Every finding on record at Sandy Health and Rehab

Based on interview and record review, the facility failed to ensure each resident was free from the misappropriation of property. Specifically, for 11 of 21 sampled residents, a nurse stole controlled substance pain medications.The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by March 19, 2026, included the following measures: an immediate facility-wide baseline narcotic audit to verify that all controlled substances were accurately accounted for, immediate investigation and resolution of identified discrepancies, implementation of a new standardized narcotic tracking process, revision of narcotic count sheets to require documentation on medication receipt, administration, discontinuation, and destruction, establishment of a new process for adding and removing medications from inventory, updated documentation requirements, reinforcement of the medication destruction protocol, in-service training for all licensed nursing staff, and initiation of narcotic documentation audits.Resident identifiers: 5, 6, 11, 12, 13, 14, 15, 16, 17, 18, and 19.The surveyor reviewed an initial incident report dated March 13, 2026. The incident report documented that on March 13, 2026, at 4:20 PM, an investigating officer arrived at the facility and met with Admin 1. The officer reported receiving information on March 12, 2026, regarding potential narcotic abuse by Staff 1. The officer presented photographs of narcotic count records and empty bubble packs containing prescription labels. The report identified the affected victims as Residents 5, 6, 11, 12, 13, 14, 15, 16, 17, 18, and 19.The surveyor reviewed the facility's internal investigation documentation. [Previous DON] and [Previous Administrator] interviewed all affected residents. Residents 5, 6, 11, 12, 13, 14, 15, 16, 17, 18, and 19 reported receiving their pain medications as ordered and stated their pain was managed. [Previous DON] reviewed the Medication Administration Records (MARs) for all affected residents, which indicated that medications were administered as prescribed. [Previous DON] concluded that Staff 1 diverted medications that were near the end of a refill or diverted discontinued medication sheets and bubble packs intended for destruction. Staff 1 was terminated from employment.On August 12, 2026, at 1:28 PM, the surveyor interviewed Admin 2. Admin 2 stated that at the time of the incident, Admin 2 functioned as the Assistant Director of Nursing. Admin 2 stated facility management became aware of the diversion when law enforcement arrived with evidence of stolen medications. Upon notification, Staff 1 was immediately suspended, and an audit was initiated to ensure all residents received their ordered medications and all narcotics were accounted for. Admin 2 stated the investigation determined Staff 1 removed medications and correlated narcotic sheets once a provider discontinued a prescription. Admin 2 stated the facility implemented a corrective action plan that included a facility-wide narcotic audit, a standardized narcotic tracking process, revised narcotic count sheets, an updated medication destruction process, ongoing audits of discontinued medications, and staff education.The surveyor reviewed the facility's corrective action plan, which was implemented on March 19, 2026. The plan included:Completion of an immediate facility-wide baseline narcotic audit to verify that all controlled substances were accurately accounted for.Immediate investigation and resolution of identified discrepancies.Implementation of a standardized narcotic tracking process to ensure consistent documentation across all units.Revision of narcotic count sheets to require documentation on key points, including medication receipt, administration, discontinuation, and destruction.Establishment of a clear process for adding and removing medications from inventory.Expansion of documentation requirements to include resident name; medication name, strength, and prescription number; quantity received, administered, and removed; dates of all transactions; and nurse verification signatures.Reinforcement of a medication destruction protocol to ensure proper witnessing and documentation.

Based on interview and record review it was determined, for 2 of 41 sample residents, that the facility did not provide the residents with the right to manage his or her financial affairs. Specifically, residents who had authorized the facility to manage any personal funds did not have ready and reasonable access to those funds. Resident identifiers: 30 and 295. Findings include: On 4/13/25 at 11:12 AM, an interview was conducted with resident 30. Resident 30 stated she could not get her money unless it was a weekday because no one was available who had access to the money, on the weekends. Resident 30 stated she was told she would just have to wait until Monday to get her money. On 4/16/25 at 11:00 AM the facility grievance binder was reviewed. A grievance form from resident 295 dated 6/4/24 documented. No one to give money out on the weekend. Business office states there is no money to give out on weekends. The response to the grievance was documented as, We spoke about collecting money on Fridays if she needs it. The follow-up action was documented on the form as, [Resident 295] didn't write this, she doesn't collect money very often and she has no issues collecting funds. The form was signed by the resident and the administrator. On 4/16/25 at 8:34 AM, an interview was conducted with the Business Office Manager (BOM). The BOM stated they have a trust and bank account for resident 30. The BOM stated the residents do not have access to their funds on the weekends. The BOM stated he was the person who gave out the money to residents and that he only worked Monday through Friday. On 4/16/25 at 1:26 PM, an interview was conducted with the Administrator (ADM). The ADM stated the residents could request funds from the BOM manager or they could request it from the ADM. The ADM stated they were in the process of allocating that responsibility to the activities staff but that had not been put into the place yet. The ADM stated they had some gaps with how the residents received their funds and there were times on the weekend that no one was available to give the money to the residents. The ADM stated that another barrier they encountered was that there was no cash in the money box due to limited funds. The ADM stated it took a couple of days for the corporate team to get them the money after it was requested. The ADM stated there had been an incident in the past where a resident did not get their money because it was not available.

Based on interviews and observation, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, the shower rooms were in disrepair and one shower room was malodorous. Resident identifier: 37, 46 and 89. Findings include: On 4/13/25 at 2:41 PM, an interview was conducted with resident 46. Resident 46 stated that the 100-hall shower room constantly smelled like soiled diapers and that it was so bad she refused to use that shower. On 4/15/25 at 9:11 AM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated resident 46 refused to go in the 100-hall shower room because it had a smell. CNA 4 stated the 100-hall shower room smelled like smoke or sewer maybe. On 4/16/25 at 8:53 AM, an observation was made of the south 300 hallway shower room. The tile on the base of divider wall was observed to be missing and broken. On 4/16/25 at 2:52 PM, an interview was conducted in the 200-hall shower room with the Maintenance Director. The Maintenance Director stated the broken tiles along the bottom of the divider wall needed to be replaced and the open gap between the tiles from top to bottom of the divider wall needed to be fixed because the humidity could penetrate the wall behind the tile. The Maintenance Director pointed to dark spots around the sprinkler head and in the corner to the left of the window with a large water spot and stated that it was mold and needed to be fixed. The toilet was covered by a plastic sheet and the Maintenance Director stated the toilet did not work because the main pipe was broken. On 4/13/25 at 10:53 AM, an interview was conducted with resident 89. Resident 89 stated that the shower room in the 100-hallway smelled bad, so she requested to get showered in a different hall ' s shower room. On 4/13/25 at 11:29 AM, an observation of the shower room in the 100 hallway was made. The shower room appeared clean but had a smell similar to sewage. On 4/15/25 at 9:08 AM, an unidentified aid and unidentified resident were observed to exit the shower room in the 100 hallway. The resident stated that the shower room smelled bad. The unidentified aid stated that the large trash can needed to be emptied, and that the facility was not very good at emptying it. Upon entering the shower room in the 100 hallway it was observed to have a strong urine odor. Outside of the shower stall sat a fabric chair with brown substance on the seat and white staining on the back and seat of the chair. There were two large 32-gallon garbage cans with lids observed in the shower room of the 100 hallway. One of the large garbage cans was unlabeled and had a plastic liner with soiled linens. The second large garbage can was labeled Trash and had no plastic liner and was half full of briefs and other trash. There was a very strong urine odor when the lid was removed from the garbage can labeled Trash. Inside the shower stall were two shower chairs. Both of the shower chairs had a brown substance on the seat area. While inside the shower stall an unpleasant odor, similar to sewage, could be smelled. On 4/15/25 at approximately 10:45 AM, an interview was conducted with resident 37. Resident 37 stated that he will not use the shower room in the 100 hallway because it stinks. On 4/16/25 at approximately 1:00 PM, an interview was conducted with CNA 3 while inside the shower room in the 100 hallway. CNA 3 stated that some residents would not use this shower due to the unpleasant odor. CNA 3 stated that she noticed the unpleasant odor the previous week when a resident refused to be showered in the shower room of the 100 hallway. The CNA stated that it was housekeeping's responsibility to empty the garbage can with the soiled linens; and that it was the CNA's responsibility to empty the garbage can labeled Trash. On 4/16/25 at 2:02 PM, an interview with the Maintenance Director was conducted. The Maintenance Director stated that he had not gotten any maintenance requests for the shower room in the 100 hallway, until 4/15/25 when a resident had reported an odor. The Maintenance Director stated that he poured chemicals down the drain in response. On 4/16/25 at 2:07 PM, an interview was conducted with the Housekeeping Supervisor. The Maintenance Director acted as a translator. The Housekeeping Supervisor stated that shower rooms were cleaned every day, in the morning. On 4/16/25 at 2:09 PM, an interview was conducted with Housekeeping Staff. The Maintenance Director acted as a translator. Housekeeping Staff stated that the shower rooms are cleaned daily with three cleaners: disinfectant, odor control, and a floor cleaner. On 4/16/25 at 2:36 PM, an interview was conducted with the Administrator. The Administrator stated that he was aware of the odor in the shower room of the 100 hallway and that it had been an off and on issue. The Administrator stated that a plumber worked on the shower room of the 100 hallway in February 2024. The Administrator further stated that the Maintenance Director had been pouring chemicals down the drain. On 4/16/25 at 2:42 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was unaware of any complaints concerning the odor in the shower room of the 100 hallway. The ADON stated that if a resident complained to a CNA, she expected the CNA to inform the floor nurse or the CNA coordinator. The ADON stated there was a program available to report maintenance needs, but she was unsure if it was utilized. On 4/16/25 at 2:56 PM, an interview was conducted with CNA 5. CNA 5 stated that a few months ago she entered a complaint into maintenance reporting system regarding the odor in the shower room on the 100 hallway. CNA 5 stated that the unpleasant odor did improve shortly after, but it had been slowly coming back. CNA 5 stated that she did not notice an odor in the shower room of the 100-hallway last week, but the unpleasant odor was noticeable this week.

Based on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and served at a safe and appetizing temperature. Specifically, for 14 out of 41 sample residents, salad was not kept at the correct temperature while serving tray line, residents complained of food quality, a test tray not attractive or palatable and resident council minutes and grievance forms revealed complaints of food quality. Resident identifiers: 2, 7, 18, 21, 30, 33, 46, 49, 60, 66, 89, 70, 73, and 145. Findings include: On 4/13/25 at 11:23 AM, an interview was conducted with resident 30. Resident 30 stated the food is not very good. Resident 30 stated that the food is awful and cold, but people eat it because that is all that they have when you can't get anything else. On 4/13/25 at 11:45 AM, an interview was conducted with resident 21 who stated the food was usually cold and just all around not good. On 4/13/25 at 10:11 AM, an interview was conducted with resident 33. Resident 33 stated that the food was okay, but did not have much flavor or look appealing. On 4/13/25 at 10:45 AM, an interview was conducted with resident 60. Resident 60 stated that the food served tasted awful and was never warm. On 4/13/25 at 11:30 AM, an interview was conducted with resident 49. Resident 49 stated the food was awful and she would not recommend eating it. Resident 49 stated the food looked like mystery meat and roadkill. On 4/14/25 at 8:00 AM, an interview was conducted with resident 66. Resident 66 stated the food tasted bad and was often cold. On 4/14/25 at 8:26 AM, an interview was conducted with resident 7. Resident 7 stated that the food was mediocre in taste and often looked unappetizing. On 4/14/25 at 8:35 AM, an interview was conducted with resident 18. Resident 18 stated that food is just okay and that sometimes the food is served cold. On 4/13/25 at 10:53 AM, an interview was conducted with resident 89. Resident 89 stated that the food was not good and often had no flavor. Resident 89 further stated that while some food is delicious, there were times she could not identify the food served. Resident 89 stated that food is often delivered at incorrect temperatures. For example, she stated that the French fries were always cold, and the ice cream was always delivered melty. On 4/13/25 at 11:35 AM, an interview was conducted with resident 2. Resident 2 stated that she would have liked better food, and that the food didn't taste good. Resident 2 stated that she did not think the meals provide balanced food groups: there is rarely fresh produce; a high amount of carbs; and the protein was usually processed meat. Resident 2 also stated that food was usually delivered cold. On 4/13/25 at 12:32 PM, an interview was conducted with resident 70. Resident 70 stated that the food is not good, and the portion sizes are too small. He stated that he has to supplement his meals with food he purchases on his own. Resident 70 stated that there was not enough protein served, and his weekly dialysis labs regularly showed he was deficient in protein. Resident 70 stated that he had requested larger portions, but it fell on deaf ears. Resident 70 stated that half of the time food was delivered cold. On 4/14/25 at 8:48 AM, an interview was conducted with resident 145. Resident 145 stated that the quality of the food was horrible. Resident 145 stated that there was not enough nutrition provided to sustain anyone. Resident 145 stated that the food was processed and did not taste good. He also stated that there is no variety, and the alternatives were not any better. Resident 145 stated that the food was rarely the correct temperature when it arrived. On 4/13/25 at 2:41 PM, an interview was conducted with resident 46 and they stated any meat served was dry and they could not chew it, carbohydrates made up most of the meal, and sometimes it was so bad they could not eat it and would be left hungry. On 4/13/25 at 10:11 AM, an interview was conducted with resident 73 and they stated the food was cold, dry, and the vegetables were always overcooked. Resident 73 stated the meat was always in a patty form and a mystery meat. Resident 73 stated the chicken patties were so hard they could not chew it. On 4/13/25 at 11:23 AM, an observation was made of the kitchen staff checking the temperatures of the food. The temperature of the salad was 66 degrees. The salads were observed to be stacked on a cart next to the tray line. On 4/13/25 at 11:45 AM, the Dietary Manager (DM) checked the salad temperatures, and they read 63 degrees. The staff were observed to place the salad cups in containers of ice. An immediate interview was conducted with the DM who stated the salads should be kept in the fridge until they are ready to be used and should not go above 41 degrees. On 4/13/25 at 11:59 AM, an observation was made of a few bowls of salad that had reached 40 degrees and were placed on trays to be served to the residents. These trays did not leave the kitchen until 12:15 PM. On 4/15/25 12:33 PM, an observation was made of the hall trays exiting the kitchen. A test tray was requested. At 12:35 PM, the following foods temperatures were obtained [Note: All temperatures were in degrees Fahrenheit.]: a. meatloaf with red sauce was 153.7 - bland to the taste b. pasta was 146.5 - bland to the taste c. potatoes were 160.9 - bland to the taste d. salad was 43.2 - ice cubes observed in salad e. dessert was 64.1 f. milk was 43.5 - warm The meat was bland to taste and left a bad aftertaste. The pasta was bland to taste and not seasoned. The potatoes were bland to the taste and not seasoned. The salad was warm and had ice cubes mixed in with the lettuce. The dessert was palatable. The milk was warm. A review of the facility resident council minutes revealed the following complaints related to food: a. December 2024, suggestions to dietary were that the food was not as hot on the evenings and weekends and meal tickets not followed as thoroughly on the weekends. b. January 2025, suggestions to dietary were to read the meal tickets better and to use the heating plates. c. April 2025, suggestions to dietary were the food was often bland, milk is sour, and Shepard's pie not good at all. A review of the facility grievance forms revealed the following complaints related to food: d. May 15, 2024, complaint that a resident was not receiving the appropriate diet. e. May 16, 2024, compliant that a resident does not like the food and cannot eat the food. f. May 20, 2024, complaint that the milk is warm continually, too many green beans, residents getting items they are not supposed to receive. g. May 23, 2024, complaint that a resident does not like the food and cannot eat the food. h. May 24, 2024, complaint that the kitchen keeps sending dislike items and when resident requests snacks they are told they are not available. On 4/15/25 at 1:30 PM, the DM stated there was an in-service done with all of the dietary staff to educate them on the importance of keeping food items at the correct temperature. An observation was made of the in-service provided to the dietary staff. On 4/16/25 at 8:42 AM, an interview was conducted with the DM. The DM stated the salads need to be kept at the correct temperature before they are served to the residents. The DM stated the salads should have been kept in the refrigerator and brought out right before they were to be used, then the temperature of the salads would not have gotten warm. The DM stated that having to cool the salads down made lunch a little late. The DM stated she was surprised by the food complaints and thought the residents were happy with the food they provided. On 4/16/25 at 2:15 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was unaware of the food not being kept at the correct temperature. The ADM stated he had been told by some of the residents that they did not like the food. The ADM stated this would be something they would try to improve.

Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the food was not served in a sanitary manner. Findings include: On 4/15/25 during the tray line of lunch service the following was observed: a. At 12:13 PM, Dietary Aide (DA) 1 was observed to Donn gloves. DA 1 was then observed to touch the thermometer, sink, refrigerator handle, and was then observed to touch the face of the plates with the same gloved right hand. [NAME] (CK) 1 was observed to place food on the plate that DA1 touched with the dirty glove. b. At 12:12 PM, CK 1 was observed to have gloves on and touch the oven doors, sink handles, the spatula handle and then touch the face of the plates prior to plating the food for the residents. c. At 12:18 PM, CK 1 was observed to slide the plates across the white cutting board in front of the tray line. CK 1 was then observed to take a scoopful of carrots and place them on the cutting board. CK 1 chopped the carrots on the cutting board with the spatula, plated the chopped carrots and they were taken to the residents. The cutting board was not cleaned before or after the chopping. d. At 12:22 PM, CK 1 was observed to slide plates across the cutting board. CK 1 was then observed to place a scoopful of carrots on the cutting board, chop the carrots then plate them for resident use. The cutting board was not cleaned prior to the carrots being placed on the cutting board; the area was observed to be cleaned after. e. At 12:25 PM, DK 1 was observed to reposition the food on the plate with gloved hands after touching the plates, covers, fridge door, cart, and sink handles. No hand hygiene was performed, and the gloves were not changed prior to touching the food. On 4/15/25 at 12:45 PM, an interview was conducted with CK 1. CK 1 stated the staff should not touch any of the food or the face of the plates with dirty gloves. CK 1 stated they cut the food on the white cutting board that they move the plates along for tray line. CK 1 stated they do not clean it before they chop food on it. On 4/16/25 at 8:42 AM, the Dietary Manager (DM) was interviewed and stated the staff should not be touching the face of the plates with dirty gloves, they should change their gloves. The DM stated the staff usually chop the food for the mechanically soft diets on the white cutting board where the plates are moved across. The DM stated they did not clean the whiteboard prior to chopping the food and stated that probably should not happen because the surface was dirty.

Based on interview and record review, the facility did not ensure that each resident was offered the influenza, pneumococcal, and the coronavirus disease 2019 (COVID-19) vaccines. In addition, residents that accepted the vaccines did not have those vaccines administered. Specifically, for 3 out of 5 sample residents, two residents had signed consent forms where they had accepted to receive the 2024/2025 COVID-19 booster, and the booster was not administered. In addition, one resident did not have documentation that they were offered vaccines for the 2024/2025 season. Resident identifiers: 4, 28, and 55. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, epilepsy. Resident 4's medical record was reviewed on 4/16/25. A form titled 2024-2025 Seasonal Vaccination Consent was reviewed. Resident 4 marked on the form that they wished to receive the 2024-2025 COVID-19 booster. Administration documentation for the COVID-19 booster was not completed. No documentation was located indicating that resident 4 had received the COVID-19 booster vaccine. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic systolic heart failure. Resident 28's medical record was reviewed on 4/16/25. A form titled 2024-2025 Seasonal Vaccination Consent was reviewed. Resident 28 marked on the form that they wished to receive the 2024-2025 COVID-19 booster. Administration documentation for the COVID-19 booster was not completed. No documentation was located indicating that resident 28 had received the COVID-19 booster vaccine. 3. Resident 55 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease. Resident 55's medical record was reviewed on 4/16/25. No documentation was located indicating that resident 55 had been offered the influenza or COVID-19 booster vaccines for the 2024-2025 season. On 4/16/25 at 1:02 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she was also the Corporate Director of Infections. The RNC stated from 10/1/24 to 3/31/25, the vaccination consents were in the admission packet. The RNC stated if the resident was already vaccinated, she would pull that information from other systems. The RNC stated the facility would pre-order the influenza vaccine and once the vaccine was received the staff would obtain consent and administer the vaccine. The RNC stated the pneumococcal vaccine consent was obtained on admission if the resident had never received the vaccine. The RNC stated the COVID-19 booster was administered in house if a resident requested it. The RNC stated the COVID-19 vaccine was offered per the Centers for Disease Control and Prevention recommendations. On 4/16/25 at 2:36 PM, a follow up interview was conducted with the RNC. The RNC confirmed that resident 4 and resident 28 did not receive the COVID-19 booster vaccines. The RNC confirmed that resident 55 did not have a 2024/2025 vaccination consent form completed.

