 359: Follow-Up Investigation Report, sent to the state agency on 08/10/2023 at 3:11 PM, revealed the facility indicated that there was not very much information given due to the elopement occurring on the same day the resident was admitted to the facility. The facility indicated that, at the time the resident was admitted , the only information provided was a diagnosis of dementia and that the resident wandered. The facility identified there was no indication that there was a risk of elopement at that time. The form revealed the investigation did not include any interviews or statements from staff or law enforcement, did not include any corrective actions taken to keep the resident safe, and did not include how the facility ensured no other residents were at risk of elopement. An undated [Facility Name] Admit Check-Off List revealed in a section titled DO: ASSESSMENTS (SHOULD AUTOMATICALLY POPULATE) that the admitting nurse should have completed a Wandering Risk Assessment for each new admission. During an interview on 10/17/2024 at 1:53 PM, the MDS Coordinator stated she was unable to find any wandering or elopement risk assessments for Resident #190. During an interview on 10/16/2024 at 11:22 AM, the Administrator stated he did not maintain any documentation regarding the incident in question and simply inputted the information into the reports that he sent to the state. He stated he could see that by not having the documents, it did not look like a full investigation. The Administrator stated, If it wasn't documented, it didn't happen. During a follow-up interview on 10/16/2024 at 1:33 PM, the Administrator stated he understood the importance of being able to show their full investigation, including any interviews conducted, skin assessments conducted, and any interventions added as a result of the incident, as well as any training of staff. During an interview on 10/16/2024 at 6:15 PM, Certified Nursing Aide (CNA) #8 stated Resident #190 would try to leave and was very physical. She stated she remembered a couple of instances where the resident would wander off during the daytime but would not wander at night. CNA #8 stated the resident was very nervous and kept asking where they were and where their children were. During an interview on 10/16/2024 at 6:37 PM, Licensed Practical Nurse (LPN) #19 stated Resident #190 was very anxious and just wanted to leave, but mentally was not in a state to do that. LPN #19 stated facility staff had the doors locked but forgot about the loading dock (this statement is in contrast to the DLBC - Form 358: Facility Reported Incidents that revealed Resident #190 eloped from the facility through a back door where the alarm sounded). LPN #19 stated it was just one of those things that happened, noting Resident #190 was so desperate that the resident tried every door. LPN #19 stated they called the police. LPN #19 stated the resident ran and the police found Resident #190 two to four blocks away. LPN #19 stated it took them a while to convince Resident #190 to come back inside. LPN #19 stated it was evening shift, not dark out yet, and might have been right around shift change. LPN #19 stated a lot of care was given to try to ease the resident's fears. LPN #19 stated that after the incident they always made sure the door in question was locked. LPN #19 stated it was Resident #190's first day in the facility. LPN #19 stated Resident #190 was strong-willed and decided they were not going to stay. LPN #19 stated the police department was struggling with the resident not wanting to come back into the facility, so LPN #19 tried to make them understand the resident did not have a choice, and they called their Captain who reassured them that the facility was responsible for the resident. LPN #19 stated she thought she was the charge nurse the night Resident #190 eloped but was not sure. She stated she did not know much about the resident, only that Resident #190 did not want to be there, and the family had admitted the resident. She stated the family could not handle the resident anymore and the resident was doing things that they were concerned about for the resident's safety. LPN #19 stated the facility's doors were locked and a code was needed to get out. During an interview on 10/16/2024 at 6:59 PM, CNA #11 stated that when she worked at the facility, Resident #190 was trying to leave and did escape sometimes (other dates of elopement, if any, were not able to be ascertained) when the nurse would unlock the door, or the resident would try to get out another door that was not locked. She stated she did not remember how long after admission the resident escaped. She stated that there were times when the resident was especially confused, and during these times staff provided one-to-one oversight. CNA #11 stated the CNAs took turns watching the resident so one person did not have to spend the whole shift with Resident #190. During an interview on 10/17/2024 at 11:15 AM, RN #16 stated they had to lock the front door because Resident #190 would try to go out the door. RN #16 stated there was a time, maybe twice, the resident climbed the fences and was found by the cops in the community (other dates of elopement, if any, were not able to be ascertained). During an interview on 10/17/2024 at 3:46 PM, the MDS Coordinator stated she documented in the MDS if the resident had been wandering, but she did not do a formal assessment. She stated she did the care planning for the residents. The MDS Coordinator stated the Director of Nursing (DON) usually told her if a person had been wandering, and they could develop a care plan. She stated that she thought the facility used a wandering assessment, but did not know if there was an elopement assessment. The MDS Coordinator stated the charge nurses completed the admission assessments. The MDS Coordinator reviewed Resident #190's electronic medical record (EMR) and said she did not see an elopement assessment. The MDS Coordinator stated that she did not generally conduct those assessments. During an interview on 10/17/2024 at 3:24 PM, RN #4 stated that when a resident was admitted , the nurses did a thorough head-to-toe skin assessment for any issues, checked for edema, reconciled the medication list with the resident/representative, and asked orientation questions. RN #4 also stated a baseline care plan was always completed and done within two hours of admission. She stated she brought a laptop to a resident's room and completed any needed assessments. RN #4 stated that, every time she did an admission, she completed a wandering risk assessment. RN #4 stated that the wandering risk assessment did not auto-populate for assessments, but it was on the admission check list staff had. During an interview on 10/18/2024 at 8:15 AM, the Maintenance Manager stated he remembered when Resident #190 got out of the facility. He stated the resident did not go out the loading dock door. The Maintenance Manager stated the resident went out the kitchen door (this statement is in contrast to the DLBC - Form 358: Facility Reported Incidents form that revealed Resident #190 eloped from the facility through a back door where the alarm sounded). The Maintenance Manager stated that, at the time, they did not keep the kitchen door locked when the dietary staff went home. The Maintenance Manager stated the resident walked through the kitchen door and right out the back door. The Maintenance Manager stated the door was not locked at the time and was not alarmed. During a telephone interview on 10/18/2024 at 9:20 AM, RN #5 stated she thought a wandering/elopement assessment was on the list of assessments that admitting nurses were supposed to do. She stated she did not complete a wandering/elopement assessment for Resident #190 because the resident did not really exhibit an issue until the resident eloped. RN #5 stated the wandering/elopement assessment was not on the list of assessments required to be completed upon admission (this statement is in contrast to the [Facility Name] Admit Check-Off List that revealed the admitting nurse should have completed the Wandering Risk Assessment for each new admission). RN #5 stated the wandering assessment did not populate in the EMR as a required assessment. During an interview on 10/18/2024 at 9:42 AM, the DON stated the charge nurses had a check list in their admission packet that included skin assessments, immunizations, nursing assessments, and vital signs. The DON stated the nurse completed a wandering assessment. The DON stated no one audited or monitored to verify the assessments were completed. The DON stated Resident #190 could not understand why their family left them there and the resident was agitated and immediately was exit-seeking. The DON stated they were supposed to do a wandering/elopement assessment, and she just saw that RN #5 missed it. The DON stated the assessment was one that popped up in the EMR. The DON stated it was after noon when the resident was admitted , though she did not remember the exact time, knowing only that it was in the late afternoon. The DON stated when the family left, the resident was actively exit-seeking. The DON stated when Resident #190 ran out the kitchen door, all she heard was that the resident got out; the resident had gone around and checked all the doors until finding the kitchen door was open and then went out the door. The DON stated they called the Administrator, and he called the police. The DON stated the resident was wandering around the building, and staff tried to call the family, who did not answer. The DON stated the family was very hard to contact. The DON stated someone should have been with Resident #190 to help calm the resident. The DON stated they did not receive a lot of information about Resident #190 as the resident was not a direct placement from the hospital. The DON stated they did not have the staff to do one-on-one monitoring, but they knew they had to keep an eye on Resident #190. The DON stated they tried to keep the resident in the common area and keep the resident distracted. The DON stated there was no other instance that the resident eloped that she was aware of. The DON stated the information should have been passed on that Resident #190 was recently admitted and was exit-seeking, and it should have been passed on in report. She stated that she did not know how often the wandering assessments should be completed, but thought they should be done quarterly, especially if they had a resident who was actively wandering. The DON stated wandering assessments were not currently being done quarterly. She stated the kitchen door was supposed to be locked. The DON stated an investigation should start as soon as staff sent the information to the Administrator. She stated the staff did not call her; they called the Administrator. She stated the Administrator told her he would handle it, so she did not come to help. The DON stated they did not do a root cause analysis that she was aware of, but there should have been one completed. She stated she expected some resolutions to be found before an elopement could happen again. She stated she expected staff to find ways to educate, redirect, and distract the resident and to keep them calm and inside the facility. The DON stated wandering assessments needed to be done. The DON stated the resident's elopement investigation needed to be more thorough, with more detail, and documented. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated that what was listed on the admission checklist should be completed. The Administrator stated a wandering assessment was not completed for Resident #190. The Administrator stated staff should have completed a wandering/elopement assessment after Resident #190's elopement. The Administrator stated when Resident #190 was admitted to the facility, the resident wandered, but they did not know that at first. The Administrator stated the family just dropped the resident off and left without even saying goodbye and did not give much history (this statement is in contrast to the admission summary Progress Notes dated 08/05/2023 at 1:43 PM that revealed the family reported that there had been multiple incid[TRUNCATED]

Based on interview, document review, and facility policy review, the facility failed to provide annual and periodic training in accordance with facility policy, to educate staff on activities that constitute abuse and procedures for reporting incidents of abuse for 2 (Certified Nurse Aide [CNA] #8 and Registered Nurse [RN] #6) of 4 staff reviewed. Findings included: A facility policy titled, Policy and Procedure for Prohibiting Abuse, dated 02/2017, indicated, 2. Training All employees will be trained through orientation and ongoing inservices on issues related to the prohibition of abuse including: - Appropriate behavioral interventions to deal with aggressive and/or catastrophic reactions of residents - How to report allegations without fear of reprisal - Signs of burnout, frustration and stress that may lead to abuse - What constitutes abuse, neglect and misappropriation of resident property. 3. Prevention of abuse This facility carefully screens potential employees. Initial orientation and periodic inservices at least twice a year regarding abuse prevention and reporting, activities that constitute abuse, neglect, exploitation and misappropriation of resident's property. Education will include procedures for reporting, prevention of resident abuse and dementia management. The policy also specified, 4. Identification of possible abuse events: Facility will offer annual and periodic inservices educating staff to identify potential signs and symptoms of abuse including behavior changes and injuries of unknown origin and to identify events and trends which may constitute abuse. A DLBC [Division of Licensing and Background] - Form 358: Facility Reported Incidents document revealed that on 11/28/2023 at 2:30 PM, the Administrator reported an allegation to the state agency that Registered Nurse (RN) #6 physically and mentally/verbally abused Resident #38. The report revealed that staff became aware of the incident on 11/24/2023 in the Early Morning, and Certified Nurse Aides (CNAs), including CNA #8, notified administration of the alleged incident on 11/28/2023 at 2:00 PM, four days after the incident. According to the report, RN #6 went into Resident #38's room, yelled in the resident's face that the resident needed to get into bed, grabbed the resident's arms and wrist, and shook the resident. Per the document, the nurse gave the resident a choice to either let the aides put the resident in bed or he would do it, then counted down from five. The document indicated that the nurse then grabbed the resident by their arms and legs and moved the resident to the bed. The document indicated that the resident told the nurse to stop hurting them. Per the report, the facility unsubstantiated the abuse allegations and indicated they would educate again on the policies on abuse. (Refer to F600, F609, and F610). During an interview on 10/16/2024 at 6:15 PM, CNA #8 stated she worked at the facility for almost two years as a CNA. She stated she did not remember receiving any training regarding abuse prohibition or reporting while she worked at the facility. CNA #8 also stated that she did not receive any retraining after she did not immediately report the abuse allegation for Resident #38 in November 2023. During an interview on 10/17/2024 at 9:41 AM, RN #6 stated he had worked at the facility for a little over two years. RN #6 stated he worked night shift and made it to some required trainings, but not all of them. He stated he recalled completing computer trainings for abuse prohibition and resident rights. RN #6 stated he was suspended for three days after the November 2023 abuse allegation but did not recall receiving abuse prohibition training after that. RN #6's RELIAS Certificate of Completion, revealed RN #6 successfully completed 0.50 training hours for Preventing, Recognizing, and Reporting Abuse on 02/01/2023. CNA #8's RELIAS Certificate of Completion revealed CNA #8 successfully completed 0.50 training hours for Preventing, Recognizing, and Reporting Abuse on 02/03/2023. A document titled, 2024 Inservices indicated the facility provided training on vital signs and abuse: kinds reporting and prevention on 03/06/2024. The Administrator was asked for a copy of the sign-in sheet for this in-service on 10/18/2024 at 9:07 AM and provided a document titled, Staff Meeting 3/13/24 [03/13/2024] that listed 20 typed staff members' names. Some were only first names while others were first and last names. The list of names did not include RN #6 and CNA #8. This document did not specify the topics that were discussed during the 03/13/2024 staff meeting, and no other sign-in sheet was provided for the 03/06/2024 abuse training. An undated Abuse Policy found in several employees' personnel records specified, All employees of [the facility] must immediately report any incidents of abuse or misappropriation of patient property. Patient abuse is defined as the willful infliction of a patient with resulting physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. Abuse may consist of verbal abuse, sexual abuse, physical abuse, involuntary seclusion, mental abuse, neglect and/or misappropriation of patient property. Abuse of any kind will not be tolerated at [the facility] and will result in termination of employment. Personnel records for RN #6 and CNAs #2, #10, #8 and #9 all contained a copy of this undated policy that had been signed by the employee as follows: - CNA #2's personnel record revealed that she signed the undated Abuse Policy on 07/23/2023. CNA #2's personnel record did not include any other evidence of abuse training. - CNA #10's personnel record revealed that she signed the undated Abuse Policy on 10/24/2023. CNA #10's personnel record did not include any other evidence of abuse training. - CNA #8's personnel record revealed that she signed the undated Abuse Policy on 08/30/2022. CNA #8's personnel record did not include any other evidence of abuse training. - RN #6's personnel record revealed that he signed the undated Abuse Policy on 07/17/2022. RN #6's personnel record did not include any other evidence of abuse training. - CNA #9's personnel record revealed that she signed the undated Abuse Policy on 08/03/2022. CNA #9's personnel record did not include any other evidence of abuse training. During an interview on 10/18/2024 at 9:42 AM, the Director of Nursing (DON) stated that the Administrator monitored the required computer training for staff. She stated if someone missed a training, the Administrator notified her, and she notified the staff member that they needed to complete the missing training. Per the DON, staff signed in when they attended an in-service, and they reviewed the training with the staff who did not attend; however, the DON stated they did not document the individual training. The DON also stated they should have staff repeat abuse prohibition trainings if there were allegations of abuse against them. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated the facility provided abuse prohibition training to the staff involved in an abuse allegation, just not right away. The Administrator stated he had no documentation of these trainings but had provided an in-service for the CNAs. The Administrator stated the facility also provided yearly abuse prohibition trainings. During a telephone interview on 11/13/2024 at 12:12 PM, the facility's corporate Chief Operating Officer (CEO) stated he knew the facility conducted annual training on abuse and reporting allegations of abuse and did so at least annually. He believed they had conducted more than one training. He indicated there should be sign-in sheets for each training, and if a staff member did not attend, they needed to come in and the facility needed to provide individual training and have the staff member sign that they received the training. He did not know why there was no sign-in sheet for the abuse training in March 2024. He stated he attended a training a couple of months ago where the facility did their annual emergency preparedness training, and he had to sign in that he attended. During a telephone interview on 11/14/2024 at 2:23 PM, the previous Assistant Director of Nursing (ADON) stated she did not remember the March 2024 training, why there were no sign-in sheets, or who attended. She indicated it had been almost a year ago and she no longer worked at the facility, so her memories had faded. During an interview on 11/15/2024 at 9:57 AM, the Business Office Manager (BOM) stated the previous ADON had provided the typed list for the March 2024 training/in-service, and she did not know if there were any sign-in sheets; she just knew that the previous ADON kept track of who attended. She indicated the previous ADON was in charge of tracking the CNAs' trainings and that the current ADON would be taking over that piece of the training. She stated when she first started working in the business office, she noticed that the personnel files were a mess. Since she had been working in the office, they had developed a new system where health records were kept in a red folder, and Human Resources (HR) took care of the onboarding and maintained the new hire personnel paperwork. She indicated HR did not start this process until June 2024, so she was not sure who maintained the onboarding paperwork prior to that. She stated she believed it was all in the blue folders that were provided to the survey team for the four CNAs and RN #6. According to the BOM, the Administrator was the only one who had access to look at the overall Relias training and pull up those training records. She indicated she did not believe the facility had any other documentation of abuse training for the four CNAs and for RN #6 if there was no other documentation found in their blue personnel files. During an interview on 11/15/2024 at 10:52 AM, the Administrator provided a printout of his own Relias trainings completed since 2020, which indicated he completed abuse training every year. He stated that what he was providing for himself was what it should look like in each staff member's file on Relias. He confirmed again that there were no training records in the Relias system for RN #6 and CNAs #2, #8, #9, and #10, other than the abuse training in 2023 that he had provided for CNA #9 and RN #6. He indicated he had no other documentation to provide for those staff members' trainings. He stated he was currently in charge of tracking staff trainings, but he could see now what was lacking. He revealed he had been behind this year but knew that was not an excuse. He stated the facility had been working to make improvements on several of the systems, and he could see they still had some things to work on. During an interview on 11/15/2024 at 11:15 AM, the HR employee stated that when a new employee started, she gave them the new hire packet, which included a lot of policies, what forms of identification they were required to bring in, I-9s, W-4s, education, employee vaccinations and the consents/declinations for those, and the employee handbook. She stated she did not do any trainings with the staff and, once she had all the information and had the background checks, she turned the files over to whatever supervisor the employee would have. She stated again that she provided no training to new hires and did not enter the new employees into the Relias system when they were hired. When asked about the Relias system, she stated, I don't even know what that is. According to the HR employee, she started her employment with the facility in June 2024. During an interview on 11/15/2024 at 6:16 PM, the Administrator stated hey needed to keep better track of sign-in sheets, track the Relias training, make sure everyone was doing the training, and document to make sure they had the documentation to show the trainings had been done.

Based on observation, interview, facility document review, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. These failures had the potential to affect 39 of 39 residents who received meals from the dietary department. Findings included: A facility policy titled, Cleaning Schedules, updated 03/2014, revealed, The Dietary staff shall maintain the sanitation of the Dietary Department through compliance with written, comprehensive cleaning schedules developed for the community by the Dietary Manager. The policy revealed, 7. Under the days of the week or the weeks the Dietary Manager or designee can check off assignments completed or the employee can initial. A facility policy titled, Operation and Sanitation, revised 11/01/2011, revealed, Operating instructions are made available and cleaning procedures are developed for all Dietary Department equipment. Observations during the initial tour of the kitchen on 10/14/1024 beginning at 8:50 AM, revealed the appliances, including the commercial oven, convection oven, grill, and steamer, were dirty with grease and splatters. An observation on 10/16/2024 at 10:53 AM revealed the appliances remained dirty. Further observation revealed the top of the microwave had a layer of fuzz and dirt that could be removed with a finger sweep. Observations also revealed that crumbs covered the counter behind the toaster and the microwave, which sat on the food preparation table, next to the steamtable in the center of the kitchen. Observations of the kitchen on 10/16/2024 at 10:59 AM revealed the following: - A thick layer of dirt and food splatters covered the front of the grill, which could be scraped off with a fingernail; - The side of the steamer was covered with food splatters; - The sides (about half-way down) and the top of the back side of the conventional stove top/oven combination were covered with splatters and felt sticky to the touch; and - The front of the convection oven was covered with a large thick area of dust along the bottom of the appliance that could be pulled off with two fingers, leaving dust and fuzz sticking out from the door. - The handles of the convection oven were covered with grease that left smudges when a finger was rubbed over them. Observation of the kitchen on 10/16/2024 at 11:49 AM revealed the following: - The knobs on the steamer were dirty and the dirt scraped off with a fingernail. - There was fuzz and dirt hanging between the convection oven and the steamer. - There was fuzz that was approximately two inches long on the wheel of the convection oven that blew in the breeze created by the fan. - The fronts of two stainless steel drawers under the grill were covered with splatters and the vent located to the side of the drawers was covered with dirt and fuzz that could be removed by rubbing with a finger. The AM [morning shift] Cook's Daily Cleaning Schedule for the week of 10/07/2024 through 10/13/2024 revealed the AM [NAME] was required to clean the grill, range top, and drip pans. The schedule revealed no one signed that the task was completed on 10/12/2024 or 10/13/2024. The cleaning schedule for the week of 10/14/2024 revealed the [NAME] had initialed the schedule on 10/14/2024 and 10/15/2024, indicating that the items had been cleaned. During an interview on 10/16/2024 at 10:59 AM, the [NAME] stated staff wiped the appliances down every day and staff deep cleaned them once a week. The PM [evening shift] Cook's Daily Cleaning Schedule for the week of 10/07/2024 through 10/13/2024 revealed that the PM [NAME] was required to clean the preparation counter/back splash, clean the range and drip pan, clean the toaster, and clean the microwave. The cleaning schedule revealed the DM had initialed the form indicating that she cleaned the items on 10/07/2024 and 10/10/2024. The cleaning schedule revealed no one initialed the form to indicate the items were cleaned on 10/11/2024, 10/12/2024, and 10/13/2024. An observation of the kitchen on 10/16/2024 at 12:10 PM revealed the PM Cook's Daily Cleaning Schedule for the week of 10/14/2024 through 10/20/2024, was hanging on a wall in the kitchen; however, no one had documented that the required cleaning had been completed for 10/14/2024 and 10/15/2024. The facility's September 2024 Chore List revealed the PM (evening shift) cook was required to wipe inside and out of the oven, stove and steamer (that includes the top) on Mondays. The chore list revealed no one signed off on the task, indicating it was completed for September 2024. The Chore List for October 2024 revealed a line through task for 10/01/2024, and no one signed off on the task on 10/14/2024, indicating the items were cleaned. During an interview on 10/16/2024 at 2:15 PM, the Dietary Manager (DM) stated the staff were supposed to wipe the appliances down every day and do a deep cleaning of the appliances weekly. She stated she had monitored in the past to ensure all the things on the lists were completed, but she had not been monitoring lately as the kitchen had been short staffed recently and she had been working shifts in the kitchen. She stated she knew the appliances were dirty. She stated she was usually the one who did the deep cleaning and tried to do it three to four times a year but had not been able to in a while. The DM stated when she cleaned, she had to use a putty knife to clean the appliances. According to the DM, if staff were wiping the appliances down daily, they may not be as bad. During an interview on 10/18/2024 at 9:42 AM, the Director of Nursing (DON) stated she thought the kitchen should be cleaned daily. The DON stated the kitchen should be cleaned and sanitized before every meal. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated he expected the kitchen to be clean. He stated the kitchen had always been in top shape when they had previous inspections. The Administrator stated he was in the kitchen often but did not look at everything while he was in there.

Based on observation, interview, record review, and facility policy review, the facility failed to develop individualized resident-centered care plans with measurable objectives for 4 (Residents #1, #3, #24, and #4) of 14 residents whose care plans were reviewed. Specifically, the facility failed to ensure care plans addressed oxygen use for Resident #1 and Resident #3, failed to ensure a care plan addressed an indwelling urinary catheter for Resident #24, and failed to ensure a care plan addressed respiratory care for a diagnosis of chronic obstructive pulmonary disease (COPD) and respiratory medications for Resident #4. Findings included: A facility policy titled, Care Plans, Comprehensive, Person-Centered, revised 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and e. reflects currently recognized standards of practice for problem areas and conditions. 1. An Admission Record revealed the facility admitted Resident #1 on 07/25/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of unspecified heart failure. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/23/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #1 received oxygen therapy. Resident #1's Order Summary Report, listing active orders as of 10/18/2024, contained an order, dated 02/08/2023, for oxygen at 2 liters per minute by nasal cannula due to heart failure with hypoxia. Resident #1's care plan, last revised on 08/18/2024, did not include a Diagnosis area or interventions addressing oxygen use. On 10/17/2024, during the survey, an intervention was added to a Diagnosis area addressing congestive heart failure, atrial fibrillation, and hypertension, initiated on 12/30/2021, that specified, OXYGEN SETTING: O2 [oxygen] via (SPECIFY: nasal prongs/mask) @ SPECIFY)L (SPECIFY FREQ [frequency]). Humidifier (SPECIFY); however, the intervention was incomplete and did not reflect the resident's ordered oxygen flow rate, the mechanism of delivery, frequency of use, or whether the resident's oxygen should be humidified. The MDS Coordinator was interviewed on 10/17/2024 at 12:09 PM. The MDS Coordinator stated she was responsible for completion of the MDS and completion of some care plans. The MDS Coordinator stated the use of oxygen should be care planned. The MDS Coordinator reviewed Resident #1's care plan and confirmed that oxygen usage was not included and stated it was an oversight. The Director of Nursing (DON) was interviewed on 10/17/2024 at 1:32 PM. The DON stated she expected the use of oxygen to be care planned and added it was important to care plan oxygen so the resident received the correct amount of oxygen. The Administrator was interviewed on 10/17/2024 at 2:29 PM and stated he expected Resident #1's oxygen usage to be care planned. 2. An Admission Record revealed the facility initially admitted Resident #3 on 03/11/2020 and most recently admitted the resident on 06/29/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of morbid (severe) obesity due to excess calories. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated Resident #3 received oxygen therapy. Resident #3's Order Summary Report, listing active orders as of 10/15/2024, contained an order, dated 02/08/2023, for oxygen at 2 liters per minute by nasal cannula continuously for hypoxia (low oxygenation) related to morbid obesity due to excess calories. Resident #3's care plan, last revised on 09/25/2024, did not include a Diagnosis area or interventions addressing oxygen use. The MDS Coordinator was interviewed on 10/17/2024 at 12:55 PM. The MDS Coordinator stated oxygen should be care planned. The MDS Coordinator reviewed Resident #3's care plan and confirmed that oxygen usage was not included and stated it was an oversight. The Director of Nursing (DON) was interviewed on 10/17/2024 at 1:32 PM. The DON stated she expected the use of oxygen to be care planned and added it was important to care plan oxygen so the resident received the correct amount of oxygen. The DON stated oxygen should have been added to Resident #3's care plan. The Administrator was interviewed on 10/17/2024 at 2:29 PM and stated he expected Resident #3's oxygen usage to be care planned. 3. An Admission Record revealed the facility initially admitted Resident #24 on 06/01/2022 and most recently admitted the resident on 01/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified obesity and chronic diastolic (congestive) heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Resident #24's Order Summary Report, listing active orders as of 10/16/2024, contained an order, dated 09/25/2024, for catheter care to be completed each shift. Resident #24's care plan, last revised on 10/01/2024, did not include a Diagnosis area or interventions addressing the resident's indwelling urinary catheter. During an interview on 10/16/2024 at 11:15 AM, the Director of Nursing (DON) stated she expected Resident #24's indwelling urinary catheter to be on their care plan. The Administrator was interviewed on 10/17/2024 at 2:29 PM and stated he expected Resident #24's indwelling urinary catheter to be part of the resident's care plan. 40141 4. An Admission Record indicated the facility admitted Resident #4 on 10/03/2019. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #4's Order Summary Report, listing active orders as of 10/15/2024, contained an order dated 12/20/2019 for fluticasone propionate suspension 50 micrograms (mcg) /(per) actuation (act) with instructions to give two spays in each nostril two times a day for nasal congestion. The Order Summary Report also contained an order dated 10/08/2021 for albuterol sulfate hydrofluoroalkane (HFA) with instructions for two puffs inhaled orally every four hours as needed for wheezing related to COPD and asthma. The albuterol sulfate HFA order specified, May keep at bedside. The Order Summary Report contained an order dated 02/16/2022 for Spiriva Respimat Aerosol Solution 2.5 mcg/act with instructions to inhale two puffs in the morning for COPD. During an observation on 10/14/2024 at 10:05 AM, Resident #4 was in their room with a Spiriva inhaler, albuterol inhaler, and fluticasone nasal spray on the overbed table. Resident #4 stated the nurse would bring their pills in, they would take them, and then the nurse left the two inhalers and the nose spray. Resident #4 stated the albuterol inhaler was their emergency inhaler. During an observation on 10/15/2024 at 8:57 AM, Resident #4 was in their room with their fluticasone nasal spray and albuterol inhaler on the overbed table. Resident #4's care plan did not address respiratory issues or the need for respiratory medications and did not address the resident's ability to keep their albuterol sulfate HFA inhaler at their bedside. During an interview on 10/17/2024 at 8:42 AM, the Director of Nursing (DON) stated the MDS Coordinator was responsible for care plans. The DON reviewed Resident #4's care plan and stated the respiratory issues and the need for the emergency inhaler were not on the care plan but should have been. The DON stated she expected respiratory issues and medications to be care planned. During an interview on 10/17/2024 at 12:08 PM, the MDS Coordinator stated she was responsible for initial comprehensive care plans. The MDS Coordinator reviewed Resident #4's care plan and stated respiratory, COPD, and asthma were not on the care plan but should have been. The MDS Coordinator further stated the resident's need for an emergency inhaler should have been care planned. The MDS Coordinator stated the information needed to be on the care plan to inform the nurses that the resident had asthma, inhalers, and oxygen, and to ensure staff were aware of the resident's needs. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated the nurses and the MDS Coordinator were responsible for ensuring respiratory issues and medications were addressed on the care plan. The Administrator stated he expected respiratory issues and medications to be addressed on the care plan.