Based on observation, interview, and record review it was determined that, for 1 of 41 sample residents, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences. Specifically, a resident was provided food that was listed as an allergy. Resident identifier: 46. Findings included: On 4/14/25 at 1:17 PM, an interview and observation were conducted with resident 46. Resident 46 was in her room with her lunch tray in front of her and there was fried rice with peas observed on her plate. Resident 46 stated she is allergic to peas because her body did not produce the enzymes that can break down the peas and it caused an upset stomach. Resident 46 stated she got served foods she was allergic to at least once a week. A meal ticket was observed on the tray that indicated, Allergies: LATEX, ORANGE JUICE, PEA [sic], SHELL FISH, STRAWBERRIES .Dislikes: .Vegetable (NO PEAS!! NO PEAS!!! NO PEAS!!! & NO BEETS). Resident 46's medical record was reviewed 4/13/25 through 4/16/25. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included lumbosacral root disorders, adult failure to thrive, irritable bowel syndrome (IBS), major depressive disorder, binge eating disorder, gastro-esophageal reflux disease (GERD), and bulimia nervosa. A care plan focus indicated, [Resident 46] is at risk for potential nutritional problem r/t [related to] Obesity, adult failure to thrive, ibs, hx [history] of binge eating, hx of bulimia, GERD, hypothyroidism Date Initiated: 10/31/2024 Revision on: 02/20/2025. It further indicated Interventions/Tasks of, Allergies: orange juice, peas, shellfish, strawberries, latex Date Initiated: 10/31/2024. A Grievance/Complaint Report, dated 12/30/24, indicated, stated she is still being served her allergies with her meals .educated staff on allergies and watching tickets carefully with allergies involved. DM [Dietary Manager] spoke to resident about concerns and how she will be addressing it with kitchen staff to fix the problem. On 4/16/25 at 2:43 PM, an interview was conducted with the DM. The DM stated allergies are highlighted in bold writing on the meal tickets and that they had had problems with residents being served listed food allergies a couple of times before. The DM stated she did not know how it got out of the kitchen because 3 staff members should have checked it. The DM stated she had recently educated staff and watched the tray line to remedy the problem and that they had not had problems for the last few months.

Based on interview and record review it was determined. for 1 out of 41 sample residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's laboratory results were not located in the electronic medical records. Resident identifier: 6 Findings included: Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of brain, chronic respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, and epilepsy. On 1/20/25 a pharmacy recommendation for resident 6 documented, This resident takes Phenytoin 300 TID [three times a day] and Phenobarbital 97.2 QD [every day], and a review of the chart could not find any serum levels in the last six months, and there are no routine orders in place for this lab to be drawn. The following intervention has been preapproved by the attending medical team through verbal communication and/or protocols: 1. Draw serum Phenytoin 2. Draw serum phenobarbital On 1/22/25 at 11:41 AM, progress note for resident 6 documented, Pharmacist completed monthly med [medication] review and recommended serum phenytoin and phenobarbital labs be drawn. MD [medical doctor] agreed, orders have been updated. It should be noted resident 6's medical record did not contain lab results for serum phenytoin or serum phenobarbital. On 4/16/25 at 8:22 AM, an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). The DON stated that staff sent all diagnostic results to medical records to be scanned into the resident's chart. The RNC stated that once medical records received the results, it typically took about a week to upload them into the resident's medical record. On 4/16/25 at 9:49 AM, an interview was conducted with Medical Records. Medical Records stated that once she received the results from staff, she uploaded them to the electronic medical record and then destroyed the originals. Medical Records stated she was instructed to upload records as quickly as possible and aimed to complete them the same day.

Based on observation, interview, and record review it was determined, for 1 out of 41 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident had a delay in getting sutures removed. Resident identifier: 55 Findings included: Resident 55 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, generalized anxiety disorder, other lack of coordination, and major depressive disorder. On 4/13/25 at 10:06 AM, an observation and interview were made of resident 55. Resident 55's left leg was in a brace, there were sutures on the bridge of her nose that appeared to have scabs over them, and her left cheek had a greenish-purple discoloration. Resident 55 stated she had fallen down and broken her knee and hit her face. On 4/15/25 at 9:23 AM, an observation was made of resident 55 sitting in her wheelchair in her room, tugging at the sutures on the bridge of her nose. A review of resident 55's progress notes revealed: a. On 3/30/25 at 6:28 PM, a nurse's note documented, Note Text: Received a call from [name redacted] hospital at 18:15pm [6:15 PM]. They told that resident had broke her nose and had open fracture so, they suture it and also told that resident had fracture patella on her knee. so, they wrapped it and they told that we can take it offwhile [sic] shower but they want to immobilize resident leg. Nurse from [name redacted] told that they put resident on oral antibiotic and said resident received antibiotic for tonight dose and said needs to give from tomorrow [sic] morning. They told they put resident on Keflex for 5 days and they are sending resident back to facility. b. On 3/30/25 at 11:04 PM, a nurse's note documented, Note Text: Patient returned to facility at around 1900 [7:00 PM]. She was diagnosed with: Open displaced fracture of nasal bone, ground level fall, DNR [Do Not Resuscitate], laceration of face, patella fracture. She returned with an order for cephalexin 500 mg [milligrams] oral capsule BID [twice a day] for 5 days. Her first dose was given tonight. She has a brace to her left leg. She will need her sutures removed in 7 days. She will also need follow up care by house provider for her knee injury. A review of resident 55's hospital discharge paperwork documented, .Return to ED [Emergency Department] for suture removal in 7 days . On 4/15/25 at 7:45 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 55 had recently had a fall and fractured her nose and leg. On 4/15/25 at 2:53 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 55 fell and landed on her kneecap. LPN 1 stated resident 55 had a cut on the bridge of her nose and it required sutures and caused bruising around her face. LPN 1 stated that resident 55 still had the sutures in and believed they needed to remain for 14-21 days, though he was unsure. On 4/15/25 at 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 55 should have had the sutures removed on 4/8/25.

Based on observation and interview, it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities. Specifically, the 200 and north 300-hall shower rooms each had one call light that did not work and there were no cords attached to the call lights in the 100, 200, and north 300-hall shower rooms. Resident identifier: 46. On 4/14/25 at 1:17 PM, an interview was conducted with resident 46 and she stated that the 300-hall shower room's call light did not work and that she could get stuck in the shower. Findings include: On 4/15/25 at 9:09 AM, an observation of the 200-hall shower room was made. There were two call lights in the room, one call light was located in the first shower area and had no cord and did not activate the call system when the switch was pushed and another call light located in the second shower area had no cord. On 4/15/25 at 9:09 AM, an interview was conducted with Certified Nursing Assistant (CNA) 6 who was observed in the 200-hall shower room and switched the call light in the first shower area. CNA 6 stated the call light did not work but that there was another call light in the second shower area which was separated by a dividing wall. On 4/15/25 at 9:43 AM, an interview was conducted with Maintenance Staff. The Maintenance Staff stated the call light cords had to be long enough for the residents to reach if the resident was on the floor, which was about 3 inches from the ground. On 4/15/25 at 9:09 AM, an observation was made of the 100 's hall shower room call light. The call light was a switch with no cord present. The call light was activated at the time of the observation. On 4/15/25 at 9:25 AM, an interview was conducted with CNA 5. CNA 5 stated that some residents required set up, but did not require assistance with showering. CNA 5 stated that the CNA ' s check on the residents that do not require assistance every 5 to 10 minutes. On 4/15/25 at 10:07 AM, an interview was conducted with resident 77. Resident 77 stated that he typically used the 200 ' s hall shower room. Resident 77 stated that the call light in the 200 ' s hall shower room did not work and did not have a cord attached to the call light switch. Resident 77 stated that the cord has been missing since the 200 's hall shower room was repaired. Resident 77 stated that staff stays in the shower room while he showers unassisted due to the call light not functioning. On 4/16/25 at 1:00 PM, an observation was made of the 100 ' s hall shower room call light. A new floor length cord was observed. On 4/15/25 at 9:04 AM an observation was made of the 300-hallway north shower. The shower door was propped open with a chair. In the first shower stall there was no call light cord. On 4/15/25 at 9:05 AM, the call light cord for the second shower in the 300-hallway north shower was pulled. A continuous observation was conducted. There was no visible light that lit up in the hallway. On 4/15/25 at 9:15 AM, an observation was made of staff taking a resident inside the 300-hallway north shower. It should be noted that no staff answered the call light for 10 minutes. On 4/15/25 at 9:27 AM an interview was conducted with CNA 2. CNA 2 stated that in the 300 hallway there were two shower rooms. CNA 2 stated that the north shower room was bigger and wider and lots of residents preferred to use this shower room. CNA 2 stated that only the first shower worked in the shower room. On 4/15/25 at 10:22 AM, an interview was conducted with the Administrator (ADM) who stated the facility had only started auditing the call light system in January. The ADM stated he was aware the north 300 hallway shower room call light had not worked in the past but he thought it had been corrected. The ADM stated the call light system was old and the bulbs went out frequently. The ADM stated until the call light system was functioning correctly an aide would stand outside the shower room if a resident was showering.

Based on interview and record review, the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, for 1 out of 41 sample residents, a resident's x-ray report was not located in the medical record. Resident identifier: 40 Findings included: Resident 40 was admitted to the facility on [DATE] with diagnoses which included, chronic respiratory failure with hypoxia, transient cerebral ischemic attack, and chronic obstructive pulmonary disease. A review of resident 40's medical record revealed the following: a. On 3/18/25 an order for Amoxicillin-Pot (Potassium) Clavulanate Tablet 875-125 MG (milligram) Give 1 tablet by mouth two times a day for infectious pneumonitis for 7 days b. On 3/21/25 an order for Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for Pneumitis (sic) for 10 days c. On 3/21/25 at 9:35 PM, a nurses note documented, [name redacted] NP [nurse practitioner] new order: Doxycycline 100mg PO [by mouth] BID [two times a day] x [times] 10 Days for Pneumonia. It should be noted that no chest x-ray results were located in the resident 40's medical record. On 4/15/25 at 1:14 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 40 had pneumonia which was why he had been taking two different antibiotics. RN 1 stated staff monitored him for and negative side effects of the antibiotics and for any signs of shortness of breath. On 4/16/25 at 8:22 AM an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). The RNC stated that resident 40 was on two different antibiotics for pneumonia. The RNC stated that the Medical Director would have ordered a chest x-ray to confirm the pneumonia diagnosis before starting the antibiotics. The DON stated she would contact the mobile radiology company to obtain the chest x-ray results. On 4/16/25 at 9:57 AM, the DON emailed a copy of the chest x-ray results. This report was not signed or dated.

Based on interview and record review, 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, for 2 out of 28 sampled residents, one resident eloped from the facility and sustained 2nd and 3rd degree burns. Additionally, another resident was found outside the facility doors while wearing a wander guard. Resident Identifiers: 10 and 26. Findings Included: 1. Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of left side hemiplegia, epilepsy, bipolar type schizoaffective disorder, cognitive communication deficit, burn of second degree of lower back, burn of second degree of buttock, burn of third degree of lower back, and personal history of traumatic brain injury. On 8/13/24 at 2:40 pm, an interview was conducted with resident 26. Resident 26 stated they had snuck out of the facility and had not informed staff of their location. Resident 26 stated they fell on the pavement and sustained burns down to their crack. Resident 26 stated the burns were uncomfortable. Resident 26's medical records were reviewed from 8/12/24 to 8/15/24. On 6/25/24, an Admission Minimum Data Set (MDS) documented Resident 26 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. On 6/19/24, an admission wandering risk scale documented, resident 26 had a history of wandering and the previous facility stated resident 26 was a frequent wanderer. Resident 26's wander score indicated they were a wander risk. Resident 26's physician orders were reviewed and documented the following wander guard orders: a. An order with a start date of 6/19/24 and end date of 7/8/24 documented, May have wander guard to right ankle: Check for Placement and Function Q [every] shift. every shift for Safety b. An order with a start date of 7/8/24 and end date of 7/10/24 documented, May have wander guard to wheelchair: Check for Placement and Function Q shift. every shift for Safety. c. An order with a start date of 7/25/24 documented, Wander Wander Guard on wheelchair every shift for safety. It should be noted resident 26 went 6 days without a wander guard order before they left the facility without informing staff of their where abouts. The Leave of Absence binder was reviewed and there was no indication resident 26 had signed out. Resident 26's progress notes were reviewed and documented the following: a. On 7/5/24 at 5:27 AM, a nurse note documented, PT [patient] used her lighter to burn off her wander guard strap. Placed the wander guard onto the back of her w/c [wheelchair] and she took it off. Administrator made aware. b. On 7/16/24 at 6:45 PM, a late entry nurse note documented, Police called and notified nurse that they had a female that stated she was a resident at [name of facility]. Police gave her name and stated she was heading south in her wheelchair down state street. Police asked if we wanted to come [NAME] her back. Police stated she said she would come back later after visiting her friends. Nurse responded resident is alert and able to leave facility at her own will. Following call from police, nurse noted resident had not signed out in LOA [leave of absence] book. Notified DON [Director of Nursing] of resident being out of building and phone call from police. Resident has spent time at friends house in the past and has returned in the time she stated she would return. c. On 7/17/24 at 7 PM, an elopement event note documented, Resident went LOA from the building on 7/16 @ [at] 6:45 pm, she did not state she would be out all night from the facility. On 7/17 resident still hadn't returned to the facility, reached out to the Case Worker for her but no answer. Reached out to a friend that resident had spent the night a couple of days before but she had not see the resident. Notified Administrator and reported the elopement to state and police. Reached out to hospitals in the area and noted that the resident was in the ER [emergency room ] at the [name of local] hospital. No further information at this time. On 7/17/24, the Hospital history and physical documented resident 26 had fallen out of their wheelchair and was unable to get themselves off the hot pavement. It documented resident 26 was sunburnt and obtained burns to their back and buttocks. The facility abuse investigation, form 358 was submitted to the State Survey Agency (SSA) on 7/17/24 at 1:39 PM. An allegation of suspected elopement was reported. It documented resident 26 stated they were going downtown to visit a friend when she left the facility. The form documented staff became aware of the incident at 10 AM and the DON was made aware at 12 pm. A detailed account of the incident documented, Resident left facility at 7 pm on 7/16/24 telling staff she was doing [sic] downtown to visit a friend and did not return for morning medications as she normally does. Shift nurse notified nurse manager when resident was not present for med pass. Nurse manager notified administrator and elopement was reported to state agency. The facility final investigation, form 359 was submitted to the SSA on 7/24/24. The documented outcomes stated, [Resident 26] went out of the facility and was found by the police. Patient stated she is a resident at [name of facility]. Police was notified she was going downtown to meet a friend. When the patient did not return that evening, we called at approximately 1:20 pm to her case worker and found her at the [local] hospital. An interview was conducted with resident 26 and stated, Per interview with resident she stated she left the facility without informing staff and took her manual wheelchair to state street. She stated she was with family and friends. Resident stated she fell out of her wheelchair and couldn't verbalize how or why or any additional clarifying details. The ambulance showed up and she was treated and the hospital let us know she was doing drugs and returned back to [name of facility]. The form documented there were no staff members that witnessed the resident leave the facility. A summary of staff interviews documented the cops located resident 26 on [a local street] but resident 26 did not want to return to the facility. The provided summary documented, Patient was placed on a wander guard on 6/19 on admission following the completion of the wander risk assessment per facility policy for safety. On 7/5 patient burned her wander guard off her wheelchair. A new wander guard was placed however, resident was not compliant with the safety plan. The Investigation verified the allegation had occurred. On 8/14/24 at 11:27 AM, an interview was conducted with the DON. The DON stated an elopement either when a resident left the building and was unable to return to the facility due to confusion or when a resident left the building without signing out the LOA book or telling staff they were leaving. The DON stated residents needed to inform staff of LOA so staff was aware of how long the resident was going to be gone for. The DON stated resident 26 was reported to be a wander risk from their previous facility and based off of their admission assessment, resident 26 was considered a high elopement/wander risk. The DON stated resident 26 had a stroke which might have contributed to cognitive issues. The DON stated resident 26 had found ways to remove their wander guard. The DON stated the previous administrator had done an assessment and made the decision to remove resident 26's wander guard. The DON stated normally a wander guard removal was a team decision to ensure the proper assessment had completed and the resident was no longer at risk to elope/wander. The DON stated staff were unaware resident 26 had left the building. The DON stated around 6 or 7 pm that night, the police had called the facility to inform them of a possible missing resident which was resident 26. The DON stated they attempted to reach resident 26 when they had not returned back to the facility in the morning. The DON stated later that day, resident 26 was located at one of the ER's with burns and positive meth use. 2. Resident 10 was admitted to the facility on [DATE] and discharged from the facility on 6/13/24 with diagnosis of wernicke's encephalopathy, alcohol abuse with intoxication delirium, alcoholic hepatitis without ascities, and altered mental status. Resident 10's medical records were reviewed on 8/12/24. A physician order with a start date of 5/3/24 and discontinue date of 6/14/24, documented as followed: check wanderguard placement: R [right] ankle. every shift. It should be noted that no wander risk assessment's were located in the resident's medical record. Resident 10's progress notes were reviewed and documented the following: a. On 5/4/24 at 10:28 AM, an admission 72 hour charting note documented, .very confused, seems to be her baseline. Wanders around looking for her room, her mom, etc .A [alert] &O [oriented] x [times]1-2, pleasantly confused, compliant with meds. b. On 5/8/24 at 9:38 PM, an elopement event note documented resident 10 had an elopement on 5/8/24 at 6:30 PM. The note stated resident 10 was found coming back inside from the side door. Resident 10 was noted to have a wanderguard placed on their left ankle and it was documented resident 10 wandered due to confusion but did not have any exit seeking behaviors. c. On 5/9/24 at 9:36 AM, an orders-administration note documented, .resident keep [sic] looking for exits but resident gets redirect easily. d. On 5/9/24 at 9:51 AM, an Intradisciplinary Team (IDT) Event Review stated the intervention for resident 10 elopement was, educate staff on importance of not allowing resident to exit outside independently. e. On 5/12/24 at 10:46 PM, an elopement note documented resident 10 had an elopement on 5/12/24 at 7 pm. The note stated resident 10 was found on the backside of the building sitting down on the grass and it was unknown how the resident got there. It was documented that resident 10 had a wander guard on their right ankle. f. On 5/13/24 at 3:39 PM, an IDT-Event note documented resident 10 was placed on hourly visual checks due an elopement. Additional interventions in response to resident 10's elopement included, doors were checked for locking/ alarm sounds and wanderguard was checked. g. On 5/14/24 at 2:50 AM, an alert note documented, Patient wandered all night long, kept opening doors and going into patient's rooms and waking them up. Many complaints from other patients. h. On 5/15/24 at 3:19 PM, a plan of care note documented, .She requires a wander guard bracelet for safety due to impulsiveness and frequent wandering. The facility Investigation was reviewed for the May 8th elopement and documented as followed: a. The facility abuse investigation, form 358 was submitted to the State Survey Agency (SSA) on 5/9/24 at 5:24 PM. An allegation of elopement was reported. Staff became aware of the incident on 5/9/24 at 6:30. The form documented, the Resident Advocate (RA) [name removed] was on their way home for the day, when they noticed resident 10 was outside the side [sic] facility. It was documented resident 10 was found on the north-west side of [facility]. The documented steps taken to protect resident 10 included bringing resident 10 back to the facility and checking all the doors to ensure they were locked. b. The facility final investigation, form 359 was submitted to the SSA on 5/16/24 at 6 PM. The form documented there were no witness to the elopement and resident 10 had no recollection of the elopement. An interview with staff documented, .Resident was found coming back from outside of the facility door. Indicating that she was outside. In the additional summary section, the form documented resident 10 had another elopement during this investigation. The investigation verified the allegation had occurred. The form listed additional interventions which included, updating and putting signs on all the doors that better and clearly state and help residents understand the use for such door; daily egress Door check system, to ensue that Doors are being properly closed. The facility Investigation was reviewed for the May 12th elopement and documented as followed: a. The facility abuse investigation form 358 was submitted to the SSA on 5/13/24 at 2:18 PM. The form documented an allegation of elopement. The form documented resident 10 had eloped from the facility on 5/12/24 at 6:45 pm. The form documented a staff member had found resident 10 outside of the emergency exit door in the back yard of the facility. b. The facility final investigation, form 359 documented resident 10 was found outside by the vending machines. Resident 10 was brought inside, and they were still on the facility grounds and no alarm had gone off. Elopement charting was started on resident 10. Additional documentation included the doors and door locks were assessed on May 20, 2024. Daily Egress Door checks were completed, and the doors checked included the therapy exit, 100 hall, laundry hall, 200 hall, 300 hall, and Maintenance door. On 8/15/24 at 11:27 AM, an interview was conducted with the DON. The DON stated a wander assessment was done on admission and then quarterly. The DON stated if a resident scored high on the assessment and exhibited exit seeking behaviors, a wander guard was ordered by the physician. The DON stated a wander guard was used to keep the residents safe and notify staff if they were trying to exit the building. The DON stated central supply checked the wander guard door weekly to make sure it was working. The DON stated the front door was the only door that alarmed and locked with the wander guard system. The DON stated they did not have a wander guard system for the entire building. The DON stated all other entry doors remained locked. The DON stated the doors alarmed if they here held for 15 seconds. The DON stated there was a key to unlock the doors and it disabled the door alarm if the door was unlocked. The DON stated resident 10 was able to get out with a wander guard either because the door had not been locked or the alarm was not answered by staff. The DON stated after resident 10's elopement, signs were put on the doors to remind residents they could not go out those doors.

Based on observation, interview, and record review, it was determined for 2 of 28 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, a resident did not receive treatment to a right foot full thickness laceration and another resident's wounds had no documented measurements. Resident Identifiers: 15 and 26. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, difficulty walking, difficulty swallowing, enlarged prostate, and a lack of coordination. Resident 15's medical record was reviewed from 8/14/24 through 8/15/24. On 3/26/24 at 4:28 PM, a facility report incident (FRI) was submitted to the State Survey Agency (SSA). It documented that on 3/26/24 at 1:00 PM, resident 15's right fifth toe had been run over while he was being propelled down the hall in his wheelchair. The wound nurse assessed the right fifth toe as having a laceration. The wound Nurse Practitioner (NP) was notified, and an order was obtained to send resident 15 to the emergency department (ED) for possible stitches. The ED physician documented resident 15 had redness and bruising to the right fifth toe with a small laceration to the adjoining web space. An x-ray was obtained and a diagnosis, of a lateral dislocation of the proximal interphalangeal (PIP) joint and a non-displaced fracture of the middle right fifth toe was made. The hospital discharge instructions were reviewed. The facility was to keep the 4th and 5th toes on the right foot buddy taped until an order to discontinue the buddy tape was received. The facility was to put a cotton ball or a piece of gauze between the taped toes to prevent friction or pressure. The March 2024 Treatment Administration Record (TAR) was reviewed. There was no documentation that the ordered dressing changes were completed to the right food open areas or that the area was monitored for signs of infection. On 4/2/24 at 4:10 PM, the wound NP documented an initial evaluation. It was documented that resident 15 had two broken toes and an opening, but sutures were not placed. The right fifth toe was assessed as being red and detached. On 4/2/24, Registered Nurse (RN) documented there was a full thickness laceration that measured 1 centimeter (cm) by 1 cm with small amount of serosanguinous (a wound drainage that is thin and watery with a light red or pink color) fluid, and 100% slough (dead skin tissue that may have a yellow or white appearance) in the wound bed. The RN documented that Medihoney was to be applied to the wound bed covered with a bordered gauze. The dressing was to be changed three times a week and as needed if the dressing was soiled or became dislodged. The April 2024 TAR was reviewed. There was no documentation that the treatment of the Medihoney was implemented until 4/6/24. Note: there was a four-day delay in the implementation of the medihoney treatment. On 4/9/24, a RN documented the wound treatment was to remain unchanged to promote autolytic debridement. The RN documented that resident 15 was to be seen by a podiatrist related to the discoloration of the right 5th toe and that the toe did not appear to be attached to the foot. On 4/15/24, the RN documented that the full thickness laceration measured 0.5 cm by 0.5 cm and had a scant amount of serosanguineous drainage with 100% slough. It was also documented that resident 15 had a podiatrist appointment scheduled for 4/18/24. In an email sent to the DON on 8/20/24 at 12:40 PM, the DON stated that she was not sure why the order for Medihoney was not implement until 4/6/2024. Note: The order was transcribed into the April TAR on 4/6/24. 46232 2.Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of left side hemiplegia, epilepsy, bipolar type schizoaffective disorder, cognitive communication deficit, burn of second degree of lower back, burn of second degree of buttock, burn of third degree of lower back, and personal history of traumatic brain injury. Resident 26's medical records were reviewed from 8/12/24 to 8/15/24. On 7/19/24, a hospital wound care progress note documented, resident 26 was seen by inpatient wound care to evaluate and treat their back and buttocks burns which resident 26 obtained from being on hot pavement for 30 minutes. The documented wound measurements for the resident 26's back was 20.9 x 19.0 x 0.1 centimeters (cm), with a total surface area of 210.5 square (sq) centimeters (cm). The documented wound measurements for the buttocks wound was 17.1 x 12.2 x 0.1 cm, with a total surface area of 125.4 sq cm. On 7/22/24, a wound care progress note documented, [Resident 26] was a [AGE] year old female seen for wound care evaluation in [name of facility]. She sustained burns after she used methamphetamine and fell outside on the pavement and was unable to get up until the fire department responded. She has 2nd and 3rd degree burns on her back in [sic] buttocks. The documented measurement was, Total surface area 27% [percent] posterior torso thoracic region thru buttocks. [ Note: no individual wound measurements were obtained for resident's back and buttocks wounds.] On 7/29/24, a weekly wound observation assessment for wounds 1 and 2 documented it was the first time the NP had observed the wounds and had no prior reference to them. In the measurement sections for both wounds, the NP documented, Unable to get an accurate measurement - burns are throughout back with epithelial bridges in between. The weekly wound observation assessment for wound 1 documented resident 26 had 3rd degree burns to bilateral buttocks. The wound tissue was described to be moist with granulation tissue and 60 % of slough tissue present. Wound 2 documented resident 26 had 3rd degree burns to their back. The wound tissue was described to be moist with granulation tissue and 80 % of slough tissue present. No foul odors were noted for either wound. On 8/5/24, a weekly wound observation assessment for wound 1 documented the wound had worsened and the wound was described as moist with 100 % slough tissue present and a foul odor. Wound 2 was documented to remain unchanged and the slough tissue had decreased by 10%. There were no documented measures for the wounds and the NP documented, Unable to get an accurate measurement - burns are throughout back with epithelial bridges in between. On 8/15/24 at 8:42 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they had wound nurse and wound NP that rounded every Monday to assess all the wounds. The DON stated the nurses were required to do the wound changes when the wound nurse was not there. The DON stated wound measurements were obtained every Monday. The DON stated wound measurements were used to see if the wound was healing, used to compare how it has progressed and if they needed to make changes to the wound care. The DON stated the purpose of wound measurements was to make sure they were providing the care they needed for the wound. The DON stated there should be wound measurements for resident 26's wounds.

Based on interview and record review, it was determined that for 1 of 28 sampled residents, in response to allegations of abuse, neglect, exploitation or mistreatment, the facility did not have evidence that the violations were thoroughly investigated. Specifically, an allegation of neglect was not thoroughly investigated to determine if neglect had occurred. Resident identifier: 7. Findings include: 1. Resident 7 was admitted to the facility on [DATE] on hospice services with diagnoses of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter- chronic obstructive pulmonary disease, unspecified- chronic hepatic failure without coma, personal history of transient ischemic attack, major depressive disorder, and generalized anxiety disorder. Exhibit 358 revealed that staff became aware of the incident on 1/26/24 at 2:30 am. The exhibit revealed that resident 7 had a fall and sustained a laceration above R[right] eye. Exhibit 359 revealed that, Staff found [resident 7] on the floor in her room in the early morning hours. They assisted her back into bed and started neuro checks. Nurse [nurse's name] stated that she was uncooperative with Neuros and sent her to the hospital. [Nurse's name] did not reach out to hospice first and sent her out and stated there was a brain bleed, which was on [resident 7] primary dx [diagnosis] when she came into [facility name] in the first place. Summary of interviews with the alleged victim stated, Resident [resident 7] is non verbal. Visual cues do not appear to have incurred psychosocial distress or harm. [Resident 7] was transferred to [facility name] from a different facility due to her decline and terminal agitation. [Resident 7] is at her baseline. [It should be noted that there was no interview with the Certified Nursing Assistant [CNA] who discovered the resident on the ground, according to the nurse's incident report documented on 1/26/24 at 1:59 am. There was no information regarding the resident's condition prior to the fall, whether the call light was within reach, what position the bed was in from which the resident fell , whether routine checks were being performed, how long since the CNA had checked on the resident, and whether the resident was presenting with agitation prior to the fall.] Resident 7's medical records were reviewed from 8/12/24 to 8/14/24. On 1/22/24, the facility put in place fall precautions in the resident's care plan for staff to Answer call lights promptly, continually educate the resident regarding safety issues, and instruct the resident about what to do should they experience a fall. Encourage the resident to not get up by him or herself, but rather to call for help. On 1/23/24, the hospice note stated the resident was admitted to hospice with a primary diagnosis of respiratory failure. The hospice nurse also stated the following .She is a high fall risk due to increased weakness and current bed bound status but because of her restless and pain patient appears uncomfortable, continues to move around in bed and trying to get out of bed, with her current disorientation and inability to recognize disabilities and weakness she is at high risk for another fall . [It should be noted that the hospice nurse did not state the resident was on hospice services for a brain bleed and did not state the resident was experiencing terminal agitation.] On 1/25/24 at 3:22 pm, the nurse documented the following in the progress notes Primary Diagnosis: stroke, R[right] wrist fx[fracture], blind in L [left] eye Focused Assessment: med [medication] and pain mgmt [management] Adjustment to Admission: well and accepting Pain Management: prn [as needed] pain medication Mental Status/Behavior: a[alert]&o[oriented] x2 Improvement/Decline: n/a[not applicable] Notification(s):. [It should be noted that the facility did not list brain bleed or terminal agitation as a primary diagnosis.] On 1/26/24 at 1:59 am, the nurse documented in the incident report, CNA was doing her rounds and found her lying face down on the right side of her bed. She notified this nurse. PT[patient] assessed and found to have a 2 laceration over the R eye. ROM[range of motion] to the bilateral upper and lower extremities, she L shoulder pain. PT didn't remember how she got to floor. Immediate action taken stated: PT transferred back to bed. PT not compliant with Neuro[neurological] checks. Bleeding over the right eye stopped, laceration cleaned and steri-stripped. EMS[emergency medical services] notified. Patient transferred to the hospital for further evaluation and TX[treatment]. On 1/26/24 at 2:29 am, the nurse stated the following in a progress note PT transferred back to bed. PT not compliant with Neuro checks. Bleeding over the right eye stopped, laceration cleaned and steri-stripped. EMS notified patient transferred to the hospital for further evaluation and TX [treatment]. MD [medical doctor] notified, Ability hospice notified. Daughter [name] was called twice and message left . At 1/26/24 at 3:53 am, the facility nurse entered the following progress note ER [emergency room ] nurse from [hospital name] hospital called to let us know that she has a brain bleed and is being transferred to [hospital name]. [It should be noted this was the first documentation of a brain bleed as one of the resident's primary diagnoses.] On 1/26/24, an IDT[interdisciplinary team] note stated Event: Unwitnessed fall in room, in the middle of the night w\ [with] a major injury. Resident status before event: Stable Risk factors: Anxiety, hx strokes, resp failure Preventive measures before event: assist with ADLs[activities of daily living], call light within reach, meds/treatments as ordered, anticipate needs, pain control. The interdisciplinary team note further stated that the resident was experiencing no weight [NAME] or dehydration, was experiencing 6/10 pain, and the resident's mobility was at baseline. On 1/26/24 a typed statement in the supporting documentation for Form 359 determination stated, Everything was normal and [resident 7] had gone to bed and was resting. We found [resident name] on the floor in her room in the early morning hours. We assisted her back into bed and started neuro checks. [Resident 7] was experiencing terminal agitation. At that time [resident 7] was not cooperative with Neuros and so we sent her to the hospital. I did not reach out to hospice first and sent her out for being non compliant with neuros. [It should be noted that the descriptive term terminal agitation was used after the resident fell and struck resident's head causing bleeding over right eye and was not used by the physician, nursing or hospice to describe the resident's behavior leading up to the fall.] On 2/2/24, the submitted form 359 report stated that the resident was sent out to the hospital where it was discovered they had a brain bleed. The report stated the brain bleed was on [resident 7's] primary dx when she came in to [facility name] in the first place. On 8/13/24, the nurse stated in a phone interview that they would not have worded the incident statement on 1/26/24 the way it was written, using the words terminal agitation, and didn't believe it was their statement. The nurse also stated that they believed the CNAs had been conducting routine checks on the resident, the call light was in place, and that the bed was in the lowest position but was unsure whether these were done.

Based on observation and interviews, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, black spots were observed in the resident showers. Findings Included: On 8/13/24 at 12:10 PM, an observation was made of the 200-hall resident shower room. Black spots were observed on the lower corner base board left of the shower entrance. On 8/13/24 at 11:50 AM, an interview was conducted with Housekeeping (HK). HK stated the certified nursing assistants (CNAs) were responsible for cleaning the resident shower rooms. HK stated the certified nursing assistants were given the supplies to clean the shower rooms. HK stated they only cleaned resident room and resident common areas. On 8/13/24 at 2:06 PM, an interview was conducted with CNA 1. CNA 1 stated housekeeping cleaned the showers once a week and the cna's were responsible for cleaning up after resident showers. CNA 1 stated they sanitized the shower chairs and housekeeping scrubbed the showers. On 8/13/24 at 2:31 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated housekeeping disinfected the shower floors and toilets. The ADON observed the black dots on the shower corner and stated the appearance was black and dotty and it was possibly scum. On 8/13/24 at 2:34 PM, an interview was conducted with the Administrator (ADM). The ADM stated the cna's wiped down the shower room and housekeeping cleaned it as needed. The ADM stated they assumed housekeeping came in and wiped down the corners and baseboards. The ADM stated the black spots looked like mold in their opinion. The ADM stated it also looked like typical moisture spots and it was something that needed a deep clean. The ADM stated the were going to find someone to clean the shower room tonight.

Based on interview and record review, it was determined that for 2 of 28 sampled residents the facility did not ensure that the residents were free from significant medication errors. Specifically, a resident was not administered antibiotics as ordered that resulted in a treatment of an autolytic debridement and prophylactic medications were not administered to a resident who had 3rd degree burns to her buttocks and back. Resident identifiers: 15 and 26. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, difficulty walking, difficulty swallowing. enlarged prostate, and a lack of coordination. Resident 15's medical record was reviewed from 8/14/2024 through 8/15/2024. On 3/26/24 at 4:28 PM, a facility report incident (FRI) was submitted to the State Survey Agency (SSA). It was documented that on 3/26/24 at 1:00 PM, resident 15's right fifth toe had been run over while he was being propelled down the hall in his wheelchair. The wound nurse assessed the right fifth toe as having a laceration. The wound Nurse Practitioner (NP) was notified and an order was obtained to send resident 15 to the emergency department (ED) for possible stitches. The ED notes documented, resident 15 had redness and bruising to the right fifth toe with a small laceration to the adjoining web space. An x-ray was obtained and a diagnosis of a lateral dislocation of the proximal interphalangeal (PIP) joint and a non-displaced fracture of the middle right fifth toe. The ED physician documented that resident 15 was to be started on Cephalexin 500 milligrams (mg) twice a day. In a progress note, dated 3/27/24 at 5:23 AM, a Registered Nurse (RN) documented that resident 15 had returned from the ED and that there was an order for liquid Keflex that was sent with instructions to administer the Keflex for 5 days. The March 2024 and April 2024 medication administration records (MARs) were reviewed. There was no documentation that the Cephalexin order was transcribed onto the MARs or that the Cephalexin was ordered from the pharmacy. On 8/14/24 at 12:15 PM, the Director of Nursing (DON) reported that patient 15 did not receive the Keflex as ordered. 2. Resident 26 was readmitted to the facility on [DATE] with diagnoses which included a second degree burn to the lower back and buttock; a third degree burn of the lower back; Schizoaffective disorder, bipolar type; hemiplegia, left non-dominant side; a history of a traumatic brain injury; and stimulant abuse. Resident 26's medical record was reviewed from 8/12/24 through 8/15/24. On 8/4/24, the facility received an order to administer Keflex 500 mg four times a day for seven days. There was an interdisciplinary review on 8/6/24 where it was identified that the Keflex had not been transcribed into the electronic medical record. On 8/15/24 at 8:42 AM, an interview was conducted with the DON related to the antibiotics that were either not initiated or not administered in a timely fashion. The DON stated that the nurse who received that order was to documented the implementation of the order in a progress note, call the pharmacy to let them know, fax the order to the pharmacy for delivery. The DON stated that there was to be a 24 hour chart check after a new order was received.

Based on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were 2 freezers in the kitchen that did not maintain appropriate temperatures to keep food items frozen. These findings resulted in immediate jeopardy. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator (Admin 2), Administrator (Admin 1), and a the Director of Leadership Development (DLD) on 7/30/23 at 12:56 PM. At that time, Admin 1, Admin 2 and the DLD were informed of the findings of Immediate Jeopardy pertaining to F812 and were asked to develop an immediate plan to ensure that the residents of the facility were free from food that had not been stored, prepared, distributed and served in accordance with professional standards for food service safety . On 7/30/23 at 11:59 PM, Admin 2 provided the following written allegation of removal of the Immediate Jeopardy: F812: Food Procurement, Store/Prepare/Serve-Sanitary Objective: The objective of this IJ (Immediate Jeopardy) Abatement Plan is to rectify the non-compliance with F812, specifically related to freezer temperatures exceeding required thresholds at [NAME] Health & Rehab. The goal is to ensure the health and safety of residents and prevent any potential harm due to improper storage of perishable items. Step 1: Immediate Action Emergency Response: The nursing home's QAPI [quality assurance and performance improvement] Team have met to review and address the elevated freezer temperatures. The team included the Dietary Manager, the Corporate Dietary Manager, Administrator, and relevant management representatives. Temperature Monitoring: All freezers in the facility have been checked to identify any other instances of temperature deviation. Thermometers have been checked inside each freezer to validate they are functioning properly to monitor the temperature accurately. Identify Affected Items: Staff have inspected all items stored in the affected freezers. All food in affected freezers was discarded. Temporary Measures: If necessary, arrangements will be made to temporarily store perishable items in a properly functioning unit and rent additional storage if needed. Step 2: Identification of Others Repair or Replace Faulty Equipment: The facility has contacted a freezer repair company who are expected to come July 31, 2023, to promptly assess and repair any malfunctioning freezers. Both malfunctioning units are locked out/tagged out. If repair is not feasible, arrangements will be made to replace the affected freezer units with properly functioning ones. Resident Audit: Facility to monitor all residents in the facility for 72 hours to identify any potential signs of foodborne illness. Step 3: System Changes Review Policies and Procedures: The policies and procedures related to food storage and equipment maintenance will be reviewed and updated, ensuring alignment with industry standards and best practices. Staff Training: Staff responsible for monitoring and maintaining the freezers have received training on proper freezer temperature management, calibration, and recording procedures. This training was provided by the Corporate Director of Nutrition Services on 7/30/2023. Temperature Logs: The Temperature log will be reviewed to record freezer temperatures twice a day. The log will include date, time, and recorded temperatures to monitor and document compliance continuously. Quality Assurance Audits: The facility will implement temperature check audits 3x/week to ensure that freezer temperatures are consistently within the required thresholds. Any deviations will be addressed promptly. Continuous Improvement: The facility will foster a culture of continuous improvement, encouraging dietary staff to report any concerns or potential issues related to freezer temperatures and food storage. Step 4: Monitoring Staff Supervision: The Corporate Director of Nutrition Services to monitor kitchen operations/temperature checks for 14 days to validate compliant operations. Date of Compliance: The facility's Date of Alleged Compliance is 7/30/2023 at 11:59pm. On 7/31/23, the State Survey Agency reviewed the immediate plan of correction for removal of the Immediate Jeopardy involving food storage and confirmed the abatement of the Immediate Jeopardy as of the alleged date of abatement on 7/30/23 at 11:59 PM. Findings include: 1. On 7/30/23 at 8:26 AM, an initial kitchen tour was conducted. There were 2 freezers that were observed. Freezer 1's temperature was 42.0 degrees Fahrenheit based on the analog thermometer inside the freezer. Freezer 2's temperature was 20 degrees Fahrenheit based on the analog thermometer inside the freezer. On 7/20/23 at 10:28 AM, a follow-up kitchen tour was conducted. Freezer 1's temperature was 51.7 degrees Fahrenheit using an infrared thermometer. Freezer 2 was 31.0 degrees Fahrenheit using the inside analog thermometer. The contents of the freezer 1 was: a. There were 3 boxes of pork sausage patties that were delivered on 7/25. b. There was a box of 20 pounds of beef patties that revealed to Keep frozen 0 of below. c. There were 2 large logs of ground beef delivered 7/25. c. There were 2 large pork items delivered 7/25. d. There was buffet ham that was fully cooked that revealed Keep refrigerated 28F -34F. e. There was a box of turkey breast that was soft on the outside. It was delivered 3/3. The box revealed Keep frozen 0 of below. f. There was a box of uncooked beef steaks stored above breaded patties and chicken cordon bleu. g. There was a box of boneless skin on chicken that was delivered 7/21. On 7/30/23 at 10:38 AM, the Dietary Manager (DM) was observed to remove the buffet ham from the freezer. The DM was observed to slice the ham with a knife. The DM was observed to obtain a temperature of the ham. The temperature was 37.0 degrees Fahrenheit. The contents of freezer 2 were: a. Rainbow fat free sherbet 48 pack and a half box that was a liquid substance. b. There were vanilla and chocolate individual cups that were a liquid. c. There were 4 lemon meringue pies revealed Keep frozen 0 of below. d. There was a box of chocolate shakes which revealed Keep frozen 0 of below. Freezer 1 temperature log for July 2023 day shift and night shift revealed the following temperatures: [Note: All temperatures were degrees Fahrenheit.] a. On 7/1 at night 20 b. On 7/2, day 14 and night 22 c. On 7/3, day 18 and night 23 d. On 7/5, night 21 e. On 7/6, night 21 f. On 7/7,night 25 g. On 7/8, night 13 h. On 7/11, night 25 i. On 7/12, night 19 j. On 7/13, night 20 k. On 7/14, night 20 l. On 7/15, night 24 m. On 7/16, night 32 n. On 7/17, night 35 o. On 7/18, night 30 p. On 7/19, day 28 and night 35 q. On 7/20, day 35 and night 30 r. On 7/21, day 40 and night 45 s. On 7/22, day 22 night 23 t. On 7/23, day 30 night 38 u. On 7/24, night 10 v. On 7/25, night 34 w. On 7/26, day 39 and night 31 x. On 7/27, day 30 and night 32 y. On 7/28, day 28 z. On 7/29, day 35 and night 40 aa. On 7/30, day 36 Freezer 2 temperature log for July 2023 day shift and night shift revealed the following temperatures: [Note: All temperatures were degrees Fahrenheit.] a. On 7/6, night 12 b. On 7/7, night 12 c. On 7/9, night 13 d. On 7/11, night 12 e. On 7/19, night 28 f. On 7/20, night 20 g. On 7/25, night 26 h. On 7/26, day 25 and night 23 i. On 7/27, day 11 and night 24 j. On 7/28, night 39 k. On 7/29, day 15 and night 28 l. On 7/30, day 12 On 7/30/23 at 11:00 AM, an interview was conducted with Cook 1. Cook 1 stated she used the hamburger patties for residents on renal diet and for special requests. Cook 1 stated when she removed the hamburger patties from the freezer they were thawed. Cook 1 stated she did not check the temperature of the patties before cooking them. Cook 1 stated that freezer 1 was usually about 35 degrees Fahrenheit. Cook 1 stated that she had come to work in the morning at 5:30 AM and the freezer was 40 degrees Fahrenheit after being closed all night. Cook 1 stated she used the food from the freezer to serve to residents. Cook 1 stated that she was aware of the cooking temperatures because residents could be poisoned if served food that was not the right temperatures. Cook 1 stated she was not sure how long meats could thaw in the refrigerator. Cook 1 stated she noticed the ham was soft to the touch when she pulled it out of the freezer to cook it. On 7/30/23 at 11:01 AM, an interview was conducted with Cook 2. Cook 2 stated she worked both the morning and evening shifts. Cook 2 stated she and the DM checked temperatures on the freezers and refrigerators every day. Cook 2 stated if the temperature in the freezer was not 10 degrees or below, she would call the DM and ask him to look at it, and call someone to fix it. Cook 2 stated if the food in the freezer was not frozen the DM had to throw all the food away. Cook 2 stated if the temperature in the freezer was 20 degrees Fahrenheit, that temperature was too high and the food should not be used. Cook 2 stated food items in the freezer should go into the refrigerator to thaw and be used within 3 days. On 7/30/23 at 11:22 AM, an interview was conducted with the DM. The DM stated that depending on the product, the frozen food should be put into the refrigerator within 3 days of use. The DM stated he has told staff to pull the chicken from the freezer the day before it is to be used. The DM stated he had noticed the temperatures for the freezers had been high. The DM stated the freezers had just been cleaned and repaired last week. The DM stated the facility lost power for about 4 hours last week, after 5:00 PM so kitchen staff were already finished with meal preparation for that day. The DM stated the following day a maintenance repair company came to the facility and cleaned the condensers. The DM stated equipment condensers were cleaned quarterly and the condensers were due for quarterly cleaning at that time. On 7/30/23 at 11:40 AM, a second interview was conducted with the DM. The DM stated when the repairman came out on Monday or Tuesday he would have that person look at the freezers. The DM stated there is not much I can say, I should have caught that. The DM also stated that having high temperatures in the freezer is not ideal. On 7/30/23 at 12:51 PM, an interview was conducted with Administrator (Admin) 1. Admin 1 stated she was not aware of any freezer problems. 2. On 7/30/23 at 8:26 AM, an observation in the meat freezer (Freezer 4) was made of a box of doughnut holes that were open to air. Freezer 3 was observed to have a box of veggie burgers open to air. The walk-in refrigerator was observed to have a box of sausage patties open to air. On 8/15/23 at 9:45 AM, a follow-up kitchen walk-through was completed. The reach-in freezer (Freezer 4) had a box of chopped beef steak that was observed to be open to air. Freezer 1 was observed to have a box of cookie dough open to air. On 7/31/23 at 8:45 AM, an interview was conducted with the Corporate Director of Nutrition Services (CDNS). The CDNS stated she provided an in-service on 7/30/23 to the dietary staff and would be doing a more in-depth in-service later in the day with a focus on citations under F812. The CDNS stated kitchen staff were in-serviced at least monthly by the DM and quarterly by the RD. The CDNS stated Cook 2 had the best English of the Spanish speaking kitchen staff, and provided interpretation for the meetings. On 7/31/23 at 9:09 AM, an interview was conducted with Cook 2. Cook 2 stated that yesterday kitchen staff received education about food storage and temperatures. On 7/31/23 at 9:10 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated she did not do much in the kitchen, but mostly filled up drinks and did the dishes. DA 1 stated she was not present at the in-service provided earlier in the day by the DM. The DM entered the conversation and stated DA 1 would be receiving the in-servicing about temperatures before lunch time. DA 1 stated if she was unsure about something in the kitchen she would ask another kitchen staff member. On 8/9/23 at 2:12 PM, an interview was conducted with the consultant Registered Dietitian (RD). The RD stated she conducted kitchen audits monthly and touched base with the DM. The RD stated she talked with the DM often if he was in need of something. The RD stated her audits covered looking at temperature logs of the equipment and the food temperatures, she looked to ensure food was covered, labeled and dated. The RD stated she looked for dented cans and that eggs were being stored appropriately in the walk-in refrigerator. The RD stated she checked to see if the dish machine was functioning properly, if foods were thawing correctly, and if staff were following sanitation guidelines. The RD stated she thought her last kitchen audit was completed on 7/18/23. The RD stated she would have checked the freezers during her audit and would have made a note if she found a problem. The RD stated she did not have any knowledge about the temperatures in the freezers. The RD stated after her audit was completed, she would send it to the CDNS and the facility administrator. The RD stated she looked at her previous month's audit to track repeated infractions. The RD stated the DM did education for the kitchen staff, but did not know how often it was done. On 8/10/23 at 7:25 AM, kitchen audits were received from the consultant RD for her June and July kitchen audits. The June kitchen audit, with no date documented, revealed, High temps recorded on last freezer (near back door) in last few days (defrosting). [Note: Freezer 1 was the freezer near the back door being referenced.] The July kitchen audit, with no date documented, had no comments related to freezer temperatures. [Note: The temperature for Freezer 1 on the evening before the RD's kitchen audit was documented as 35 degrees Fahrenheit. Evening temperatures for Freezer 1 were above above 19 degrees Fahrenheit for the 7 days prior to the RD's audit.] On 8/14/23 at 9:09 AM, an email was received from the consultant RD. The email confirmed the dates of the kitchen audits. The June audit was conducted on 6/20/23 and the July audit was conducted on 7/18/23. The RD stated she had added a column to her audit so the date of the audit could be recorded as it was being conducted. On 8/15/23 at 10:03 AM, the CDNS was interviewed. The CDNS stated when shipments arrived, the DM or the assistant DM were responsible for dating the food items. The CDNS stated the boxes should have an open date and a used by date. The CDNS stated after a box was opened and food items were removed, the package inside should be sealed back up. The CDNS stated bulk items should be sealed from open air as well. 30563