Based on interview, facility document review, and facility policy review, the facility failed to consistently follow up on concerns presented by the Resident Council (RC) and provide a verbal or written response to the RC regarding any actions taken to address their concerns. There was incomplete or no follow-up documented for 5 (January, May, July, August, and September 2024) of 10 months of RC minutes reviewed. Findings included: A facility policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, indicated, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The policy also specified, 5. The grievance officer will record and maintain all grievances and complaints on the 'Resident Grievance Complaint Log.' The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received; b. The name and room number of the resident filing the grievance/complaint (if available); c. The name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); d. The date the alleged incident took place; e. The name of the person(s) investigating the incident; f. The date the resident, or interested party, was informed of the findings; and g. The disposition of the grievance (i.e. [id est, that is], resolved, dispute, etc [et cetera]). A review of the grievance log for the timeframe from 01/2024 through 10/2024 revealed no RC grievances were logged into the grievance log. Resident Council Minutes, for the timeframe from 01/2024 through 10/2024 were reviewed with the following findings: - The RC minutes dated 01/10/2024 indicated New Business included concerns of hot water situation and other residents yelling out. The minutes form did not provide a space to document any planned actions that would be taken to follow up on the concerns. The following month's RC minutes, dated 02/07/2024, indicated the hot water issues were discussed and the residents felt the action taken for that concern was sufficient. The minutes did not specify what action was taken to address the concern or by whom. There was no documentation on the 02/07/2024 minutes to indicate any response was provided to the RC regarding the 01/10/2024 concern of other residents yelling out. - The RC minutes dated 05/02/2024 indicated concerns of taking juice from residents before they are finished and notice about room changes written statement. The minutes form indicated the Resident Advocate (RA) spoke to the kitchen about the juice concern and, They will ask before they take it. The form indicated action taken by the RA for the room change concern was, They will provide written form before they change rooms. The question, Do residents feel action taken is sufficient? did not have a yes or no response for either concern, and the following month's RC minutes, dated 06/06/2024, did not include any documentation to indicate the two concerns from the May RC meeting were discussed with the RC to determine if the actions taken by the RA had improved or resolved the concerns. - RC minutes that were not dated but that appeared to be from the July 2024 RC meeting, based on the bottom of the form indicating, Date of Next Meeting: August revealed residents discussed new concerns of Be able to leave facility 12 consecutive days and More brownies. The form did not include any planned actions to address these two concerns/requests, and the following month's RC minutes, dated 08/14/2024 did not include any documentation to indicate any follow-up discussion with the RC about the two concerns/requests from the July meeting. - The RC minutes dated 08/14/2024 indicated the RC discussed new concerns that included: 1.) Beds not being made. 2.) Food not up to par lately - veggies cooked more. 3.) Eye exam not up to par. 4.) More gravy on biscuits. The minutes form did not include any planned actions to be taken to address the concerns. The RC minutes dated 09/05/2024 did indicate a follow-up discussion occurred regarding the food not up to par concern and that residents felt the action taken was sufficient; however, there was no documentation to indicate any follow-up actions or discussion with the RC regarding the other three concerns discussed during the August 2024 meeting (eye exams, beds not made, and more gravy). - The RC minutes dated 09/05/2024 indicated the RC discussed new concerns that included: 1) To [sic - too] rough when changing briefs. 2) Checking garbage at 01:00 to 1:30 AM. 3) Ticking [Resident #13's] feet in night. There was no documentation on the minutes form of any planned actions related to these concerns. The following month's minutes, dated 10/08/2024, indicated the concerns related to brief changes and checking garbage were discussed. There was no documentation of any follow-up discussion of Resident #13's concern related to someone tickling their feet at night. - The RC minutes dated 10/08/2024 indicated the RC discussed a new concern of a resident keeping their television volume too loud at night. A member of the survey team conducted a meeting with RC members on 10/16/2024 at 10:00 AM. The meeting was attended by Resident #11, who was the RC President, as well as Residents #6, #22, #13, and #32. The Resident Council Minutes were reviewed with the group as follows: - Regarding the February 2024 concern related to sheets not being changed, the resident's stated sheets were still not being changed regularly. Resident #6 added that their sheets had not been changed in two weeks, but they had not reported this to anyone. - Regarding the 08/14/2024 concern related to beds not being made, Resident #13 stated they had specifically asked staff to make the bed, and their bed still was not made. Resident #11 added that beds were not consistently made. - Regarding the 08/14/2024 concerns related to the food and eye exams, Resident #11 stated there had not been much improvement in the food and that eye examinations had not been discussed with the group. - Regarding the 09/05/2024 concerns, Resident #13 stated someone was still waking them at night by tickling their feet. - Regarding the 10/08/2024 concern related to a resident keeping their television volume too loud at night, Resident #13 stated even with their hearing aids out, the roommate's loud television and the lights kept them awake at night. The Resident Advocate (RA) was interviewed on 10/16/2024 at 10:58 AM. The RA stated she was the one who typically took notes during the RC meetings. The RA stated that when residents had concerns, she documented them on the Resident Council minutes and verbally communicated the concerns to the appropriate department managers. The RA stated the residents were then spoken to as a group to make sure any issues were resolved. The RA stated that to make sure issues were resolved, she followed up and documented a quarterly note or a monthly note. The RA agreed that if an issue appeared twice during Resident Council meetings, then the issue had not been resolved. A review of issues identified in the 10/16/2024 meeting as unresolved was made with the RA. The RA stated no plan for resolution of those issues was provided verbally or in writing to the RC. The RA stated the Director of Nursing (DON) had in-serviced the staff on bed-making. The RA stated that once the RC indicated a problem was resolved, there was no further follow-up. She stated the RC concerns had never been managed as grievances with a written plan, written summary of actions taken, and resolution. The DON and the Assistant Director of Nursing (ADON) were interviewed on 10/16/2024 at 11:31 AM. The ADON stated if a bed was not made as soon as the resident got out of it, there were a few residents who complained. The DON stated she had received no concerns from the RC about beds not being made. The DON stated she had received a concern about a resident's television being too loud and had instructed staff to turn the television down in the evening so other residents could rest but acknowledged she had not followed up to see if the issue was resolved. The DON stated she had completed written plans for the RC about their concerns because she had not received any concerns from the RC; she added that without knowing about their grievances, there was no opportunity to fix the issues. The Administrator was interviewed on 10/17/2024 at 2:23 PM. The Administrator stated he and the DON had spoken with the staff about changing sheets but had not followed up with the RC. The Administrator stated he expected the RA to take all concerns from the RC to the appropriate department managers. The Administrator stated he expected changes to address the RC's concerns to happen immediately and expected follow-up with the RC within a week.

Based on observation, interview, record review, and facility policy review, the facility failed to implement infection control and prevention policies. Specifically, the facility failed to ensure staff followed enhanced barrier precautions (EBP) when completing indwelling urinary catheter care for 1 (Resident #24) of 1 resident reviewed for indwelling urinary catheter care. Additionally, the facility failed to conduct annual tuberculosis (TB) risk screenings for 4 (Residents #1, #3, #4, and #27) of 5 residents whose immunization histories were reviewed. Findings included: 1. A facility policy titled, Enhanced Barrier Precautions Policy and Procedure, revised 03/27/2024, indicated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms ([NAME]) [sic - MDROs] in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a [NAME] as well as those at increased risk of [NAME] acquisition (e.g. [exempli gratia, for example], residents with wounds or indwelling medical devices). High-contact resident activities include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing. An Admission Record revealed the facility initially admitted Resident #24 on 06/01/2022 and readmitted the resident on 01/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified obesity and chronic diastolic (congestive) heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was always incontinent of bowel and bladder but had no indwelling urinary catheter. The MDS indicated Resident #24 was at risk of developing pressure ulcers but, at the time of the assessment, had no pressure ulcers. The MDS indicated Resident #24 did not have either a neurogenic bladder or obstructive uropathy. Resident #24's care plan included a focus area, revised 09/24/2024, that indicated the resident had frequent bladder incontinence related to impaired mobility. The care plan did not address the use of, or care required for, an indwelling urinary catheter. Resident #24's Order Summary Report, with active orders as of 10/16/2024, did not include a physician's order for the use of an indwelling urinary catheter, but did include a physician's order, dated 09/25/2024, for catheter care to be completed each shift and to ensure the catheter was patent and in a down draining position with no signs or symptoms of infection or other problems. An observation of care provided to Resident #24's on 10/16/2024 at 9:25 AM revealed Registered Nurse (RN) #4 providing indwelling urinary catheter care and personal hygiene care with the assistance of Nurse Aide (NA) #7, after Resident #24 had a bowel movement. RN #4 and the NA #7 both donned gloves, but neither staff member donned a gown while providing care to the resident. RN #4 was interviewed on 10/16/2024 at 9:47 AM. RN #4 stated she was unaware of the term enhanced barrier precautions and had not been educated to wear a gown or mask while providing catheter care. She did state that EBP was used for residents with wounds. NA #7 was interviewed on 10/16/2024 at 11:12 AM. NA #7 stated she had not heard the term enhanced barrier precautions and had not been taught to wear a gown and gloves when providing care for Resident #24, who had an indwelling urinary catheter. The Director of Nursing (DON) was interviewed on 10/16/2024 at 11:15 AM. The DON stated the facility policy instructed EBP usage with any task dealing with fluids. The DON stated there was the potential to come in contact with fluids when caring for an indwelling urinary catheter. The DON stated EBP training had been provided. She indicated EBP training was not provided to nursing staff during orientation, but the use of personal protective equipment (PPE) was discussed. The Infection Preventionist (IP) was interviewed on 10/16/2024 at 1:30 PM. The IP stated she had not heard about EBP until she started her employment with the facility and had no idea what staff had been taught. The IP stated any resident with catheters and wounds should be placed on EBP. The IP stated she knew there were a few residents in the facility with wounds. Certified Nurse Aide (CNA) #2 was interviewed on 10/17/2024 at 9:22 AM. CNA #2 stated she had not heard the term EBP. CNA #2 stated she had not received any instruction to wear a gown when providing care to Resident #24. The MDS Coordinator was interviewed on 10/17/2024 at 12:09 PM. The MDS Coordinator stated there were no residents in the facility on EBP. The MDS Coordinator stated she had not been trained on EBP and, therefore, did not think there were any residents who required EBP and had not care planned EBP for Resident #24. Registered Nurse (RN) #6 was interviewed on 10/17/2024 at 10:53 AM. RN #6 stated he had received education on EBP, but then said he was unaware of the term EBP. RN #6 stated he thought it was mandatory to wear a gown when taking care of residents with indwelling urinary catheters due to the potential of disease and added that, at the very least, gloves were worn. RN #6 stated he was unable to recall CNAs wearing gowns when emptying a urine collection bag but stated the CNAs did wear gloves. RN #6 stated that when providing treatments to pressure ulcers, the personal protective equipment (PPE) worn depended on the type of dressing change and added that most of the wound care in the facility for pressure ulcers only required gloves be worn. A telephone interview was held with RN #16 on 10/17/2024 at 11:07 AM. RN #16 stated she no longer worked at the facility but was previously employed as the facility's IP. RN #16 stated she had received education on IP and EBP when she attended a conference in Salt Lake City. RN #16 stated, upon return to the facility, she shared the education she had received with the DON, the Assistant Director of Nursing (ADON), and the Administrator. RN #16 stated she felt dismissed about the information she tried to share and was told by the DON there was no need to go to extreme measures with infection control and no need to initiate EBP. RN #17 was interviewed on 10/17/2024 at 11:39 AM. RN #17 stated no residents in the facility required EBP. RN #17 stated she had been taught about EBP in nursing school. RN #17 stated if a resident required EBP, there would be a sign on the resident's room door alerting her to the precautions that were to be taken. RN #17 stated the facility had residents with pressure ulcers and with catheters, but she had not been instructed to wear gowns, gloves, or eye protection when providing care to those residents. RN #17 confirmed Resident #24 had an indwelling urinary catheter and stated she had not been told the resident was on EBP or that she needed to wear any type of PPE. The DON was interviewed on 10/17/2024 at 2:08 PM and stated she did not have a good reason for EBP not having been initiated for residents with catheters and those that required wound care. The Administrator was interviewed on 10/17/2024 at 2:13 PM. The Administrator stated he was unaware staff were not following EBP but expected EBP to be followed. 2. A facility policy titled, Tuberculosis, Screening Residents for, revised 07/2016, indicated, Policy Statement - This facility shall screen all residents for tuberculosis infection and disease (TB). The policy also indicated under the section, Serial Testing of Residents, that, 1. The facility will conduct an annual risk assessment to determine TB risk classification (low or medium). 2. If the risk classification is identified as 'low risk' for transmission of TB the facility shall screen residents for TB if the develop symptoms of active TB disease or if there has been an incident of known exposure to a person with active TB. Otherwise, annual screening is not routine. 3. If the risk classification is identified as 'medium risk' for transmission of TB, residents will receive an annual TST [tuberculin skin test], with the exception of known 'converters' (those whose previous skin tests are positive). A review of the immunization record for Resident #1 revealed the resident had their last tuberculosis (TB) testing on 08/01/2021. The record did not specify whether annual risk assessments had been completed since that date. A review of the immunization record for Resident #27 revealed the resident had their last TB testing on 03/14/2023. The record did not specify whether annual risk assessments had been completed since that date. A review of the immunization record for Resident #3 revealed the resident had their last TB testing on 03/19/2020. The record did not specify whether annual risk assessments had been completed since that date. A review of the immunization record for Resident #4 revealed the resident had their last TB testing on 10/14/2019. The record did not specify whether annual risk assessments had been completed since that date. The Infection Preventionist (IP) was interviewed on 10/16/2024 at 1:30 PM. The IP stated TB testing was completed on admission or a break in care, such as when a resident went home, but not after a hospitalization . During an interview with the Administrator on 10/16/2024 at 2:48 PM, the Administrator stated either the Director of Nursing (DON) or the IP would know where to find the annual TB risk assessments. The DON was interviewed on 10/17/2024 at 2:08 PM and stated there had been no annual TB risk assessments completed for residents. The DON stated there had recently been a couple of different IPs and added that may be the reason the risk assessments had not been completed. The Administrator was interviewed on 10/17/2024 at 2:13 PM. The Administrator stated the yearly risk assessments were done for staff, but he was not aware the assessments had not been completed for residents.

Based on interview, record review, and facility policy review, the facility failed to ensure physician's orders included all necessary components, including the specified dosages for 2 (Residents #13 and Resident #20) of 3 residents who were observed during the medication administration task. Findings included: A facility policy titled, Physician Medication Orders, revised in 04/2010, specified, 6. Orders for medications must include: a. Name and strength of the drug and c. Dosage and frequency of administration. A facility policy titled, Medication Orders, revised in 11/2014, specified, 1. Medication Orders- When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. 1. An Admission Record indicated the facility admitted Resident #13 on 01/03/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, chronic kidney disease, hypertension, intervertebral disc degeneration, and osteoporosis. Resident #13's Order Summary Report, listing active orders as of 10/16/2024, revealed orders dated 01/03/2024 for vitamin C, one tablet by mouth one time a day for immunity and vitamin D3, one capsule by mouth one time a day for vitamin deficiency; however, the physician's orders did not include the specified dosages. 2. An Admission Record indicated the facility admitted Resident #20 on 01/11/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hypertensive heart disease with heart failure, tremor, atherosclerotic heart disease, and atrial fibrillation. Resident #20's Order Summary Report, listing active orders as of 10/16/2024, revealed an order dated 01/11/2022 for a vitamin D3 tablet by mouth one time a day for supplement; however, the physician's order did not include the specified dosage. During an interview on 10/17/2024 at 8:42 AM, the Director of Nursing (DON) stated physician's orders for vitamin C and vitamin D should include the intended dosages. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated he expected staff to ensure physician's orders included the specified dosages.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was secured to prevent potential pulling/trauma to the urethral meatus for 1 (Resident #24) of 1 sampled resident observed for indwelling urinary catheter care. Findings included: A facility policy titled, Catheter Care, Urinary, revised 08/2022, indicated under General Guidelines, to, 4. Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site. The State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities guidance at tag F690 specified additional care practices related to catheterization included, Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. An Admission Record revealed the facility initially admitted Resident #24 on 06/01/2022 and readmitted the resident on 01/06/2023. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified obesity and chronic diastolic (congestive) heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident # 24 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was always incontinent of bowel and bladder but had no indwelling urinary catheter. The MDS indicated Resident #24 was at risk of developing pressure ulcers but, at the time of the assessment, had no pressure ulcers. The MDS indicated Resident #24 did not have either a neurogenic bladder or obstructive uropathy. Resident #24's care plan included a focus area, revised 09/24/2024, that indicated the resident had frequent bladder incontinence related to impaired mobility. The care plan did not address the use of, or care required for, an indwelling urinary catheter. Resident #24's Order Summary Report, with active orders as of 10/16/2024, did not include a physician's order for the use of an indwelling urinary catheter, but did include a physician's order, dated 09/25/2024, for catheter care to be completed each shift and to ensure the catheter was patent and in a down draining position with no signs or symptoms of infection or other problems. An observation of Resident #24's indwelling urinary catheter care, on 10/16/2024 at 9:25 AM with Registered Nurse (RN) #4 assisted by Nurse Aide (NA) #7, revealed the resident's urinary catheter was not secured. During a concurrent interview, RN #4 stated Resident #24 had a reaction to the adhesive on the catheter stabilization device, but she was unsure if there was documentation regarding the reaction since she had not been the one that placed the catheter. RN #4 stated that Resident #24's indwelling urinary catheter had been placed less than a month ago due to a red groin. An observation of Resident #24's skin revealed redness in the groin area but no pressure ulcers. NA #7 was interviewed on 10/16/2024 at 9:43 AM. NA #7 stated she had previously seen a device used to secure Resident #24's indwelling urinary catheter, but one of the nurses had removed the device due to the resident's leg being red. NA #7 stated she had seen only one type of device used. RN #4 was interviewed on 10/16/2024 at 9:47 AM. RN #4 stated the indwelling urinary catheter had been placed due to Resident #24's fragile, sensitive skin. RN #4 stated that even with every two hour or hourly brief changes, Resident #24's skin remained painful, red, and raw. RN #4 stated there had been discussions with Resident #24's family member regarding the positives and negatives of using an indwelling urinary catheter, and the decision was made to use the catheter. RN #4 stated a stabilization device had been used to secure the indwelling urinary catheter, but Resident #24 had a reaction to the adhesive on the device. RN #4 stated she was unsure if any other type of securing device had been used. The Director of Nursing (DON) was interviewed on 10/16/2024 at 11:15 AM. The DON stated indwelling urinary catheters were used for residents who had issues with urination, chronic infections, or wounds that had not healed. The DON stated Resident #24 had a Stage 2 pressure ulcer that had not healed and had redness in the groin. The DON stated Resident #24 was allergic to the adhesive on the catheter stabilization devices that were usually used. The DON stated no other methods of securing the indwelling urinary catheter had been attempted and added that it was important to secure the indwelling urinary catheter to keep the catheter from being pulled out. The DON reviewed progress notes for Resident #24 and stated there was no documentation about the Resident #24's reaction to the adhesive on the stabilization device. The Administrator was interviewed on 10/17/2024 at 2:29 PM. The Administrator stated if Resident #24 was allergic to the adhesive on the stabilization device, he expected another type of stabilization device to be tried.

Based on interview, record review, facility document review, and facility policy review, the facility failed to maintain accurate medical records for 1 (Resident #190) of 19 sampled residents. Findings included: A facility policy titled, Record of Admission, revised December 2006, revealed, A record of admissions will be maintained for each resident admitted to the facility. The policy revealed, 1. At the time of the resident's admission, a resident identification and summary record is completed. 2. A copy of this record must be placed on the resident's chart, and a copy must be provided to the medical records department. 3. Our identification and summary record includes, but is not limited to: a. the resident's full name and social security number; b. the date and time of this admission. An Admission Record revealed the facility admitted Resident #190 on 08/04/2023. According to the Admission Record, the resident had a medical history that included Alzheimer's disease, insomnia, dementia with agitation, and bipolar disorder. An admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 08/14/2023, revealed Resident #190 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the facility admitted the resident on 08/04/2023. Resident #190's Care Plan, included a diagnosis area initiated 08/22/2023, that indicated the resident was an elopement risk and wanderer related to a history of attempts to leave the facility unattended, and the resident wandered aimlessly. Interventions directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Interventions also directed staff to provide structure activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Interventions also indicated that the resident usually triggered for wandering/eloping in the afternoon. Resident #190's Progress Notes revealed an Admission Summary dated 08/05/2023 at 1:43 PM written by Registered Nurse (RN) #5 that indicated Resident #190 had arrived at the facility with their family. An Admission Agreement revealed the resident's date of admission was 08/04/2023. The agreement revealed the financial responsible party and witness signatures were dated 08/05/2023. During an interview on 11/11/2024 at 3:04 PM, the MDS Coordinator reviewed the electronic health record for Resident #190 and stated the resident's entry MDS indicated an admitted [DATE], the resident's admission document also indicated an admitted [DATE], and the resident's admission summary indicated an admitted [DATE]. During an interview on 11/11/2024 at 3:22 PM, the Business Office Manager (BOM) stated the resident was admitted on [DATE]. The BOM provided a copy of the resident's baseline care plan that had an admitted [DATE], and a referral note from the hospital dated 08/04/2023. The BOM stated she had billed the resident for 08/04/2023. During an interview on 11/11/2024 at 3:41 PM, the Director of Nursing (DON) stated that she remembered talking back and forth with the hospital on 08/04/2023 about transportation for Resident #190. The DON stated the hospital felt the resident would not be comfortable going with the facility's transportation, so a decision was made that the resident's family member would bring them to the facility on [DATE]. During a follow-up interview on 11/12/2024 at 8:10 AM, the DON stated that on 08/04/2023, Resident #190's family member had taken the resident to the clinic at the hospital hoping they could admit the resident. The DON stated the hospital told the family that the resident could not be admitted for dementia. The DON stated that was when the clinic did a referral for the resident to be in long term care. The DON stated the resident's family member did not bring the resident to the facility until 08/05/2023. During an interview on 11/12/2024 at 8:35 AM, RN #5 stated she documented the admission summary progress note on the day that Resident #190 was admitted to the facility. RN #5 stated they would always document a progress note on the same day a resident was admitted . RN #5 stated there was some back and forth with the family on the resident being at the facility, so there may have been an issue with the date based on that. During an interview on 11/12/2024 at 9:18 AM, the Administrator stated he felt what happened with Resident #190's admitted was that the resident was supposed to come to the facility on the fourth (08/04/2023) and that was when everything was started in the electronic health record system, but the family did not bring the resident to the facility until the fifth (08/05/2023). During an interview on 11/12/2024 at 9:58 AM, the MDS Coordinator stated she received residents' admitted s for the MDS from the BOM because she was the one that would verify the resident was qualified to be at the facility. The MDS coordinator stated new admissions were discussed in the morning meetings. The MDS coordinator stated she was not present on the day Resident #190 was admitted to the facility. The MDS coordinator stated there could have been a mix up on the paperwork that the BOM received, but she was not sure. During an interview on 11/12/2024 at 10:04 AM, the DON stated her expectation was that dates were correct in the electronic health record. The DON stated Resident #190's paperwork should have reflected the admitted [DATE] and not 08/04/2023. The DON stated when they found out the resident was not coming on 08/04/2023, they should have taken the resident out of electronic health record system and then entered the resident back in when they came in on 08/05/2023. During a follow-up interview on 11/12/2024 at 11:46 AM, the Administrator stated his expectation was that medical records were accurate.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure an as-needed (PRN, pro re nata) psychotropic medication order specified the duration of use for 1 (Resident #26) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, dated 07/2022, specified, 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. An Admission Record indicated the facility admitted Resident #26 on 04/03/2022. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia and paranoid personality disorder. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #26 had moderate impairment in cognitive skills for daily decision-making and had a short-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS revealed the resident received an antipsychotic, antianxiety, antidepressant, an opioid, and a hypoglycemic medication during the assessment period. Resident #26's Order Summary Report, with active orders as of 10/15/2024, contained an order dated 07/22/2024 for lorazepam 2 milligrams (mg) one tablet by mouth every 12 hours as needed for anxiety. Further review revealed the order did not indicate an end date. The Order Summary Report also contained an order dated 09/25/2024 for lorazepam injection 2 mg per one milliliter (ml) with instructions to inject 1 ml intramuscularly every 24 hours as needed for severe anxiety. Further review revealed the order did not indicate an end date. During an interview on 10/16/2024 at 8:29 AM, Registered Nurse (RN) #12 stated Resident #26 took PRN lorazepam every one or two days. RN #12 stated PRN psychotropic medications should have a stop date on the physician order. RN #12 stated Resident #26's physician order for the PRN lorazepam did not have a stop date and should have had one. During an interview on 10/16/2024 at 8:40 AM, RN #4 stated a stop date was required on PRN psychotropic medications so the medication could be reviewed for effectiveness. RN #4 indicated she did not see a stop date on the physician's order for Resident #26's PRN lorazepam. Resident #26's July Pharmacy Consulting Report, dated 08/08/2024, indicated PRN lorazepam must have a 14-90 day auto-stop date. During a telephone interview on 10/16/2024 at 1:02 PM, the Consultant Pharmacist state he came to the facility every third month to participate in a psychotropic medication review meeting. The Consultant Pharmacist stated the Director of Nursing (DON) was always present in the psychotropic review meeting. The Consultant Pharmacist stated that in the meeting he would sit with his laptop and go over each psychotropic medication and tell the facility if it needed a stop date. The Consultant Pharmacist stated the facility had a hard time placing stop dates on physician orders. The Consultant Pharmacist stated the facility did not follow the recommendations on the pharmacy consulting report, and if the report read there were no new irregularities or no new concerns it was because he had already pointed out the need for a stop date. During an interview on 10/17/2024 at 8:42 AM, the DON stated the first physician order for a resident's psychotropic medication should have a 14-day stop date, then after, the physician reviewed the need for the medication. The DON stated after the physician's review the stop date should be 90 days and should be reflected on the physician order. The DON reviewed Resident #26's physician order then indicated it did not have a stop date. The DON stated she expected for any PRN psychotropic medication to have a stop date. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated a 14-day stop date was needed to reassess psychotropic medications. The Administrator stated he expected for there to be a stop date on PRN psychotropic medications.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure pharmacy recommendations were addressed for 1 (Resident #26) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Pharmacy Services Committee, revised 12/2009, indicated, Duties and responsibilities of the Pharmacy Services Committee include, but are not limited to: 12. Reviewing the reports of the Consultant/Supervising Pharmacist. An Admission Record indicated the facility admitted Resident #26 on 04/03/2022. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia and paranoid personality disorder. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #26 had moderate impairment in cognitive skills for daily decision-making and had a short-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS revealed the resident received an antipsychotic, antianxiety, antidepressant, an opioid, and a hypoglycemic medication during the assessment period. Resident #26's Order Summary Report, with active orders as of 10/15/2024, contained an order dated 07/22/2024 for lorazepam 2 milligrams (mg) one tablet by mouth every 12 hours as needed for anxiety. Further review revealed the order did not indicate an end date. The Order Summary Report also contained an order dated 09/25/2024 for lorazepam injection 2 mg per one milliliter (ml) with instructions to inject 1 ml intramuscularly every 24 hours as needed for severe anxiety. Further review revealed the order did not indicate an end date. Resident #26's July Pharmacy Consulting Report, dated 08/08/2024, indicated PRN (pro re nata, as needed) lorazepam must have a 14-90 day auto-stop date. Resident #26's Medication Administration Record [MAR] for the timeframe from 10/01/2024 through 10/15/2024, contained a transcription of an order for lorazepam 2 mg one tablet by mouth every 12 hours as needed with a start date of 07/22/2024. The MAR revealed that staff documented the medication had been administered to the resident eight times during the month. During an interview on 10/16/2024 at 8:29 AM, Registered Nurse (RN) #12 stated the Director of Nursing (DON) handled all the pharmacy recommendations. During an interview on 10/16/2024 at 8:40 AM, RN #4 stated a stop date was required on PRN psychotropic medications so the medication could be reviewed for effectiveness. RN #4 stated she was not familiar with pharmacy recommendations, but the pharmacist did a monthly review and discussed it with the DON. During a telephone interview on 10/16/2024 at 1:02 PM, the Consultant Pharmacist stated he remotely conducted pharmacy reviews for two months then came to the facility every third month to participate in the psychotropic medication review meeting. The Consultant Pharmacist stated the pharmacy report was sent to the DON and the Medical Director. The Consultant Pharmacist stated the DON was always present in the psychotropic review meeting. The Consultant Pharmacist stated the facility did not follow the recommendations on the report, and if the report read there were no new irregularities or no new concerns it was because he had already pointed out the need for a stop date. During an interview on 10/17/2024 at 8:42 AM, the DON stated PRN psychotropic medications were evaluated every month by the pharmacist. The DON stated the Medical Director, the Consultant Pharmacist, and she met quarterly to review psychotropic medications. The DON stated she was responsible for the monthly medication reviews. The DON stated she missed the recommendation on the 08/08/2024 pharmacy review for Resident #26. The DON stated she expected for the monthly medication reviews to be reviewed and recommendations for PRN psychotropic medication stop dates completed. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated a 14-day stop date was needed to reassess psychotropic medications. The Administrator stated the Medical Director, and the DON were responsible for the pharmacy reviews. The Administrator state he expected the DON and Medical Director to communicate and discuss the need for the residents.