Based on interview and record review it was determined, for 5 of 68 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. Specifically, a resident was forced to do Activities of Daily Living (ADL's), a male resident did not have the mental capacity to consent prior to moving in with a female resident, a resident was transferred inappropriately resulting in a femur fracture, and a Certified Nursing Assistant (CNA) was allowed to work with a specific resident after the CNA caused the resident to fall. This resulted in a finding of HARM for 3 residents. Resident identifiers: 16, 20, 22, 44 and 78. Findings include: HARM 1. Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Multiple Sclerosis (MS), chronic obstructive pulmonary disease, dysphagia, muscle weakness, dementia, anemia, hypertension and age related osteoporosis without pathological fracture. Resident 22's medical record was reviewed on 7/30/23 - 8/16/23. A quarterly Minimum Data Set (MDS) dated [DATE], revealed resident 22 required extensive assistance with a two person physical assist for bed mobility and transfers. A care plan focus dated 12/6/18 with a revision date of 4/6/20 revealed, resident had limited physical mobility r/t (related to) MS and is at risk for falls r/t MS disease process, impaired mobility. Interventions in place were, resident is NON-WEIGHT BEARING, the resident used an electric wheelchair for locomotion, provide supportive care, assistance with mobility as needed . OT (Occupational Therapy) to educate CNAs on proper Hoyer protocol. A care plan focus dated 5/27/19 with a revision date of 4/6/20 revealed, resident wants the Hoyer lift sling to be left underneath her after she is transferred to her wheelchair. Interventions in place were, Check proper placement of the sling PRN (as needed). A resolved care plan focus dated 3/1/23 with a revision date of 6/6/23 revealed, resident had a R (right) femur fx (fracture). [Note: Interventions in place did not include education or training for CNAs when transferring residents who required a two person physical assist.] Resident 22's progress notes were reviewed and revealed the following: a. On 2/18/23 at 11:00 AM, CNA was transferring res. (resident) from power w/c (wheelchair) to bed using the gait belt around the res. CNA explained to the res. what she was going to do with transfer, she put the sheet around the thigh then lifted the feet on to bed at the very edge, cna was on res. bed halfway lifted by gait belt and moved res. towards the bed while res. held onto arm, res. moved towards the bed and heard there was a pop. Res. said she did not feel anything, she was not sure, when positioning the legs and feet CNA noticed the rt. (right) thigh did not look right, res, denies pain, affected thigh immobilized, asked PT (Physical Therapy) to assesses, NP (Nurse Practitioner), DON (Director of Nursing), and sister [name omitted] notified. b. On 2/18/23 at 11:15 AM, When transferring the res. from w/c to bed CNA heard a pop on her rt. thigh, reported to NP with order and noted, for X-ray rt. femur and rt. hip stat (immediately) requested. c. On 2/18/23 at 1:40 PM, X-ray RESULTS with FX, reported to NP with order to send to [local hospital] for further evaluation and management. d. On 2/23/23 at 6:12 PM, Resident return to facility from [local hospital] after right femur fx, surgery to right femur . Requires extensive assist with bed mobility, transfers, and other ADL's. PT. OT needs treat and eval. An IDT (Interdisciplinary Team) review was conducted on 2/20/23 the following interventions were documented, MD (Medical Doctor) notified, x-ray obtained of the right leg, NP notified that the leg appeared to have a fx, sent resident to the ER (emergency room ) for further evaluation. The exhibit 358 had alleged that on 6/1/23 at 12:58 PM, the facility reported that on 2/18/23 at 11:00 AM, the Resident was being transferred to bed by 2 unidentified staff members. During the transfer a pop was heard and the CNA had noted the right thigh looked abnormal but the Resident denied any pain. STAT X-ray was ordered and per the results of the X-ray the Resident was sent to [local hospital] for further evaluation. A fracture was detected. Ombudsman was notified. The investigation was completed by Administrator (Admin) 1. The allegation was Not verified: Abuse can not be verified at this time as resident is at risk for fractures related to her diagnosis of osteoporosis. Furthermore, there was no intent to cause harm. Patient is at baseline as evidence by participating in facility activities, ambulate via electric wheelchair throughout facility, and continues to participate in family events outside facility. The corrective actions taken were Education completed on correct transfer techniques. Facility ordered more slings to be available for resident use. There was an interview documented with resident 22 by the Admin 1. A form titled Interview with [Resident 22] on 6/7/23, [Resident 22] stated she was transferred by a CNA into her bed without the use of the Hoyer lift. When the aid transferred her it resulted in a fracture to her right femur. Resident stated she has no lasting pain, resident stated she feels safe at the facility. Resident 20 had signed the form by signing her initials and the form had been witnessed by the Admin 1's signature. No interventions were found in the medical record for CNA education on transferring residents who required a two person physical assist. On 8/7/23 at 11:36 AM, an interview was conducted with resident 22. Resident 22 stated they were moving her from her chair to her bed and they did not use the proper lift. Resident 22 stated there was not a sling available and they did not want to wait for one. Resident 22 stated, I can't remember everything that happened but I can remember that it hurt. They have used the sling since then and I am glad that it is over. I did not like it happening and I did not like going to the hospital. Resident 22 was observed to be in her motorized wheelchair during the interview, and she stated she was unable to move either leg. Resident 22 was observed to have had a blanket under each leg, resident was seat belted in place. Resident 22 was observed to have a Hoyer sling in place beneath her. On 8/9/23 at 4:45 PM, an interview was conducted with CNA 9. CNA 9 stated the day resident 22 broke her femur she was sitting in her wheelchair and there was not a Hoyer lift sling underneath her. CNA 9 stated she did not know why the previous aide had not left one there and stated resident 22 was anxious to get back to bed. CNA 9 stated she was not resident 22's aide but was trying to help out. She went out into the hallway to find someone to help her transfer resident 22 but could not find anyone. CNA 9 stated she then moved resident to the side of her bed, so that her wheelchair was parallel with the bed. CNA 9 stated she then lifted resident 22's legs up on the bed so that her heels were on the bed. CNA 9 then placed a sheet around both of resident 22's legs just above the knee level. CNA 9 stated she then climbed onto resident 22's bed so that she was facing the resident. CNA 9 stated she had resident 22 put both her arms around her neck. CNA 9 then grabbed hold of the gait belt resident 22 had on with her left hand and wrapped the sheet around her right hand and tucked it under her right armpit. CNA 9 stated at that time she pulled resident 22 over onto the bed in one smooth motion, kindof like a slide board situation. CNA 9 stated the resident's legs did not get caught on anything and she didn't know how this happened. CNA 9 stated she noticed something was wrong when there was an audible sound and resident 22's right thigh didn't look quite right. CNA 9 stated at that time she went out to get someone to help her and the nurse came in to assess the resident. CNA 9 stated the resident did not appear to be in any pain and was sent to the ER for evaluation. CNA 9 stated she did not remember if there was enough staff working in the facility that day. CNA 9 stated she did not know why there were not enough Hoyer slings that day. CNA 9 she had done this maneuver many many times and stated she had seen this technique used at the facility before. CNA 9 stated the best practice would have been to wait for another staff member to help use the Hoyer lift, if there was a sling under resident 22. The next would have been, since there was no sling, to have 2 other staff help move her over to the bed, the next safest option would be to have just one staff help move her over - kind of like a fireman carry. The method I used would be that last option to use. CNA 9 stated she was taught this in training and was sure she was taught it at the facility by someone but was unsure who. CNA 9 stated, If she had the sling under her this would not have happened, this was avoidable in every way. On 8/9/23 at 5:03 PM, an interview was conducted with Registered Nurse (RN) 9. RN 9 stated the agency aide went down to resident 22's room and was down there for a very long time. RN 9 stated the aide was from agency, but she was a regular at the facility and came there a lot and had worked with resident 22 before. RN 9 stated she was sitting at the nurses desk when CNA 9 came out and called to her for help. RN 9 stated resident 22 was already lying in the bed when she entered the room. RN 9 stated she then assessed resident 22 and could see an obvious dislocation, resident 22 did not complain of any pain or discomfort. RN 9 stated emergency services were called, and when they came they gave resident 22 some morphine and transferred her out. RN 9 stated she did not remember seeing a Hoyer sling in the room and there was not a Hoyer lift in the room. RN 9 stated CNA 9 told her she had lifted resident 22 under her arms to get her over to the bed. RN 9 stated resident 22 is always a two person assist using the Hoyer lift, and that resident 22 can not walk or put any weight on her legs. Her arms are weak also. RN 9 stated there was enough staff on that day to have two people transfer resident 22. On 8/10/23 at 12:35 PM, a follow up interview was conducted with resident 22. Resident 22 stated she was unable to lift her arms high enough to place them around anyone's neck. Resident 22 stated her hands are folded from arthritis and too weak to lift up. On 8/10/23 at 12:50 PM, an observation was made of CNA 10 and NA (Nursing Assistant) 2. Resident 22 was observed to be in the wheelchair, CNA 10 was observed to move resident 22 close to the end of the bed. CNA 10 and NA 2 were observed to attach the Hoyer sling that was underneath resident 22. CNA 10 lifted resident 22 out of the wheelchair using the Hoyer lift, NA 2 was observed to stay close at the side or resident 22 during the transfer. CNA 10 then moved the Hoyer lift and resident 22 parallel to resident 22's bed. Resident 22 was placed over the bed and gently lowered down onto the middle of the bed, NA 2 stood on the opposite side of the bed and guided resident 22 down. Resident 22 was rolled to her left side with the NA 2 blocking her from falling and then rolled to the right side with CNA 10 blocking her from falling while the Hoyer lift sling was removed and then placed on resident 22's wheelchair for future use. An immediate interview was conducted with CNA 10. CNA 10 stated there are not enough Hoyer lift slings, especially when they are sent to the laundry to get washed. CNA 10 stated there is always two people to transfer resident 22 with the Hoyer. If there isn't a Hoyer lift available then we use more than two people to transfer her, never only one person. On 8/10/23 at 9:19 AM, CNA 5. CNA 5 stated she had worked the day shift that resident 22 had gotten injured. CNA 5 stated she came back from break, and CNA 9 had answered resident 22's call light. CNA 5 stated she remembered a Hoyer sling was not in resident 22's room, it was being washed. CNA 5 stated we have a shortage of slings and there were not any other Hoyer slings available. CNA 5 stated she remembered that her and another aide had manually transferred resident 22 to her wheelchair from her bed using the fireman carry. CNA 5 stated that CNA 9 told her that she was transferred resident 22 by putting a gait belt around her knees, then she used resident 22's arm and pulled her across the bed. CNA 5 stated it was a shock to see resident 22's leg. CNA 5 stated she had never seen anything like that. CNA 5 stated when she came into the room the nurse was already in there. CNA 5 stated when she entered resident 22's room it was too late for me to tell CNA 9 that there wasn't a Hoyer sling. CNA 5 stated we do not transfer residents that way. CNA 5 stated they did get Hoyer lift training. CNA 5 stated physical therapy came in to check resident 22, then the nurse called the ambulance and resident 22 was sent out that day. Resident 22 didn't complain of any pain but her right leg looked deformed. CNA 5 stated that resident 22 did say, please use the Hoyer sling when we were going to move her again. On 8/10/23 at 2:16 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated the CNAs are never taught to get on the bed when doing transfers. The CNAC stated upon hire the CNAs are shown how to use the Hoyer lift and we take them in a room and demonstrate with them as patients, so they can experience it and to show them how to use it. On 8/10/23 at 3:03 PM, an interview was conducted with the Physical Therapy Director (PTD). The PTD stated he was part of the orientation team. The PTD stated he would go over the Hoyer lift, Sit to Stand, and Stand Pivot Therapy. The PTD stated he would simulate the transferring of a resident with the CNAs. The PTD stated he did not ever teach aides to get on the bed to transfer a resident from a chair to a bed. The PTD stated the CNAs should definitely use two people when transferring resident 22, her legs would not hold her up so a Sit to Stand would not work. The PTD stated he would not do a stand pivot with her, her legs would not hold her. The PDT stated he would recommend a Hoyer left with resident 22, and it's always a two person. On 8/10/23 at 4:01 PM, an interview was conducted with the Admin 1. The Admin 1 stated the incident was not reported timely because they had not been reporting significant injuries prior to a training they completed that required them to do so. The Admin 1 stated this incident was not verified as abuse because it was not intentional to harm the resident as a transfer was done so it was not verified as abuse. Admin 1 stated it was not viewed as neglect because we provided goods and services the resident as requested. We transferred the resident to her bed and that is the service she requested so we don't view it as neglect at this time. The Admin 1 stated we did offer education to the staff in regards to transfers. The Admin stated the staff member was not able to locate the Hoyer when the accident occurred. The Admin 1 stated this happened in February and I was reporting it in June. The Admin 1 stated we do not view it as neglect or abuse, we were providing the services to the resident but the employee did not think it through and caused the resident an injury. 2. Resident 78 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain, dementia, chronic respiratory failure, type II diabetes, hyperlipidemia, full incontinence of feces, anorexia and palliative care. Resident 78's medical record was reviewed on 7/30/23 - 8/16/23. On 7/30/23 at 2:00 PM, an interview was conducted with Resident 78's family member (FM). The FM stated she was not 100% sure what had happened with her mother's right hand and wrist. The FM stated her other family member (FM) 2 told her the CNA came into the room to care for resident 78 and was rough with her. The FM stated FM 2 told her that he had yelled for the CNA to stop but the CNA would not stop. The FM stated they had to insist on the X-ray of resident 78's hand and wrist because the facility did not want to do anything about it. On 7/30/23 at 2:15 PM, an interview was conducted with FM 2. FM 2 stated the CNA came in and roughed her up. FM 2 was observed to point toward resident 78. FM 2 stated he told the CNA to stop but she wouldn't stop. FM 2 stated resident 78 did not want to get changed and the CNA told her that it needed to happen and then she did it and roughed her up. On 7/30/23 at 2:18 PM, an observation was made or resident 78's right hand and wrist. The right hand and wrist of resident 78 was swollen. An admission MDS assessment dated [DATE] documented resident required extensive assistance with a two person physical assist with bed mobility, transfers, toilet use, personal hygiene and eating. A care plan focus dated 7/11/23 revealed, [Resident 78] has pain in R wrist. Interventions in place were, X-ray to R wrist, pain medication as ordered, monitor for ROM (Range of Motion), if resident refuses cares, check back to see if resident needs help with anything. This care plan entry was entered 6 days after the facility was made aware of resident 78's right wrist pain. Physician Order dated 6/7/23 documented, FentaNYL Transdermal Patch 72 Hour 12 MCG (microgram)/HR (hour) Apply 1 patch transdermally every 72 hours for pain and remove per schedule. The Pain Level Summary with a pain scale range of 0-10 (0 being no pain and 10 being extreme pain) for resident 78 was reviewed on 8/8/23 for the dates beginning after 6/7/23 when the pain patch was started and revealed the following: a. The highest pain score for June 6th - 30th, 2023 was a 2 on the 0-10 pain scale. b. The highest pain score for the month of July 2023 was a 3 on the 0-10 pain scale. Resident 78's pain level was elevated to a 3 on July 5th, the day of the incident. c. The highest pain score for August 1 - 8, 2023 was a 2 on the 0-10 pain scale. Resident 78's progress notes were reviewed and revealed the following: d. On 7/6/23 at 11:59 AM, RA (Resident Advocate) talked to Pt. (patient) daughter about some concerns. RA addressed all concerns. e. A Physician Progress note dated 7/6/23 documented, [Resident] is in her bed. Discussed care plan. No concerns noted at this time. f. A Nurse Progress note dated 7/7/23 documented, New order from Hospice noted, for X-ray rt wrist/hand one time only for Pain until 07/07/2023. (Note: this was 2 days after the incident was reported to the facility). g. A Nurse Progress note dated 7/8/23 documented, X-ray results show no definite evidence of acute fracture or dislocation. Old fracture 5th metacarpal bone healed withhold deformity. MD notified. On 08/14/23 12:21 PM, an interview was conducted with the Social Services Assistant (SSA). The SSA stated she had talked to the family about the X-ray for Resident 78, they just wanted to make sure the X-ray was ordered. The family just wanted the follow through. The SSA stated that she let the family know the nurses would be contacting them. So the concern we discussed on 7/6/23 was about the X-ray being done on resident 78. The SSA stated she did know the X-ray was ordered at the families request, not because the facility wanted it. The SSA stated she did not think that hospice would cover the X-ray since it happened here. The SSA stated she can't remember the exact date she heard about resident 78's wrist hurting but that they did report it to the Ombudsman on 7/5/23. The SSA stated she thought it was the hospice nurse who let them know, then they reported it to the Administration and they completed the 358 report. The SSA stated the X-ray was done because the family requested it. An IDT (Interdisciplinary Team) review was conducted on 7/11/23 the following interventions were documented, X-ray as ordered, pain medications as ordered, monitoring for changes in ROM. An IDT review was conducted on 7/17/23 the following interventions were documented, Resident had swelling to the right wrist, investigation completed and further education of the CNA, training the CNA on days and monitoring for proper turning and positioning of resident. The exhibit 358 had alleged that on 7/5/23 at 12:50 PM, the facility reported that on 7/5/23 at 5:00 AM, the staff member was rough while doing personal care. The right hand of the resident was swollen and tender to the touch and the resident did not want anything touching her wrist. The staff member was removed from the schedule and APS and Ombudsman report was done. The investigation was completed by Administrator (Admin) 1. The allegation was Not verified: Per the findings of the investigation physical abuse was unable to be verified as the staff member believed she was providing cares necessary for health and wellness of the resident. There was no contact made with the resident wrist during cares. The corrective actions taken were In-service training completed on residents right to refuse cares & bed mobility techniques. [NA 3] is a new staff member to the facility and is receiving ongoing training's by facility. Facility will complete additional days of training and education to [NA 3]. There was an interview documented with resident 78 by the Admin 1. [Resident 78] stated the night CNA changed her after she had let her know she did not need to be changed. Resident stated CNA was rough with her and during the care her wrist was hurt by the night CNA. Resident stated her wrist did not hurt before CNA changed her. Resident was unable to elaborate further details on how her wrist was hurt, s/s (signs/symptoms) of pain where observed. Admin 1 documented an interview with NA 3. NA 3 stated, the resident did not want incontinence care but it was done anyway She stated the resident did not want the incontinence care. [NA 3] stated she did not touch her wrists and that her wrists were visible during the encounter. Admin 1 documented an interview with [CNA 4]. CNA 4 stated when she came in on Wednesday to care for [resident 78]. FM 2 informed Hospice CNA the night aid had provided care with [resident 78] and that her arm was hurting. CNA stated that [resident 78] had a previous history of refusing cares due to pain. Since new pain patch was added approx 1-2 weeks ago, [resident 78] has been doing good and not refusing cares. Admin 1 documented an interview with RN 10. Per interview with RN 10, she stated when she came in on Wednesday for her visit she noted [Resident 78] c/o (complained of) pain in her wrist due to night CNA being rough with her. [RN 10] evaluated resident and noted there was redness and swelling. RN stated [resident 78] has a hx (history) of refusing cares due to pain with cares. Resident refused pain medication due to behaviors. A new pain patch was added to med list to assist with pain and resident s/s of pain have decreased. Hospice RN stated on 7/10/23 she eval (evaluated) resident and resident was still showing minor s/s of pain in wrist. On 7/12/23 at 6:22 PM, Admin 1 documented the following systemic actions that were identified and the steps that have been taken to address the systems. Facility will complete and audit to identify residents who frequently decline cares due to current diagnosis or behaviors. Facility will update careplan's and the Kardex to ensure floor staff are aware of these residents specific care needs. Kardex will describe individualized resident care needs. (Note: the audit to identify residents, and the update to the careplan and Kardex of identified residents was not provided by the facility.) In-service training completed on residents right to refuse cares & bed mobility techniques. [NA 3] is a new staff member to the facility and is receiving ongoing trainings by facility. Facility will complete additional days of training and education to [NA 3]. A CNA training meeting was held on 7/20/23 with an itinerary to go over Resident's rights and repositioning. NA 3's signature could not be located on the training meeting sign in sheet. On 8/9/23 at 9:24 AM, a telephone interview was conducted with NA 3. NA 3 stated she had only worked at the facility for one day, and that she did not want to give this surveyor any information. When NA 3 was asked if she remembered caring for Resident 78, the NA 3 hung up the phone. This surveyor attempted to call the NA 3 back and was unable to leave a message due to the mailbox being full. A text message with return call information was sent to NA 3 with no response. On 8/8/23 at 12:26 PM, an interview was conducted with CNA 4. CNA 4 stated she came in on the 7/5/23 for the day shift. CNA 4 stated FM 2 stated that they have been hurting her. He stated they were really rough with it and he was completely paranoid about someone coming in and hurting her. The CNA 4 stated resident 78's right wrist was red and swollen. CNA 4 stated the facility ordered the X-ray because it was their staff that caused the incident. CNA 4 stated she did not know when they ordered the X-ray, but resident 78's right wrist just kept getting more red and swollen. On 8/8/23 at 12:47 PM, an interview was conducted with RN 10. RN 10 stated she was the hospice nurse for resident 78. RN 10 stated that CNA 4 had let her know that resident 78 was complaining of pain in her right wrist and that she let the facility nurse know that day. RN 10 stated that resident 78 usually has a flat affect, but when she went in to see her on 7/5/23 she looked scared that day to me. RN 10 stated resident 78 wouldn't verbalize, but she was shaky and her upper arms were shaky, I could tell she was scared. RN 10 stated that resident 78 was careful of her right wrist and that the wrist was tender. RN 10 stated she notified the family, the hospice doctor, the DON and the SSA. RN 10 stated resident 78 complained of pain pain for a week and a half, and that the redness went away in a week. RN 10 stated the facility ordered the X-ray because requested, but hospice didn't order it since it was facility staff that caused it, RN 10 stated it was an agency aide that had changed resident 78. On 8/10/23 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was, if a resident was hurt the nurse was to assess them immediately to find out what was going on. The nurse was to contact the doctor, administration and the family and the hospice company if they are on hospice. The DON stated even if they are on hospice it is still the responsibility of the on duty nurse to assess the resident. The DON stated when we need an X-ray done, the mobile X-ray company will come and do that for us. The DON stated that if she remembered right, there was something wrong with [Resident 78's] wrist. The DON stated she was unsure if it was reported to us, if it was then she would have expected the nurse to go in and ask what happened, see what is going on, assessed the wrist and take it from there. The DON stated the nurses should have notified her and the Administrator. The DON stated she could not see any entries in the progress notes regarding the incident on 7/5/23. The DON stated the nurse on duty should have assessed the wrist, called the hospice and done the X-ray. 30563 3. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, disorder of central nervous system, peripheral vascular disease, and dysphagia. On 7/31/23 at 11:23 AM, an interview was conducted with resident 20. Resident 20 stated a while back Agency CNA 1 was working with him and he left on the side of the bed. Resident 20 stated he fell off the bed flat on his back and hit his shoulder and head. Resident 20 stated there was an accident report completed. Resident 20 stated the other day Agency CNA 1 came into his room. Resident 20 stated he did not think he was working at the facility anymore. Resident 20 stated that CNA answered his call light and he was mortified and traumatized when he was Agency CNA 1. Resident 20 stated Agency CNA 1 should not have been hired again. Resident 20 stated the Agency CNA 1 was gone for quite a while. Resident 20 stated I shouldn't be subjected to him, I'm traumatized by him. Resident 20 stated he was administered pain medication and after the accident he felt weak. Resident 20 stated That just wasn't right. Resident 20's medical record was reviewed 7/30/23 through 8/15/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 20's Brief Interview of Mental Status (BIMS) score was 9 which indicated moderate cognitive impairment. There were no progress notes around 4/5/23 when resident reported a fall while being assisted. A nursing progress notes dated 4/10/23 at 3:26 PM revealed, Resident had reported to staff that he was having pain in his left shoulder,he hasn't been asking for pain meds [medications] for this pain. He states that the pain in annoying and would like to take something for it. Spoke with MD [Medical Doctor] and will schedule Tylenol 650 mg [milligrams] every 6 hours for pain. No other issues noted at this time. Another nursing progress note dated 8/10/23 at 5:57 PM, He had MRI [magnetic resonance imaging] today. no new orders. The exhibit 358 had alleged Details that Self reported. [Resident 20] alleged he was left unattended by [Agency CNA 1] and he fell off his bed. Pain in back, shoulder and head. [Agency CNA 1] has been removed from the schedule until an investigation can be completed. [Resident 20] feels safe at this time. The investigation was completed by the Corporate Marketing Director (CMD). It was documented that this allegation happened over a year ago and staff were not available for interview. The allegation was Not verified: Staff left after resident had fallen per policy to report the nurse and have pt [patient] evaluated for injuries. The corrective actions taken were Agency staff [Agency CNA 1] will not be scheduled to work with resident anymore. MD ordered to schedule Tylenol. An in-service will be competed [sic] with staff on proper transferring and bed mobility techniques and fall policy. Patient will continue on therapy services. There was an interview documented with resident 20 by CMD. A form titled Conversation with [Resident 20] on 4/10/23 at 1:15 PM. I had asked '[resident 20]' about the incident and he was able to recall most of the details. He states he was in bed and a CNA was working with him and the next thing he knew was that he was on his back on the floor. He stated that the CNA left and came back with a nurse to report fall. Resident 20 asked for the following since our conversation: 1. More pain medication 2. More training with staff on proper transfers 3. Physical therapy which was added on 4/10/23 at 1:28 PM. It was noted that all of these were completed on 4/10/23 immediately after the conversation with resident 20. Resident 20 had read and approved the note by signing on 4/10/23. Agency CNA 1 had documented that he provided cares to another resident on 8/5/23 at 3:38 AM. On 8/14/23 at 2:18 PM, an interview was conducted with CNA 7. CNA 7 stated that resident 20 was pushed too far by a CNA and fell off the bed. CNA 7 stated it was a few years ago. On 8/16/23 at 9:50 AM, an interview was conducted with Social Services Assistant (SSA). SSA stated that resident 20 told her that about a year ago he fell out of bed. SSA stated that resident 20 stated to her that he wanted to make sure the CNA assisting him did not care for him again. SSA stated that resident 20 told her that his shoulder hurt sometimes since falling out of bed. SSA stated it was Agency CNA 1 that assisted him when he fell out of bed. SSA stated that she had not seen Agency CNA 1 for about 6 months. On 8/15/23 at 2:18 PM, an interview was conducted with the Corporate Marketing Director (CMD). The CMD stated that when Administrator 1 took over the building, she did rounds through the building to get to know the residents [TRUNCATED]