Based on interview and record review, the facility did not ensure that 4 of 21 sample residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifiers: 19, 27, 35, and 87. Findings include: 1. Resident 87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included displaced supracondylar fracture without intracondylar extension of lower end of right femur, osteoporosis, acute kidney failure, generalized anxiety disorder and diabetes mellitus. Resident 87's medical record was reviewed on 3/13/23. Resident 87's progress notes were reviewed. The progress notes indicated that resident 87 had been seen by the facility physician on the following dates: a. 9/1/21 b. 10/15/21 c. 12/15/21 d. 12/31/21 No other documentation could be located to indicate that resident 87 had been seen by the physician in addition to the above listed dates. On 3/15/23, the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator were asked to provide any additional documentation of physician visits for resident 87, but were unable to do so. 2. Resident 19 was admitted to the facility on [DATE] with chronic obstructive pulmonary disease, polyosteoarthritis, alcohol dependence, schizoaffective disorder bipolar type, history of pulmonary embolism, insomnia and gastroesophageal reflux. On 3/13/23 at 3:35 PM, an interview was conducted with resident 19. Resident 19 stated that he was unhappy with the Medical Director (MD), and the lack of physician visits. When asked to clarify, resident 19 stated, it took me three months of complaining to get [the MD] to see me. Resident 19 stated that he had been experiencing pain, and the MD had not been seeing him regularly. Resident 19's medical record was reviewed on 3/13/23. Resident 19's progress notes were reviewed. The progress notes indicated that resident 19 had been seen by the facility physician on the following dates: a. 12/13/22 b. 1/24/23 No other documentation could be located to indicate that resident 19 had been seen by the physician in addition to the above listed dates. On 3/15/23, the DON and MDS Coordinator were asked to provide any additional documentation of physician visits for resident 19, but were unable to do so. 3. Resident 35 was admitted to the facility on [DATE] and with diagnoses that included diabetes mellitus, osteomyelitis, polyneuropathy, and adjustment disorder with depressed mood. Resident 35 was discharged on [DATE] to the hospital. Resident 35's medical record was reviewed on 3/13/23. Resident 35's progress notes were reviewed. The progress notes indicated that resident 35 had been seen by the facility physician on the following dates: a. 8/9/22 b. 10/13/22 c. 10/25/22 d. 1/12/23 On 3/15/23, the DON and MDS Coordinator were asked to provide any additional documentation of physician visits for resident 35, but were unable to do so. 43212 4. Resident 27 was admitted to the facility initially on 6/1/22, and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, hypertension, type 2 diabetes, dysarthria, obesity, congestive heart failure, atrial fibrillation, hyperlipidemia, and obstructive sleep apnea. Resident 27's medical records were reviewed on 3/13/23. Progress notes revealed that after admission on 6/1/22: a. No physician visit for the month of June 2022 (30 days). b. No physician visit for the month of July 2022 (60 days). c. The physician saw resident 27 on 8/9/22 at 2:52 PM. The physician note stated Pt (patient) is new to facility. Seen in common area by me for the first time. d. The physician saw resident 27 on 9/7/22 at 5:53 PM. e. The physician saw resident 27 on 10/13/22 at 2:06 PM. [Note: The physician visit documentation by the Minimum Data Set (MDS) coordinator has dysuria written on the document by the provider. The document is not signed by the provider, and the progress note documentation does not mention dysuria.] No other physician visit notes were found in the medical record after 10/13/22. On 3/14/23 at 3:50 PM, an interview was conducted with the MDS coordinator who scheduled the physician visits. The MDS stated when resident 27 went to the hospital in January 2023, she considered that to be a physician visit counting toward physician visit requirements. On 3/15/23 at 2:46 PM, an interview was conducted with the DON. The DON stated the MDS coordinator scheduled physician visits. The DON stated there was a list by the nurse's station where residents could request to see the physician at the next visit. The DON also stated that nurses could request a visit for a resident if they had a concern. The DON stated the physician came to the facility every other week on no particular day. The DON stated the expectation is that the physician document resident visits in the electronic medical record within 24 hours of each visit.

Based on interview and record review, the facility did not make information on how to file a grievance or complaint available, specifically an anonymous grievance. In addition, the facility did not have a grievance log. Findings include: On 3/15/23 at 10:15 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the facility did not have any written grievances or evidence of a grievance log because any concerns the residents voiced were addressed immediately. The ADM stated that the Resident Advocate (RA) was the facility Grievance Officer and all grievance forms were kept in her office. When asked how a resident would file an anonymous grievance, the ADM stated he did not know. When asked if there were other locations that the residents could obtain grievance forms, the ADM stated he did not know. On 3/15/23 at 10:45 AM, a follow up interview was conducted with the ADM. The ADM stated that he located grievance forms in a drawer at the nurses station. The ADM stated that he would move the forms to a more prominent location where residents had access to them without having to ask a staff member. On 3/15/23 at 2:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident voiced a concern, facility staff just solve them right now. We watch for issues . and deter possible grievances from that. The facility's policy regarding Grievances/Complaints, Filing was reviewed. The policy indicated the following: . 5. Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously. . 8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. . 14. The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.

Based on interview and record review, the facility did not ensure that the pharmacist's recommendations and physician's approval were acted upon. Specifically, for 1 of 21 sampled residents, the facility did not implement the Medical Director's (MD) orders as they pertained to the pharmacist's recommendations. Resident identifier: 4. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, neuromuscular dysfunction of bladder, mild cognitive impairment, bipolar disorder, morbid obesity, chronic pain, dysarthria, anarthria, major depressive disorder, panic disorder, and Horner's syndrome. Resident 4's medical records were reviewed on 3/13/23. Physician orders revealed the following: a. Clopidogrel Bisulfate Tablet 75 mg (milligrams) dated 4/24/20 and revised on 1/6/22. b. Aspirin Tablet 81 mg, dated 3/12/20 and revised on 2/24/22. On 1/6/23 progress notes revealed that a pharmacy review was conducted. The pharmacist recommended to discontinue DAPT [dual antiplatelet therapy] in favor of apixaban. Pharmacy consultation documents were reviewed and revealed a document dated 1/7/23 with recommendation: Dr. [physicians name]-[resident] has been receiving aspirin and clopidogrel (DAPT) since April 2020 for secondary stroke prevention related to internal carotid dissection, with reported history of multiple strokes. DAPT is not recommended longer than six months due to increased risk of bleeding without significant benefit over single drug treatment. Recommendation: 1. Discontinue aspirin and clopidogrel, and start apixaban (Eliquis) 2.5 mg PO (by mouth) twice daily for stroke prevention. The physician checked the reply I agree with the above suggestions(s); please implement (indicate order changes}. [It should be noted that at the bottom of the form are items for checking off when completed-noted to nursing, changed in MAR (medication administration record), changed in chart/computer, pharmacy notified. These items were not checked off as being completed.] The pharmacy signature was dated 1/7/23 and the physician signature is dated 1/11/23. Review of resident 4's physician orders revealed that no order for apixaban was found. In addition, Clopidogrel Bisulfate and Aspirin were still active orders as of 3/13/23. On 3/14/23 at 2:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she gave the pharmacy recommendations to the physician to sign when in the facility, then the orders were documented in the resident's medical record and implemented. The DON did not know why the Clopidogrel Bisulfate and Aspirin had not been discontinued.

Based on observation and interview the facility failed to properly prevent or contain COVID-19. Specifically, facility staff were not wearing personal protective equipment appropriately. Additionally, a container with a biohazard bag for soiled linen was placed in a resident hallway next to a cart with clean personal protective equipment (PPE). Findings include: The facility was surveyed during a COVID-19 outbreak, with both resident and staff, who had recently tested positive for COVID-19. When a facility is in Substantial or High Community Transmission OR During an Outbreak The Personal Protective Equipment (PPE) Requirements for Long-Term Care Facility Staff guide, outlines that staff should wear eye protection when there are Aerosol generating procedures (suctioning, nebulizer, [CONDITION(S)], etc.), in Resident rooms and in Resident common areas. OBSERVATIONS On 11/04/21 at 10:12 AM an observation was made of Registered Nurse (RN) 1 wearing no eye protection in resident hallways. On 11/04/21 at 10:20 AM an observation was made of the Director of Nursing (DON) and the Infection Preventionist (IP) wearing no eye protection in resident hallways and common areas. Additionally, the IP was wearing only a disposable procedure mask. On 11/04/21 at 10:25 AM an observation was made of the Medical Records (MR) employee wearing no eye protection and only a disposable procedure mask in resident common areas. On 11/04/21 at 10:25 AM an observation was made of the Administrator (ADM) and Physical Therapist (PT) standing in a resident hallway wearing no eye protection. On 11/04/21 at 10: 35 AM an observation was made of RN 3 doffing PPE outside of the North COVID-isolation room, in a resident hallway, across from a non-isolated resident room. RN 3 was observed to put the soiled PPE in a red biohazard bag located in the resident hallway. On 11/3/21 at 10:46 AM the housekeeper supervisor was observed without eye protection in a resident common area (Solarium) near the couches where residents were sitting. On 11/3/21 at 10:52 AM, an observation was made of the facility's Administrator (ADM) in the hallway talking with a therapy staff member. Neither the ADM nor the therapist had eye protection. Both were wearing N95 masks. On 11/3/21 at 11:05 AM, RN 1 was observed not wearing eye protection near the medication cart in a resident hallway. On 11/3/21 at 11:08 AM, an observation was made of Certified Nursing Assistant (CNA) 1 wearing a gown outside of room [ROOM NUMBER] and getting a surgical mask to put on over her N95 mask. CNA 1 had already put a gown on. CNA 1 then put gloves on. The gown CNA 1 was wearing did not cover the back of her clothing. At 11:15 AM, CNA 1 entered the COVID-19 positive area. The surveyor heard CNA 1 knock and enter the resident's room. At 11:19 AM, CNA 1 doffed the gown, gloves and surgical mask inside the COVID-19 barrier and sanitized her hands as she exited the area. On 11/3/21 at 11:12 AM a yellow container with a biohazard bag with soiled laundry from a COVID-19 positive resident in room [ROOM NUMBER]-B was observed in the hallway next to a cart containing clean PPE to be used for staff, who enter the COVID-19 positive resident's room to provide care. On 11/3/21 at 1:26 PM the administrator and DON were observed not wearing eye protection in a resident common area (Solarium) near the couches where residents were nearby. INTERVIEWS On 11/04/21 at 10:38 AM an interview with RN 3 was done. RN 3 stated that while she was outside of a COVID-positive room and not providing direct patient cares she should be wearing an N95 mask and eye protection. RN 3 was observed to be wearing no eye protection while being interviewed. On 11/3/21 at 10:55 AM, an observation was made of RN 1 and RN 3. Both were sitting at the Nurse's Station wearing N95 masks but not wearing eye protection. RN 1 stated no residents were on transmission based precautions that were not COVID-19 positive. RN 1 stated there were 2 residents that were COVID-19 positive in the facility. RN 1 stated one was at the end of one hall, and one was at the end of the other hallway. RN 1 stated both were behind a tarp barrier. RN 3 stated CNA 1 was the COVID aide, and she was caring for the COVID-19 positive residents. RN 3 and CNA 1 were not designated COVID staff as they were also providing care for other residents in the facility. On 11/3/21 at 11:22 AM, an observation was made of an Occupational Therapy Aid (OTA). The OTA was helping a resident who was starting therapy. The OTA was wearing an N95 mask and goggles, however, the goggles were down on her nose and not covering her eyes. The resident that the OTA was helping had a mask below his chin and was wearing oxygen. An interview was conducted with the OTA. The OTA stated the therapy staff were doing in-room therapy as well as therapy in the therapy gym. The OTA stated that lately therapy staff were just doing one person at a time in the therapy gym. Another resident in the gym, who was more than 6 feet away from the first resident was not wearing a mask. During the interview a third resident came in the therapy gym to do more therapy. The OTA stated that in the COVID-19 positive resident's rooms the therapy staff wore a full gown, face shield or goggles, and a face mask. The OTA stated if doing therapy in a regular room, staff only wore goggles and a masks. The OTA confirmed therapy staff had been doing therapy with some of the COVID-19 positive residents. The OTA stated she saved the therapy until the end of the day so she did not have to go back and forth between areas. As the surveyor was leaving the therapy room, a 4th resident was brought into the therapy gym by another therapist. On 11/3/21 at 11:30 AM, an interview was conducted with a laundry staff member (LS). The LS stated she was only required to wear gloves when sorting the laundry. On 11/3/21 at 2:16 PM, an interview was conducted with the administrator and DON. The administrator and DON stated that they did not know that staff should have been wearing eye protection in resident common areas. On 11/3/21 at 11:30 AM, an interview was conducted with a laundry staff member (LS). The LS stated she was only required to wear gloves when sorting the laundry. On 11/3/21 at 10:52 AM, an observation was made of the facility's Administrator (ADM) in the hallway talking with a therapy staff member. Neither the ADM nor the therapist had eye protection. Both were wearing N95 masks. On 11/3/21 at 10:55 AM, an observation was made of RN 1 and RN 3. Both were sitting at the Nurse's Station wearing N95 masks but not wearing eye protection. RN 1 stated no residents were on transmission based precautions that were not COVID-19 positive. RN 1 stated there were 2 residents that were COVID-19 positive in the facility. RN 1 stated one was at the end of one hall, and one was at the end of the other hallway. RN 1 stated both were behind a tarp barrier. RN 3 stated Certified Nursing Assistant (CNA) 1 was the COVID aide, and she was caring for the COVID-19 positive residents. RN 3 and CNA 1 were not designated COVID staff as they were also providing care for other residents in the facility. On 11/3/21 at 11:08 AM, an observation was made of CNA 1 wearing a gown outside of room [ROOM NUMBER] and getting a surgical mask to put on over her N95 mask. CNA 1 had already put a gown on. CNA 1 then put gloves on. The gown CNA 1 was wearing did not cover the back of her clothing. At 11:15 AM, CNA 1 entered the COVID-19 positive area. The surveyor heard CNA 1 knock and enter the resident's room. At 11:19 AM, CNA 1 doffed the gown, gloves and surgical mask inside the COVID-19 barrier and sanitized her hands as she exited the area. On 11/3/21 at 11:22 AM, an observation was made of an Occupational Therapy Aid (OTA). The OTA was helping a resident who was starting physical therapy. The OTA was wearing an N95 mask and goggles, however, the goggles were down on her nose and not covering her eyes. The resident OTA was helping had a mask below his chin and was wearing oxygen. Another resident in the room, more than 6 feet away from the first resident was not wearing a mask. An interview was conducted with the OTA. The OTA stated the therapy staff were doing in-room therapy as well as in the therapy room. The OTA stated lately therapy staff were just doing one person at a time in the therapy room. During the interview a third resident came in the therapy room to do more therapy. The OTA stated that in the COVID-19 positive resident's rooms the therapy staff wore a full gown, face shield or goggles, and a face mask. The OTA stated if doing therapy in a regular room, staff only wore goggles and a masks. The OTA confirmed therapy staff had been doing therapy with some of the COVID-19 positive residents. The OTA stated she saved the therapy until the end of the day so she did not have to go back and forth between areas. As the surveyor was leaving the therapy room, a 4th resident was brought into the therapy room by another therapist. On 11/04/21 at 10:12 AM an observation was made of Registered Nurse (RN) 1 wearing no eye protection in resident hallways. On 11/04/21 at 10:20 AM an observation was made of the Director of Nursing (DON) and the Infection Preventionist (IP) wearing no eye protection in resident hallways and common areas. Additionally, the IP was wearing only a disposable procedure mask. On 11/04/21 at 10:25 AM an observation was made of the Medical Records (MR) employee wearing no eye protection and only a disposable procedure mask in resident common areas.On 11/04/21 at 10:25 AM an observation was made of the Administrator (ADM) and Physical Therapist (PT) standing in a resident hallway wearing no eye protection.On 11/04/21 at 10:30 AM an observation was made of Nursing Assistant (NA) 1 entering the South COVID-isolation area, donning and doffing personal protective equipment (PPE) appropriately. On 11/04/21 at 10: 35 AM an observation was made of RN 3 doffing PPE outside of the North COVID-isolation room, in a resident hallway, across from a non-isolated resident room. RN 3 was observed to put the soiled PPE in a red biohazard bag located in the resident hallway. On 11/04/21 at 10:38 AM an interview with RN 3 was done. RN 3 stated that while she was outside of a COVID-positive room and not providing direct patient cares she should be wearing an N95 mask and eye protection. RN 3 was observed to be wearing no eye protection while being interviewed.

Based on interview and record review the facility did not document that testing was completed and the results of each staff test according to criteria for conducting testing of asymptomatic individuals specified by the positivity rate of COVID-19 in the county. Specifically two staff members were not tested twice a week for COVID-19 during the facility's outbreak period. Additionally, the facility did not have procedures for addressing residents and staff that refuse testing for COVID-19. Findings include: For outbreak testing the CMS Memo QSO-20-38-NH, revised on 4/27/21, reads all staff and residents should be tested , regardless of vaccination status, and all staff and residents that test negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. On 11/3/21 at 11:34 an interview was conducted with the facility's Infection Preventionist (IP). The IP stated that facility staff had been tested twice a week during their outbreak period. The IP stated that the facility had been in outbreak throughout the month of October and that the most recent COVID-19 positive cases in the facility were a resident, who tested positive 11/1/21, and a staff member, who tested positive 11/3/21. 1. Facility testing documentation revealed Certified Nursing Assistant (CNA) 1 was tested as follows: a. Week 1 (10/3/21 to 10/9/21): CNA 1 was tested twice this week on 10/4/21 and 10/8/21. b. Week 2 (10/10/21 to 10/16/21): CNA 1 was tested on ce this week on 10/11/21. CNA 1 also worked on 10/13/21 and 10/14/21 that week. [Note: This staff member worked on 10/14/21, which was 3 days after her negative test on 10/11/21.] c. Week 3 (10/17/21 to 10/23/21): CNA 1 was tested on ce this week on 10/21/21. CNA 1 also worked on 10/20/21, 10/22/21 and 10/23/21 that week. d. Week 4 (10/24/21 to 10/30/21): CNA 1 was tested twice this week on 10/25/21 and 10/28/21. 2. Facility testing documentation revealed Registered Nurse (RN) 2 was tested as follows: a. Week 1: RN 2 was tested on ce this week on 10/9/21. RN 2 worked only on 10/9/21 during Week 1. b. Week 2: RN 2 was tested on ce this week on 10/11/21. RN 2 also worked on 10/13/21 and 10/14/21 that week. [Note: This staff member worked on 10/14/21, which was 3 days after her negative test on 10/11/21.] c. Week 3: RN 2 was tested on ce this week on 10/21/21. RN 2 also worked on 10/19/21 and 10/20/21 that week. d. Week 4: RN 2 did not work this week. On 11/3/21 at 1:57 PM, an interview was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP). The DON stated that they had not had any residents or staff refuse COVID-19 testing. Both the DON and IP stated they did not have any procedures in place that would address residents or staff that refuse COVID-19 testing. On 11/3/21 at 2:02 PM an interview was conducted with the facility's Administrator (ADM) and DON. The DON stated staff refusals were not being kept in the staff employee files. The ADM stated when the vaccinations became available, all employees were given risk/benefit education material on both the Moderna and the Pfizer vaccines. The ADM stated the facility ended up using the Moderna vaccine. The DON stated if employees consented for the vaccine, the sheet was kept in their employee file, but not for employees, who refused to COVID-19 vaccine. The ADM stated that every time staff are tested for COVID-19, staff are asked if they would like to get the COVID-19 vaccination. The ADM stated that a few of the staff members [Certified Nursing Assistant (CNA) 3 and CNA 4] had stated that their parents would not allow them to get the vaccination. The DON stated [Registered Nurse (RN) 2 and RN 4], had just started working at the facility and she did not have information on them yet. The DON stated that the refusals have been word of mouth and there was no documentation for that. The ADM stated he would send the education information given to employees and what they have had on their staff/group information web page so they could prove they have provided some education. No information was provided.

Based on observation, interview, and record the review it was determined, for 1 of 19 sample residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident that complained of pain was unable to get a change in pain relief from the facility Medical Director (MD) for a week. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/21 at 10:36 AM, an interview was conducted with resident 17. Resident 17 stated that her pain was not managed but the nursing staff had tried. Resident 17 stated she had asked the staff to call the doctor and they had tried twice and the doctor would not call the staff back. Resident 17 stated her pain was located on her right side under her abdominal pannus. Resident 17 stated the pain was relieved when she lied down but she preferred not to be in bed all day. Resident 17 stated the doctor would not pay attention or listen to her when she complained about pain. Resident 17 stated the doctor came in to visit her when she had covid19 but would not address her pain issue. Resident 17 was observed during the interview to attempt to shift her position and resident 17 facial grimaced during the interview. Resident 17 verbally expressed pain during the interview. Resident 17's medical record was reviewed on 6/15/21. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented resident 17 had scheduled pain medications, as needed pain medications, and non-medication interventions for pain. A pain assessment interview was completed and revealed resident had occasional pain. Resident 17's pain intensity was a numeric rating of a 10 on a scale of 00 - 10. A Care Plan diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Goal initiated on 1/29/20 and revised on 5/5/21, documented The resident will not have an interruption in normal activities due to pain through the review date. Some of the Interventions initiated on 1/29/20, documented Administer [MEDICATION(S)] as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on condition. Identify, record and treat the resident's existing conditions which may increase pain and or discomfort. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/record pain characteristics PRN (as needed): Quality (e.g. sharp, burning): Severity (1 to 10 scale): Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors, Chart in MAR (Medication Administration Record) as well as progress notes. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/27/20, [MEDICATION(S)] 50 milligrams (mg) 2 tablets every 4 hours as needed for pain r/t idiopathic peripheral autonomic [CONDITION(S)]. [Note: Out of 84 opportunities resident 17 requested [MEDICATION(S)] on 46 occasions. Pain ratings were a 7 or greater. On one occasion the pain rating was a 5.] b. On 1/28/20, [MEDICATION(S)] 15 mg daily for pain c. On 12/7/20, [MEDICATION(S)] Gel 2% apply to affected areas topically every 4 hours as needed for rash with pain. d. On 4/3/21, [MEDICATION(S)] 300 mg daily for diabetic [CONDITION(S)] e. On 6/12/21, Tylenol 325 mg every 4 hours as needed for pain On 6/15/21 at 3:26 PM, a Nurses Note documented Resident stated having pain underneath perineal area and pannus. NA (Nursing Assistant) [name removed] helped me while I assessed. Resident has a 2x2 cm (centimeter) wound, a 1x1 cm wound, and about a 1 inch slit underneath pannus. I cleaned and dried wounds. There was some bloody drainage. I put [MEDICATION(S)] on perineal area and under pannus. ABD (abdominal) gauze placed under pannus to help with moisture. Resident stated she was in pain but tolerated it well. Will continue to monitor. On 6/16/21 at 9:38 AM, a Nurses Note documented Sent a msg (message) to [MD name removed] about increasing pain in right hip area on 06-11. He stated that we could give her PRN [MEDICATION(S)] until Monday. Called and advised nurses. Text [MD name removed] again on Monday 06-15-2021 about increasing pain as I still had not heard from him. The end of the day he sent me a text to talk with his nurse that he was at the hospital. Sent another message to his nurse in his office. Will continue to monitor. RN's (Registered Nurses) are keeping area dry, applying cream and keeping gauze in area to keep dry. Will continue to monitor. On 6/16/21 at 3:39 PM, an Order Note documented Oxycodone 10 mg every 6 hours as needed for pain. On 6/15/21 at 3:49 PM, an interview was conducted with RN 2. RN 2 stated the new MD came in once every other week on Fridays. RN 2 stated the old MD was responsive to the nursing staff calling for orders or concerns; the new MD was not responsive when the nurses called and he was not willing to make adjustments that the nursing staff felt were appropriate. RN 2 stated the MD did not answer quickly regarding issues at the facility and the MD was not really involved. RN 2 stated regarding pain medications the MD was often very resistant to making pain medication changes sometimes the physician just won't do it and then if he doesn't come into the facility that week then it cannot be done; sometimes the MD may even just do the opposite of what the nursing staff asked for. RN 2 stated that resident 17 wanted something more for pain, but the MD did not respond when he had asked to provide her more pain medications. RN 2 stated resident 17's pain was due to wounds in the perineal area and pannus; she becomes more aggressive and agitated because she is in pain. On 6/16/21 at 8:57 AM, an interview was conducted with RN 3. RN 3 stated if she was unable to get a hold of the MD she was able to get a hold of his nurse. RN 3 stated the MD came to the facility every other Friday. RN 3 stated the MDS Coordinator would do rounds with the MD and would input any new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 3 stated she had been giving resident 17 pain medications as frequently as she could have them. RN 3 stated resident 17 did not like to rotate as often as she should to alleviate pain. RN 3 stated the [MEDICATION(S)] powder did not help but resident 17 did have [MEDICATION(S)] gel at bedside and that seemed to help at times. RN 3 stated that resident 17 liked to lie in bed but staff encouraged resident 17 to be up more. RN 3 stated resident 17's pain did restrict her but resident 17 was not very active prior. RN 3 stated there was not a big difference in resident 17's restriction but resident 17 did vocalize it was harder to do things with the pain. RN 3 stated the Director of Nursing (DON) was the last to send a message to the MD regarding resident 17's pain and the MD replied that he was going to do something on Monday (6/14/21) but RN 3 was not sure if anything had been changed. On 6/16/21 at 9:39 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated resident 17 had expressed on occasion prior to a shower refusal that she was in pain. On 6/16/21 at 2:07 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 17 would refuse showers frequently due to pain. CNA 1 stated resident 17 was working with restorative at the beginning of June and CNA 1 would assist resident 17 with her showers a couple days a week. On 6/16/21 at 12:46 PM, an interview was conducted with the DON. The DON stated if the nursing staff called the facility MD he would get back to the them hours later. The DON stated the MD did not respond in a timely manner if the MD responded at all. The DON stated the MD's clinic was priority. The DON stated resident 17 had chronic pain issues and last week resident 17 had developed a new sore under her pannus down the right side that caused [CONDITION(S)] pain. The DON stated the staff have tried to bandage the area to keep it dry and apply powders. The DON stated resident 17 had [MEDICATION(S)] gel at bedside to help numb the [CONDITION(S)]. The DON stated RN 2 sent the MD a message on Tuesday, 6/8/21, and the MD never responded. The DON stated she had sent the MD a message on Thursday, 6/10/21, and the MD never responded. The DON stated she had sent the MD a message on Friday, 6/11/21, and the MD responded . Hate [MEDICATION(S)]. Use it until. The DON stated the MD was not in his office or where he could write a paper order for pain medications. The MD responded Only thing we can do now. Fix it Monday. The DON stated on Monday, 6/14/21, she had to message the MD to follow up regarding resident 17 and the conversation they had on Friday. The DON stated she had received no response from the MD and sent another message on Tuesday, 6/15/21, the MD responded to message his office the information on resident 17. The DON stated she had to message the MD again today about the pain medication for resident 17. [Note: The DON provided copies of cell phone messages .]

Based on observation, interview, and record review it was determined, for 2 of 19 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two residents that had multiple falls were not provided interventions or adequate supervision to prevent falls from occurring. One resident had to be transported to the emergency roiagnom on two occasions after sustaining lacerations that required sutures. In addition, a resident was not provided adequate supervision during smoking. Resident identifiers: 6 and 10. Findings include: 1. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to [CONDITION(S)], fall on same level from slipping, tripping and stumbling without subsequent striking against object, strain of muscle, fascia and tendon of lower back, laceration without foreign body of other part of head, weakness, presence of artificial knee joint, long term (current) use of anticoagulants, and major depressive disorder. Resident 6's medical record was reviewed on 6/17/21. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 6 was requiring extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and locomotion on and off the unit. Resident 6 was not steady, only able to stabilize with human assistance during surface to surface transfer (transfer between bed and chair or wheelchair). A Quarterly MDS assessment dated [DATE], documented that resident 6 had a Brief Interview for Mental Status (BIMS) score of a 5. A BIMS score of 0 to 7 indicates a severe cognitive impairment. A Care Plan Diagnosis initiated on 1/18/21, documented The resident is at risk for falls r/t (related to) Confusion and history of falls at home. The Goal initiated on 1/18/21 and revised on 4/16/21, documented The resident will be free of falls through the review date. The Interventions initiated on 1/18/21, documented Anticipate and meet needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Follow facility fall protocol. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). On 2/2/21 at 9:22 AM, a Nurses Note documented Resident fell in room at 0850 (8:50 AM) found by Aid (Certified Nursing Assistant) [name removed]. Resident appeared to have fallen from wheelchair onto floor underneath bed. Resident had bleeding and skin tear to face on nose and complained of pain to back, hips, and B (bilateral) legs. Vital signs taken at 0855 (8:55 AM):temp (temperature) 98.6, 02 (oxygen) 78, pulse 44, and BP (blood pressure) 113/67, respirations of 18. 02 rechecked at 97% and pulse of 81. Ambulance contacted, daughter [name removed], and [local hospital name removed]. Resident transported to ER (emergency room ) by ambulance. DON (Director of Nursing) notified. [Note: No new fall interventions were implemented.] On 2/2/21, resident 6 was categorized high risk for falling with a score of 75 on the Nursing Morse Fall Scale Form. On 2/5/21, a Patient Discharge Summary Report from the local hospital documented laceration without foreig (sic) as one of the secondary encounter diagnoses. On 2/6/21 at 8:30 AM, an Incident Report documented Aide (Certified Nursing Assistant) was walking passed resident room and noticed resident on floor. Emergency call light was pushed. Went into room and observed resident on floor at the end of his bed. Resident denied any pain but does have bruise under left eye. Resident denies falling, stated he slipped out of chair. [Note: No new fall interventions were implemented.] On 2/6/21, resident 6 was categorized high risk for falling with a score of 55 on the Nursing Morse Fall Scale Form. On 2/16/21 at 9:11 AM, a Skin/Wound Note documented Took 2 sutures out of right side of nose. No steri stripes needed. Clean and dry. No signs of infection. On 5/12/21 at 2:00 PM, a Nurses Note documented Resident had unwitnessed fall in room from motorized wheelchair to floor at 1400 (2:00 PM). Aide [name removed] came and reported this to RN's (Registered Nurses) [names removed]. Resident hit head off of heater and has 3-4 moderate sized open and bleeding lacerations to L (left) side of face. Resident reports no other pain or injuries on any other parts of body besides head and face. Resident's post fall vitals are as followed: BP 125/66, pulse 95, RR (respiratory rate) 18, and 02 94% on 3L (liters) NC (nasal cannula). Resident alert and oriented x4 (person, place, time, situation). Pupils equal and reactive to light. Resident cognition baseline. [Name of Medical Director (MD) removed], DON, and ADON (Assistant Director of Nursing) notified and resident taken to [name of local hospital removed] ER in ambulance. [Name of local hospital removed] called and given report of resident's current condition. Risk management completed. Resident's son notified and at facility when resident was taken by ambulance. [Note: No new fall interventions were implemented.] On 5/12/21 at 5:00 PM, a Nurses Note documented Resident arrived back to the facility after visit to [name of local hospital removed] ER due to fall in resident's room at 1400. Resident arrived back to facility via ambulance in stable condition via stretcher. Resident received 6 stitches to facial lacerations and got CT (computed tomography) of Brain and Head w/o (without) contrast which was negative findings. On 5/12/21, resident 6 was categorized high risk for falling with a score of 75 on the Nursing Morse Fall Scale Form. On 5/25/21 at 11:46 AM, a Nurses Note documented Bee aware program implemented. On 6/17/21 at 10:17 AM, an interview was conducted with resident 6. Resident 6 stated he had the seat belt so he did not fall out of his motorized wheel chair. Resident 6 stated if he did fall the chair would fall him. On 6/17/21 at 10:26 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 6 had the seat belt in his motorized wheelchair because he would fall out of his wheelchair. CNA 1 stated once a month during a CNA meeting she had training on the seat belt, restraints, and safety. CNA 1 was not aware of any special requirements with the seat belt. CNA 1 stated resident 6 had the seat belt on the motorized wheelchair when he was at home prior to coming to the facility. CNA 1 stated that resident 6 was unable to toilet himself and he wore briefs. CNA 1 stated that resident 6 was in his motorized wheelchair from approximately 7:00 AM until 7:00 PM or 8:00 PM. An observation was made of resident 6 self releasing the seat belt without assistance from CNA 1. CNA 1 stated the seat belt had been a problem in the past because resident 6 would self release the seat belt, put his feet on the floor, put the wheelchair in reverse, and the wheelchair would come out from underneath resident 6 and resident 6 would fall out of the wheelchair. On 6/17/21 at 11:30 AM, an interview was conducted with RN 1. RN 1 stated resident 6's motorized wheelchair that he brought from home did not have the seat belt attachment. RN 1 stated the facility tried to put resident 6 in a standard wheelchair for safety reasons but resident 6 was unable to get around the facility in the standard wheelchair. RN 1 stated resident 6's family requested that resident 6 have the motorized wheelchair back so he was able to get around. RN 1 stated the facility got resident 6 a motorized wheelchair with the seat belt attachment. RN 1 stated that resident 6 preferred to spend most of the day in his room looking out the window but he did come to the dining room for meals. RN 1 stated if resident 6 was in his room the staff would ensure resident 6 had his seat belt on, glasses, oxygen, bed side table, and call light within reach. RN 1 stated resident 6 was on the Bee Program. RN 1 stated the if a resident had a lot of falls they would have a bee placed outside of their door. RN 1 stated the bee was to remind the staff to look in on the resident each time they passed the room. RN 1 stated if a resident had a fall the CNAs were to notify the nurse and vital signs were done with a complete assessment. RN 1 stated if the resident could tell her they hit their head or the fall was not witnessed neurological checks would be initiated. RN 1 stated if the resident had hit their head she would notify the family and send the resident to the hospital unless the family said no. RN 1 stated the DON implemented a Bee Aware program where staff could make suggestions on how to prevent falls and the DON would pick the best suggestion. RN 1 stated residents have there own individualized care plans in the medical record. On 6/17/21 at 12:04 PM, an interview was conducted with the DON. The DON stated the MDS Coordinator updated the resident care plans with interventions. The DON stated the team meets every Thursday to discuss care plans and the team meets with resident families once a month. The DON stated last month there were a lot of resident falls. The DON stated when a resident had a fall the staff would complete a 72 hour charting and the resident would be on the bee aware program. The DON stated residents with cognitive issues would be brought to the day room so the staff could watch them. The DON stated the higher fall risk residents were on the same hall. The DON stated residents had individualized fall interventions. The DON stated a fall intervention implemented for resident 6 was the bee program but resident 6 required a lot of communication. The DON stated resident 6's family wanted the seat belt on the motorized wheelchair but resident 6 would take off the seatbelt and reach to turn up the heater. The DON stated residents were generally checked every 2 hours and resident 6 was on a hourly check and he was brought to the dining room for meals. The DON stated resident 6 was to be checked more frequently because he would remove his oxygen and his oxygen levels would decrease. The DON clarified during the interview the MDS Coordinator did not update resident care plans with interventions. 2. Resident 10 was admitted to the facility on [DATE] with diagnoses which included but not limited to [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, muscle weakness, essential hypertension, [CONDITION(S)], hereditary and idiopathic [CONDITION(S)], cerebral infarction, and generalized [CONDITION(S)]. On 6/14/21 at 2:32 PM, an interview was conducted with resident 10. Resident 10 stated he had a burn on his finger. Resident 10 stated it was an old burn from smoking cigarettes. Prior to exiting resident 10's room a cigarette butt was observed on the floor under resident 10's bed. Resident 10's medical record was reviewed on 6/16/21. An Admission MDS assessment dated [DATE], documented that resident 10 was requiring supervision with setup help only for bed mobility, transfers, walk in corridor, locomotion on and off the unit, dressing, and eating. Resident 10 was requiring limited assistance of one person for walk in room, toilet use, and personal hygiene. Resident 10 was not steady, but able to stabilize without human assistance during transitions and walking. An Admission MDS assessment dated [DATE], documented that resident 10 had a BIMS score of 13. A BIMS score of 13 to 15 indicates a intact cognitive response. a. A Care Plan Diagnosis initiated on 5/4/21, documented The resident is at risk for falls r/t Confusion, incontinence. The Goal initiated on 5/4/21, documented The resident will be free of falls through the review date. The Interventions initiated on 5/4/21, documented Anticipate and meet The resident's needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Follow facility fall protocol. On 4/24/21 at 12:42 PM, a Nurses Note documented Resident had a witnessed fall/ tipped over sideways in chair in dining area at 1245 (12:45 PM) while trying to move independently from wheeled walker to dining room chair. Resident appeared to miss chair and fell on to L side, appearing to hit head on floor.Resident (sic) denies any pain or discomfort, examined for injuries, none at this time. Neuro (neurological) exam WNL (within normal limits): BP 156/91, HR (heart rate) 94, R (respirations) 18, and temp 98.2. Neuro sheet initiated. [Note: A fall care plan was not developed until 5/4/21, for resident 10.] On 4/24/21, resident 10 was categorized high risk for falling with a score of 90 on the Nursing Morse Fall Scale Form. On 5/17/21 at 2:26 PM, a Nurses Note documented Cleaning heard a noise at approximately 1330 (1:30 PM) and went to check residents room, resident was on floor next to sink. Cleaning pushed emergency call light. Aids and I went into room to find resident on floor as well sitting on buttocks. Resident is alert andoriented (sic) X4. Resident stated that he hit head and that his neck was sore but his head did not hurt. He did not complain of any other injuries at this time. Did residents vitals at time of fall, all within normal limits. Started neuros. Helped resident back up. Gave him Tylenol for neck pain. Will continue neuros. [Note: No new fall interventions were implemented and a Morse Fall Scale Form was not completed reassessing resident 10's fall risk.] On 5/25/21 at 11:45 AM, a Nurses Note documented Bee aware program implemented. On 5/31/21 at 8:35 AM, a Nurses Note documented Resident had an unwitnessed fall outside while smoking on smoking deck with other resident. Kitchen Aide [name removed] heard resident fall onto ground from chair to butt and came to get floor nurse. Nurse assessed resident for any injuries,head (sic) injuries, or bruising. Resident reports he did not hit head, has no pain, only slight redness to R (right) side of neck. Resident reports he fell from his butt off of chair to the ground landing on his butt, denying hitting his head at all. Neuro exam performed, PERRLA (pupils are equal, round, and reactive to light and accommodation), pupils reactive, grasps equal, resident's A/O (alert and oriented) x4. Contacted resident's emergency contact/ sister [name removed], left message. Messaged DON, ADON, and [MD name removed]. Resident refused to have neuro fall sheet vitals performed stating he 'did not hit hishead (sic) and would not be having that done.' Post fall vitals: BP 138/70, P (pulse) 88, o2 90% on RA (room air), and RR 18. [Note: No new fall interventions were implemented and a Morse Fall Scale Form was not completed reassessing resident 10's fall risk.] b. A Care Plan Diagnosis initiated on 4/22/21, documented The resident is a smoker. The Goal initiated on 4/22/21 and revised on 4/26/21, documented The resident will not suffer injury from unsafe smoking practices through the review date. The Interventions initiated on 4/22/21, documented Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette [CONDITION(S)]. The resident's smoking supplies are stored at the nurses station. On 3/31/21, a Nursing Admission Assessment documented No open wounds or skin issues at this time. Burn (blister) to R pointer finger at home, bandaid in place. On 4/5/21 at 10:33 AM, a Nurses Note documented . Resident has onewound (sic) on right hand on first finger that looks like a burn. It is completely closed. On 4/19/21 at 9:10 AM, a Nurses Note documented . Resident has one wound on right hand on first finger that looks like a burn, this was previous to admit. On 4/22/21 at 2:34 PM, a Plan of Care Note documented . Yesterday, RA (Resident Advocate) spoke with his sister, [name removed] and she addressed his smoking and would like him to have a patch. She is worried his smoking will get out of hand and won't be able to afford his habit. RA informed her that his cigarettes are kept at the nurses desk and they try monitoring them. RA also told her when he doesn't have a smoke he continually picks up butts off the ground and smokes them. [Name removed] asked about a patch, DON advised her that they are unable to put a patch on as long as he continues smoking and picking up butts. Sister said she was going to talk with Resident and tell him only 3 cigarettes a day. RA will continue to encourage Resident to smoke lightly. On 5/11/21, an Admission Smoking - Safety Screen was completed. Resident 10 was documented as Safe to smoke without supervision. Resident 10 needs to store cigarettes and lighter at the nurses station. Resident 10 forgets and lights cigarettes in his room. Safe and stable outside. On 5/12/21 at 11:15 PM, a Nurses Note documented SMOKING/FIRE INCIDENT: [Resident 10] came in the door after going outside to smoke. As soon as he entered through the door, I was able to smell something burning. Aide [name removed] went out the door to investigate and returned stating the burning smell was only right here in the entry and hallway nearby. I stated that it smells like clothes are on fire. We both promptly followed [resident 10] down the hall. We were able to see embers moving down the inside of [resident 10's] pant leg and with the dimly lit hallway it was very visible. His sweatpants were immediately removed and stomped on. We shook out the pant legs and out fell a dry wipe that still had embers glowing. His sweatpants were charred. We asked resident if he got burned, he stated that he did not. Upon inspection,there (sic) were no burn marks on the skin of the resident's right leg. [Note: No new smoking interventions were implemented.] On 6/11/21, a Quarterly Smoking - Safety Screen was completed. Resident 10 was documented as Safe to smoke without supervision. Resident 10 able to light his own cigarette and smoke without any complications. On 6/17/21 at 11:40 AM, an interview was conducted with RN 1. RN 1 stated resident 10 used a wheeled walker and required safety reminders. RN 1 stated since resident 10's urinary catheter had been removed he had been better as far as falls and safety. RN 1 stated she provided resident 10 a lot of education regarding falls and safety. RN 1 stated that resident 10 was safe to smoke most of the time. RN 1 stated If resident 10 ran out of cigarettes he would try and find cigarette butts and then resident 10 was not safe. RN 1 stated she had to remind resident 10 not to look for cigarette butts and smoke them. RN 1 stated that smoking aprons were available for the residents and they had tried to implement them in the past but the residents would not wear them. On 6/17/21 at 11:45 AM, an interview was conducted with CNA 2. CNA 2 stated she frequently checked on resident 10 every 2 hour. CNA 2 stated when resident 10 was in the day room she would remind resident 10 to use his walker. CNA 2 stated she would look out the window at the smoking area to check on resident 10 to ensure that he was safe and resident 10's cigarettes were at the nurses station. On 6/17/21 at 11:52 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated she would keep an eye on resident 10 every two hours. NA 1 stated she had been given no instructions on watching resident 10 in the smoking area. On 6/17/21 at 12:22 PM, an interview was conducted with the DON. The DON stated resident 10 required constant reminders regarding fall safety and he had advanced [CONDITION(S)]. The DON stated that resident 10 worked with Physical Therapy because he had a shuffle gait. The DON stated resident 10 would get excited and the shuffle gait would become worse. The DON stated resident 10's sister was medical Power of Attorney and did not want resident 10 smoking. The DON stated a [MEDICATION(S)] patch was tried on resident 10 but he would smoke with the patch on. The DON stated resident 10's cigarettes were kept at the nurses station desk. The DON stated resident 10 was a safe smoker except when he tried to smoke the little cigarette butts. The DON stated resident 10 would go outside and pick cigarette butts off the ground and would light them. The DON stated the maintenance worker was going to hire an assistant to help clean up the cigarette butts. The DON stated she had tried putting buckets and cigarette receptacles in the smoking area but resident 10 would dig in them to look for the cigarette butts when he was out of cigarettes. The DON stated resident 10 was only unsafe smoking when he was out of cigarettes. The DON stated it would probably help to have a staff member outside to watch resident 10 while he smoked. The DON stated the smoking incident with resident 10 was caused when resident 10 walked in the facility with his cigarette and tried to put it in his pocket. The DON stated smoking assessment were completed on admission and quarterly. The DON was not sure why resident 10's admission smoking assessment was not completed until 5/11/21.

Based on interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 sample residents. Specifically, a there was as two hour delay in seeking a higher level of care after a resident sustained [REDACTED]. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 3/8/17. On 11/30/16 at 2:15 PM, Licensed Practical Nurse (LPN) 1 documented, Vital signs: BP (blood pressure) 138/92, P (pulse) 114, RR (respiration rate) 16, Temp (temperature) 99.3 and O2 (oxygen) Sats (saturations) 64% on RA (room air). (Certified Nurse Assistant (CNA) 1) requested my presence's (sic) in resident's room, where it was explained to me that (resident 1) had asked (CNA 1) to help him walk. During this activity (CNA 1) said (resident 1) slipped, falling to the floor where he hit the back of his head against the closet door. (Resident 1) sustained a laceration to the back of his head. Alert and confused, O2 Sats 64% on RA; usually he is above 90% on RA. Oxygen started on 2 L/M (liters per minute) per NC (nasal cannula). Vital signs became unstable, heart rate 134. FWB (Full weight bearing) and FROM (full range of motion) with out (sic) pain. He was transported to (hospital via) ambulance. Resident unable to explain what happened. (Resident 1's significant other) was present in the room. (Resident 1's primary care physician) was notified per fax; was unable to contact him by phone as his voice mail box was full. (The Director of Nursing (DNS) and Administrator (ADM)) also notified. On 11/30/16 at 2:35 AM, LPN 1 documented, Notified by (Hospital) ER (emergency room ) that (resident 1) had coded in the ambulance on the way to the hospital and they were unable to revive him. The NEUROLOGICAL RECORD was reviewed. LPN 1 documented the following: 1. 11/29/16 at 9:00 PM: BP 138/92, P 114, Respirations (R) 16, Temperature (T) 99.3, O2 sat on RA 65%. The level of consciousness was not documented. Resident 1's pupils were 0.4 millimeters (mm) and were reactive. Resident 1 opened his eyes spontaneously. Resident 1 appropriately obeyed commands and/or moved all extremities. Resident 1 had confused conversations. 2. 11/29/16 at 9:30 PM: BP 168/88, P 126, R 36, T 99.4, O2 sat 78% on 2 l/m via nasal cannula. The level of consciousness was not documented. Resident 1's pupils were 0.4 millimeters (mm) and were reactive. Resident 1 opened his eyes spontaneously. Resident 1 appropriately obeyed commands and/or moved all extremities. Resident 1 had confused conversations. The total Eye-Motor-Verbal (EMV) Response was scored at 14. (Per the NEUROLOGICAL RECORD, a full conscious resident would score 15 points. A comatose resident would score 3 points.) 3. 11/29/16 at 10:00 PM: BP 168/88, P 137, R 30, T 100.2, O2 sats 74% on 2 l/m via nasal cannula. Resident 1's pupils were 0.4 mm and were reactive. Resident 1 opened his eyes to speech, had flaccid extremities and confused conversations. The EMV response was scored as an 8. 4. 11/29/16 at 10:30 PM: BP 80/42, P 134, R 30, T 98.0, O2 sats 69% on 2 l/m via nasal cannula. Resident 1's pupils were 0.4 mm and were reactive. Resident 1 opened his eyes to speech, had flaccid extremities and confused conversations. The EMV response was scored as an 8. (Note: It was 1 1/2 hours after resident 1 sustained a ground level fall with a head injury, unstable vital signs and a significant change in his neurological status before emergency medical services were activated.) On 3/9/17 at 8:53 AM, CNA 3 was interviewed. CNA 3 stated that resident 1 was slurring his words and could talk for a few seconds immediately following the fall, but then went down hill after that. CNA 3 further stated that resident 1 was pretty much out of it. CNA 3 stated that he had grayish color and that his breathing was rapid. CNA 3 stated that resident 1 appeared to be hurting and was holding onto the right abdominal area. On 3/9/17 at 9:33 AM, the DNS was interviewed. The DNS stated that resident 1 should have been sent to the hospital shortly after he fell and stated that she did not know why LPN 1 waited until 10:30 PM to active emergency medical services. On 3/9/17 at 10:15 AM, CNA 2 was interviewed. CNA 2 stated that resident 1 was not appropriately responding to questions directly after he fell , that he was slurring his words and wasn't making sense. CNA 2 stated that she immediately notified LPN 1 when resident 1's respirations increased at 9:30 PM and his oxygen saturation remained low despite the use of oxygen. On 3/9/17 at 11:50 AM, the ADM was interviewed. The ADM stated that it was the facility protocol to immediately active emergency medical services after a resident sustained [REDACTED]. On 3/9/17 at 2:33 PM, LPN 1 was interviewed. LPN 1 stated that upon her initial assessment of resident 1 immediately following his fall revealed that resident 1 had sustained a laceration to the back of his head that was not complicated and stopped bleeding easily. LPN 1 stated that resident 1 was his normal self and was alert and agitated with no change in his demeanor. LPN 1 stated that resident 1 remained on 2 l/m via nasal cannula despite the low oxygen saturation levels. LPN 1 stated that the CNA reported to her the high pulse, respirations and low oxygen saturations that were obtained at 9:30 PM. LPN 1 stated that she became concerned at 10:30 PM when resident 1's pulse and respirations remained high and the blood pressure and oxygen saturations were low. LPN 1 stated that she activated emergency medical services despite the no response from resident 1. LPN 1 stated that she did not active emergency medical services prior to 10:30 PM because she had to get permission from resident 1's 'significant other' prior to resident 1 being sent to the hospital.