Based on interview, observation and record review, the facility did not ensure that 10 of 68 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, residents eloped from the facility, water temperatures were at a level that could cause burns, interventions were not put into place after falls to prevent additional falls, a door was not working correctly, and staff transfers resulted in resident injury. Three of the findings were determined to have occurred at a harm level. Resident identifiers: 18, 22, 35, 39, 40, 49, 50, 51, 54, and 156. Findings include: HARM 1. Resident 156 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, Alzheimer's disease, dementia, and major depressive disorder. Resident 156's medical record was reviewed from [DATE] through [DATE]. Resident 156's admission Minimum Data Set (MDS) assessment dated [DATE] indicated that resident 156 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Regarding inattention, disorganized thinking and altered level of consciousness, the MDS Assessment indicated that these behaviors were continuously present, does not fluctuate. The MDS also indicated that resident 156 was not steady when walking but able to stabilize herself. The MDS indicated that the resident was not steady when moving from a seated position to a standing position, and was only able to stabilize with human assistance. Resident 156's care plans were reviewed and indicated the following: a. Care plan dated [DATE] - Focus: Resident is at risk for falls s/t (secondary to) impaired mobility, altered ADL (activities of daily living) ability, poor safety awareness. The interventions included Frequent visual checks and Provide safe environment. b. Care plan dated [DATE] - Focus: Resident has delirium/confusion, disorganized thinking/inattention secondary to paranoid schizophrenia, dementia. The interventions included monitoring for changes in behavior, altered mental status, disorientation, lethargy, restlessness and agitation. c. Care plan dated [DATE] - Focus: Resident had an elopement. A Wandering Risk Scale was completed for resident 156 on [DATE]. The scale indicated that the resident's son reported to the facility that resident 156 had a history of wandering. The scale also indicated that a wanderguard would be placed on resident 156, and that she also had a GPS watch to her left watch that would alert the son's phone. Facility staff determined that the resident had a score of 14 on the scale, indicating that the resident was at a high risk to wander. A Montreal Cognitive Assessment (MoCA) was completed for resident 156 on [DATE]. The test indicated that resident 156 scored 4 out of 30, indicating severe cognitive impairment. Nursing notes for resident 156 revealed the following: a. [DATE]: Admission Summary . uses walker, unsteady . hx (history) of frequent falls, frequent checks . b. [DATE]: Primary Diagnosis: Dementia, frequent falls, wander risk. Pt (patient) ambulates x 1 (with one person) assist with a walker. c. [DATE]: Wander guard placed on pt's left wrist per family request. MD aware, management aware, consent received. d. Pt is confused at times and is not always understood. e. [DATE]: CNA (Certified Nursing Assistant) found pt on floor beside bed between bed and w/c (wheelchair) attempting to get up. Bed mattress was lopsided and hanging over side of bed that pt was on. Nurse was notified. No injuries noted . Resident 156's [DATE] Medication Administration Record (MAR) was reviewed. The MAR indicated that on [DATE], resident 156 was not administered her morning medications of Aripiprazole, Calcium-Magnesium, Centrum, Cholecalciferol, Cynanocobalmin, Fish oil, Lamotrigine, and levothyroxine as ordered. The corresponding progress notes indicated that on [DATE] the resident was not in her assigned room at the facility as of 10:23 AM. On [DATE] at 11:24 AM, a nurse documented not here on 100 hallway. Unknown whereabouts. No documentation could be located to indicate that an attempt to locate resident 156 was made after the resident's whereabouts were unknown at 10:23 AM on [DATE]. Resident 156's meal intake was not recorded for [DATE] lunch and dinner, and [DATE] breakfast, lunch and dinner. Resident 156's vital sign records were reviewed from the facility. No evidence could be located to indicate that resident 156 had had any vitals taken since [DATE] at 6:21 AM. Resident 156's Treatment Administration Record (TAR) indicated that resident 156 did not receive her evening snack, wanderguard placement check, behavior monitoring, or pain monitoring on [DATE]. Resident 156's progress notes also included the following entries after the resident had been documented as not being able to be located throughout the day: a. [DATE] at 6:32 PM a late entry was made for an effective date of [DATE] at 6:32 PM: . unwitness fall [at 12:30 AM), resident was found outside on the southeast side of the building on the ground in the snow. Root Cause Analysis: ambulating outside of the facility without assistance . sent to the hospital for hypothermia and evaluation . b. [DATE] Late Entry Resident had elopement/unwitnessed fall on [DATE] at 0000 (12:00 AM) resident was reported missing to floor RN (Registered Nurse) by CNA at 0000 (12:00 AM), floor staff initiated elopement protocol. Resident was found outside of the southwest side of the building by RN And CNA at approximately 0020 (12:20 PM) resident was brought into the building and gotten into clean dry clothing and layed (sic) down in bed to begin warming resident. Physician was notified and EMS (Emergency Medical Services) was called. EMS arrived and obtained vitals blood pressure of ,d+[DATE] resident was taken to [name of local hospital] and admitted to ICU (Intensive Care Unit) for severe hypothermia. RN attempted to contact family immediately after EMS was called but family did not answer voicemail left to return call, Son called back shortly after resident arrived to [name of local hospital]. Resident 156's emergency room notes dated [DATE] were reviewed. Resident 156 was diagnosed with hypothermia. The notes indicated that the resident had been found outside the facility in temperatures close to freezing, last seen 10 hours prior. Pt presents from a facility, who stated patient last seen 1400 (2:00 PM [DATE]. She was found hypothermic outside at 0030 (12:30 AM) outside of [NAME] Rehab. The notes also indicated that resident 156's body temperature was 87.8 degrees Fahrenheit. Resident 156 was provided with warm intravenous fluids as a rewarming measure. In addition, resident 156 was placed under bearhugger forced air active external rewarming with improvement of internal temp to [94.64 degrees Fahrenheit] upon arrival to STICU (short term intensive care unit). Resident 156 was also noted to have abrasions with dried blood on bilateral knuckles on 4 digits each, ecchymoses on bilateral knees with superficial abrasions. The notes also indicated possible rhabdomyolysis and an increased white blood cell count that may be due to a stress response. The notes also indicated that the resdient had significant lactic acidosis. On [DATE] at 3:31 PM, an interview was conducted with resident 156's family member (FM 1). FM 1 stated that he was resident 156's power of attorney. FM 1 stated that on the evening of [DATE] he received a call from a local emergency room telling him that his family member was being treated for frostbite and hypothermia. FM 1 stated that the doctor thought they could warm her (resident 156) back up with warm fluids, but that it might cause a heart attack. FM 1 stated that he was given the choice by emergency room physicians to either see if his mother recovered from the hypothermia, but that she might die, or warm the resident up, which might cause the resident's death as well. FM 1 stated that after he received a call from the emergency room , he spoke with staff members at the facility. FM 1 stated that staff members at the facility told him that they could not locate his family member, that she had not been seen since 8:00 PM on [DATE], and they did not currently know the resident's whereabouts. FM 1 stated that resident 156 was in the hospital for 3 days to be treated for hypothermia and that resident 156 almost died . FM 1 stated that hospital staff reported to him that resident 156 was brought in to the emergency room after being found face down in the show with flashing holiday lights around her neck as well as bells. FM 1 stated that his family member can barely walk with a walker. She can only go 40 feet before she runs out of breath. FM 1 stated that resident 156 was absolutely dependent on facility staff and was literally unable to care for her basic daily needs. FM 1 stated that he had been taking care of his loved one for 18 months prior to the resident being admitted to the facility. FM 1 stated that facility staff told him that there was a door that had been propped open for staff to take the trash out, but that someone had forgotten to close it. FM 1 stated he had also provided the facility with a GPS watch that would alert staff if resident 156 was outside a pre-set perimeter. FM 1 stated that he did not think the staff had programmed the watch with the perimeter of the facility. On [DATE], the facilty submitted an Exhibit 359 from for the incident on the evening of [DATE] with regard to resident 156. The form indicated the following: a. A nurse reported seeing resident 156 in her room at approximately 7:00 PM on [DATE]. b. A CNA reported that resident 156 was unable to be located during midnight rounds. c. All other nurses and CNAs reported they did not see the resident during the evening of [DATE]. d. Nurse [name of Corporate Resource Nurse (CRN) 1] states she received the report from CNA [name of CNA] was not in her room at midnight and immediately began searching for the resident. Staff searched all interior areas of the facility. She states she also drove around the area attempting to locate the resident. [CRN 1] states that she and a CNA found the door to the maintenance department open, entered the maintenance area and found a wheelchair in the maintenance department. She exited a door from the maintenance department to the exterior of the facility which is when she located the resident on the ground attempting to get up. She and a CNA helped the resident from the ground, brought her inside the facility and contacted EMS (Emergency Medical Services). e. Facility staff were negligent in allowing a door to the maintenance department to be left open. The investigation failed to identify a specific individual who may have been responsible for using the door and not assuring it closed properly behind them. On [DATE] at 10:51 AM, an interview was conducted with Administrator (Admin) 3, who was the Admin at the time of the incident with resident 156. Admin 3 stated that the investigation into the cause of resident 156's elopement determined that the resident had gone through the maintainance shop door and was able to get to the east side of the building to the roadway by the dumpsters. Admin 3 stated that the maintainance shop door was supposed to be closed and locked at all times because it did not have a wanderguard monitor in that location. Admin 3 stated that someone had been working on [the door] that day ([DATE]), and the door was not physically closed after facility staff had finished their work. On [DATE] at 9:30 AM, an interview was conducted with the Director of Nursing (DON) and CRN 1. When asked about the incident with resident 156 on [DATE]. The DON stated that resident 156 unfortunately got out of an unsecured door that was open and that didn't shut all the way. all we can think is that it hadn't completely shut and she was trying to get to physical therapy which was the room adjacent to the maintainance room. CRN 1 stated that she was on shift the night of [DATE]. CRN 1 stated that she had been informed by a CNA that resident 156 was unable to be located during midnight rounds. CRN 1 stated that she knew she (resident 156 ) was a wanderer so facility staff began searching the facility. CRN 1 stated that resident 156's wheelchair was located inside the maintanance room, approximately 10 feet from the door to the outside. CRN 1 stated that resident 156 was located 10 feet from the facility dumpster, which was approximately 50 feet outside the maintainance door. CRN 1 stated that at the time staff located resident 156, the resident was trying to stand up and her fingertips were bloody from scratching. She was cold and had snot running down her face. She was whining when she saw us. CRN 1 stated that resident 156 was sent out to the emergency room due to suspicions of hypothermia. CRN 1 stated that after the incident, staff determined that resident 156 had changed rooms, but that the information had not changed in the computer, so they knew she was there because she was on the report sheet, but she wasn't popping up on the computer. 44640 2. Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Multiple Sclerosis (MS), chronic obstructive pulmonary disease, dysphagia, muscle weakness, dementia, anemia, hypertension and age related osteoporosis without pathological fracture. Resident 22's medical record was reviewed on [DATE] - [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE], revealed resident 22 required extensive assistance with a two + (plus) persons physical assist for bed mobility and transfers. A care plan focus dated [DATE] with a revision date of [DATE] revealed, resident had limited physical mobility r/t (related to) MS and resident is at risk for falls r/t MS disease process, impaired mobility. Interventions in place were, resident is NON-WEIGHT BEARING, the resident uses a electric wheelchair for locomotion. And provide supportive care, assistance with mobility as needed . OT (Occupational Therapy) to educate CNAs on proper Hoyer protocol. A care plan focus dated [DATE] with a revision date of [DATE] revealed, resident want the Hoyer lift sling to be let underneath her after she is transferred to her wheelchair. Interventions in place were, Check proper placement of the sling PRN (as needed). A resolved care plan focus dated [DATE] with a revision date of [DATE] revealed, resident had a R (right) femur fx (fracture). Interventions in place did not include education or training for CNAs when transferring residents who require a two person physical assist. Resident 22's progress notes were reviewed and revealed the following: a. [DATE] at 11:00 AM: CNA was transferring res. (resident) from power w/c (wheelchair) to bed using the gait belt around the res. CNA explained to the res. what she was going to do with transfer, she put the sheet around the thigh then lifted the feet on to bed at the very edge, cna was on res. bed halfway lifted by gait belt and moved res. towards the bed while res. held onto arm, res. moved towards the bed and heard there was a pop. Res. said she did not feel anything, she was not sure, when positioning the legs and feet CNA noticed the rt. (right) thigh did not looks right, res, denies pain, affected thigh immobilized, asked PT (Physical Therapy) to assesses, NP (Nurse Practitioner), DON (Director of Nursing), and sister [name omitted] notified. b. [DATE] at 11:15 AM: When transferring the res. from w/c to bed CNA heard a pop on her rt. thigh, reported to NP with order and noted, for X-ray rt. femur and rt hip stat requested. c. [DATE] at 1:40 PM: X-ray RESULTS with FX, reported to NP with order to send to [local hospital] for further evaluation and management. d. [DATE] at 6:12 PM: Resident return to facility from [local hospital] after right femur fx, surgery to right femur . Requires extensive assist with bed mobility, transfers, and other ADLs. PT. OT needs treat and eval. An IDT (Interdisciplinary Team) review was conducted on [DATE] the following interventions were documented, MD notified, x-ray obtained of the right leg, NP notified that the leg appeared to have a fx, sent resident to the ER (emergency room ) for further evaluation. No intervention was put in place for CNA education on transferring residents. The exhibit 358 had alleged that on [DATE] at 12:58 PM, the facility reported that on [DATE] at 11:00 AM, the Resident was being transferred to bed by 2 unidentified staff members. During the transfer a pop was heard and the CNA had noted the right thigh looked abnormal but the Resident denied any pain. STAT X-ray was ordered and per the results of the X-ray the Resident was sent to [local hospital] for further evaluation. A fracture was detected. Ombudsman was notified. The investigation was completed by Administrator (Admin) 1. The allegation was Not verified: Abuse can not be verified at this time as resident is at risk for fractures related to her diagnosis of osteoporosis. Furthermore, there was no intent to cause harm. Patient is at baseline as evidence by participating in facility activities, ambulate via electric wheelchair throughout facility, and continues to participate in family events outside facility. The corrective actions taken were Education completed on correct transfer techniques. Facility ordered more slings to be available for resident use. There was an interview documented with resident 22 by the Admin 1. A form titled Interview with [Resident 22] on [DATE], [Resident 22] stated she was transferred by a CNA into her bed without the use of the Hoyer lift. When the aid transferred her it resulted in a fracture to her right femur. Resident stated she has no lasting pain, resident stated she feels safe at the facility. Resident 20 had signed the form by signing her initials and the form had been witnessed by the Admin 1's signature. On [DATE] 11:36 AM, an interview was conducted with resident 22. Resident 22 stated they were moving me from me from bed to chair and the didn't use the proper lift. Resident 22 stated there wasn't one available and they didn't want to wait for one. Resident 22 stated, I can't remember everything that happened but I can remember that it hurt. They have used the sling since then and I am glad that it is over. I didn't like it happening and I didn't like to go to the hospital. Resident 22 was observed to be in her motorized wheelchair, she was unable to move either leg, she had a blanket under each leg, resident was seat belted in place. Resident 22 was observed to have a Hoyer sling in place underneath her. On [DATE] at 4:45 PM, in interview was conducted with CNA 9. CNA 9 stated on the day resident 22 broke her femur she was sitting in her wheelchair and there wasn't a Hoyer lift sling underneath her. CNA 9 stated she didn't know why the previous aide hadn't left one there and stated resident 22 was anxious to get back to bed. CNA 9 stated she wasn't resident 22's aide but was trying to help out. She went out into the hallway to find someone to help her transfer resident 22 but couldn't find anyone. CNA 9 stated she then moved resident to the side of her bed, so that her wheelchair was parallel with the bed. CNA 9 stated she then lifted resident 22's legs up on the bed so that her heels were on the bed. CNA 9 then placed a sheet around both of resident 22's legs just above the knee level. CNA 9 stated she then climbed onto resident 22's bed so that she was facing resident 22. CNA 9 stated she had resident 22 put both her arms around her neck. CNA 9 them grabbed hold of the gait belt resident 22 had on with her left hand and wrapped the sheet around her right hand and tucked it under her right armpit. CNA 9 stated at that time she pulled resident 22 over onto the bed in one smooth motion, kindof like a slide board situation. CNA 9 stated the resident's legs did not get caught on anything and she didn't know how this happened. CNA 9 stated she noticed something was wrong when there was an audible sound and resident 22's right thigh didn't look quite right. CNA 9 stated at that time she went out to get someone to help her and the nurse came in to assess the resident. CNA 9 stated the resident did not appear to be in any pain and was sent to the ER for evaluation. CNA 9 stated she did not remember if there was enough staff working in the facility that day. CNA 9 stated she did not know why there were not enough Hoyer slings that day. CNA 9 she had done this maneuver many many times and stated she had seen this technique used at the facility before. CNA 9 stated the best practice would have been to wait for another staff member to help use the Hoyer lift, if there was a sling under resident 22. The next would have been, since there was no sling, to have 2 other staff help move her over to the bed, the next safest option would be to have just one staff help move her over - kind of like a fireman carry. The method I used would be that last option to use. CNA 9 stated she was taught this in training and was sure she was taught it at the facility by someone but was unsure who. CNA 9 stated, If she had the sling under her this wouldn't have happened. This was avoidable in every way if the Hoyer was used. On [DATE] at 5:03 PM, an interview was conducted with Registered Nurse (RN) 9. RN 9 stated the agency aide went down to resident 22's room and was down there for a very long time. RN 9 stated the aide is agency, but she is a regular at the facility and comes there a lot and has worked with resident 22 before. RN 9 stated she was sitting at the nurses desk when CNA 9 came out and called to her for help. RN 9 stated resident 22 was already in bed when she entered resident 22's room. RN 9 stated she assessed resident 22 and could see an obvious dislocation, resident 22 did not complain of any pain or discomfort. RN 9 stated emergency services were called, and when they came they gave her some morphine and transferred her out. RN 9 stated she did not remember seeing a Hoyer sling in the room and there was not a Hoyer lift in the room. RN 9 stated CNA 9 told her she had lifted resident 22 from under her arms to get her over to the bed. RN 9 stated resident 22 is always a two person assist using the Hoyer lift, resident 22 can't walk or put any weight on her legs. Her arms are weak also. RN 9 stated there was enough staff on that day to have two people transfer resident 22. On [DATE] at 12:35 PM, a follow up interview was conducted with resident 22. Resident 22 stated she was unable to lift her arms high enough to place them around anyone's neck. Resident 22 stated her hands are folded from arthritis and too weak to do that. On [DATE] at 12:50 PM, an observation was made of CNA 10 and NA (Nursing Assistant) 2. Resident 22 was observed to be in the wheelchair, CNA 10 was observed to move resident 22 close to the end of the bed. CNA 10 and NA 2 were observed to attach the Hoyer sling that was underneath resident 22. CNA 10 lifted resident 22 out of the wheelchair using the Hoyer lift, NA 2 was observed to stay close at the side or resident 22 during the transfer. CNA 10 then moved the Hoyer lift and resident 22 parallel to resident 22's bed. Resident 22 was placed over the bed and gently lowered down onto the middle of the bed, NA 2 stood on the opposite side of the bed and guided resident 22 down. Resident 22 was rolled to her left side with the NA 2 blocking her from falling and then rolled to the right side with CNA 10 blocking her from falling while the Hoyer lift sling was removed and then placed on resident 22's wheelchair for future use. An immediate interview was conducted with CNA 10. CNA 10 stated there are not enough Hoyer lift slings, especially when they are sent to the laundry to get washed. CNA 10 stated there is always two people to transfer resident 22 with the Hoyer. If there isn't a Hoyer lift available then we use more than two people to transfer her, never only one person. On [DATE] at 9:19 AM, CNA 5. CNA 5 stated she had worked the day shift that resident 22 had gotten injured. CNA 5 stated she came back from break, and CNA 9 had answered resident 22's call light. CNA 5 stated she remembered a Hoyer sling was not in resident 22's room, it was being washed. CNA 5 stated we have a shortage of slings and there weren't any other Hoyer slings available. CNA 5 stated she remembered that her and another aide had manually transferred resident 22 to her wheelchair from her bed using the fireman carry. CNA 5 stated that CNA 9 told her that she was transferred resident 22 by putting a gait belt around her knees, then she used resident 22's arm and pulled her across the bed. CNA 5 stated it was a shock to see resident 22's leg. CNA 5 stated she had never seen anything like that. CNA 5 stated when she came into the room the nurse was already in there. CNA 5 stated when she entered resident 22's room it too late for me to tell CNA 9 that there wasn't a Hoyer sling. CNA 5 stated we do not transfer residents that way. CNA 5 stated they did get Hoyer lift training. CNA 5 stated physical therapy came in to check resident 22, then the nurse called the ambulance and resident 22 was sent out that day. Resident 22 didn't complain of any pain but her right leg looked deformed. CNA 5 stated that resident 22 did say, please use the Hoyer sling when we were going to move her again. On [DATE] at 2:16 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated the CNAs are never taught to get on the bed when doing transfers. The CNAC stated upon hire the CNAs are shown how to use the Hoyer lift and we take them in a room and demonstrate with them as patients, so they can experience it and to show them how to use it. On [DATE] at 3:03 PM, an interview was conducted with the Physical Therapy Director (PTD). The PTD stated he was part of the orientation team. The PTD stated he would go over the Hoyer lift, Sit to Stand, and Stand Pivot Therapy. The PTD stated he would simulate the situation. The PTD stated he did not ever teach them to get on the bed to transfer a resident from a chair to a bed. The PTD stated the CNAs should definitely use two people when transferring resident 22, her legs won't hold her up so a Sit to Stand would not work. The PTD stated he would not do a stand pivot with her, her legs would not hold her. The PDT stated he would recommend a Hoyer left with resident 22, and it's always a two person. On [DATE] at 4:01 PM, an interview was conducted with the Admin 1. The Admin 1 stated the incident wasn't reported timely because they had not been reporting significant injuries prior to a training they completed that required them to do so. The Admin 1 stated this incident was not verified as abuse because it was not intentional to harm the resident as a transfer was done so it was not verified as abuse. Admin 1 stated it was not viewed as neglect because we provided goods and services the resident as requested. We transferred the resident to her bed and that is the service she requested so we don't view it as neglect at this time. The Admin 1 stated we did offer education to the staff in regards to transfers. The Admin stated the staff member was not able to locate the Hoyer when the accident occurred. The Admin 1 stated this happened in February and I was reporting it in June. The Admin 1 stated we do not view it as neglect or abuse, we were providing the services to the resident but the employee did not think it through and caused the resident an injury. 30563 3. Resident 54 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, dysphagia, protein-calorie malnutrition, nicotine dependence, delirium, repeated falls and alcohol dependence. On [DATE] at 10:28 AM, observed resident 54 in the hallway with a 4-wheeled walker and a boot on her right foot. Resident 54 stated that she went out to smoke and the door did not open all the way. Resident 54 stated when she pushed the handicap button to open the door, after it rained the door only opened half way because something in the door swole up. Resident 54 stated that she tried to push the door the rest of the way open with her foot and she heard a pop in her foot. Resident 54 stated she got an x-ray and there was no fracture but it was really sore. Resident 54's medical record was reviewed [DATE] through [DATE]. Resident 54's progress notes revealed the following: a. On [DATE] at 11:26 AM, Patient has swelling of right ankle. She is not sure of how injury occurred. Provider informed. X-ray ordered. b. On [DATE] at 5:48 PM, Patient's right ankle x-ray results came back with findings of total normality. c. On [DATE] at 5:50 PM, Provider informed of normal ankle findings.: d. On [DATE] at 5:52 PM, Patient was sent to [name of local] hospital upon her insistence that she go to 'get help with her leg.' Patient has been informed her x-ray was negative. Provider informed. [Name of local] hospital ER [emergency room ] was informed of her future arrival and of today's events. e. On [DATE] at 12:46 AM, Event/Alert Charting following Event, Document every shift until resolved: Monitor resident for intoxication, slurred speech, aggressive towards staff/residents, notify md about possible intoxication and if medications should be held. - Patient came back from the [name of local hospital] ER and is asleep and did not have any s/s [signs and symptoms] of intoxication at this time. Continuing with care. f. On [DATE] at 7:20 AM, Resident informed RN that she was walking out to the smoking area on the evening/night of [DATE] and kicked the door with her ankle. Resident recited this story multiple times to this RN and multiple other staff members and residents. g. On [DATE] at 8:45 AM, IDT Event Review revealed the date of the incident was [DATE]. Resident 54 complained of swollen right ankle with discomfort at site. Preventive measures prior to event were assist with activities of daily living, call light within reach, medications/treatments as ordered, anticipate needs and pain control. The root cause analysis was possible edema and possible overexertion. The interventions were ankle x-ray as ordered, sent to ER per [resident 54's] request, monitoring changes in pain and in mobility. On [DATE] at 9:09 AM, an observation was made of the door to the smoking area. CNA 12 and CNA 13 were observed to exit through the door to the smoking area and the door stopped half way. CNA 12 and CNA 13 were observed to push the doorway the rest of the way back open. At 9:15 AM, an observation was made of CNA 12 and CNA 13 opening the door to enter the facility from the smoking area. CNA 12 and CNA 13 observed to drag the door on the concrete and open the door halfway. CNA 13 stated that happened a lot. On [DATE] at 9:10 AM, an interview was conducted with resident 50. Resident 50 was observed in the smoking area. Resident 50 stated that he pushed the handicap door button for the door to open but it did not open. Resident 50 stated he had to use the key card, push the button and then back up in his electric wheelchair. Resident 50 stated the bottom of the door dragged on the cement and did not open all the way. Resident 50 stated the door not opening has almost pushed him into the grass. On [DATE] at 9:19 AM, an interview was conducted with resident 51. Resident 51 stated that the door did not always open all the way and she had to pull it all the way open when she went to the smoking area. On [DATE] at 1:34 PM, an interview was conducted with ADON 1. ADON 1 stated he was not sure why resident 54 had a boot on. At 1:46 PM, ADON 1 stated he reviewed the notes and resident stated she kicked the door to