Based on observation, interview, and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 3 of 24 sample residents. Specifically, two residents were not adequately assessed following changes of condition and one resident did not receive timely incontinence care. Resident identifiers: 18, 13. and 12. Findings include: 1. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/2/15 at 5:30 PM, an observation was made of resident 18. Resident 18 was observed to be lying slumped down in her bed with her chin resting on her chest. Resident 18 was observed to be having difficulty breathing with coarse wet, breath sounds noted. Resident 18's eyes were observed to be partially closed and she attempted to open her eyes when spoken to with no additional response. In addition, resident 18 was observed to be receiving 2 liters of oxygen via a nasal cannula. On 8/2/15 at 5:40 PM and 6:00 PM, additional observations were made of resident 18. Resident 18 remained lying slumped down in bed with her chin resting on her chest. Resident 18 was observed to be having continued difficulty breathing with coarse wet, breath sounds noted. In addition, resident 18 was observed to be unresponsive when an attempt to speak with her was made. On 8/2/15 at 6:20 PM, an additional observation was made of resident 18. Resident 18 was observed to remain lying slumped down in bed with her chin resting on her chest. Resident 18 was observed to be having continued difficulty breathing with coarse wet, breath sounds noted. On 8/2/15 at 6:20 PM, an interview was conducted with resident 18 immediately following the previous observation. With some observed difficulty, resident 18 stated that it was very hard to breath and no one had repositioned her since she laid down in her bed a while ago. Resident 18 further stated the facility wanted her to go to the hospital but she preferred not to go unless it was serious. In addition, resident 18 stated she did not believe her family had been contacted regarding her condition. On 8/2/15 at 6:22 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 18 was usually really alert and clear and her change of condition occurred that day. LPN 1 further stated resident 18 went to the hospital a while ago and had not been her usual self since. In addition, LPN 1 stated she planned to notify resident 18's daughter and had already spoken to the physician about ordering an antibiotic. On 8/2/15 at 6:30 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 18 normally layed in bed with the head of the bed angled upward. RN 1 further stated that he did not notice how the resident was positioned when he went in to check on her a few minutes prior to the interview. In addition, RN 1 stated resident 18 had stated that she wanted to see how things went during the night then would decide if she needed to go to the hospital. The facility administrator (FA) provided a document that revealed the doctor was notified of resident 18's change of condition on 8/2/15 at 10:14 AM via telephone. On 8/2/15 at approximately 6:30 PM, LPN 1 was observed to notify resident 18's daughter of her mother's change of condition via telephone. On 8/2/15 at 6:30 PM, an interview was conducted with LPN 1. LPN 1 stated resident 18's daughter told her that her mother's condition did not sound good and she trusted staff's judgement on whether or not to send her to the hospital. When LPN 1 was asked if resident 18 had received the antibiotic dose the physician had ordered earlier that day, LPN 1 stated resident 18 had not received the antibiotic yet but she planned to give it to resident 18 immediately. On 8/2/15 at 6:40 PM, observations were made of resident 18. Resident 18 was observed to be sitting up in bed with the head of the bed at a 45 degree angle. Resident 18 was observed to be more alert with increased ease of breathing. Resident 18's breath sounds were observed to continue to be coarse and wet, and she was receiving 2 liters of oxygen via nasal cannula. Resident 18's medical record was reviewed on 8/3/15. A Daily Skilled Nurses Note, Labs dated 7/29/15 at 8:27 AM documented the following information: (Resident 18) came out to meals in the dining room. She is alert and oriented with pleasant mood. She is reporting dysuria, urine sample obtained and sent to lab. She had a bath this am (morning). Her weight is 203 (pounds). She worked with therapy on strengthening and ambulation. Her lungs are clear on auscultation and her bowel sounds are active. A Daily Skilled Nurses Note dated 7/30/15 at 11:36 AM documented the following information: (Resident 18) came out to meals in the dining room. She is alert and oriented with quiet mood. She took [MEDICATION NAME] after breakfast for anxiety with good results. Her lungs are clear but diminished on auscultation and her bowel sounds are active. Her [MEDICAL CONDITION] is patent. A Daily Skilled Nurses Note dated 7/31/15 at 6:05 PM documented the following information: (Resident 18) is stable but c/o (complains of) feeling disconnected and sleepy. Hydration encouraged. Her pain is well controlled with Rx (prescription) PRN (as needed) medication. She has a UA (urine analysis) pending. No other sign of infection. VS (vital signs) normal with BP (blood pressure) 132/80, HR (heart rate) 75, RR (respiratory rate) 18, Temp (temperature) 97.3 and oxygen sats (saturation) 94% on 2L (two liters) per nasal cannula. She has lung sounds CTA (clear to auscultation) all lobes. Bowel sounds active all quads (quadrants). No change in diet or appetite. She comes to dining room for meals. No change in bowel or bladder habits. She is cooperative with staff but a bit subdued for her. No skin issues. A Daily Skilled Nurses Note, Change of Condition dated 8/2/15 at 3:27 PM documented the following information: Patient is alert yet confused and lethargic at times. Patient prior to dinner was found by vending machines resting. Patient was difficult to arouse and vs (vital signs) except o2 (oxygen) which was in mid 80's on 2 liters o2 increased to 3 saturations slowly increased and stopped at 91 percent. Lungs clear yet diminished throughout. HR (sic). warm pink dry 1 plus [MEDICAL CONDITION] bilateral. Patient assisted to table and drank her fluids. Patient was more alert upon going to sleep. During round patient has increased congestion. Able to clear with cough. New onset of congestion to monitor and report to family and MD (medical director). Patient stated she does not want to go to hospital will continue to check and reassess through the night. A Medication, General Nurses Note dated 8/2/15 at 6:53 PM documented the following information: The aide brought (resident 18) to me and asked if I would listen to her lungs. She has wheezing on expiration in all 4 lobes. The Dr. (doctor) was contacted and had her put on [MEDICATION NAME] 300 mg (milligrams) BID (two times per day) x (for) 10 days. About 5:30 (sic) the aids (sic) came and asked if I could look at (resident 18) again, she was very unbalanced as she sat on her bed. She was layed back down. She was asked if she wanted to go to the hospital and get checked out, she stated that she did not want to go. Her daughter was called and informed of the situation. Her daughter responded saying that it did not sound good and that she would trust in our decision if we did chose to send her. A General Nurses Note dated 8/2/15 at 7:30 PM documented the following information: (Resident 18's) Lungs have Expiratory wheezes and rails. (sic) in bilateral upper lobes. faint expiratory wheezes to Bilateral LL (lower lobes). Asked if she wants to go to the hospital and be checked. She said she doesn't want to go there but if she has too she will go. I called the transport person to take over to the hospital. A General Nurses Note dated 8/2/15 at 9:13 PM documented the following information: (Resident 18) went with Transport lady at 1945 (7:45 PM) to hospital. Called report to ER (emergency room ). Sent all papers with her meds (medications) and diagnosis. A General Nurses Note dated 8/2/15 at 11:39 PM documented the following information: (Resident 18) is being admitted to the hospital with [REDACTED]. A General Nurses Note dated 8/2/15 at 11:44 PM documented the following information: Called (resident 18's daughter) and let her know the hospital will be keeping her for a few days. A Medication, General Nurses Note dated 8/3/15 at 3:25 PM documented the following information as a correction to the note dated 8/2/15 at 6:53 PM: (Resident 18) was brought to me at 9:00 (AM). The aide took her vitals while I was listening to her lungs. BP 142/68 P (pulse) 68 R (respirations) T (temperature) 98.0 O2 (oxygen) 92 2L. (Doctor) was called at approx. (approximately) 10:15 am to discuss her condition. He told me to start her on [MEDICATION NAME] 300 Mg (milligrams) PO (by mouth) BID x10 days. She did come out to lunch then returned to her room. I checked on her about 14:20 (2:20 PM) and she was sleeping. At approx. 17:00 (5:00 PM) (Nursing Assistant (NA) 2) asked if I could check on her, that she did no (sic) look good. When I went to her, she was sitting on the side of the bed very unbalanced. She wanted to get into her chair, I advised her that that would be unsafe, that she was not balanced enough to sit in it. She said that she would lay back down. She had her vitals taken BP 147/77 P 62 R 16 T 98.0 O2 91 2 L (liters). During report, (RN 1) was informed of (resident 18's) situation. The Change of Condition Log: Infections, Falls, Decline in ADL's (activities of daily living) etc. (et cetera) document was reviewed. Resident 18 was documented to have a Change of Condition Requiring F/U (follow up) on 8/2/15. A review of resident 18's Vital Parameters documentation revealed her vitals were obtained on 7/28/15 at 12:53 PM, 7/29/15 at 12:22 PM, 7/30/15 at 11:34 AM, and 7/31/15 at 6:10 PM. (Note: There is no documentation that resident 18's vital signs were obtained upon noticing her change of condition and notifying the physician.) The Communication Form and Progress Note provided from the facility to the hospital upon transfer that pertained to resident 18's condition was reviewed. The form documented resident 18's change of condition started on 8/4/15 and was getting worse. The form further documented resident 18's primary [DIAGNOSES REDACTED]. (Note: Resident 18 was admitted to the hospital on [DATE], and the Communication Form and Progress Note documented that her change of condition occurred two days following transfer.) The hospital admission assessment was reviewed and documented the following information: [AGE] year-old female complaining that over the past few days she is having more and more difficulty in breathing. She recently had wraps on her legs for swelling. This was taken off a few days ago. She does have a cough that is essentially nonproductive. Possibly a fever. Patient states she just does not feel well and is getting worse and worse. She has had routine and consistent followup (sic) with her primary care physician. Preliminary [DIAGNOSES REDACTED]. On 8/3/15 at 8:46 AM, an interview was conducted with RN 2. RN 2 stated resident 18 was having difficulty breathing based on the report she received from the night staff and was admitted to the hospital with [REDACTED]. On 8/3/15 at 10:42 AM, a follow up interview was conducted with RN 2. RN 2 stated resident 18 was normally alert and oriented and although she tended to become less responsive when she felt sick, she was still capable of communicating with staff. RN 2 further stated resident 18 was having difficulty breathing the previous week, but was unaware of when her change of condition occurred and did not how she was being treated. On 8/3/15 at 10:47 AM, an interview was conducted with NA 2. NA 2 stated resident 18 normally remembers everything and she noticed a change in resident 18's level of consciousness maybe Friday night or early Saturday morning. On 8/3/15 at 12:55 PM, an interview was conducted with resident 18's daughter. Resident 18's daughter stated she was not aware that her mother experienced altered mental status prior to being transported to the hospital and wondered if she had been promptly notified by the facility regarding her mother's change of condition since her mother was transported to the hospital soon after she was contacted. Resident 18's daughter further stated she wondered if her change in condition had occurred earlier in the day and the facility did not contact her until they had to intervene. On 8/3/15 at 1:35 PM, an interview was conducted with the FA. The FA stated her staff should have picked up on resident 18's symptoms because she tended to follow the same pattern of symptoms each time she had to be transported to the hospital. 2. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13's medical record was reviewed on 8/3/15. A care plan for Pain was dated 7/23/15 and documented .pain to left shoulder, MRI scheduled. A General Nurses Note, Doctor's Visit, Pain mamagement (sic), Change of Condition dated 7/13/15 at 3:42 PM documented the following information: Has been LOA (leave of absence) to EMC (local hospital) since midday to see (doctor). He has been c/o (complaining of) increase in pain in his L (left) arm, shoulder, collarbone and neck area. He has started avoiding using L (left) arm and sometimes appears that he can hardly raise it. He is still LOA, did not get noon dose of meds (medications) as he was LOA. Has had 2 PRN (as needed) doses of pain med. A Weekly Nursing Note dated 7/17/15 at 6:31 PM documented the following information: .Resident 13 has had a lot of issues with pain, mostly in his R (right) shoulder and clavicle area. He has had x-rays, they were negative. He has had an ok mood and behavior. He is continent with his bowel and urinary systems. His respiratory system functions normally. He has no new skin issues this week. His appetite and hydration is adequate. He is alert and oriented with person and place. He will work with PT (physical therapy) on strength and balance. He takes his meals in his room. A Doctor's Visit note dated 7/23/15 at 4:11 AM documented the following information: (Doctor) in to visit during the evening of 7/22/15 at which time he made no changes to resident's treatments or medications. After (doctor) had left resident began to c/o (complain of) break through pain and stated he feels something is still wrong, even though his X-ray of his left shoulder was negative. He would like to have an MRI done, request was faxed to (doctor) at his office in (nearby town). A Labs note dated 7/23/15 at 9:28 AM documented the following information: (Doctor's name) ordered MRI of left shoulder without contrast per (resident 13's) request. A Weekly Nursing Note dated 7/25/15 at 3:25 AM documented the following information: (Resident 13) is stable. He has had Neck and shoulder pain since last week's X-ray. (Doctor) has ordered an MRI. He has no sign of infection. VS (vital signs) normal with BP (blood pressure) 116/76, HR (heart rate) 83, RR (respiratory rate) 18, Temp (temperature) 97.9, and oxygen sats (saturation) 93%. He is well hydrated. No change in bowel or bladder habits. No change in diet or appetite. His Bowel sounds are active all squads (sic). Lung sounds CTA (clear to auscultation) all lobes but slightly diminished on right lower lobe. He is alert and oriented. No changes in ADL's (activities of daily living). No skin issues. He continues with lymph [MEDICAL CONDITION] wraps on both lower extremities. An Appointment Request form for resident 13 was reviewed. The form was completed for resident 13 regarding left shoulder MRI s (with) contrast, but was not dated and did not indicate that the appointment was scheduled. The appointment scheduling calendars for July and August 2015 were reviewed. There was no appointment scheduled for resident 13 to have an MRI. On 8/2/15 at 5:32 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 13 had been complaining of being sore, had x-rays done which were negative, and she was working on getting an MRI scheduled for him. On 8/2/15 at 4:47 PM, an interview was conducted with resident 13. Resident 13 stated he did not bother using his call light anymore to receive assistance with toileting due to poor response times. In addition, resident 13 stated he had pain in his neck and shoulder area and was waiting for an MRI to be scheduled. On 8/4/15 at 9:45 AM, an interview was conducted with RN 2. RN 2 stated resident 13 had an MRI scheduled for July 28th, but refused anything that day with the doctor and did not know if the MRI had been rescheduled. (Note: There was no MRI appointment for resident 13 on July 28th according to the July 2015 appointment scheduling calendar.) On 8/4/15 at 9:47 AM, an interview was conducted with resident 13. Resident 13 stated the pain in his shoulder began when he fell a month ago, and he thought he had an MRI scheduled but the doctor assessed a lump in his chest instead. Resident 13 stated there was no possibility that he refused the MRI because he was in pain and wanted the MRI to be completed. On 8/4/15 at 1:25 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 13 began complaining of pain in his shoulder and neck area approximately a week and a half ago, and had x-rays completed that were negative. On 8/4/15 at 1:40 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated resident 13 began complaining of pain two weeks ago, she notified the RN, and knew resident 13 had x-rays done. On 8/5/15 at 8:55 AM, an interview was conducted with LPN 1. LPN 1 stated she was not sure when resident 13 began complaining of pain but it was not a result of his last fall that occurred approximately a month ago. LPN 1 further stated he had x-rays done and they were negative. On 8/5/15 at 9:10 AM, an interview was conducted with LPN 2. LPN 2 stated she was unsure when resident 13 began complaining of pain, but it was present when she began working at the facility on 7/22/15. On 8/5/15 at 9:20 AM, an interview was conducted with NA 2. NA 2 stated resident 13 began complaining of neck pain about a week ago and it was not related to his last fall. 3. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/2/15 resident 12's medical record was reviewed. Resident 12's Minimum Data Set (MDS) was reviewed. The most recent MDS was completed on 7/2/15 and revealed that resident 12 was a 2 person assist with toileting. According to Interdisciplinary Progress Notes dated 8/5/15 resident 12 was a one to two person assist with transfers and toileting and is incontinent of bowel and bladder. On 8/2/14 at 1:20 PM, resident 12 was observed in a wheelchair in the dining room. Resident 12 was able to self propel and approached a surveyor. Resident 12 stated I have to take a sh*#. The surveyor immediately approached Licensed Practical Nurse (LPN) 1 to ask if there was a staff member available to assist resident 12 with toileting. LPN 1 stated no sorry, everyone is helping with dining right now, she will have to wait. On 8/2/15 at 1:23 PM, resident 12 was observed becoming incontinent in the the wheelchair in the dining room. A strong odor of bowel movement was noted. On 8/2/15 at 1:45 PM, Certified Nursing Assistant 1 was observed to take resident 12 to her room. CNA 1 stated that resident 12 had become incontinent and was in the process of assisting resident 12 with cleaning up. On 8/4/15 at approximately 2:00 PM, CNA 2 was interviewed. CNA 2 stated that resident 12 was able to let the staff know when resident 12 needed to be toileted. On 8/4/15 at approximately 2:02 PM, Nursing Assistant (NA) 2 was interviewed. NA 2 stated that resident 12 was able to let her bathroom needs be known to the facility staff and that resident 12 is a 1-2 person assist with toileting.

Based on interview, observation, and record review it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. Specifically, hot water temperatures in 2 resident rooms throughout the facility were observed to range in temperatures from 124.2 to 149.9 degrees Fahrenheit. The deficient practice identified, in regards to the hot water, was found to have occurred at an Immediate Jeopardy level due to the potential risk of scalding and 3rd degree burns to the residents residing within the facility. Additionally, chemicals were observed to be left unattended and unsecured in the facility. The deficient practice identified, in regards to the chemicals was found to have occurred at a potential for harm and was not included in the Immediate Jeopardy. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 10/29/13 at 5:00 PM. The Administrator was asked to develop an immediate plan of correction to ensure resident safety related to hot water temperatures. PLAN: On 10/29/13 at 5:30 PM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated October 29, 2013 stated the following: "Survey 10/29/13: Water Temperatures out of compliance, IJ (Immediate Jeopardy) tag issued. Plan of Correction ECCR (Emery County Care and Rehabilitation) has used (a plumbing company) to correct faulty valves in the plumbing system. I have retrieved the contact information for (the plumbing company) and will call them to come and inspect and correct the issues. Management will In-Service Staff tonight 10/209/13 about the inconsistent water temperatures and fix the temperatures. ECCR management will regularly review water temperatures to ensure compliance and will audit Maintenance logs. All patients are at risk of harm when water temperatures do not fall within regulatory windows of acceptance. The maintenance Department is primarily responsible for ongoing compliance. Maintenance will report to the QA (Quality Assurance) team and the team will report to the Administrator on a regular basis. QA will regularly review water temperatures to ensure compliance and will audit." Prior to leaving the facility on 10/29/13, the surveyors confirmed the components outlined above in the written plan of action had been implemented. On 11/1/13, the Administrator provided the surveyors with an electronic plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated November 1, 2013 stated the following: " . . . Utah Dept. of Health Long-Term Care Survey Section PO Box 3 SLC, UT RE: Abatement of IJ for Water Temps Dear (Manager), After three replacement valves and numerous hours of time off line we can safely report and contend that, as of this date, our water temperatures are within the regulated ranges and no longer pose harm to our residents. We have had a plumber here to make the appropriate changes to the system and are confident that the new configuration and replacement parts will keep the temps within the designated ranges. Evidence of this is substantiated by the documentation attached. It reflects the last three tests to be within the required temperatures. . . " During the survey on 11/4/13 the surveyors confirmed removal of the Immediate Jeopardy situation as of November 1, 2013. Deficient practice with the potential for more than minimal harm remained for the risk of injury. Findings include: 1. The following listed temperatures were taken with both a digital and analog thermometer: a. 10/28/13 at 7:24 AM: Room 1 - 123.3 degrees b. 10/28/13 at 7:12 AM: Room 13 - 142.1 degrees c. 10/28/13 at 1:44 PM: Room 2 - 133 degrees d. 10/29/13 at 7:19 AM: Room 15 - 134 degrees e. 10/29/13 at 7:12 AM: Room 14 - 130 degrees f. 10/29/13 at 9:08 AM: Room 16 - 131 degrees g. 10/29/13 at 1:38 PM: Room 4 - 139 degrees h. 10/29/13 at 3:39 PM: Room 13 - 149.1 degrees i. 10/29/13 at 3:30 PM: Room 15 - 149.4 degrees j. 10/29/13 at 4:00 PM: Room 8 - 138.6 degrees On 10/29/13 at 9:50 AM, an interview was conducted with the Maintenance Director (MD). The MD stated that the water temperatures on all halls were monitored by a random selection weekly. He stated that there were several temperatures obtained in resident rooms that exceeded 120 degrees. On 10/29/13 at 4:21 PM, the facility Administrator and the MD (via telephone) were interviewed. The MD stated that the facility temperatures were "not falling in ranges." The Administrator stated that the MD had reported the high water temperatures to him previously but the concern had not been addressed yet. The MD stated that the high temperatures had started approximately nine months ago. On 10/29/13 at 4:31 PM, the water temperature in room 13 was again tested , in the presence of the Administrator, with the facility digital thermometer. The temperature obtained after four and a half minutes was 130.8 and 136.5 at five minutes. On 10/29/13 at 5:14 PM, the analog water temperature, that serviced the east and west sections of the facility, was 145 degrees. The analog temperature after the mixing valve was fixed was 98 degrees. The facility Administrator, with the Maintenance Director via telephone, were unable to provide information as to why the discrepancy. On 10/28/13 at 2:30 PM, CNA (Certified Nurse Assistant) 1 was interviewed. CNA 1 stated she turned the hot/cold faucets on at the same time because the hot faucet water was too hot to use. On 10/28/13 at 2:35 PM, CNA 2 was interviewed. CNA 2 stated, "The water gets pretty hot. I have to be careful I don't burn myself." On 10/28/13 at 5:22 PM, an interview was conducted with CNA 7. CNA 7 stated that in room 10, the water got "pretty hot, pretty quickly." CNA 7 stated that she had noticed that the water in resident rooms that was hot enough to burn or scald a resident and "that's not good if you have a confused resident who would turn on the water to the hot side." Potential for more than Minimal Harm: 2. On 10/22/13 the nursing supply room behind the nurses station was unlocked. In the top drawer to the right of the sink was found a bottle of pain reliever (acetaminophen) with approximately 25-30 tabs. In the lower cupboard to the right of the sink a spray bottle was found approximately 1/2 full labeled as a "Disinfectant". 3. An initial tour of the facility was conducted on 10/28/13. The following chemicals were observed to be unlocked and unsecured: a. The utility room on the "West River Drive" had: 1. One bottle of "Hydrokleen Multi Surface Cleaner" with the warning "caution - may be harmful if swallowed. May be irritating to eyes and skin. Do not take internally. Avoid contact with eyes and prolonged contact with skin"; 2. One bottle of "Disinfectant Cleaner" labeled with "warning, keep out of reach of children, harmful if absorbed through skin. Do not get in eyes or on clothing"; 3. One bottle of "Degreaser" with the warning, "keep out of reach of children". b. The shower room by the physical therapy department was unlocked. In the shower room an unmarked spray bottle was laying on the floor approximately 1/4th full of clear fluid. The bottle had been labeled "Do Not Drink". c. The "Bath/Tub" room on the West hall was observed to be unlocked with a razor, disinfectant cleaner in a spray bottle, a spray bottle labeled as "bleach" and barbacide that was unsecured. d. Room 10 had an unsecured oxygen tank that was placed next to the sink. e. Room 21 had a door to the wardrobe closet that was propped up against the wall. 4. On 10/28/13 at 1:15 PM, the shower room on the "Deer Park Run" hall had a container labeled "barbacide" that was unsecured.

Based on interview and record review, it was determined that the facility failed to maintain a quality assessment and assurance committee that identified quality concerns. Specifically, (1) The facility was observed to have water temperatures that had the potential of causing serious injury or death to the residents on the East and West wings of the facility which resulted in a finding of Immediate Jeopardy, (2) The facility did not care for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life for 5 of 35 sample residents which resulted in a finding of Harm in Substandard Quality of Life, (3) The facility did not provide medically related social services for 4 of 35 residents which resulted in Harm in Substandard Quality of Life; (4) The facility did not provide treatment and services for mental and/or psychosocial difficulties for 3 of 35 results which resulted in Harm in Substandard Quality of Life; (5) The facility transferred/discharged in an unsafe manner for 2 of 35 residents which resulted in Harm; (6) The facility failed to readmit a resident after a hospitalization for 1 of 35 residents that resulted in Harm; (7) The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns; and failed to maintain systems that resulted in five repeat deficiencies from the recertification survey that was conducted on 2/13/13. Resident identifiers: 3, 9, 14, 25, 26, 28, 47 and 48. Findings include: 1. The facility administration failed to provide an environment free of accident hazards. This failure resulted in a finding of Immediate Jeopardy. (Cross refer to F323) 2. The facility did not care for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life for 5 of 34 sample residents which resulted in a finding of Harm in Substandard Quality of Life. Resident identifiers: 3, 14, 26, 47 and 48. (Cross refer to F240) 3. The facility did not provide medically related social services for 5 of 35 residents which resulted in a finding of Harm in Substandard Quality of Life. Resident identifiers: 3, 9, 25, 47, and 48. (Cross refer to F250) 4. The facility did not provide treatment and services for mental and/or psychosocial difficulties for 3 of 35 results which resulted in a finding of harm in Substandard Quality of Life. Resident identifiers: 3, 9 and 47. (Cross refer to F319) 5. The facility transferred/discharged in an unsafe manner for 2 of 35 residents which resulted in Harm. Resident identifiers: 9 and 47. (Cross refer to F201) 6. The facility failed to readmit a resident after a hospitalization for 1 of 35 residents that resulted in Harm. Resident identifier: 28. (Cross refer to F206) 7. The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. A. The facility failed to maintain systems that resulted in five repeat deficiencies from the recertification survey that was conducted on 2/13/13. B. On 11/5/13, the facility Administrator (ADM) was interviewed. The ADM stated that the facility had monthly Quality Assurance (QA) meetings with all department heads, with the facility Medical Director (MD) attending the QA meetings quarterly. On 11/6/13, the facility QA meetings were reviewed from February to October 2013. There was no documentation that the facility MD attended the QA meetings at least quarterly as required. On 10/31/13 at 12:15 PM, an interview was conducted with the MD regarding his involvement in the QA process. The MD stated that he had not attended any QA meetings and had not reviewed the minutes of the QA meetings. (Cross refer to F332, F353, F428, F431, F514, F501 and F490)

Based on interview and record review, it was determined that the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. Specifically, (1) The facility was observed to have water temperatures that had the potential of causing serious injury or death to the residents on the East and West wings of the facility which resulted in a finding of Immediate Jeopardy, (2) The facility did not care for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life for 5 of 35 sample residents which resulted in a finding of Harm in Substandard Quality of Life, (3) The facility did not provide medically related social services for 4 of 35 residents which resulted in Harm in Substandard Quality of Life; (4) The facility did not provide treatment and services for mental and/or psychosocial difficulties for 3 of 35 results which resulted in Harm in Substandard Quality of Life; (5) The facility transferred/discharged in an unsafe manner for 2 of 35 residents which resulted in Harm; (6) The facility failed to readmit a resident after a hospitalization for 1 of 35 residents that resulted in Harm; (7) The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns; and failed to maintain systems that resulted in five repeat deficiencies from the recertification survey that was conducted on 2/13/13. Resident identifiers: 3, 9, 14, 25, 26, 28, 47 and 48. Findings include: 1. The facility administration failed to provide an environment free of accident hazards. This failure resulted in a finding of Immediate Jeopardy. (Cross refer to F323) 2. The facility did not care for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life for 5 of 34 sample residents which resulted in a finding of Harm in Substandard Quality of Life. Resident identifiers: 3, 14, 26, 47 and 48. (Cross refer to F240) 3. The facility did not provide medically related social services for 5 of 35 residents which resulted in a finding of Harm in Substandard Quality of Life. Resident identifiers: 3, 9, 25, 47, and 48. (Cross refer to F250) 4. The facility did not provide treatment and services for mental and/or psychosocial difficulties for 3 of 35 results which resulted in a finding of harm in Substandard Quality of Life. Resident identifiers: 3, 9 and 47. (Cross refer to F319) 5. The facility transferred/discharged in an unsafe manner for 2 of 35 residents which resulted in Harm. Resident identifiers: 9 and 47. (Cross refer to F201) 6. The facility failed to readmit a resident after a hospitalization for 1 of 35 residents that resulted in Harm. Resident identifier: 28. (Cross refer to F206) 7. The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. A. The facility failed to maintain systems that resulted in five repeat deficiencies from the recertification survey that was conducted on 2/13/13. B. On 11/5/13, the facility Administrator (ADM) was interviewed. The ADM stated that the facility had monthly Quality Assurance (QA) meetings with all department heads, with the facility Medical Director (MD) attending the QA meetings quarterly. On 11/6/13, the facility QA meetings were reviewed from February to October 2013. There was no documentation that the facility MD attended the QA meetings at least quarterly as required. On 10/31/13 at 12:15 PM, an interview was conducted with the MD regarding his involvement in the QA process. The MD stated that he had not attended any QA meetings and had not reviewed the minutes of the QA meetings. (Cross refer to F332, F353, F428, F431, F514, F501 and F520)