Based on interview, record review, and observation, multiple system failures were identified during the survey, and the facility was found to be in non-compliance at a harm level with F600, F644, F679, F686, F689, F692, F726, F742; and F812 at an Immediately Jeopardy level, indicating substandard quality of care. Resident identifiers: 16, 18, 20, 22, 35, 39, 40, 44, 49, 50, 51, 54, 62, 65, 78, 88, 156, and 158. Findings include: 1. Based on interview and record review it was determined, for 5 of 68 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. Specifically, a resident was forced to do Activities of Daily Living (ADL's), a male resident did not have the mental capacity to consent prior to moving in with a female resident, a resident was transferred inappropriately resulting in a femur fracture, and a Certified Nursing Assistant (CNA) was allowed to work with a specific resident after the CNA caused the resident to fall. This resulted in a finding of HARM for 3 residents. Resident identifiers: 16, 20, 22, 44 and 78. [Cross refer to F600]. 2. Based on interview and record review, it was determined for 1 of 68 sampled residents, the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for this deficiency were determined to have occurred at a harm level. Resident identifier: 62. [Cross refer to F644] 3. Based on observation, interview and record review it was determined, 6 out of 68 sampled residents, that the facility did not provide an ongoing program to support resident in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the residents comprehensive assessment and care plan. Specifically, residents complained about not having activities, observations were made of less than 10 residents per activity, and one on one activities were not being provided. The findings for one resident were determined to have occurred at a harm level. Resident identifiers: 16, 20, 49, 51, 54 and 62. [Cross refer to F679] 4. Based on interview, observation and interview, the facility did not ensure that for 2 of 68 sample residents without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services. Specifically, a resident developed a pressure ulcer during his stay, and did not receive timely skin checks or wound treatments. The findings for this resident were determined to have occurred at a harm level. In addition, a resident was not repositioned appropriately. Resident identifiers: 65 and 158. [Cross refer to F686] 5. Based on interview, observation and record review, the facility did not ensure that 10 of 68 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, residents eloped from the facility, water temperatures were at a level that could cause burns, interventions were not put into place after falls to prevent additional falls, a door was not working correctly, and staff transfers resulted in resident injury. Three of the findings were determined to have occurred at a harm level. Resident identifiers: 18, 22, 35, 39, 40, 49, 50, 51, 54, and 156. [Cross refer to F689] 6. Based on interview, observation and record review, the facility did not ensure that 4 of 68 sampled residents maintained acceptable parameters of nutritional status. Specifically, residents experienced weight loss and pressure sores without timely and appropriate interventions. This will be cited at a harm level for resident 65. In addition, residents were not provided interventions to prevent weight loss further weight loss. Resident identifiers: 16, 44, 65 and 88. [Cross refer to F692] 7. Based on observation, interview, and record review, it was determined for 2 of 68 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility must ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs. Specifically, facility staff transferred a resident who required a two person physical assist resulting in a femur fracture. Also, a resident who sustained a fall was not assessed by the nurse or monitored after the fall. The findings for resident 22 were determined to have occurred at a harm level. Resident identifier: 18 and 22. [Cross refer to F726] 8. Based on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with a mental disorder or a psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident with suicidal ideation and a Pre-Admission Screening Resident Review (PASRR) Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for resident 62 were found to have occurred at a harm level. Resident identifier: 62. [Cross refer to F742] 9. Based on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were 2 freezers in the kitchen that did not maintain appropriate temperatures to keep food items frozen. These findings resulted in immediate jeopardy. [Cross refer to F812] 10. In addition, the facility was found to be in non-compliance with F584, F656, F677, F686, F689, F692, F761, F812, F842, and F880 during this recertification survey as well as the previous recertification survey conducted in October 2021. On 8/16/23 at 2:28 PM an interview with Administrator (Admin 2) was conducted. Admin 2 stated he started as the administrator for this facility the end of July 2023. Admin 2 stated that he likes to have monthly Quality Assurance and Performance Improvement (QAPI) meetings. Admin 2 stated wants to have all the department heads in the meetings; dietary, nursing, housekeeping, and activities then task out the different interventions. Admin 2 stated he goes to morning meetings to learn about issues from the previous day. Admin 2 stated then he learns how the team is addressing the issues like falls and abuses. Admin 2 stated by going to morning meeting he can verify and quantify data, like last month if there were 10 falls, he expects that interventions are put into place. Admin 2 stated the interventions would be reviewed again at the next meeting and if falls have dropped then it is showing interventions are working. Admin 2 stated situations change all the time, when you think things are good, something always pops up. Admin 2 stated then it is time to reevaluate interventions and this done with audits, logs, consult reports, just keeping track, and document.