Based on interview and record review, it was determined the facility failed to ensure that 4 of 35 residents who displated mental or psychosocial adjustment difficulty received the appropriate treatment and services to correc the assessed problem. Specifically, (1) There were no facility staff interventions for four residents that demonstrated behavioral complex concerns, and (2) There was no social services oversight for a two month period of time. Resident identifiers: 3, 9, 47 and 48. Findings include: 1. On [DATE] at 9:30 AM, the facility LCSW (Licensed Clinical Social Worker) was interviewed. The LCSW stated that from June to [DATE], she was not in the building since the facility had not paid her. 2. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on [DATE]. The "Psychosocial Assessment", completed by the LCSW, dated [DATE], was reviewed. The LCSW documented: "...Nursing reports that the resident is friendly and cooperative with cares most of the time. (Resident 9) is easily frustrated and irritated. She will strike out physically and recently when she was told that she had to wait for something, she returned to her room, and ripped the door off the cabinet. Because of her communication challenges, the resident has difficulty making connections with their peers. ...Assessment of behavioral concerns: None noted so far. Recommendations: 1. Encourage resident to be an active part of decision about her health and any personal issues. The resident should be included in her IDT (Interdisciplinary Team) planning, and encouraged to make choices about her treatment. 2. Engage the resident in facility activities to help her maintain her cognitive skills. Encourage the resident to participate in sensory based activities to stimulate her interest, and help her focus on the present as much as possible." (Note: The LCSW did not develop interventions which addressed resident 9 "being easily frustrated', would "strike out physically", or that she had "ripped the door off the cabinet.") The care plans that were developed for resident 9 were reviewed. The facility staff developed: a) "Potential for Alteration in Activity Patterns" was developed on [DATE] and updated on [DATE] related to "I am physically abusive and I scream in group and 1X1 (one-on-one) settings." The goals that were developed included "When approached with respect I will respond with respect." The interventions that were developed to achieve the goal included: (1) "Send me out of the reach of others as I am abusive and (2) When I get upset and abusive in 1X1 contact or group, remove me from activities until I am calm." b) "Cognitive loss/Dementia" was developed on [DATE], and was not updated. The goals that were developed included: (1) "Each day: I want to be validated as a person. I want to feel safe and care for, and (2) I will be able to participate in daily decision making and self-determination of routines and be able to adjust to my living environment and have everyone become familiar and custom to my way of interacting and communicating." The interventions that were developed to achieve those goals included: "...(5) If I become agitated or upset, stay with me until I relax, talk to me quietly, and let me know I am not alone; (6) Use cheerful dialogue; ...(8) Observe me for signs of frustration and/or combativeness. Stop performing care and attempt to do task later, after I am calmed down. I like banana's (sic) so if you give me a banana it helps me to calm down." c. "Communication" was developed on [DATE] related to "I like banana's (sic) they used it at the behavioral hospital to calm me down. Unsure of how much resident can hear, ss (social services) worker says she can hear has carried on conversations with her in the past - deaf according to MD (Medical Doctor) orders. The interventions that were developed included: "(1) Reassurance and patience for me when I communicate with you. I sign some things and I am hard to communicate with the therapy aide (name redacted) can sign with me and (name redacted) from the kitchen can use a note pad I do not always respond to simple direct commands. Make sure you have my attention and keep it short and simple I can read lips a little. I am deaf/mute. I can speak some words but I mostly babble talk and sound; ...(3) Use gentle, touch and gestures when interacting with me; ...(5) If I am having trouble understanding you - write it down or find someone who can sign and interpret try and learn basic sign letters in order to communicate with me; (6) Allow me time to respond to you, and give me extra time to sign/gesture to you. Ask one question at a time; (7) Make sure you have my attention before speaking to me; (8) Find other ways to express myself such as with pictures, writing, gestures, computer, etc. Use nonverbal communication such as pointing or touching; and (9) Use short phrases and questions which require yes or no answers." d. "Nutritional status - own teeth in poor condition, uses scoop plate, [MEDICAL CONDITION]. Strengths: pt (patient) like (sic) banana's (sic)" that was developed on [DATE]. The interventions that were developed included: "...(4) Staff will assist me as needed to eat meals/snacks. [DATE] - structured time at 10 and 3 pm to get snack and drink substantial snack such as a sandwich and drink. (5) Encourage, document, and monitor intakes. I tend to like pop and go after any one who has a pop in their hand or has one laying around. Please redirect me and do not leave your food laying around. Please redirect me and do not leave your food unattended in open areas. Do not push me away or confront me when I am in a rage. Allow me space and do not get within striking distance of me. I tend to hit/push/kick..." The "Interdisciplinary Progress Notes" were reviewed. The facility staff documented: a. [DATE] at 5:44 PM: "...Does tend to yell and will interrupt other people at times when she is wanting something..." b. [DATE] at 10:08 AM: "has refused a couple of times follow staff to get her dress pulled down so that she is appropriately covered. Did allow this but only after 5 tries. She has yelled several times, upsetting other residents. She has no sodas of her own and she is aware of this, however, she has gone into the nourishment room several times and helped herself to sodas belonging to other residents. As many sodas as could be moved out of her reach were moved." c. [DATE] at 3:22 PM: "...was at the front desk yelling and pounding on the desk but I was in the middle of taking care of another resident who had fallen and was being readied to go to the clinic to be checked out. I was trying to call and speak with her family. (Resident 9) would not stop yelling and pounding even though I asked her to several times. The aides put her in her wheelchair and took her to her room because she refused to walk away from the desk with them. When they got her to her room she began pounding on her closet door and banging it until she broken it off the hinges. As soon as I was able, I went to her room and she was curled up on her bed. I gave her a headache pill..." (Note: Resident 9 was physically removed from the area by two staff members.) d. [DATE] at 6:43 AM: "(Primary Care Physician (PCP) in to visit resident on [DATE] and made the following changes to her medications. Increase [MEDICATION NAME] to 80 mg (milligrams) 1 Capsule po (by mouth) BID (twice a day) and start [MEDICATION NAME] 50 mg, 1 Tablet po QHS (at hour of sleep)." e. [DATE] at 1:41 PM: "CNA (Certified Nurse Assistant) was in supply closet by vending machines, CNA was trying to get her out of the closet because resident started grabbing everything she could get her hands on, resident slapped CNA with open hand across the face. Nurse heard commotion, went to see, told resident she needed to get out of closet, we would get her what she needed, resident started to yell, CNA's got her out of the way and shut the door to the closet, she was pulling against them, told CNA's to ease her to the floor, she then kicked CNA in the stomach. She got herself up off of the floor, telling nurse with nonverbal communication that she needed mouth wash, told her I was going to look in her room and see if she needed some, she followed me down to room, had a full bottle on her sink, again told her that she could have what she needed, staff would get it for her, she could not take whatever she wanted." (Note: The resident was "eased" to the floor by the staff.) f. [DATE] at 2:10 PM: "noted that she has used call lights in excess, sometimes pushing call light less than min. (minute) after last answered. Pushing emergency light as she knows that she will get answered not in the order that her light occurred but sooner than someone who has waited longer. She has paced, yelled and asked for an excess of warm blankets and then to have ice jug refilled many times." g. [DATE] at 12:30 PM: "...has been having problems with going into other people's rooms and taking things that don't belong to her. She also has the habit of taking people's drinks - whether out of the fridge, or if they set them down, she will grab them. ...I approached (resident 9) and she nodded "yes" to my direction to her not go into other people's rooms, do not take things that don't belong to her, and do not take their drinks ..." h. [DATE] at 1:53 PM: "... is using her Emergency call light to call aides for nonemergency things. She has been reminded that she shouldn't do that but is still doing it." i. [DATE] at 7:10 AM: "multiple episodes of trying to leave, hitting, resisting care trying to escape." j. [DATE] at 10:45 AM: "...has had an increase in behaviors today.. she has yelled, hit people, refused to walk. She has tried to leave the bldg. (building) and when staff tries to redirect her she has refused to bear wt (weight), causing staff to bear her wt and slide her on her stocking feet until she will bear wt. She has also had to be carried 4 man lift. She has went (sic) up and down the halls yelling and screaming." (Note: The resident was physically removed and dragged down the hall in her stocking feet, against her will.) k. [DATE] at 5:53 PM: "This am at 0600 (6:00 AM), (resident 9) was at the front door, waiting for people to punch in the code on the door, so that she could exit the bldg. She tried multiple times to leave after the doors unlocked. Very difficult to redirect her and she was not cooperative with that. She would not bear wt herself and would try to sit down, necessitating that she be physically removed to a safe loc (location). She would hang on to us and slide along the floor in her tread socks until finally she would stand up and walk back to a safer area. At one time she had to be carried by person lift out of the foyer area. She has been treated for [REDACTED]. She has been very loud and disruptive, other residents have c/o (complained of) her being loud and yelling." (Note: Resident 9 was again physically removed and slid along the floor in nonskid soled socks, against her will.) l. [DATE] at 7:28 PM: "...(PCP) reviewed resident's medications et (and) recent acute escalation of behaviors at visit. Order increase in [MEDICATION NAME] from 50 mg PO Q (every) HS (hour of sleep) to 100 mg PO BID. " m. [DATE] at 4:37 PM: "The aide found the resident in her room with no clothes on, was able to dress her with no problems." n. [DATE] at 8:54 AM: "...has tried repeatedly to leave the building. She kicked, hit and tried to strangle the aides. She took her am (morning) medications, including [MEDICATION NAME] and [MEDICATION NAME]. She refused to take anything stronger for her mouth, denying that it was hurting after the [MEDICATION NAME]. After she became violent with the aides, we called the clinic, spoke with (the on-call physician). He wants us to try to get a ua (urinalysis), also wanted me to give an additional, one time, [MEDICATION NAME], which I did. He said he will fax orders for either prn (as needed) [MEDICATION NAME] or [MEDICATION NAME] and [MEDICATION NAME] if we can't get the urine sample." (Note: Review of the Event/Incident Report revealed that facility staff documented: "(3 staff members) was (sic) trying to get (resident 9) back inside. (Resident 9) kept refusing. (Two staff members) was (sic) going to grab (resident 9) under the arms when she punched (a staff member) in the chest and hit (the other staff member). I was standing in front of her when she lunged at me and put her hand around my neck. I shoved her hands away then we escorted her in the building." o. [DATE] at 9:09 AM: "Has had several episodes of screaming, crying, wandering, yelling loudly and being disruptive. She cannot be distracted and will not try to use her actual words so it is very difficult to understand what she needs or wants." (Note: The PCP documented that resident 9 was deaf and mute.) p. [DATE] at 9:03 AM: "Resident was attempting to get into the kitchen area, (the PTA (Physical Therapy Assistant)) explained to her that she was not to be in the kitchen and pulled her wheelchair out and the resident reached back and hit (the PTA) in the chest area. No Injury noted to staff member. Resident was informed that was not appropriate." q. [DATE] at 5:44 AM: "Res stole aids big mt (mountain) dew from the closed closet by the nurses station, takes things and runs to her room, drinks what she can then hides them. We caught her going into the supply closet and told her to come out of there." r. [DATE] at 10:15 AM: "...was observed to be in the dirty utility room this am (morning) and digging through the dirty laundry with her bare hands. When I could finally get her to stop that, she stood up and wiped her hand across her mouth. She was also observed to have left the bldg. and did not stay on the bench that had been placed near the front door for her, but was in the parking lot trying to get into vehicles. Has been angry and combative with staff trying to work with her or redirect her." s. [DATE] at 4:02 PM: "...has been up to the nurses station numerous times today, yelling loudly. She has had Tylenol and [MEDICATION NAME] alternately with good results. She walked outside and wandered in the parking lot. She appeared to be looking in the facility transport car..." t. [DATE] at 9:44 AM: "...put her light on and when the aid went to answer it she began hitting her, the aid told her she couldn't hit her, left the room and came to tell me. ...She has gone outside and come right back in 5 or 10 times, setting off the alarm every times (sic) she passes it." u. [DATE] at 11:21 AM: "...went to the kitchen, sat down in the back of the kitchen on a chair and took off her shoes. She could not be distracted or redirected to leave the kitchen by dietary staff. When I went back there to help her she still would not come out or put her shoes back on, though she did steal a soda that one of dietary staff had in a non food area and drink it even though she knew it was not hers to take. She was brought back out to the patient areas and did not allow CNT (Certified Nurse Trainee) to help her get her shoes on properly. She then returned to the dietary area and banged on all their doors and the walls and yelled so loudly that residents on the other end of the bldg. watching tv (television) could hear her and were disturbed by her, as demonstrated by yelling back to shut up. Several of these residents yelling back are confused and/or mentally handicapped and do not understand when she does this, nor do they typically yell out to 'shut up.'" v. [DATE] at 4:17 PM: "Has chased dietary staff, trying to get in the kitchen she cannot be in there. Has tried to pull cups or mugs out of staff members hands, believing that she will be able to drink their soda, even when it is not soda, they are drinking water or the mug is empty. [MEDICATION NAME] has had little effect. She has cont (continued) to pace, yell and try to run after staff and others. She did participate in bingo for a short time." w. [DATE] at 7:28 PM: "...has yelled and been very loud and disruptive most of the day. She has been medicated with routine and PRN meds for behavior and for c/o toothache or headache. She has been observed to follow people when they are trying to give care to others or be at the nursing station at times when it is inappropriate for her to be there and loudly demanding care, such as in front of family members or other residents when an officer from the Sheriff's department was here about another issue. She has tried to have visitors get her meds." x. [DATE] at 4:52 PM: "she was very verbal, yelling. Tried to take someone's soda and started drinking it before I could stop her. She got very physical when trying to take away the pop can. Started to physically fight with the DON (Director of Nursing)..." y. [DATE] at 6:46 PM: "Per (PCP's) assessment et review, [MEDICATION NAME] 10 mg to begin tomorrow or as soon as medication is available..." hh. [DATE] at 4:12 PM: "Resident was in her wheelchair and was going down the hall, she had attempted to run over and hit another resident." z. [DATE] at 10:17 AM: "Resident was getting aggressive and attempting to throw items at the staff due to that she was impatient on getting something for her headache." aa. [DATE] at 7:15 AM: "Hitting staff trying to take things that belong to others." bb. [DATE] at 5:37 AM: "Staff aid was removing res (resident) from aid station and supply closet the res was grabbing their drinks and going through the drawers. Staff was trying to get her out of things res tried to bite her, she did hit her and grab and twist her arm then down the hall she took off her shoe and hit aid in the head." (Note: The facility licensed nurse did not notify the PCP of the incident.) cc. [DATE] at 11:32 PM: "(Medications) held due to resident not available." The "Event/Incident Reports" for resident 9 were reviewed. In addition to the above, the staff documented: a. [DATE] at 11:20 AM: "...(Resident 9) saw a soda can on a shelf and tired to get it. They were afraid she would cut herself on it & (and) took it away from her. (An employee) took it to the garbage and (resident 9) was trying to get in the dirty utility room and retrieve it from the garbage. Hitting at myself or (another employee). Door was then locked and she cont (continued) to yell & pound on the door. She started to fall & we tried to prevent her falling. She cont to try to sit on the floor. As I started easing her to the floor, she stood up. We set her in w/c (wheelchair) & moved away from the area. I retrieved a shoe she had lost in her scuffling and she took it and hit (an employee). ...The DNS (Director of Nursing Services) removed the shoes." b. [DATE] at 11:30 AM: "I was walking by (an employee's) office and she asked me to help her get (resident 9) out. She was taking soda pop that was not hers. Me and the other CNA (Certified Nurse Assistant) got her out of the office and I took the soda away from her. She tried to hit me and I move (sic) to throw the soda away and was pushing her in her wheelchair to move her from the trash can and she took her shoe and hit me in the arm. Shoes removed by DNS." c. [DATE] at 8:45 AM: "Resident went in to nutrition room. I pulled w/c back but she got out. I tried to get behind her. (Another employee) pulled her out ..." d. [DATE] at 11:40 AM: "I was cleaning up Bingo and (Resident 9) wanted a pop off of the cart. I told her no because she would not play today. She grab the cart and I took her hand off the cart and she punched me in the leg. " There was no documentation available for review which indicated that the facility LCSW reassessed resident 9's physical, mental or psychosocial well-being, or implemented interventions to manage resident 9's behaviors. Additionally, no information was available for review which indicated that the LCSW provided in-service education or training to the facility employees on how intervene and manage resident 9's behaviors. On [DATE], the facility LCSW provided a written letter to the survey staff. The LCSW documented "...Since (resident 9's) accident, that resulted in her head trauma, she has struggled to negotiate the outside world. She has very little insight into her behaviors and how unsafe she is at times. She is very impulsive and does not know how to function without very strict rules, guidelines, and being constant redirection (sic). Much of the restrictions that (resident 9) needs to function are not allowed in a skilled nursing facility." On [DATE] at 8:15 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that she had not received education or training on how to manage resident 9's behaviors. On [DATE] at 8:20- AM, RN 1 was interviewed. RN 1 stated that she had not received education or training on how to effectively manage resident 9's behaviors. On [DATE] at approximately 8:45 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that she had not received any education or training on how to manage resident 9's behaviors. The DON stated that she didn't "know how to deal with residents that have these behaviors." On [DATE] at 10:41 AM, the Resident Advocate (RA) was interviewed. The RA stated that she had not received any training from the facility LCSW on how to manage resident 9's behaviors. The RA stated that she was not aware that resident 9 was physically drug down hallways or that she was physically removed by staff. On [DATE] at 9:50 AM, RN 3 was interviewed. RN 3 stated that he/she had not been trained on how to manage residents with complex behaviors. On [DATE] at 9:46 AM, RN 4 was interviewed. RN 4 stated that she had not received training on behavior management. She stated that the facility staff tried to "diffuse (the situation) the best we could" and redirected the resident out of the area. A confidential interview was conducted with Staff Member (SM) 8. SM 8 stated that she had not been trained on how to manage residents with complex behaviors. On [DATE] at 9:40 AM, an interview was conducted with the LCSW regarding resident 9. The LCSW stated "I'm only here once a month, and I didn't have any idea that she had had any behaviors." The LCSW stated that when residents displayed verbal or aggressive behaviors, she did not include that in her psychosocial assessment. The LCSW stated that she was not aware of the circumstances of resident 9's discharge until after it had already occurred. The LCSW stated that she felt it was a safe discharge because they "didn't leave her on a street corner. . . It was safer than what she was going through here. She couldn't defend herself and couldn't comprehend her actions." The LCSW stated "I know that staff haven't had the training and don't have the right mindset to take care of certain people." When asked about staff training, the LCSW stated that "there is no training on mental health at this facility." The LCSW then stated "I did an inservice there at one point but it has been difficult lately because of staff turnover and my billing. I try to do that at least once a year." The LCSW stated "I knew we needed to have a conversation about discharges and put a policy in place but I haven't been back yet so we haven't had that conversation." The LCSW then stated "I only consult. I tell them my opinion and have no input into things unless they ask. . . I don't tell them what to do, I just tell them their options. I don't do anything unless they ask me to." There was no additional information available for review which indicated that the family staff provided appropriate treatment and services to correct resident 9's psychosocial adjustment difficulty. 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on [DATE]. An initial Minimum Data Set (MDS) Assessment was completed on [DATE]. The facility staff assessed resident 3 as being alert and oriented. The facility staff documented that resident 3 was not a wander risk. A "Cognitive loss" care plan was developed on [DATE] related to "TBI ([MEDICAL CONDITION]), major [MEDICAL CONDITION], impulse control disorder, predominant psychomotor disturbance of reaction to stress, impulse control disorder." The goals that were developed included: (1) "Each day: I want to be validated as a person. I want to feel safe and cared for;" and (2) "I will be able to participate in daily decision making and self-determination of routines." The interventions that were developed to achieve those goals included: "...(5) If I become agitated or upset, stay with me until I relax, talk to me quietly, and let me know I am being heard; (6) Watch me closely for signs of becoming upset; ...(12) Observe me for signs of frustration and Stop performing care/talking with me and attempt to do task later or talk to me after I am calmed down or if I want to argue just calmly excuse yourself and explain that you will talk later." An elopement risk assessment was not available for review in resident 3's medical record. Review of resident 3's admission contract to the facility revealed that resident 3 had not consented to being placed in a "lock down" facility. On [DATE], the facility Resident Advocate (RA) received a copy of "WHEN TO CONTACT THE OFFICE OF PUBLIC GUARDIAN" letter, dated [DATE]. The letter directed the facility to immediately notify the Office of Public Guardian if resident 3 "...leaves your facility against medical advice" or if resident 3"...checks-out for the night or fails to return from a visit or an outing." There was no documentation that resident 3 was on "house arrest" or on "lock down." The "Interdisciplinary Progress Notes" for resident 3 were reviewed. The facility staff documented: a. [DATE] at 12:54 PM: "(Resident 3) came to the nurses station and asked to check out. We reminded him that he needs to ask (the Administrator (ADM)) or (the Resident Advocate (RA)) about that and he left, not wanting to do that..." b. [DATE] at 10:37 AM: "...does not want to stay here and said he wants to go back to his homeless shelter. In asking him where he would go and how he would get there, he stated he would hitch hike." c. [DATE] at 5:00 PM: "...requested to go to the store. I told him that he can not go down town, he started calling me a (expletives deleted), and throwing things off the desk at me. I call abd (sic) spoke with (the ADM) and he stated that he can't go down town. I told the patient that and he became very angry and started yelling at me again and demanding to talk to (the Director of Nursing (DON)) or (the ADM). I attempted to call (the DON) and (the ADM), while calling he doubled up his fist at me and then punched the phone. I let his (sic) know that (the DON) was on her way in and would speak to him." d. [DATE] at 9:14 PM: "...thinks this is an old persons place and he does not want to be here..." e. [DATE] at 2:09 PM: "Resident had left to go to town this morning, when he came back he was attempting to sneak in beer under his arm, when the 6 pack fell from his arm and onto the floor breaking a glass bottle, he bent down and grabbed 2 of the bottles and walked quickly out to the back. Attempted to inform him that he was not allowed to have that in here. He just kept walking and ignoring staff. He came back into the facility and when confronted about the policy and not having beer he stated 'I can have what ever I want, you can't tell me what I can have.' Explained that he not bring alcohol into the facility he stated 'We will see about that.' Informed the director of nursing and also the administrator. Per the administrator 'He has lost his privileges to check out of the facility to go to town, due to his actions the last couple of days. According to the Noc (night) shift he returned from town on (sic) a drunken state and was inappropriate with another resident. When confronted last night about his behavior he stated to the staff 'I am drunk I can do what ever I want.'" f. [DATE] at 2:22 PM: "...came back with another resident from walking down to the local store. He came back with heavy alcohol on his breath and claimed he only drank one beer. The resident that went with him said he had 6. The Administrator, DON and myself went down to (resident 3's) room to talk about it. He held that he only drank one, but acted that it was much more. Administrator told him that he is limited to 2 cans 12 oz (ounces) each a day, and that the rule is that you can buy it, but that he needs to bring it back to the nurse's station so that it can be monitored - if it is not done this way to have it monitored that his privilege would be taken away..." On [DATE] at 2:10 PM, an interview was conducted with resident 3. Resident 3 stated that he had to be at the facility for twenty days before he was allowed to leave the facility. Resident 3 stated that after the first 20 days, he had requested to leave the facility on several occasions and that he was told that he could not leave the facility. Resident 3 further stated, "I'm a man. I should be treated like a man and be allowed to make my own decisions." A confidential staff interview was conducted with Staff Member (SM) 13. SM 13 stated "special locks" were installed on the front door of the facility to prevent resident 3 from leaving the facility. SM 13 stated that resident 3 was verbally violent and used foul language at times. SM 13 stated that resident 3 had to have permission from the ADM prior to leaving the facility. SM 13 stated that resident 3 had previously left the facility, walked downtown, and got drunk. SM 13 stated that the ADM informed the staff that resident 3 had "lost his time to check out of the facility for one month." SM 13 further stated that revoking resident 3's privileges to leave the facility were punitive in nature. A confidential staff interview was conducted with SM 10. SM 10 stated that resident 3 was admitted by his "Guardian" and was told that resident 3 "couldn't leave" the facility. SM 10 stated that resident 3 had an episode of "demanding to leave" and that the ADM told resident 3 that he had to "stay and couldn't leave the building." SM 10 further stated that resident 3 was placed on "house arrest" to prevent him from hitchhiking out of town. A confidential interview was conducted with SM 8. SM 8 stated that the facility was placed in "lock down" to prevent resident 3 from leaving the facility. SM 8 stated that resident 3 was only allowed to leave the facility if permission was obtained from the ADM and that resident 3 reported where he was going and when he would be returning. A confidential staff interview was conducted with SM 15. SM 15 stated that the facility was placed on "lock down" prior to resident 3 being admitted to the facility as he was a "flight risk." A confidential interview was conducted with SM 16. SM 16 stated that the locks were installed on the front door of the facility prior to resident 3 being admitted to the facility. On [DATE] at 3:24 PM, an interview was conducted with the ADM. The ADM stated that he was told that resident 3 was a "difficult person with a TBI ([MEDICAL CONDITION]), flight risk, physical risk, and was asked to give special consideration and admit him to the facility related to the location of the facility." The ADM stated that the location of the facility would make it "more difficult (for resident 3) to leave" and was asked to "consider keeping him in the building." The ADM stated a preadmission/post admission elopement assessment was not completed. The ADM stated that after resident 3 was admitted to the facility, that resident 3 was not allowed to leave the the facility for 1 ,[DATE] weeks, and that resident 3 was "highly upset." The ADM stated that resident 3 was alert and oriented and was capable of making his own decisions, but that there were some decisions that he "was