Based on observation, interview, and record review the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, and act on available data to make improvements. Specifically, deficient practices identified during the survey included repeat deficiencies in the areas of prevention of accident hazards, develop and or implement comprehensive care plans, provide activities of daily living (ADLs) care for dependent residents, maintenance of nutrition, label and store drugs and biologicals, maintaining identifiable information in the resident records, infection prevention, and Food storage. Resident identifiers: 16, 18, 20, 22, 35, 39, 40, 44, 49, 50, 51, 54, 62, 65, 78, 88, 156, and 158. Findings include: 1. Based on interview and record review it was determined, for 5 of 68 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. Specifically, a resident was forced to do Activities of Daily Living (ADL's), a male resident did not have the mental capacity to consent prior to moving in with a female resident, a resident was transferred inappropriately resulting in a femur fracture, and a Certified Nursing Assistant (CNA) was allowed to work with a specific resident after the CNA caused the resident to fall. This resulted in a finding of HARM for 3 residents. Resident identifiers: 16, 20, 22, 44 and 78. [Cross refer to F600]. 2. Based on interview and record review, it was determined for 1 of 68 sampled residents, the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for this deficiency were determined to have occurred at a harm level. Resident identifier: 62. [Cross refer to F644] 3. Based on observation, interview and record review it was determined, 6 out of 68 sampled residents, that the facility did not provide an ongoing program to support resident in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the residents comprehensive assessment and care plan. Specifically, residents complained about not having activities, observations were made of less than 10 residents per activity, and one on one activities were not being provided. The findings for one resident were determined to have occurred at a harm level. Resident identifiers: 16, 20, 49, 51, 54 and 62. [Cross refer to F679] 4. Based on interview, observation and interview, the facility did not ensure that for 2 of 68 sample residents without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services. Specifically, a resident developed a pressure ulcer during his stay, and did not receive timely skin checks or wound treatments. The findings for this resident were determined to have occurred at a harm level. In addition, a resident was not repositioned appropriately. Resident identifiers: 65 and 158. [Cross refer to F686] 5. Based on interview, observation and record review, the facility did not ensure that 10 of 68 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, residents eloped from the facility, water temperatures were at a level that could cause burns, interventions were not put into place after falls to prevent additional falls, a door was not working correctly, and staff transfers resulted in resident injury. Three of the findings were determined to have occurred at a harm level. Resident identifiers: 18, 22, 35, 39, 40, 49, 50, 51, 54, and 156. [Cross refer to F689] 6. Based on interview, observation and record review, the facility did not ensure that 4 of 68 sampled residents maintained acceptable parameters of nutritional status. Specifically, residents experienced weight loss and pressure sores without timely and appropriate interventions. This will be cited at a harm level for resident 65. In addition, residents were not provided interventions to prevent weight loss further weight loss. Resident identifiers: 16, 44, 65 and 88. [Cross refer to F692] 7. Based on observation, interview, and record review, it was determined for 2 of 68 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility must ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs. Specifically, facility staff transferred a resident who required a two person physical assist resulting in a femur fracture. Also, a resident who sustained a fall was not assessed by the nurse or monitored after the fall. The findings for resident 22 were determined to have occurred at a harm level. Resident identifier: 18 and 22. [Cross refer to F726] 8. Based on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with a mental disorder or a psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident with suicidal ideation and a Pre-Admission Screening Resident Review (PASRR) Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for resident 62 were found to have occurred at a harm level. Resident identifier: 62. [Cross refer to F742] 9. Based on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were 2 freezers in the kitchen that did not maintain appropriate temperatures to keep food items frozen. These findings resulted in immediate jeopardy. [Cross refer to F812] 10. In addition, the facility was found to be in non-compliance with F584, F656, F677, F686, F689, F692, F761, F812, F842, and F880 during this recertification survey as well as the previous recertification survey conducted in October 2021. On 8/16/23 at 2:28 PM an interview with Administrator (Admin 2) was conducted. Admin 2 stated he started as the administrator for this facility the end of July 2023. Admin 2 stated that he likes to have monthly Quality Assurance and Performance Improvement (QAPI) meetings. Admin 2 stated wants to have all the department heads in the meetings; dietary, nursing, housekeeping, and activities then task out the different interventions. Admin 2 stated he goes to morning meetings to learn about issues from the previous day. Admin 2 stated then he learns how the team is addressing the issues like falls and abuses. Admin 2 stated by going to morning meeting he can verify and quantify data, like last month if there were 10 falls, he expects that interventions are put into place. Admin 2 stated the interventions would be reviewed again at the next meeting and if falls have dropped then it is showing interventions are working. Admin 2 stated situations change all the time, when you think things are good, something always pops up. Admin 2 stated then it is time to reevaluate interventions and this done with audits, logs, consult reports, just keeping track, and document.

Based on interview and record review, it was determined for 1 of 68 sampled residents, the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for this deficiency were determined to have occurred at a harm level. Resident identifier: 62. Findings include: Resident 62 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included chronic post-traumatic stress disorder, anxiety disorder, insomnia and depression. On 7/30/23 at 12:00 PM an interview was conducted with Resident 62. Resident 62 stated that she spends most of her time in her bed and that it is hard for her to get around. She stated that she eats all meals in bed and will watch TV or purchase things on amazon for her activities. Resident 62 stated that since the first day in the facility she had told multiple staff members she needed mental health services. Resident 62 stated that she would like to see a psychiatrist to talk about her feelings, and to hopefully get on the right medications to help her with the anxiety and depression. Resident 62 stated that she had been having night terrors and anxiety attacks, and felt it was because she was not getting the mental health she needed. Resident 62 stated that she had suicidal ideation and often felt she would be better off dead. Resident 62 stated the last time the facility asked about her suicidal ideation was three or four months ago, but she has had those thoughts more recently. Resident 62 stated that she had been receiving mental health services since she was a teenager and that her psychiatrist retired a year ago and that she does well when she has mental health services. Resident 62's medical record was reviewed from 7/30/23 through 8/16/23. Resident 62 was discharged from a local hospital on 3/18/23 and admitted to [NAME] health and rehab. Resident 62's hospital care plan goals, discharge treatment orders revealed, Consult to case management- psychosocial needs (consult to social work). On 4/12/23, a level II PASRR assessment was completed for resident 62. The assessment indicated that the evaluator's diagnostic impression was that resident 62 had major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder. The assessment also indicated that [Resident 62] reported a history of 'chronic complex PTSD'(posttraumatic stress disorder) secondary to multiple traumas in her life. She reported that in 1996 she was assaulted by her boyfriend who beat, raped & strangled her and left her for dead; she stated that he 'hit me on the head with a rock like 30 times trying to break my head open'. She was able to survive this attack and rehabilitate but has suffered from severe PTSD since then. She reported about [AGE] years ago she became severely ill with sepsis, and that after this she was no longer able to concentrate enough to work, and that anytime she is in a medical setting like a hospital she goes back to the time she was severely ill with sepsis. She reports sxs (signs and symptoms) of PTSD including recurring nightmares/night terrors, flashbacks, intrusive memories, dissociative episodes in which pt (patient) reports she will 'zone out', avoidant behaviors, irritability, poor sleep, impaired concentration, heightened startle response . She has experienced sxs including depressed mood, anhedonia, loss of energy and motivation, increased eating leading to weight gain . disrupted sleep, feelings of worthlessness and hopelessness, chronic thoughts of being better off dead, and SI (suicidal ideation) with one past suicide attempt in 2006 when she cut her wrist with a razor . She has been involved in outpatient mental health treatment, and reported seeing a therapist/psychiatrist for 5-6 years until this psychiatrist retired in April 2022 . The Current Psychiatric Functioning section stated, sleep/night terrors, which pt (patient) reports have been present since SNF (skilled nursing facility) admission. She feels that her anxiety is quite high, and her mood has been poor. Sleep has been very poor per pt's report. She reports chronic feelings of hopelessness and that things are not likely to get better for her. She denies active SI but endorses chronic thoughts of being better off dead/ 'it would be better if I wasn't alive' given all of her medical concerns. She is very open to a referral for mental health services as she found counseling/talk therapy to be very helpful in the past; the SNF (skilled nursing facility) social worker was advised of this. The PASRR assessment listed the following: Recommendation for Specialized Services for mental illness treatment: Pt would like to have a referral for mental health services. It should be noted that in reviewing resident 62's medical record, the PASRR Level II recommendations for specialized services for mental illness treatment revealed no indication of mental health treatment or consults could be located. There is no documentation of a plan of care or action for the outcomes on the PASRR II. A Minimum Data Set (MDS) assessment dated [DATE], documented resident 62 with a Brief Interview for Mental Status (BIMS) score of 15. (Note: A resident that was intact cognitively would have a BIMS score of 13-15.) A review of Resident 62's MDS assessment dated [DATE], MDS 3.0 section D- Mood, revealed that a resident mood interview was conducted. The residents total severity score was 23 out of 27 (Note: A score of 20-27 would indicate severe depression). A care plan dated 3/29/23 revealed, a focus care area was, Resident is at risk for suicidal impulsive/ideation of self-harm A goal developed was, Resident will remain safe from self-harm by next review. Interventions were A staff member will remain with the resident until Licensed staff member arrives to assess the resident. After performing a suicide assessment, the licensed staff member shall notify the resident's attending MD and responsible party. Immediately report to the charge nurse, nursing supervisor, and physician/NP(nurse practitioner) if resident verbalizes thoughts of hurting themselves. Licensed staff member to perform suicide assessment if suicidal ideation is identified. Assess suicidal thought by asking the resident/patient to share suicidal history, feelings, plans and behavior. Nursing personnel and other staff involved in caring for the resident shall be informed of the suicidal ideation and instructed to report changes in the resident's behavior immediately. A care plan dated 4/1/23 revealed, a focus care area was, Resident is at risk for mood impairment. A goal developed was, The resident will have improved mood state through the review date. Interventions were Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc). A review of the Suicide/Homicide Risk Evaluation dated 3/29/23, documented, 1. Suicide/Homicide Risk Evaluation. Take the threat of suicide or homicide seriously A. Is the resident making suicidal statements? Yes 2. Determine Risk. A. Is the resident considered High or Low Risk? Low risk B. Will the resident agree to a safety plan? Yes 3. Plan. To ensure resident safety for LOW RISK A. Work with the resident on a safety plan C. Contact manager on duty, NHA, DON and Social services D. Notify MD Resident 62's progress notes revealed the following: a. On 3/19/23, a nurses note entry indicated the staff would monitor resident 62 for 72 hours upon admission. The entry documented on the first day of admission, Mental Status/Behavior: AA/Ox4 (alert and oriented to name, date, time and place). Anxious . b. On 3/20/23, a nurses note entry indicated the staff would monitor resident 62 for 72 hours upon admission. The entry documented on the second day of admission, Mental Status/Behavior: Anxious, cooperative . c. On 3/22/23, a social services note documented, SS (social services) was informed that Pt. (patient) had a Suicidal Ideation Pt. states that she was not wanting to live any longer has no plan. ADMIN (administrator), DON (Director of Nursing), ADON (Assistant Director of Nursing), SS Consultant and MD is aware. A suicidal Ideation Assessment was done Pt. has no plan MD feels like Pt. is no harm to herself or others. staff is aware and will monitor for any signs and will report it immediately. d. On 3/22/23, a nurses note entry documented resident 62 had taken a PHQ9 (Patient Health Questionnaire 9) triggered high. We reviewed with resident. She denied suicidal ideation. She made contract for safety. e. On 3/22/23, a nurses note documented that resident 62 was Being sent to [a local hospital] for further medical evaluation . f. On 3/27/23, a nurses note documented the facility nurse had spoken with the nurse at the hospital to get a nurse to nurse report. The entry documented a Nurse to Nurse .Psych Dx: Pt c/o(complained of) anxiety. Hospital gave hydroxyzine . A review of resident 62's hospital admission paperwork dated 3/22/23 the physician documented, Patient states her 'anxiety and depression are through the roof.' g. On 3/29/23, a nurses note documented during the 72 hour readmission monitoring, Mental status/Behavior: AA/O x4, anxious . h. On 3/29/23, a social service note documented, SS (social services) was informed that Pt. had a Suicidal Ideation Pt. states that she was not wanting to live any longer has no plan. ADMIN, DON, ADON, SS consultant and MD is aware. A suicidal ideation Assessment was done Pt. has no plan MD feels like Pt. is no harm to her self or others. Staff is aware and will monitor for any signs and will report it immediately. i. On 3/30/23, a physician admission note documented the reason for resident 62's hospital admission. The note revealed on 3/22/23 Transferred to[name of local hospital]- Suicidal ideations. 3/27/23: readmitted to [NAME] Rehab. j. On 4/18/23, a physician progress note documented a visit was conducted for the Psych IDT meeting. The note revealed, Team met to review psychotropic medications .Says she doesn't sleep much .Discussed sleep hygiene. she is tearful, says 'it doesn't work for me.' Discussed sleep debt, says 'i'll try.' k. On 5/16/23, an order note revealed an anxiety medication increase, Note Text: hydrOXYzine HCI Oral Tablet 50 MG . Give 50 mg by mouth every 6 hours as needed for itching/anxiety for 14 days . to increase hydroxyzine dose to 50 mg from 25 mg. pt c/o heart palpitations, upset stomach, and presented with anxiety. pt explained she felt like she may have had a mild heart attack . increased dose administered. wctm (will continue to monitor) behavior and VS (vital signs) and report any changes PRN (as needed). l. On 5/16/23, a nursing note entry documented resident 62's appointment with the infectious disease physician and during the appointment resident 62 was having, having atypical chest pain . anxiety?, MI? (myocardial infarction), PE? (pulmonary embolism)-sending to ER (emergency room ) . (Note: the emergency room notes could not be located in the residents chart.) m. On 5/17/23, a nursing note entry revealed hospital visit findings, This nurse spoke with [Resident 62] regarding her observation in the ER (emergency room ) d/t (due to) paperwork having minimal information. [Resident 62] states that hospital completed EKG (electrocardiogram) and labs to assess for signs of a heart attack or blood clot. [Resident 62] states that the results came back all within normal limits and that's why they sent her back. She states that they believe it was anxiety associated d/t her self reporting she had had a panic attack earlier in the day . n. On 5/17/23, an IDT (interdisciplinary team) Event review note indicated the team discussed resident 62's most recent hospital visit. The not revealed, Event: Chest pain . Root Cause Analysis: palpitations potentially from anxiety -Intervention: Sent to ER for eval[evaluation] from clinic . No concerns were noted. Monitor for SOB, recurring chest pain, anxiety symptoms . The note did not indicate what, if any, recommendations the IDT had for the residents mental health needs. o. On 5/19/23, a medication order note documented,start buspirone 10 mg TID (three times a day) for anxiety . p. On 7/13/23, a physician progress note documented he saw the resident for a follow up visit. The physician documented that, Resident stated she had a panic attack and night terrors. q. On 7/18/23, a Physician progress note documented that he saw the resident for a psychotropic visit. The physician documented that resident 62 . has the same complaints as usual . r. On 7/18/23, a Psychotropic note reviewing the psychotropic medication resident 62 was taking documented, Resident is taking Buspirone, Duloxetine, Trazodone, Hydroxyzine. Discussed increasing Buspirone to 20 mg TID (three times daily) for increased anxiety, Hydroxyzine will fall off 8/17/23. Resident is also asking to be seen by a therapist, will have resident advocate send request to [name of local county mental health services] . s. On 7/18/23, a medication order note documented to, start hydroxyzine 50 q6hrs(every six hours) prn(as needed) 30 days for anxiety. t. On 7/19/23, a medication order note documented another increase in anxiety medication, busPIRone HCI Oral Tablet 10 MG . Give 20 mg by mouth three times a day for Anxiety . u. On 7/24/23, a nurses note documented an increase in medication for PTSD, Prazosin from 2mg to 3 mg QHS (hour of sleep) for PTSD . v. On 7/31/23, a social services note documented, Pt application was sent in to [local county mental health services]. (Note: Resident 62's PASRR II dated 4/13/23 recommended a referral for mental health services.) On 8/8/23 at 12:55 PM an interview was conducted with the Resident Advocate (RA) and the social services assistant (SSA). The SSA stated that if a resident scores high on PHQ9 (Personal Health Questionnaire 9), the resident will be sent out to the therapy team at the local county mental health provider. The RA stated that the facility treats the questionnaire as a serious SI (suicide ideation). The RA stated that when the therapy consultants come to see the residents they do not have a record of when they come, they do not receive any notes to demonstrate when the therapy consultant met with the residents. The RA did not have a list of residents that were currently being seen by the local county mental health provider. The RA and the SSA stated that they had not personally seen the mental health representatives from the local county mental health provider. The RA stated that the local county mental health provider had sent an email stating the Licensed clinical social worker (LCSW) was leaving. The RA provided a copy of the email sent on 2/21/23 at 2:11 PM which stated, We will need to temporarily put a pause on admits from your facility. Our social workers and APRN will still be at the facility to conduct visits for emotional support and psychotropic medication consulting. If you have a resident that is needing help, please reach out to me and I will coordinate with the team to facilitate that. The RA stated that she took over resident 62's case in May 2023. RA 1 stated that she was unaware of resident 62's mental health needs when she started. RA 1 stated that she was only aware of mental health needs of resident 62 beginning July 2023. The RA stated that paperwork was sent to the local county mental health provider on 7/31/23, and that she was unaware of request for mental health services in resident 62's PASRR that was completed 4/12/23. On 8/8/23 at 1:43 PM, an interview with resident 62 was conducted. Resident 62 stated that she has complained of suicidal ideation, anxiety, panic attacks and night terrors to multiple staff members since her admission to the facility in March, and has not received the help she requests. Resident 62 stated that she has not seen by a mental health professional while at the facility and that she constantly feels she is on the verge of crying. On 8/8/23 at 2:00 PM, an interview conducted with a Registered Nurse (RN) 5. RN 5 stated that when a resident has suicidal ideation they will complete a suicide risk assessment, then inform the DON (director of nursing), ADMIN (administrator), MD (medical director), and Social services to come up with a plan and determine the safety of the resident. RN 5 stated the resident 62 complains of anxiety and night terrors frequently, and that resident 62 will take medications to help with the anxiety symptoms. RN 5 stated that she had not seen any mental health service providers at the facility, and was not aware of if they visit resident 62. RN 5 stated social services would be aware of mental health needs for resident 62.