Based on interview and record review, it was determined the facility failed to provide medically-related social services to attain or maintain the highest practical physical, mental, and psychosocial well-being for each resident for 5 of 35 sample residents. Specifically, (1) There were no social services interventions for four residents that demonstrated complex behaviorally, (2) There was no social services oversight for a two month period of time; and (3) the social work consultant was not informed of concerns related to residents' psychosocial well being. Resident identifiers: 3, 9, 25, 47 and 48. Findings include: 1. On [DATE] at 9:30 AM, the facility LCSW (Licensed Clinical Social Worker) was interviewed. The LCSW stated that from June to [DATE], she was not in the building because the facility had not paid her. 2. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on [DATE]. The "Psychosocial Assessment", completed by the LCSW, dated [DATE], was reviewed. The LCSW documented: "...Nursing reports that the resident is friendly and cooperative with cares most of the time. (Resident 9) is easily frustrated and irritated. She will strike out physically and recently when she was told that she had to wait for something, she returned to her room, and ripped the door off the cabinet. Because of her communication challenges, the resident has difficulty making connections with their peers. ...Assessment of behavioral concerns: None noted so far. Recommendations: 1. Encourage resident to be an active part of decision about her health and any personal issues. The resident should be included in her IDT (Interdisciplinary Team) planning, and encouraged to make choices about her treatment. 2. Engage the resident in facility activities to help her maintain her cognitive skills. Encourage the resident to participate in sensory based activities to stimulate her interest, and help her focus on the present as much as possible." (Note: The LCSW did not develop interventions which addressed resident 9 "being easily frustrated', would "strike out physically", or that she had "ripped the door off the cabinet.") The care plans that were developed for resident 9 were reviewed. The facility staff developed: a) "Potential for Alteration in Activity Patterns" was developed on [DATE] and updated on [DATE] related to "I am physically abusive and I scream in group and 1X1 (one-on-one) settings." The goals that were developed included "When approached with respect I will respond with respect." The interventions that were developed to achieve the goal included: (1) "Send me out of the reach of others as I am abusive and (2) When I get upset and abusive in 1X1 contact or group, remove me from activities until I am calm." b) "Cognitive loss/Dementia" was developed on [DATE], and was not updated. The goals that were developed included: (1) "Each day: I want to be validated as a person. I want to feel safe and care for, and (2) I will be able to participate in daily decision making and self-determination of routines and be able to adjust to my living environment and have everyone become familiar and custom to my way of interacting and communicating." The interventions that were developed to achieve those goals included: "...(5) If I become agitated or upset, stay with me until I relax, talk to me quietly, and let me know I am not alone; (6) Use cheerful dialogue; ...(8) Observe me for signs of frustration and/or combativeness. Stop performing care and attempt to do task later, after I am calmed down. I like banana's (sic) so if you give me a banana it helps me to calm down." c. "Communication" was developed on [DATE] related to "I like banana's (sic) they used it at the behavioral hospital to calm me down. Unsure of how much resident can hear, ss (social services) worker says she can hear has carried on conversations with her in the past - deaf according to MD (Medical Doctor) orders. The interventions that were developed included: "(1) Reassurance and patience for me when I communicate with you. I sign some things and I am hard to communicate with the therapy aide (name redacted) can sign with me and (name redacted) from the kitchen can use a note pad I do not always respond to simple direct commands. Make sure you have my attention and keep it short and simple I can read lips a little. I am deaf/mute. I can speak some words but I mostly babble talk and sound; ...(3) Use gentle, touch and gestures when interacting with me; ...(5) If I am having trouble understanding you - write it down or find someone who can sign and interpret try and learn basic sign letters in order to communicate with me; (6) Allow me time to respond to you, and give me extra time to sign/gesture to you. Ask one question at a time; (7) Make sure you have my attention before speaking to me; (8) Find other ways to express myself such as with pictures, writing, gestures, computer, etc. Use nonverbal communication such as pointing or touching; and (9) Use short phrases and questions which require yes or no answers." d. "Nutritional status - own teeth in poor condition, uses scoop plate, [DIAGNOSES REDACTED]. Strengths: pt (patient) like (sic) banana's (sic)" that was developed on [DATE]. The interventions that were developed included: "...(4) Staff will assist me as needed to eat meals/snacks. [DATE] - structured time at 10 and 3 pm to get snack and drink substantial snack such as a sandwich and drink. (5) Encourage, document, and monitor intakes. I tend to like pop and go after any one who has a pop in their hand or has one laying around. Please redirect me and do not leave your food laying around. Please redirect me and do not leave your food unattended in open areas. Do not push me away or confront me when I am in a rage. Allow me space and do not get within striking distance of me. I tend to hit/push/kick..." The "Interdisciplinary Progress Notes" were reviewed. The facility staff documented: a. [DATE] at 5:44 PM: "...Does tend to yell and will interrupt other people at times when she is wanting something..." b. [DATE] at 10:08 AM: "has refused a couple of times follow staff to get her dress pulled down so that she is appropriately covered. Did allow this but only after 5 tries. She has yelled several times, upsetting other residents. She has no sodas of her own and she is aware of this, however, she has gone into the nourishment room several times and helped herself to sodas belonging to other residents. As many sodas as could be moved out of her reach were moved." c. [DATE] at 3:22 PM: "...was at the front desk yelling and pounding on the desk but I was in the middle of taking care of another resident who had fallen and was being readied to go to the clinic to be checked out. I was trying to call and speak with her family. (Resident 9) would not stop yelling and pounding even though I asked her to several times. The aides put her in her wheelchair and took her to her room because she refused to walk away from the desk with them. When they got her to her room she began pounding on her closet door and banging it until she broken it off the hinges. As soon as I was able, I went to her room and she was curled up on her bed. I gave her a headache pill..." (Note: Resident 9 was physically removed from the area by two staff members.) d. [DATE] at 6:43 AM: "(Primary Care Physician (PCP) in to visit resident on [DATE] and made the following changes to her medications. Increase Geodon to 80 mg (milligrams) 1 Capsule po (by mouth) BID (twice a day) and start Seroquel 50 mg, 1 Tablet po QHS (at hour of sleep)." e. [DATE] at 1:41 PM: "CNA (Certified Nurse Assistant) was in supply closet by vending machines, CNA was trying to get her out of the closet because resident started grabbing everything she could get her hands on, resident slapped CNA with open hand across the face. Nurse heard commotion, went to see, told resident she needed to get out of closet, we would get her what she needed, resident started to yell, CNA's got her out of the way and shut the door to the closet, she was pulling against them, told CNA's to ease her to the floor, she then kicked CNA in the stomach. She got herself up off of the floor, telling nurse with nonverbal communication that she needed mouth wash, told her I was going to look in her room and see if she needed some, she followed me down to room, had a full bottle on her sink, again told her that she could have what she needed, staff would get it for her, she could not take whatever she wanted." (Note: The resident was "eased" to the floor by the staff.) f. [DATE] at 2:10 PM: "noted that she has used call lights in excess, sometimes pushing call light less than min. (minute) after last answered. Pushing emergency light as she knows that she will get answered not in the order that her light occurred but sooner than someone who has waited longer. She has paced, yelled and asked for an excess of warm blankets and then to have ice jug refilled many times." g. [DATE] at 12:30 PM: "...has been having problems with going into other people's rooms and taking things that don't belong to her. She also has the habit of taking people's drinks - whether out of the fridge, or if they set them down, she will grab them. ...I approached (resident 9) and she nodded "yes" to my direction to her not go into other people's rooms, do not take things that don't belong to her, and do not take their drinks ..." h. [DATE] at 1:53 PM: "... is using her Emergency call light to call aides for nonemergency things. She has been reminded that she shouldn't do that but is still doing it." i. [DATE] at 7:10 AM: "multiple episodes of trying to leave, hitting, resisting care trying to escape." j. [DATE] at 10:45 AM: "...has had an increase in behaviors today.. she has yelled, hit people, refused to walk. She has tried to leave the bldg. (building) and when staff tries to redirect her she has refused to bear wt (weight), causing staff to bear her wt and slide her on her stocking feet until she will bear wt. She has also had to be carried 4 man lift. She has went (sic) up and down the halls yelling and screaming." (Note: The resident was physically removed and dragged down the hall in her stocking feet, against her will.) k. [DATE] at 5:53 PM: "This am at 0600 (6:00 AM), (resident 9) was at the front door, waiting for people to punch in the code on the door, so that she could exit the bldg. She tried multiple times to leave after the doors unlocked. Very difficult to redirect her and she was not cooperative with that. She would not bear wt herself and would try to sit down, necessitating that she be physically removed to a safe loc (location). She would hang on to us and slide along the floor in her tread socks until finally she would stand up and walk back to a safer area. At one time she had to be carried by person lift out of the foyer area. She has been treated for [REDACTED]. She has been very loud and disruptive, other residents have c/o (complained of) her being loud and yelling." (Note: Resident 9 was again physically removed and slid along the floor in nonskid soled socks, against her will.) l. [DATE] at 7:28 PM: "...(PCP) reviewed resident's medications et (and) recent acute escalation of behaviors at visit. Order increase in Seroquel from 50 mg PO Q (every) HS (hour of sleep) to 100 mg PO BID. " m. [DATE] at 4:37 PM: "The aide found the resident in her room with no clothes on, was able to dress her with no problems." n. [DATE] at 8:54 AM: "...has tried repeatedly to leave the building. She kicked, hit and tried to strangle the aides. She took her am (morning) medications, including Ativan and ibuprofen. She refused to take anything stronger for her mouth, denying that it was hurting after the ibuprofen. After she became violent with the aides, we called the clinic, spoke with (the on-call physician). He wants us to try to get a ua (urinalysis), also wanted me to give an additional, one time, Ativan, which I did. He said he will fax orders for either prn (as needed) valium or Ativan and perhaps cipro even if we can't get the urine sample." (Note: Review of the Event/Incident Report revealed that facility staff documented: "(3 staff members) was (sic) trying to get (resident 9) back inside. (Resident 9) kept refusing. (Two staff members) was (sic) going to grab (resident 9) under the arms when she punched (a staff member) in the chest and hit (the other staff member). I was standing in front of her when she lunged at me and put her hand around my neck. I shoved her hands away then we escorted her in the building." o. [DATE] at 9:09 AM: "Has had several episodes of screaming, crying, wandering, yelling loudly and being disruptive. She cannot be distracted and will not try to use her actual words so it is very difficult to understand what she needs or wants." (Note: The PCP documented that resident 9 was deaf and mute.) p. [DATE] at 9:03 AM: "Resident was attempting to get into the kitchen area, (the PTA (Physical Therapy Assistant)) explained to her that she was not to be in the kitchen and pulled her wheelchair out and the resident reached back and hit (the PTA) in the chest area. No Injury noted to staff member. Resident was informed that was not appropriate." q. [DATE] at 5:44 AM: "Res stole aids big mt (mountain) dew from the closed closet by the nurses station, takes things and runs to her room, drinks what she can then hides them. We caught her going into the supply closet and told her to come out of there." r. [DATE] at 10:15 AM: "...was observed to be in the dirty utility room this am (morning) and digging through the dirty laundry with her bare hands. When I could finally get her to stop that, she stood up and wiped her hand across her mouth. She was also observed to have left the bldg. and did not stay on the bench that had been placed near the front door for her, but was in the parking lot trying to get into vehicles. Has been angry and combative with staff trying to work with her or redirect her." s. [DATE] at 4:02 PM: "...has been up to the nurses station numerous times today, yelling loudly. She has had Tylenol and ibuprofen alternately with good results. She walked outside and wandered in the parking lot. She appeared to be looking in the facility transport car..." t. [DATE] at 9:44 AM: "...put her light on and when the aid went to answer it she began hitting her, the aid told her she couldn't hit her, left the room and came to tell me. ...She has gone outside and come right back in 5 or 10 times, setting off the alarm every times (sic) she passes it." u. [DATE] at 11:21 AM: "...went to the kitchen, sat down in the back of the kitchen on a chair and took off her shoes. She could not be distracted or redirected to leave the kitchen by dietary staff. When I went back there to help her she still would not come out or put her shoes back on, though she did steal a soda that one of dietary staff had in a non food area and drink it even though she knew it was not hers to take. She was brought back out to the patient areas and did not allow CNT (Certified Nurse Trainee) to help her get her shoes on properly. She then returned to the dietary area and banged on all their doors and the walls and yelled so loudly that residents on the other end of the bldg. watching tv (television) could hear her and were disturbed by her, as demonstrated by yelling back to shut up. Several of these residents yelling back are confused and/or mentally handicapped and do not understand when she does this, nor do they typically yell out to 'shut up.'" v. [DATE] at 4:17 PM: "Has chased dietary staff, trying to get in the kitchen she cannot be in there. Has tried to pull cups or mugs out of staff members hands, believing that she will be able to drink their soda, even when it is not soda, they are drinking water or the mug is empty. Valium has had little effect. She has cont (continued) to pace, yell and try to run after staff and others. She did participate in bingo for a short time." w. [DATE] at 7:28 PM: "...has yelled and been very loud and disruptive most of the day. She has been medicated with routine and PRN meds for behavior and for c/o toothache or headache. She has been observed to follow people when they are trying to give care to others or be at the nursing station at times when it is inappropriate for her to be there and loudly demanding care, such as in front of family members or other residents when an officer from the Sheriff's department was here about another issue. She has tried to have visitors get her meds." x. [DATE] at 4:52 PM: "she was very verbal, yelling. Tried to take someone's soda and started drinking it before I could stop her. She got very physical when trying to take away the pop can. Started to physically fight with the DON (Director of Nursing)..." y. [DATE] at 6:46 PM: "Per (PCP's) assessment et review, olanzapine 10 mg to begin tomorrow or as soon as medication is available..." hh. [DATE] at 4:12 PM: "Resident was in her wheelchair and was going down the hall, she had attempted to run over and hit another resident." z. [DATE] at 10:17 AM: "Resident was getting aggressive and attempting to throw items at the staff due to that she was impatient on getting something for her headache." aa. [DATE] at 7:15 AM: "Hitting staff trying to take things that belong to others." bb. [DATE] at 5:37 AM: "Staff aid was removing res (resident) from aid station and supply closet the res was grabbing their drinks and going through the drawers. Staff was trying to get her out of things res tried to bite her, she did hit her and grab and twist her arm then down the hall she took off her shoe and hit aid in the head." (Note: The facility licensed nurse did not notify the PCP of the incident.) cc. [DATE] at 11:32 PM: "(Medications) held due to resident not available." The "Event/Incident Reports" for resident 9 were reviewed. In addition to the above, the staff documented: a. [DATE] at 11:20 AM: "...(Resident 9) saw a soda can on a shelf and tired to get it. They were afraid she would cut herself on it & (and) took it away from her. (An employee) took it to the garbage and (resident 9) was trying to get in the dirty utility room and retrieve it from the garbage. Hitting at myself or (another employee). Door was then locked and she cont (continued) to yell & pound on the door. She started to fall & we tried to prevent her falling. She cont to try to sit on the floor. As I started easing her to the floor, she stood up. We set her in w/c (wheelchair) & moved away from the area. I retrieved a shoe she had lost in her scuffling and she took it and hit (an employee). ...The DNS (Director of Nursing Services) removed the shoes." b. [DATE] at 11:30 AM: "I was walking by (an employee's) office and she asked me to help her get (resident 9) out. She was taking soda pop that was not hers. Me and the other CNA (Certified Nurse Assistant) got her out of the office and I took the soda away from her. She tried to hit me and I move (sic) to throw the soda away and was pushing her in her wheelchair to move her from the trash can and she took her shoe and hit me in the arm. Shoes removed by DNS." c. [DATE] at 8:45 AM: "Resident went in to nutrition room. I pulled w/c back but she got out. I tried to get behind her. (Another employee) pulled her out ..." d. [DATE] at 11:40 AM: "I was cleaning up Bingo and (Resident 9) wanted a pop off of the cart. I told her no because she would not play today. She grab the cart and I took her hand off the cart and she punched me in the leg. " There was no documentation available for review which indicated that the facility LCSW reassessed resident 9's physical, mental or psychosocial well-being, or implemented interventions to manage resident 9's behaviors. Additionally, no information was available for review which indicated that the LCSW provided in-service education or training to the facility employees on how intervene and manage resident 9's behaviors. On [DATE], the facility LCSW provided a written letter to the survey staff. The LCSW documented "...Since (resident 9's) accident, that resulted in her head trauma, she has struggled to negotiate the outside world. She has very little insight into her behaviors and how unsafe she is at times. She is very impulsive and does not know how to function without very strict rules, guidelines, and being constant redirection (sic). Much of the restrictions that (resident 9) needs to function are not allowed in a skilled nursing facility." On [DATE] at 8:15 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that she had not received education or training on how to manage resident 9's behaviors. On [DATE] at 8:20- AM, RN 1 was interviewed. RN 1 stated that she had not received education or training on how to effectively manage resident 9's behaviors. On [DATE] at approximately 8:45 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that she had not received any education or training on how to manage resident 9's behaviors. The DON stated that she didn't "know how to deal with residents that have these behaviors." On [DATE] at 10:41 AM, the Resident Advocate (RA) was interviewed. The RA stated that she had not received any training from the facility LCSW on how to manage resident 9's behaviors. The RA stated that she was not aware that resident 9 was physically drug down hallways or that she was physically removed by staff. On [DATE] at 9:50 AM, RN 3 was interviewed. RN 3 stated that he/she had not been trained on how to manage residents with complex behaviors. On [DATE] at 9:46 AM, RN 4 was interviewed. RN 4 stated that she had not received training on behavior management. She stated that the facility staff tried to "diffuse (the situation) the best we could" and redirected the resident out of the area. A confidential interview was conducted with Staff Member (SM) 8. SM 8 stated that she had not been trained on how to manage residents with complex behaviors. On [DATE] at 9:40 AM, an interview was conducted with the LCSW regarding resident 9. The LCSW stated "I'm only here once a month, and I didn't have any idea that she had had any behaviors." The LCSW stated that when residents displayed verbal or aggressive behaviors, she did not include that in her psychosocial assessment. The LCSW stated that she was not aware of the circumstances of resident 9's discharge until after it had already occurred. The LCSW stated that she felt it was a safe discharge because they "didn't leave her on a street corner. . . It was safer than what she was going through here. She couldn't defend herself and couldn't comprehend her actions." The LCSW stated "I know that staff haven't had the training and don't have the right mindset to take care of certain people." When asked about staff training, the LCSW stated that "there is no training on mental health at this facility." The LCSW then stated "I did an inservice there at one point but it has been difficult lately because of staff turnover and my billing. I try to do that at least once a year." The LCSW stated "I knew we needed to have a conversation about discharges and put a policy in place but I haven't been back yet so we haven't had that conversation." The LCSW then stated "I only consult. I tell them my opinion and have no input into things unless they ask. . . I don't tell them what to do, I just tell them their options. I don't do anything unless they ask me to." There was no additional information available for review which indicated that the LCSW had been consulted and provided oversight to ensure that resident 9's rights to a safe discharge were upheld and her behaviors were appropriately managed. 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on [DATE]. An initial Minimum Data Set (MDS) Assessment was completed on [DATE]. The facility staff assessed resident 3 as being alert and oriented. The facility staff documented that resident 3 was not a wander risk. A "Cognitive loss" care plan was developed on [DATE] related to "TBI (traumatic brain injury), major depressive disorder, impulse control disorder, predominant psychomotor disturbance of reaction to stress, impulse control disorder." The goals that were developed included: (1) "Each day: I want to be validated as a person. I want to feel safe and cared for;" and (2) "I will be able to participate in daily decision making and self-determination of routines." The interventions that were developed to achieve those goals included: "...(5) If I become agitated or upset, stay with me until I relax, talk to me quietly, and let me know I am being heard; (6) Watch me closely for signs of becoming upset; ...(12) Observe me for signs of frustration and Stop performing care/talking with me and attempt to do task later or talk to me after I am calmed down or if I want to argue just calmly excuse yourself and explain that you will talk later." An elopement risk assessment was not available for review in resident 3's medical record. Review of resident 3's admission contract to the facility revealed that resident 3 had not consented to being placed in a "lock down" facility. On [DATE], the facility Resident Advocate (RA) received a copy of "WHEN TO CONTACT THE OFFICE OF PUBLIC GUARDIAN" letter, dated [DATE]. The letter directed the facility to immediately notify the Office of Public Guardian if resident 3 "...leaves your facility against medical advice" or if resident 3"...checks-out for the night or fails to return from a visit or an outing." There was no documentation that resident 3 was on "house arrest" or on "lock down." The "Interdisciplinary Progress Notes" for resident 3 were reviewed. The facility staff documented: a. [DATE] at 12:54 PM: "(Resident 3) came to the nurses station and asked to check out. We reminded him that he needs to ask (the Administrator (ADM)) or (the Resident Advocate (RA)) about that and he left, not wanting to do that..." b. [DATE] at 10:37 AM: "...does not want to stay here and said he wants to go back to his homeless shelter. In asking him where he would go and how he would get there, he stated he would hitch hike." c. [DATE] at 5:00 PM: "...requested to go to the store. I told him that he can not go down town, he started calling me a (expletives deleted), and throwing things off the desk at me. I call abd (sic) spoke with (the ADM) and he stated that he can't go down town. I told the patient that and he became very angry and started yelling at me again and demanding to talk to (the Director of Nursing (DON)) or (the ADM). I attempted to call (the DON) and (the ADM), while calling he doubled up his fist at me and then punched the phone. I let his (sic) know that (the DON) was on her way in and would speak to him." d. [DATE] at 9:14 PM: "...thinks this is an old persons place and he does not want to be here..." e. [DATE] at 2:09 PM: "Resident had left to go to town this morning, when he came back he was attempting to sneak in beer under his arm, when the 6 pack fell from his arm and onto the floor breaking a glass bottle, he bent down and grabbed 2 of the bottles and walked quickly out to the back. Attempted to inform him that he was not allowed to have that in here. He just kept walking and ignoring staff. He came back into the facility and when confronted about the policy and not having beer he stated 'I can have what ever I want, you can't tell me what I can have.' Explained that he not bring alcohol into the facility he stated 'We will see about that.' Informed the director of nursing and also the administrator. Per the administrator 'He has lost his privileges to check out of the facility to go to town, due to his actions the last couple of days. According to the Noc (night) shift he returned from town on (sic) a drunken state and was inappropriate with another resident. When confronted last night about his behavior he stated to the staff 'I am drunk I can do what ever I want.'" f. [DATE] at 2:22 PM: "...came back with another resident from walking down to the local store. He came back with heavy alcohol on his breath and claimed he only drank one beer. The resident that went with him said he had 6. The Administrator, DON and myself went down to (resident 3's) room to talk about it. He held that he only drank one, but acted that it was much more. Administrator told him that he is limited to 2 cans 12 oz (ounces) each a day, and that the rule is that you can buy it, but that he needs to bring it back to the nurse's station so that it can be monitored - if it is not done this way to have it monitored that his privilege would be taken away..." On [DATE] at 2:10 PM, an interview was conducted with resident 3. Resident 3 stated that he had to be at the facility for twenty days before he was allowed to leave the facility. Resident 3 stated that after the first 20 days, he had requested to leave the facility on several occasions and that he was told that he could not leave the facility. Resident 3 further stated, "I'm a man. I should be treated like a man and be allowed to make my own decisions." A confidential staff interview was conducted with Staff Member (SM) 13. SM 13 stated "special locks" were installed on the front door of the facility to prevent resident 3 from leaving the facility. SM 13 stated that resident 3 was verbally violent and used foul language at times. SM 13 stated that resident 3 had to have permission from the ADM prior to leaving the facility. SM 13 stated that resident 3 had previously left the facility, walked downtown, and got drunk. SM 13 stated that the ADM informed the staff that resident 3 had "lost his time to check out of the facility for one month." SM 13 further stated that revoking resident 3's privileges to leave the facility were punitive in nature. A confidential staff interview was conducted with SM 10. SM 10 stated that resident 3 was admitted by his "Guardian" and was told that resident 3 "couldn't leave" the facility. SM 10 stated that resident 3 had an episode of "demanding to leave" and that the ADM told resident 3 that he had to "stay and couldn't leave the building." SM 10 further stated that resident 3 was placed on "house arrest" to prevent him from hitchhiking out of town. A confidential interview was conducted with SM 8. SM 8 stated that the facility was placed in "lock down" to prevent resident 3 from leaving the facility. SM 8 stated that resident 3 was only allowed to leave the facility if permission was obtained from the ADM and that resident 3 reported where he was going and when he would be returning. A confidential staff interview was conducted with SM 15. SM 15 stated that the facility was placed on "lock down" prior to resident 3 being admitted to the facility as he was a "flight risk." A confidential interview was conducted with SM 16. SM 16 stated that the locks were installed on the front door of the facility prior to resident 3 being admitted to the facility. On [DATE] at 3:24 PM, an interview was conducted with the ADM. The ADM stated that he was told that resident 3 was a "difficult person with a TBI (traumatic brain injury), flight risk, physical risk, and was asked to give special consideration and admit him to the facility related to the location of the facility." The ADM stated that the location of the facility would make it "more difficult (for resident 3) to leave" and was asked to "consider keeping him in the building." The ADM stated a preadmission/post admission elopement assessment was not completed. The ADM stated that after resident 3 was admitted to the facility, that resident 3 was not allowed to leave the the facility for 1 ,[DATE] weeks, and that resident 3 was "h

Based on interview and record review, it was determined the facility did not care for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life for 5 of 35 sample residents. Specifically, (1) A mechanism was installed on the front door of the facility in August 2013 to prevent an alert and oriented resident from leaving the facility; (2) An alert and oriented resident was denied the right to leave the facility as a "consequence" on multiple occasions; (3) Three residents were unable to enter/exit the facility, as was their normal routine, after the the facility was placed on "lock down"; and (4) The facility did not assess the residents to identify which residents were at risk for elopement. Resident identifiers: 3, 14, 26, 47 and 48. Findings include: A confidential interview was conducted with Staff Member (SM) 9. SM 9 stated a mechanism was installed on the front door of the facility to prevent a resident that was to be admitted to the facility in August 2013 from leaving the facility. SM 9 stated that the facility was placed on "lock down" related to resident 3's court order for "house arrest." SM 9 further stated that resident 26 used to walk the outside perimeter of the facility independently. SM 9 stated that resident 26 was locked out of the facility on several occasions and was now fearful of being "kicked out" of the facility. SM 9 stated that resident 26 now only ambulated independently in the fenced courtyard. Additionally, SM 9 stated that resident 14 was not able to gain entrance into the facility on several occasions and that resident 14's family lodged a complaint with the facility administration. SM 9 stated that the facility was on "lock down" from August 2013 to approximately 10/22/13. 1. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on 10/30/13. An initial Minimum Data Set (MDS) Assessment was completed on 8/15/13. The facility staff assessed resident 3 as being alert and oriented. The facility staff documented that resident 3 was not a wander risk. A "Cognitive loss" care plan was developed on 8/5/13 related to "TBI ([MEDICAL CONDITION]), major [MEDICAL CONDITION], impulse control disorder, predominant psychomotor disturbance of reaction to stress, impulse control disorder." The goals that were developed included: (1) "Each day: I want to be validated as a person. I want to feel safe and cared for;" and (2) "I will be able to participate in daily decision making and self-determination of routines." The interventions that were developed to achieve those goals included: "...(5) If I become agitated or upset, stay with me until I relax, talk to me quietly, and let me know I am being heard; (6) Watch me closely for signs of becoming upset; ...(12) Observe me for signs of frustration and Stop performing care/talking with me and attempt to do task later or talk to me after I am calmed down or if I want to argue just calmly excuse yourself and explain that you will talk later." An elopement risk assessment was not available for review in resident 3's medical record. Review of resident 3's admission contract to the facility revealed that resident 3 had not consented to being placed in a "lock down" facility. On 9/5/13, the facility Resident Advocate (RA) received a copy of "WHEN TO CONTACT THE OFFICE OF PUBLIC GUARDIAN" letter, dated 9/4/13. The letter directed the facility to immediately notify the Office of Public Guardian if resident 3 "...leaves your facility against medical advice" or if resident 3 "...checks-out for the night or fails to return from a visit or an outing." There was no documentation that resident 3 was on "house arrest" or on "lock down." The "Interdisciplinary Progress Notes" for resident 3 were reviewed. The facility staff documented: a. 8/14/13 at 12:54 PM: "(Resident 3) came to the nurses station and asked to check out. We reminded him that he needs to ask (the Administrator (ADM)) or (the Resident Advocate (RA)) about that and he left, not wanting to do that..." b. 8/19/13 at 10:37 AM: "...does not want to stay here and said he wants to go back to his homeless shelter. In asking him where he would go and how he would get there, he stated he would hitch hike." c. 8/30/13 at 5:00 PM: "...requested to go to the store. I told him that he can not go down town, he started calling me a (expletives deleted), and throwing things off the desk at me. I call abd (sic) spoke with (the ADM) and he stated that he can't go down town. I told the patient that and he became very angry and started yelling at me again and demanding to talk to (the Director of Nursing (DON)) or (the ADM). I attempted to call (the DON) and (the ADM), while calling he doubled up his fist at me and then punched the phone. I let his (sic) know that (the DON) was on her way in and would speak to him." d. 9/10/13 at 9:14 PM: "...thinks this is an old persons place and he does not want to be here..." e. 10/6/13 at 2:09 PM: "Resident had left to go to town this morning, when he came back he was attempting to sneak in beer under his arm, when the 6 pack fell from his arm and onto the floor breaking a glass bottle, he bent down and grabbed 2 of the bottles and walked quickly out to the back. Attempted to inform him that he was not allowed to have that in here. He just kept walking and ignoring staff. He came back into the facility and when confronted about the policy and not having beer he stated 'I can have what ever I want, you can't tell me what I can have.' Explained that he not bring alcohol into the facility he stated 'We will see about that.' Informed the director of nursing and also the administrator. Per the administrator 'He has lost his privileges to check out of the facility to go to town, due to his actions the last couple of days. According to the Noc (night) shift he returned from town on (sic) a drunken state and was inappropriate with another resident. When confronted last night about his behavior he stated to the staff 'I am drunk I can do what ever I want.'" f. 10/21/13 at 2:22 PM: "...came back with another resident from walking down to the local store. He came back with heavy alcohol on his breath and claimed he only drank one beer. The resident that went with him said he had 6. The Administrator, DON and myself went down to (resident 3's) room to talk about it. He held that he only drank one, but acted that it was much more. Administrator told him that he is limited to 2 cans 12 oz (ounces) each a day, and that the rule is that you can buy it, but that he needs to bring it back to the nurse's station so that it can be monitored - if it is not done this way to have it monitored that his privilege would be taken away..." On 10/30/13 at 2:10 PM, an interview was conducted with resident 3. Resident 3 stated that he had to be at the facility for twenty days before he was allowed to leave the facility. Resident 3 stated that after the first 20 days, he had requested to leave the facility on several occasions and that he was told that he could not leave the facility. Resident 3 further stated, "I'm a man. I should be treated like a man and be allowed to make my own decisions." A confidential staff interview was conducted with Staff Member (SM) 13. SM 13 stated "special locks" were installed on the front door of the facility to prevent resident 3 from leaving the facility. SM 13 stated that resident 3 was verbally violent and used foul language at times. SM 13 stated that resident 3 had to have permission from the ADM prior to leaving the facility. SM 13 stated that resident 3 had previously left the facility, walked downtown, and got drunk. SM 13 stated that the ADM informed the staff that resident 3 had "lost his time to check out of the facility for one month." SM 13 further stated that revoking resident 3's privileges to leave the facility were punitive in nature. A confidential staff interview was conducted with SM 10. SM 10 stated that resident 3 was admitted by his "Guardian" and was told that resident 3 "couldn't leave" the facility. SM 10 stated that resident 3 had an episode of "demanding to leave" and that the ADM told resident 3 that he had to "stay and couldn't leave the building." SM 10 further stated that resident 3 was placed on "house arrest" to prevent him from hitchhiking out of town. A confidential interview was conducted with SM 8. SM 8 stated that the facility was placed in "lock down" to prevent resident 3 from leaving the facility. SM 8 stated that resident 3 was only allowed to leave the facility if permission was obtained from the ADM and that resident 3 reported where he was going and when he would be returning. A confidential staff interview was conducted with SM 15. SM 15 stated that the facility was placed on "lock down" prior to resident 3 being admitted to the facility as he was a "flight risk." A confidential interview was conducted with SM 16. SM 16 stated that the locks were installed on the front door of the facility prior to resident 3 being admitted to the facility. On 10/30/13 at 3:24 PM, an interview was conducted with the ADM. The ADM stated that he was told that resident 3 was a "difficult person with a TBI ([MEDICAL CONDITION]), flight risk, physical risk, and was asked to give special consideration and admit him to the facility related to the location of the facility." The ADM stated that the location of the facility would make it "more difficult (for resident 3) to leave" and was asked to "consider keeping him in the building." The ADM stated a preadmission/post admission elopement assessment was not completed. The ADM stated that after resident 3 was admitted to the facility, that resident 3 was not allowed to leave the the facility for 1 1/2 weeks, and that resident 3 was "highly upset." The ADM stated that resident 3 was alert and oriented and was capable of making his own decisions, but that there were some decisions that he "wasn't allowed to make." The ADM stated that after resident 3 was admitted to the facility, that "they" (the facility) worked on establishing a "level of trust". The ADM stated that during the period of time that they were establishing the "level of trust", the doors to the facility were locked to prevent resident 3 from leaving the facility. The ADM stated that the resident also had to demonstrate that he would "come back" to the facility after he was given permission to leave the facility. On 10/31/13 at 9:30 AM an interview was conducted with the facility Licensed Clinical Social Worker (LCSW) regarding resident 3. The LCSW stated that she was familiar with resident 3 from a previous facility. The LCSW stated that resident 3's mental function was similar to that of a [AGE] year-old, and that he "doesn't function as adult." The LCSW stated that although she was not in the facility when resident 3 was admitted (due to billing issues), afterwards she had attempted to clarify to facility staff that resident 3 was only court committed to have counseling by the local county health department, but was not court committed to the facility. The LCSW stated that facility administration had had "some confusion about that." The LCSW stated that resident 3 had displayed both physical and verbal aggressiveness toward staff members and "this staff is not used to dealing with that." When asked if she had done any training with the staff about appropriate behavior interventions, the LCSW stated that she had not. The LCSW stated that resident 3 expressed frustration to her about the facility doors being locked, however the RA had not. The LCSW stated that she was unaware that rsident 3 was being locked in the building for long periods of time. When asked about the lockdown situation, the LCSW stated, "I worry about all the rights of all people to come and go. It makes it harder for other residents to get out and enjoy being outside. A lot of people like to go outside and do laps in the parking lot." When asked about the facility's response to her concerns regarding the lockdown, the LCSW stated that she had not reported her concerns because "my opinion was not solicited . . . it's not my call." 2. Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 48's medical record was reviewed on 10/30/13. On 9/4/13, the facility staff completed an initial MDS Assessment for resident 48. The facility staff assessed resident 48 as being alert and oriented. The facility staff documented that resident 48 was not a wander risk. The "Interdisciplinary Progress Notes" were reviewed. The facility staff documented: a. 9/24/13 at 12:13 AM: "This evening on the 23rd res (resident) climbed over the fence outside where the res go to smoke this was witnessed by another res who told don (Director of Nursing), all grounds were searched don went downtown and store owner had seen her heading south on highway 10 don found her and brought her back to the facility. Res told don that she wanted a library book no harm to res just stated she was cold, coffee and jacket applied will monitor q (every) 1 hr (hour) for the next 72 hours mother notified grateful she is ok and safe." b. 10/7/13 at 10:21 AM: "...resident is not permitted to leave building per administrator." On 10/30/13 at 9:50 AM, resident 48 was interviewed. Resident 48 stated that she was not allowed to leave the facility, so she climbed the chain link fence in the courtyard because she "didn't want to be here." She stated that the facility staff found her while she was trying to walk out of town and brought her back to the facility. Additionally, resident 48 stated that she took some merchandise at the local grocery store without paying for it. Resident 48 stated that the Police department was called and she received a citation from the Police. Resident 48 stated that the Police gave her a ride back to the facility and notified the facility Administrator about what had happened. Resident 48 stated that she was "grounded" for a month and was being "punished." Resident 48 stated that the Administrator had to verbally approve any leaves of absence before she was allowed to leave the facility. Resident 48 stated that she felt that she was "trustworthy" and that she was "angry" that she was being "punished" by the Administrator. Resident 48 further stated that the Administrator "intimidated" her. A confidential staff interview was conducted with SM 10. SM 10 stated that resident 48 was on a leave of absence from the facility when she stole a beer from the local grocery store. SM 10 stated that resident 48 was returned to the facility by the local Police department. SM 10 stated that the facility Administrator "restricted" resident 48 because she got drunk. SM 10 stated that the Administrator reported that resident 48 was "restricted from leaving the building" for 2-3 weeks. A confidential staff interview was conducted with SM 13. SM 13 stated that resident 48 had her "beer privileges" removed by the Administrator, DON, and primary care physician as a consequence for getting drunk while on an outing and for stealing a beer. A confidential interview was conducted with SM 8. SM 8 stated resident 48 was only allowed to leave the facility if permission was obtained from the facility Administrator and that resident 48 reported where she was going and when she would be returning. On 10/30/13 at 3:24 PM, the ADM was interviewed. The ADM stated that resident 48 was "escaping" the facility. The ADM stated that resident 48 had several attempts at "escaping" by using the patio furniture and attempting to climb the fence. The ADM stated that the patio furniture and the chairs from the "Butt Hut" were removed to prevent her from climbing over the fence. The ADM stated that there were several attempts by resident 48 to climb over the fence while the doors were locked. The ADM stated that resident 48 was "deemed appropriate to come and go as she pleased." and that resident 48 was alert and oriented. The ADM stated that he had not initiated a written contract with resident 48 but that they had a verbal contract that "this is what she is going to need to do (referring to not leaving the facility)." The ADM stated that he had a meeting with resident 48 after she was brought back to the facility by the local Police department. The ADM stated that he told her that she was "not allowed to go to (the local grocery store) anymore for approximately 1 week." The ADM stated, "I don't think anything we did was inappropriate because we didn't do anything to inhibit the safety of the residents." The ADM stated that "patients have to understand that there are guidelines and rules" and that there were "consequences" for certain behaviors. The ADM stated that he had not discussed with the RA or contacted the LCSW about resident 48 not leaving the facility. The ADM stated that "it was largely (the DON) and I that made those decisions." 3. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/15/13, resident 26's medical record was reviewed. The quarterly MDS assessment completed by facility staff on 7/24/13 was reviewed. The facility staff assessed resident 26 as having a BIMS (Brief Interview for Mental Status) of 7 with no episodes of wandering. On 10/30/13 at 1:53 PM, resident 26 was interviewed. Resident 26 stated that there was a time when she "had to knock on the door for a little while" before she was able to gain access to the facility after going for a walk. Resident 26 stated that it would sometimes take the facility staff 15 minutes or longer to let her back in. A confidential staff interview was conducted with SM 11. SM 11 stated the facility was placed in "lock down" several months ago. SM 11 stated that the facility administration instructed the staff to ensure that the code to enter/exit the facility was not given to residents, families or visitors. SM 11 stated that after the facility was placed in "lock down", resident 26 became "afraid" that she wouldn't be able to get back in the facility after she went for her usual walk outside the facility. A confidential staff interview was conducted with SM 16. SM 16 stated that resident 26 was "extremely upset" and "freaked out" after the locks were placed on the front door of the facility. SM 16 stated that resident 26 "thought she couldn't be get in the facility and was shaking the doors". On 10/30/13 at 1:31 PM, an interview was conducted with resident 26's family member. The family member stated that resident 26 was "upset because she could not get outside." On 10/31/13 at 3:24 PM, the ADM was interviewed. The ADM stated that resident 26 was confused and forgetful at times. The ADM stated that he did not believe that resident 26's rights were violated and that resident 26's ability to leave and return to the facility was not "impeded." 4. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's medical record was reviewed on 10/29/13. On 10/7/13, the facility staff completed a quarterly MDS assessment for resident 14. The facility staff assessed resident 14 as having BIMS score of 12 and had no episodes of wandering. On 10/30/13 at 3:24 PM, the ADM was interviewed. The ADM stated that resident 14 felt like he was "more secluded and didn't have the freedom to leave" after the locks were installed on the front door. The ADM stated that resident 14's family complained to the facility about the locks on the door approximately one month ago. On 11/5/13 at 1:00 PM, resident 14's daughter was interviewed. Resident 14's daughter stated that resident 14 was able to get around in a power chair and that since she lived a block away, resident 14 would come visit frequently. Resident 14's daughter stated that after the facility locked the doors, resident 14 didn't feel like he "could get out." She stated that she tried to teach resident 14 the code to get in and out of the facility, but that his fingers shook too badly and he was physically unable to use the key pad. Resident 14's daughter stated that resident 14 kept saying, "...doors locked, can't get out." She stated that resident 14 was clearly frustrated. 5. On 11/5/13 at 9:05 AM an interview was conducted with resident 47. When asked about the facility "lockdown", resident 47 stated that "it was ridiculous. . . they had key pads installed and no one could go out. . . . the nurses would buzz you out but by the time you got to the doors, the doors were locked again and the nurses were doing something else." 6. The medical records for all current residents were reviewed. There was no documentation available for review which indicated that any of the residents admitted to the facility were assessed as being an elopement risk. A confidential interview was conducted with SM 14. SM 14 stated that the facility was placed on "lock down" off and on since August 2013. SM 14 stated that each department was given a code to enter/exit the facility. SM 14 stated that the facility staff were not allowed to give the code to residents, families, or visitors. A confidential staff interview was conducted with SM 16. SM 16 stated that the facility was on "lock down for a couple of months." SM 16 further stated that the facility was the residents home and that they "have rights to go outside." SM 16 stated, "I don't agree with the building being locked." SM 16 stated. "There are residents and family that are extremely upset and even community members asked about the 'lock down' when visiting the facility." On 10/31/13 at 9:30 AM, the facility LCSW was interviewed. The LCSW stated, "My opinion was not solicited about the lock down as I was not in the building." The LCSW stated that from June to August 2013, she was not in the building since the facility had not paid her. The LCSW stated that when she returned in August 2013, the facility was already locked. She further stated, "I worry about the rights about all of the people to come and go. It makes it harder for other residents to get out and enjoy being outside." The LCSW stated that previous to the facility being placed on "lock down", she had seen residents doing "laps in the parking lot." The LCSW stated that the RA did not report any resident concerns to her.

Based on interview and medical record review, it was determined that the facility did not permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs cannot be met by the facility for 2 of 35 sample residents. Specifically, (1) The facility transported a moderately impaired, deaf and mute resident to an acute care hospital approximately 170 miles away from the facility. The facility staff members escorted the resident into the emergency room , told the admission clerk at the hospital that the facility staff could no longer care for the resident, and then walked out of the hospital. (2) a morbidly obese gentleman with a leg injury requiring ongoing physical therapy was discharged to his own home without ensuring that it was a safe discharge. Resident identifiers: 9 and 47. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 10/22/13. The electronic "Interdisciplinary Progress Notes" for resident 9 were reviewed. The facility licensed nursing staff documented: a. 10/9/13 at 9:19 PM: "MD (Medical Doctor) made visit. No changes made." b. 10/13/13 at 6:48 PM: (Resident 9 was) "yelling X 6 (six times)." c. 10/15/13 at 1:05 AM: "flu shot to right deltoid." d. 10/15/13 at 11:32 PM: "Held due to Resident not available." (Note: There was no further documentation as to when or why resident 9 was "not available.") On 10/23/13 at 8:20 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that she was working on 10/23/13 and was assigned to care for resident 9 on the day she was transported to the acute care facility. RN 1 stated that resident 9 exhibited her "normal" behavior of yelling out but could not recall any physical behaviors. RN 1 stated that resident 9 was transported to the hospital when she was at lunch and that she did not transport resident 9 out of the facility. RN 1 stated that two facility staff members transported resident 9 in the facility van to an acute care hospital that was located approximately 170 miles away. RN 1 further stated that additional information related to resident 9's discharge would have to be obtained from the facility Director of Nursing (DON). On 10/23/13 at 8:35 AM, Physical Therapist Assistant (PTA) 1 was interviewed. PTA 1 stated that on 10/15/13 at approximately 2:00 PM, she was told to take resident 9 to (the acute care hospital approximately 170 miles away from the facility.) PTA 1 stated that the DON had instructed her to "Just drop her (resident 9) off." PTA 1 stated that resident 9 had a pleasant drive to the hospital without any behaviors during the three hour drive. PTA 1 stated that she spoke with the personnel in the emergency department and told them "The facility could no longer care for her (resident 9)." PTA 1 stated that the emergency department personnel told her that she (PTA 1) "Couldn't leave (resident 9)" in the emergency department. PTA 1 stated that she told the emergency department personnel that she had to move the facility van, as instructed by the DON. PTA 1 stated that she then exited the emergency department and did not return, as instructed by the DON. On 10/23/13 at approximately 9:00 AM, the facility DON was interviewed. The DON stated that resident 9 was transported to the acute care hospital because the facility could no longer meet her needs. The DON stated that resident 9 would yell and hit at staff and other residents. The DON stated that she instructed the staff that transported resident 9 to the acute care hospital to tell the hospital personnel "We (the facility) can't meet her needs." The DON stated that resident 9's discharge was not documented in the medical record related to the way she was left at the hospital and that she couldn't "document that in the medical record." On 10/23/13 at 9:53 AM, the facility Administrator (ADM) was interviewed. The ADM stated that resident 9 had behaviors which included screaming, pounding on things, and had "ripped the closet door off." The ADM stated that the facility worked with the Medical Director to reduce her behaviors to find out why the behaviors were present and what manifested them. He stated that resident 9 went for a period of time before her behaviors escalated to taking things, and hitting staff and other residents. The ADM stated that the facility attempted to obtain assistance from other resources in the area with managing resident 9's behaviors. He stated, "However, we kept getting blocked." The ADM stated that resident 9 had no reported behaviors the day she was transferred to the acute care hospital and further stated, "I don't need a specific behavior to initiate a transfer or discharge." The ADM stated that the facility staff were told to tell the emergency room personnel that "They (the facility) need more resources." He stated that the emergency room personnel were provided a copy of resident 9's history of physical and then the staff left the hospital. The ADM stated that he was "...not going to create a liability of hitting another resident or staff member" and that resident 9 would not be allowed to return to the facility. The facility ADM stated that he did not know how long resident 9 remained in the emergency room at the hospital or what resident 9's status was. On 10/23/13 at 2:00 PM, the facility Transport Aid (TA) was interviewed. The TA stated that she was told to transport resident 9 to an acute care hospital for dental concerns. The TA stated that during the transport, she received a phone call from the facility DON who instructed her (the TA) to transport resident 9 to the emergency department and to tell the staff in the emergency department that the facility "...didn't have the resources to care for her (resident 9)." The TA stated that she told the emergency room personnel that resident 9 had been violent and then she (the TA) left the emergency room as instructed by the DON. On 11/5/13 at 9:40 AM, an interview was conducted with the Licensed Clinical Social Worker (LCSW) regarding resident 9. The LCSW stated, "I'm only here once a month, and I didn't have any idea that she had had any behaviors." The LCSW stated that when residents displayed verbal or aggressive behaviors, she did not include that in her psychosocial assessment. The LCSW stated that she was not aware of the circumstances of resident 9's discharge until after it had already occurred. The LCSW stated that she felt it was a safe discharge because they "didn't leave her on a street corner. . . It was safer than what she was going through here. She couldn't defend herself and couldn't comprehend her actions." The LCSW stated, "I know that staff haven't had the training and don't have the right mindset to take care of certain people." The LCSW then stated, "I knew we needed to have a conversation about discharges and put a policy in place but I haven't been back yet so we haven't had that conversation." The LCSW then stated, "I only consult. I tell them my opinion and have no input into things unless they ask. . . I don't tell them what to do, I just tell them their options. I don't do anything unless they ask me to." On 10/31/13 at 12:15 PM, resident 9's primary care physician (PCP) was interviewed. The PCP stated that resident 9 was transported to the acute care hospital "Without me knowing it." The PCP was given the information above as to the specifics of resident 9's discharge to the acute care hospital. The PCP stated, "You can't just abandon someone in the ER (emergency room ), something could have happened to her. That's ridiculous. That was inappropriate." Note: Resident 9, a resident with dementia and [MEDICAL CONDITION], was transported to an acute care hospital approximately 170 miles away from the facility, left in the emergency department with an admissions clerk, without personal care supplies, someone to assist her with communicating with the emergency room personnel, someone to ensure that she did not leave the hospital, or to ensure that her personal care needs were addressed. 2. Resident 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 47's closed medical record was reviewed on 10/29/13. A document entitled "Discharge Plan" and dated 9/9/13 was reviewed. The discharge plan revealed that resident 47 had been discharged home due to "Behaviors not conducive to nursing Home Care. Therapy goals met 40-50%." Resident 47's nurses notes were reviewed and revealed the following: a) On 9/8/13: "At 4:15 am (name of Certified Nurse Assistant (CNA)) reported to me that (resident 47) was using a cigarette lighter in his room. I entered the room and there was a spoon in front of him on the bedside table with a liquid white substance in it poking it in his wrist vein. I asked him what he was doing and if he was shooting up the [MEDICATION NAME] I had just given him. He stated that he was. I said you know what I have to do don't you and he said yes. I took the paraphernalia to the nurses station and called his Mother to let her know. Then I called . . . the DON and let her know. Then I called the . . . county sheriffs department to report the incident. The Sheriff came at about 0430 (4:30 AM) am and talked with (resident 47) and took the paraphernalia. He stated he would let us know what will go one (sic). (Resident 47) is not having any signs of overdose. His VS (vital signs) are stable and WNL (within normal limits) for him. He apologized to us about what happened." b) On 9/9/13: "Resident has been discharged to home with home health. . . Resident left facility at 1200 (12:00 PM) in his own vehicle, driving himself. All medications, including narcotics were sent with him, along with instructions on when to take them. . . All belongings from room were taken to his truck by staff. Recliner, wheel chair, and cane included. . . " An incident report dated 9/8/13 revealed that a CNA "noticed patient useing (sic) cigarett (sic) lightor (sic) in room (and) notified me. Entered room (undecipherable) sitting in recline (sic) (with) bedside stand in from of him (with) spoon (with) cooked white substance Patient had syring (sic) (with) needle in hand (and) needle (with) blood in it. Asked him what he was doing. He stated he was cooking the [MEDICATION NAME] I just gave him. I took spoon syring (sic) (with) needle (and) lighter to nurses station. called his mother. and . . .Director of Nursing. Called Sherriff (sic) office to report incident." Facility staff documented on the incident report that they had notified the Primary Care Physician (PCP) on 9/8/13 at 4:30 AM. On 10/31/13 at 12:15 PM, resident 47's PCP was interviewed. The PCP stated that resident 47 was discharged from the facility without his knowledge. The PCP stated that facility staff called him and stated "We discharged (resident 47) because he was cooking his medicine." On 11/5/13 at 9:05 AM, an interview was conducted with resident 47. Resident 47 stated that he had been having problems with his leg fracture for over three years, and was admitted to the facility to complete physical therapy and heal his leg. Resident 47 was asked about the events surrounding his discharge from the facility. Resident 47 stated, "I got kicked out of there pretty much." Resident 47 confirmed that he was injecting drugs, and stated that after he was caught the ADM and DON came in to speak to him. Resident 47 stated that the ADM told him "you can take the charges or we can kick you out." Resident 47 stated that he told the ADM and DON that he would "rather stay and take the charges because I needed the physical therapy." Resident 47 stated that despite his wishes, the ADM and DON entered his room on 9/9/13 and stated "pack your stuff. You are leaving. You have until noon to get out of here." Resident 47 confirmed that staff packed up his belongings and that he drove himself home. Resident 47 stated that due to the short notice of the discharge, he was without his supplemental oxygen for three days and two nights. In addition, resident 47 stated that because of the discharge "I haven't gotten the therapy like I wanted. . . . the whole thing really upset me." On 11/5/13 at at 12:30 PM, an interview was conducted with the facility ADM regarding resident 47. The ADM stated that because resident 47 had been caught "shooting up" his medications, the decision was made to discharge the resident from the facility, and send him home. Note: Resident 47, a morbidly obese gentleman with a leg injury requiring ongoing physical therapy was discharged to his own home without ensuring that it was a safe discharge.

Based on interview and record review, the facility did not follow a written policy under which 1 of 35 sample residents whose hospitalization exceeded the bed-hold period was readmitted to the facility immediately upon the first availability of a bed. Specifically, a resident who went to the hospital was not allowed to return to the facility due to staffing issues. Resident identifier: 28. Findings include: Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 28's medical record was reviewed on 10/23/13. On 10/18/13, a licensed nurse documented resident 28 "has stated that she feels that she needs to be seen at the hospital. She states that h (sic) now the (sic) her R (right) foot is not getting better, that the pain goes up her entire leg and that the pain stays constant at an 8. She has routine pain meds (medications) and a [MEDICATION NAME] in place. She still has abx (antibiotics) for URI (upper respiratory infection) and has no acute respiratory sx's (symptoms) though her liter flow remains high. . . Ambulance dispatched to take her to (local emergency room ) . . . " On 10/23/13 at 3:30 PM, an interview was conducted with the facility Director of Nursing (DON) regarding resident 28. The DON confirmed that resident 28 was still at the hospital, but would be eligible to return to the facility as soon as the hospital discharged her. A confidential interview was conducted with Staff Member (SM) 9. SM 9 stated that the Administrator (ADM) was not allowing resident 28 to return to the facility after her hospital stay. SM 9 stated that resident 28 was unhappy with the decision because she wanted to return to the facility. SM 9 stated that the ADM decided that resident 28 required "a lot of staff time and there's not enough staff to meet her needs." On 10/31/13 at 12:15 PM, an interview was conducted with the facility Medical Director (MD). The MD stated he had "no idea" the resident was at the hospital, and that he had not "been involved in these decisions."The MD stated that he was unaware that facility staff were not allowing resident 28 to be readmitted to the facility. On 10/30/13, an interview was conducted with the ADM. The ADM confirmed that resident 28 was still at the hospital. The ADM stated that the facility would not be readmitting resident 28. The ADM stated "We don't have an obligation to bring her back when she is admitted to a hospital, and they (the residents) are not ours anymore. . . . ." When asked why the facility would not readmit resident 28 after her hospital stay, the ADM stated that he had met with the facility Interdisciplinary Team (IDT) and determined that the facility could no longer provide care for resident 28. The ADM stated that resident 28 was a "liability" to the facility because she weighed over 500 pounds, and had experienced falls which required the help of outside agencies such as the fire department to assist her back into her bed/wheelchair. The ADM stated that the outside agencies were refusing to assist staff anymore with resident 28's falls, and so resident 28 could not return. The ADM then stated "our staffing would be maxed if she was to come back, because we have staffing challenges and many people who need other cares. . . we only had 1.5 nurses and 2 aides at the time. . . we weren't able to meet her needs when she was here. . . our staffing levels were stretched because she took 3 hours for a bath. . . she was highly dissatisfied and tried to have other agencies take her but one one would. She's not ours anymore." The ADM confirmed that he had not consulted with the MD regarding the readmission of resident 28. The ADM also confirmed that resident 28's level of care and weight had not changed between the time of her previous stay and her current condition. On 10/31/13 at 11:20 AM, an interview was conducted with the Chief Nursing Officer (CNO) at the local hospital where resident 28 was admitted for treatment. The CNO stated that the hospital had admitted resident 28 for a blister on the resident's foot. The CNO stated that the resident had been administered intravenous antibiotics, but had then changed to oral antibiotics on day five of her admission. The CNO stated that on day 5 of resident 28's hospital stay, a call was placed to the facility to readmit the resident, but the facility staff refused stating that "she required a lot of care and was greater than 500 pounds." The CNO stated that she was unclear as to the refusal of readmission, because resident 28 had been admitted to the facility several times in the last two years, and was "back at her baseline". The CNO stated that the hospital administrator had contacted the facility ADM, but that the facility ADM still refused to readmit resident 28. The CNO stated that resident 28 had now been in the hospital 14 days, instead of the five required. On 10/31/13 at 11:35 AM, an interview was conducted with resident 28 via telephone while resident 28 was still residing in the hospital. Resident 28 stated that the physicians at the hospital wanted to discharge her after her 5 days at the hospital, but she had been at the hospital for 19 days because "they (the facility) won't take me back. They told me that I take too much time and they don't have enough staffing." Resident 28 stated that she had a conversation directly with the ADM who told her that she "take(s) too much time and we don't have enough staff to take care of you." Resident 28 stated that "all of my stuff is still there. . . my brand new sewing machine, stuffed animals, and bingo tickets." Resident 28 stated that she felt "homeless" because she could not live with her husband at his home, and now the facility had "kicked her out." Resident 28 stated that she was "mad" and "frustrated" because this incident was "a hospital dumping." Resident 28 then stated that although she had had concerns with the way the ADM treated her she "would like to go home, and that (the facility) is my home."