Based on interview, observation and interview, the facility did not ensure that for 2 of 68 sample residents without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services. Specifically, a resident developed a pressure ulcer during his stay, and did not receive timely skin checks or wound treatments. The findings for this resident were determined to have occurred at a harm level. In addition, a resident was not repositioned appropriately. Resident identifiers: 65 and 158. Findings include: HARM 1. Resident 65 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included, spiral fracture of the left femur, type 2 diabetes, muscle weakness, and arthritis. On 7/30/23 at 8:57 AM, an interview was conducted with resident 65. Resident 65 stated that he came to the facility because he broke his femur and was now bed ridden but participated in physical therapy. He stated that he had developed sores on his heels during the beginning of his stay at the facility. Resident 65 stated he admitted to the facility in February 2023 and ended up getting covid, and once he had COVID-19 he stated he was quarantined for 27 days. He stated staff would ask how he was doing, assist with brief changes and bring his food in, but did not perform skin checks, and no visitors were allowed. Resident 65 stated that he would try to move around in his bed but with his femur fracture he had a difficult time repositioning, and that he eventually complained of pain in his feet, and he stated that is when staff saw he had sores on both heels. Resident 65 stated that once staff saw the wound they started treating them. Resident 65's medical record was reviewed from 7/30/23 through 8/16/23. An admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident 65 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. In addition the MDS assessment documented that resident 65 was at risk of developing pressure ulcers and resident 65 had no unhealed pressure ulcers on admission. A care area assessment (CAA) summary for the admission MDS in February 2023, the facility documented that the CAA for skin was triggered secondary to potential impairment of skin integrity. Contributing factors included ADL (activities of daily living)/functional/mobility impairment, incontinence, nutritional deficits, cognitive deficits, and acute/chronic conditions. Resident admitted with surgical wound. Requires staff to monitor/assess daily risks associated with skin impairment and decrease risk. Care plan will be developed/continued for current skin conditions. A care plan dated 2/7/23 with a focus care area documented resident is at risk for impaired skin integrity rt (related to) impaired mobility, episodes of incontinence. Interventions put in place were to encourage good nutrition and hydration (if not contraindicated). Keep peri area clean and dry. Apply barrier cream PRN (as needed) and with each incontinent episode. Notify wound nurse of any open areas of change in skin condition. The care plan did not address resident 65's need for assistance with repositioning in bed. A care plan dated 3/14/23 with a focus care area documented, The resident has Diabetes Mellitus with a goal of the resident will have no complications related to diabetes through the review date. Interventions put in place were to Check all body for breaks in skin and treat promptly as ordered by doctor. Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen . A care plan dated 3/28/23 with a focus care area documented, Resident has impaired skin integrity: Diabetic foot ulcers to Left Heel. A goal was The resident will have no complications related to impaired skin integrity through the review date. Interventions put in place were to carefully dry between toes but do not apply lotion between toes. Monitor/document wound: size, depth, margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify MD (medical director) as indicated. Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of infection . Monitor/document/report PRN changes in wound color, temp, sensation, pain, or presence of drainage and odor. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length depth, type of tissue and exudate and any other notable changes or observations. A Braden Scale for Predicting Pressure Sore Risk dated 2/4/23 documented that resident 65 was at risk for pressure sores with a score of 16. [Note: A score of 15-18 indicated At Risk.] The Braden Scale indicated that resident 65's sensory perception was slightly limited: responds to verbal commands, but cannot always communicate discomfort or the need to be turned. Activity chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and /or must be assisted into chair or wheelchair. The intervention guideline tool documented implement weekly skin checks. The intervention tool did not indicate how often staff were supposed to assist resident 65 with repositioning in bed. On 2/5/23 a physicians order documented weekly skin checks to occur every Sunday for monitoring. The order was discontinued 3/8/23 when resident 65 discharged to the hospital. An order dated 3/10/23 documented weekly skin checks to occur every Sunday for monitoring. A review of resident 65's weekly skin checks documented skin checks were preformed on the following dates: a. On 2/3/23 b. On 2/5/23 c. On 2/12/23 d. On 2/20/23 e. On 3/12/23 (No documentation could be located to indicate that resident 65 had his weekly skin check from 2/20/23 through 3/12/23, a period of 20 days). f. On 4/3/23 (No documentation could be located to indicate that resident 65 had his weekly skin check from 3/12/23 through 4/3/23, a period of 22 days). [Note: A nurses note dated 3/27/23 indicated that resident 65 developed a wound during this time when resident 65 was not having skin checks weekly as ordered.] g. On 4/9/23 h. On 4/16/23 (No documentation could be located to indicate that resident 65 had his weekly skin check from 4/16/23 through 5/8/23, a period of 22 days.) i. On 5/8/23 [Note: After this date, resident 65 had weekly skin checks as ordered through 7/30/23.] Resident 65's medical record review revealed the following regarding his development of a wound: a. On 2/7/23 an admission skin and weight review occurred documenting resident 65's skin was intact. b. On 2/20/23 a weekly skin review/ assessment documented there was no new skin integrity problems. c. On 2/22/23 a nurses progress note documented Pt complained of a sore throat, noted fever of 101.2 . tested him for covid and the result was positive. d. On 3/7/23 a Nursing progress not documented Pt went to ortho [orthopedic] appt [appointment], ortho sent to [Name of local hospital] ED for operation to L[left] femur to clean out. Pt admitted MD [medical director] and Admin [administrator] notified. e. On 3/10/23 a nursing note documented Pt readmitting from [local hospital]. f. On 3/12/23 a weekly skin review/ assessment documented ble [bilateral lower extremities] lower extremities dusky and dry. g. On 3/16/23 a quarterly MDS for resident 65 indicated that he required extensive assistance of two people for bed mobility, and extensive assistance of one person for transfers. The MDS also indicated that resident 65 had limited range of motion on one of his lower extremities. h. On 3/27/23, a nursing note documented a change in condition reported: skin wound or ulcer . found new DM [diabetes mellitus] ulcers to bilateral heels, inform wound np [nurse Practitioner]. i. On 3/27/23 a weekly wound observation tool documented the wound location to be on resident 65's right heel, acquired during the residents stay, the type of wound was a diabetic wound with necrotic tissue present. The note documented educated pt to reposition every 1 too [sic] 2 hours while in bed and to float heel while in bed with 2 pillows or Podus boot. [Note: The resident had been assessed 10 days earlier in the MDS Assessment as requiring extensive assistance of two staff members for bed mobility.] j. On 3/28/23 a skin and weight review documented, he has wounds to both ankles possible diabetic wounds. k. On 3/28/23 a physician order documented bilateral heels (DM)- wipe with iodine then cover with silicone dressing. wound nurse to change Mondays floor nurse to change PRN if soiled or dislodged as needed. [Note: in resident 65's Treatment Administration Record (TAR) there was no documentation of this dressing change occurring in March, April, or May 2023. l. On 4/3/23 a weekly skin review/assessment documented, Pt has no new skin breakdown or concerns. [Note: The altered skin integrity section does not list any problem sites] m. On 4/4/23 a skin and weight review documented the reason for review was for weight loss of 2% loss in 7 days. Most recent weights documented on 3/28/23 weight was 274. Lbs, and on 4/3/23 weight was 260.6 Lbs. Resident has had a recent weight loss, he is on diuretics that can cause a fluctuation in weight . no other concerns noted. The summary/ comments documented Weight fluctuations continue with fluid shifts (260-274 lbs x 1 month); continue with edema and on diuretics. Good appetite/ intake. Continue as set. [Note: The skin and weight review did not document any interventions with regard to resident 65's wounds.] n. On 4/9/23 a weekly skin review/assessment documented Pt has no new skin breakdown or concerns. [Note: the altered skin integrity section lists the Left Trochanter (hip) Surgical incision as the only skin integrity problem.] o. On 4/13/23 a physician order documented, bilateral heels (DM)- clean with NS [normal saline] or wound cleanser then apply Medihoney then Bactroban the cover dressing. wound nurse to change Mondays, Wednesdays and Friday floor nurse to change PRN if soiled or dislodged dressing. The order was not documented as completed per the TAR between 5/31/23 and 6/14/23. p. On 4/16/23 a weekly skin review/assessment documented decreased redness noted to rash bilat [bilateral] upper and lower extremities. Skin tear to forearm resolved, bruising noted. [Note: the altered skin integrity section lists the Left Trochanter (hip) Surgical incision as the only skin integrity problem.] q. On 4/18/23 a skin and weight review documented the reason for review was weight loss, a 2% loss in 7 days. Most recent weights documented on 4/10/23 weight was 266.0 Lbs and on 4/17/23 weight was 256.0 Lbs. Resident has had a recent weight loss this week, he is on diuretics which can cause fluctuations in weight, he has a rash to BLE and BUE [bilateral upper extremities] treating by hydrocortisone . no other issues noted at this time. The summary/comments documented noted to have a 3.8% loss x1 week. Tolerating diet well . Weight fluctuations persist, attributed to fluid shifts with edema + diuretics. Overall weight loss is desired d/t [due to] elevated BMI [body mass index]. Continue as set. [Note: The skin and weight review did not document any interventions with regard to resident 65's wounds.] r. On 4/25/23, a skin and weight assessment documented that resident 65 has had a weight loss this week. He is currently taking Lasix, mvi [multivitamin] and vit (vitamin) c, doxycycline. He is not taking any dietary supplements. No new skin issues at this time. There are no dietary recommendations at this time. No other concerns. [Note: The skin and weight review did not document any interventions with regard to resident 65's wounds.] s. On 4/26/23 a Skin/Wound note documented that Wound RN [Registered Nurse] and wound NP assessed patient's right big toe (DM), and bilateral heels (DM). Wounds are improving. New wound orders placed and implemented today . Right heel- cleanse wound, apply betadine and leave open to air. Left heel-cleanse wound, apply Medihoney then cover dressing. t. On 5/2/23 a skin and weight review documented the reason for review was weight loss, 2% loss in 7 days. Resident 65's skin was documented as intact. [Resident 65] has had a weight loss this week. He is currently taking Lasix . No new skin issues at this time Dietary recommendations listed below will be implemented no other concerns at this time. new intervention add large protein portions. u. On 5/8/23 a weekly skin review/assessment documented skin wdi [warm, dry, and intact] no new skin issues at this time. v. On 5/9/23 a skin and weight review documented the reason for review was weight loss, 2% loss in 7 days, 5% loss in 30 days, and 7.5% loss in 90 days. [Resident 65] has had a weight loss this week. He is currently taking Lasix . No new skin issues noted at this time. Dietary recommendation listed below have been approved by provider and will be updated. No other concerns at this time. New interventions add NSA house shake BID [twice a day]. w. On 5/21/23 a weekly skin review/assessment documented Pt continues to have no new skin issues at this time. x. On 5/29/23 a weekly skin review/assessment documented Patient skin is clean, dry and intact. No new significant skin issues at this time. Continuing with care. y. On 6/4/23 a weekly skin review/assessment documented Patient skin is clean, dry and intact. No new skin issues noted at this time. z. On 6/7/23 a weekly wound observation tool documented the right heel wound worsening. Staff documented that the wound then became an acquired pressure ulcer stage 1 educated pt to reposition 1 too [sic] 2 hours while in bed and to keep podus boots on feet while in bed to help protect heels. aa. On 6/11/23 a weekly skin review/assessment documented Patient skin is clean, dry and intact. Pt has wounds to right and left feet heels and to big right toe. Wounds cleaned and dressed per wound nurse orders. No new skin issues noted at this time. bb. On 6/16/23 a quarterly MDS Assessment for resident 65 was completed. The MDS indicated that resident 65 required extensive assistance from one staff member for bed mobility, and extensive assistance from two staff members for transfers. The MDS indicated that resident 65 had a range of motion limitation on one of his lower extremities. cc. On 6/18/23 a weekly skin review/assessment documented Patient skin is clean, dry and intact. No new skin issues noted at this time. dd. On 6/27/23 a skin and weight review documented the reason for review was a wound. Weight documented as stable. Resident 65's skin documented as not intact. The wound type documented as Pressure the wound stage documented as Stage 1. The description documented Left Heel (DM)- wound is stable . Residents wounds are healing without any issues at this time with the wound treatment ordered at this time. ee. On 6/28/23 a weekly wound observation tool indicated that resident 65's right heel wound was now a stage 3 pressure ulcer. On 8/9/23 at 11:52 AM, an interview was conducted with the wound nurse (WN). The WN stated that she was currently not wound care certified. The WN stated that when a resident was identified to acquire a wound she was notified by the certified nursing assistant (CNA) or the nurse. The WN stated that nurses performed weekly skin checks which include checking a resident from head to toe and if any changes were on the skin such as scratches or wounds the WN was notified. The WN stated that she became the WN in May 2023 and was not working as the WN when resident 65's wounds were discovered in March 2023. The WN stated that resident 65's wounds on his heels both started at diabetic wounds. The WN stated that the wound on resident 65's right heel then became a deep tissue injury and progressed into a stage 3 pressure ulcer. The WN stated that she was not involved in the facility's skin and weight meetings. The WN stated she would inform the Director of nursing (DON) of any information regarding residents wounds and any new findings. The WN stated she was unsure how this was communicated previously to her working as the WN. The WN stated that she was not directly involved with the dietitian in regards to communication with a resident's nutrition status in aiding wound healing. The WN stated that resident 65 had poor circulation, dry skin and was scared to move a lot with his healing fracture, and that could be the reason his diabetic sore progressed to a stage 3 pressure ulcer. The WN stated that protein would help with stabilizing blood sugar and help with wound healing. On 8/9/23 at 2:34 PM an interview with the Registered Dietitian (RD) was conducted. The RD stated that she gave the DON a list of residents she was monitoring. The RD stated that she was not physically at the skin and weight meetings, and that the DON notified her if a resident needed an intervention to prevent weight loss or wounds. The RD stated that protein was added to a resident's diet, if they had a pressure injury and were not eating well. On 8/9/23 at 3:03 PM an interview the DON was conducted. The DON stated that for the skin and weight meetings the RD gathered information and submitted the information to the DON. The DON stated that the skin and weight committee looked at the wound notes and whether or not a wound was healing. The DON stated that the committee relied on the wound progress notes and assessments for the skin and weight meeting. The DON stated that resident 65 did not move when he was in his bed when he was first admitted . When the DON was asked about resident 65's bilateral heel wounds and continual weight loss the DON stated that they were not receiving any communication from the previous wound nurse and that he was admitted to the facility on diuretics which caused his fluctuating weights. The DON stated that it was difficult to find a time for the WN to join the skin and weight meetings. 44640 POTENTIAL FOR HARM 2. Resident 158 was admitted to the facility on [DATE] with diagnoses which included hydrocephalus, muscular dystrophies, aphasia, lack of coordination, osteoporosis, epilepsy, and major depressive disorder. Resident 158 was discharged from the facility on 2/9/23. The APS (Adult Protective Services Report) complaint investigation dated 2/24/23 revealed, [Resident] developed a really bad sore above his buttock the staff allowed it to go so long without treatment, it developed a deep ulcer . The case of caretaker neglect is being closed inconclusive due to allegation factors not being met as well as insufficient evidence. [NAME] is a vulnerable adult due to physical impairment. He has limited capacity to consent and understand choice and consequence. Resident 158's medical record was reviewed on 7/30/23 through 8/16/23. An admission MDS assessment dated [DATE], documented that resident 158 required extensive assistance of two persons for bed mobility and resident 158 was always incontinent of bladder and frequently incontinent of bowel. Bed mobility included how a resident moved to and from a lying position, turned side to side, and positioned body while in bed or alternate sleep furniture. In addition, the MDS assessment documented that resident 158 was at risk of developing pressure ulcers and that resident 158 had no unhealed pressure ulcers. A Brief Interview for Mental Status (BIMS) was conducted and resident 158 score was 00, severely impaired and unable to complete the interview. A care plan Focus dated 9/22/22 with a revision date of 2/14/23, documented Resident is at risk for skin impairment r/t impaired mobility, episodes or incontinence. A care plan Goal documented, Target date: 2/20/23 Resident will be free from skin impairment by the review date. The care plan Interventions included: a. Encourage good nutrition and hydration (if not contraindicated). Keep peri area clean and dry. Apply barrier cream PRN and with each incontinent episode. Notify wound nurse of any open areas of change in skin condition. Skin checks per schedule/order. A Braden Scale for Predicting Pressure Sore Risk dated 9/22/22, documented that resident 158 was at Moderate Risk for pressures sores with a score of 13. A score of 13 to 14 indicated Moderate Risk. [Note: This was the most recent Braden Scale for Predicting Pressure Sore Risk in resident 158's medical record.] The Point of Care History for September and October 2022 was reviewed. The following was documented regarding how the resident moved in bed, was assisted with toileting and repositioned. Total dependence indicated the resident did not participate in the activity and it was full staff performance with 2 person assist. Extensive assistance indicated the resident was involved in the activity, staff provided weight-bearing support with 2 person assist. According to documentation resident 158 was not repositioned every two to three hours on the following dates leading up to the development of the pressure ulcer: a. On 9/22/22, resident 158 required total dependence and was documented as being repositioned one time on this date. b. On 9/23/22, resident 158 required total dependence and was documented as being repositioned three times on this date. c. On 9/24/22, resident 158 required extensive assistance and was documented as being repositioned twice on this date. d. On 9/25/22, resident 158 required total dependence and was documented as being repositioned three times on this date. e. On 9/26/22, resident 158 required total dependence and was documented as being repositioned twice on this date. f. On 9/27/22, resident 158 required total dependence and was documented as being repositioned three times on this date. g. On 9/28/22, resident 158 required total dependence and was documented as being repositioned twice on this date. h. On 9/29/22, resident 158 required total dependence and was documented as being repositioned twice on this date. i. On 9/30/22, resident 158 required total dependence and was documented as being repositioned one time on this date. j. On 10/1/22, resident 158 required total dependence and was documented as being repositioned twice on this date. k. On 10/2/22, resident 158 required total dependence and was documented as being repositioned four times on this date. l. On 10/3/22, resident 158 required total dependence and was documented as being repositioned twice on this date. m. On 10/4/22, resident 158 required total dependence and was documented as being repositioned twice on this date. n. On 10/5/22, resident 158 required total dependence and was documented as being repositioned four times on this date. o. On 10/6/22, resident 158 required extensive assistance and was documented as being repositioned four times on this date. p. On 10/7/22, resident 158 required total dependence and was documented as being repositioned twice on this date. q. On 10/8/22, resident 158 required extensive assistance and was documented as being repositioned three times on this date. r. On 10/9/22, resident 158 required total dependence and was documented as being repositioned twice on this date. s. On 10/10/22, resident 158 required total dependence and was documented as being repositioned twice on this date. A Nursing Weekly Skin Review/assessment dated [DATE] documented that there was a new skin integrity problem as being triggered. The notes documented, No skin issues at this time. On 10/12/22 a Weekly Wound Observation Tool documented, Resident had a deep tissue injury that was acquired on 10/10/22 with a length of 6.7 cm (centimeters), width of 2 cm, and depth of 0 cm. No tunneling was present, no odor was present. Treatment plan was documented as, Calazinc or zinc oxide, A and D ointment or Anasept. Therapy getting pt (patient) air cushion for chair. Educated pt to stay in bed longer and to reposition every 1 to 2 hours. A Physician order dated 10/14/23, documented right buttocks (PI) [Pressure Injury] and left buttocks (MASD) [Moisture Associated Skin Disease] -clean with NS or wound cleanser then apply Calazinc or zinc oxide then A and D ointment or Anasept then foam cover dressing. Wound nurse to change Mondays, Wednesdays and Friday floor nurse to change PRN if soiled or dislodged dressing one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday). A care plan Focus dated 10/14/22 with a revision date of 2/14/23, documented [Resident] has Pressure Injurie(s): R [right] buttock Stage IV [four]. A care plan Goal documented Long Term Goal Target Date: 2/20/23 [Resident 158] will have no complications from Pressure Injury through the review date. Revised: 2/14/23. The care plan Interventions included: a. Approach start date 10/14/22. Keep HOB [Head of Bed] at 30 degrees or lower to reduce sheering/friction unless contraindicated when in bed. Keep resident off affected area as tolerated. Physician order to obtain skin barrier for incontinent residents. b. Approach start date 10/17/22. Low-air-loss mattress. The Treatment Administration Record (TAR) for September 2022 revealed the following: a. The treatment to the right and left buttocks was not completed on the following dates: 9/27/22 and 9/30/22. b. The order for the w/c cushion was put into place on 10/22/22, this was 10 days after the deep tissue injury was found. c. The order for the low air mattress was put into place on 10/17/22, this was 5 days after the deep tissue injury was found. A Physician's order dated 10/19/22 at 9:56 AM, documented Pro-Stat Liquid [Amino Acids-Protein Hydrolys] Give 30 ml by mouth two times a day for Supplement. On 10/26/23 at 4:06 PM, a Dietary progress note documented Dietary suggested to start Prostat 30 ml [milliliters] BID [twice daily]. MD [medical doctor] approved. The October MAR for resident 158 revealed, Pro-Stat Liquid Supplement was not started until 10/26/22. This was 7 days after the physician's order. The October MAR for resident 158 revealed, Pro-stat Liquid Supplement 30 ml was missed on the following dates: a. 10/30/22 AM (morning) and PM (evening) dose. b. 10/31/22 AM dose, medication unavailable. c. 11/6/22 PM dose. d. 11/12/22 PM dose, resident refused. e. 11/13/22 PM dose, resident sleeping - no follow up attempt documented. f. 12/9/22 AM dose, medication unavailable. The Nursing Weekly Wound Observation Tool in the medical record revealed the following for resident 158's wound: a. On 10/12/22, deep tissue injury measuring 6.7 cm x 2.0 cm x 0 cm b. On 10/19/22, worsening deep tissue injury measuring 7.0 cm x 2.5 cm x 0 cm. c. On 10/26/22, unchanged deep tissue injury measuring 6.0 cm x 3.5 cm x 0 cm d. On 11/3/22, unchanged deep tissue injury measuring 6.0 cm x 3.5 cm x 0 cm e. On 11/10/22, worsening deep tissue injury measuring 5.0 cm x 4 cm x 0 cm. Changes documented as undermining 1.5 cm, increase in size and drainage, erythema. Wound Care Progress note dated 11/9/22, documented resident 158's wound was not a stage IV pressure ulcer after debridement with measurements of 4.2 cm x 5.7 cm x 1.2 cm. On 11/10/22, Resident 158 was started on Levaquin for 14 days for infection to pressure ulcer. f. From 11/16/22 through 11/21/22 the pressure ulcer was documented as unchanged or improving, although documentation of worsened undermining of the pressure ulcer measured up to 6.5 cm. The Point of Care History for November 2022 was reviewed. According to documentation resident 158 was not repositioned every two to three hours on the following dates leading up to the placement of the wound vacuum 11/18/22 for the pressure injury: On 11/1/22, 11//3/22, 11/4/22, 11/6/22, 11/8/22, 11/9/22, 11/10/22, 11/13/22, 11/14/22 and 11/18/22. Physician order dated 11/17/22 revealed, WOUND VAC [vacuum] PLACEMENT- right buttocks (PI): Irrigate/cleanse wound gently with NS, dry with gauze. Apply skin prep barrier wipe to periwound skin. Apply black or green foam to wound. Secure with Tegaderm dressing. Change Vac dressing 3 times a week. Vac setting at (150) mm/Hg [millimeters of mercury] continuous therapy. Check dressing placement each shift. One time a day every Mon, Wed, Fri for vac therapy. Resident 158 was not repositioned every two to three hours on the following dates after the placement of the wound vacuum: On 11/19/22, 11/22/22, 11/26/22, 11/28/22, and 11/30/22. On 8/16/23 at 12:03 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated the CNAs were supposed to turn or reposition a resident who was a physical assist at least every 2 hours. The CNAC stated the residents needed to be repositioned whether they were in a bed or a chair, moving them was considered a reposition. The CNAC stated the CNAs were supposed to chart after each transfer or care that they provide, if they did not then it did not happen. The CNAC stated the medical charting was set up so they can easily chart everything that they did with each resident. The CNAC stated there should be documentation on transfers and resident care every two hours. The CNAC stated she remembered working with resident 158 and stated taking care of him was easy. The CNAC stated he was a total assist, so you had to do everything for him. The CNAC stated resident 158 would get pressure sores really fast if he wasn't turned every two hours, but he had a chair that would automatically tilt so it would be easy to reposition him. The CNAC stated resident 158 would be in bed all of the time, the CNAC stated she did not know why. The CNAC stated resident 158 did not have any sores when he came to the facility, he got the wounds here. The CNAC stated she was working as a CNA and would get upset when she would come back and he would be lying in the same position for an entire shift. On 8/16/23 at 12:47 PM, an interview with CNA 18. CNA 18 stated we are supposed to chart after we do anything, if we have time we do, if not we chart at the end of the shift. Sometimes we just chart it when we can. CNA 18 stated if we want to show when we actually do it we need to chart it every time we do it. On 8/16/23 at 12:43 PM, an interview was conducted with the Wound Nurse (WN). The WN stated she did her full assessment on the residents on Wednesdays. The WN stated she would sometimes chart a progress note but most of the time she would just do an assessment. The WN stated the floor nurses chart in the TAR that the wound care was done by the wound nurse. The WN stated she did not chart in the TAR that she had done the wound care, even if she performed it, the WN stated the floor nurses chart it. The WN stated there was the chance that the wound care on a resident could not be getting done when the person who was doing it was not the person charting it, especially if the nurse who was not charting it did not do the work. On 8/16/23 1 at 12:49 PM, an interview was conducted with the Corporate Resource Nurse (CRN) and the Chief Nursing Officer (CNO). The CRN stated the wound care could be charted by either. The CRN stated the wound nurse is supposed to round on the residents with the doctor and update the medical record. The CRN stated if it is in the TAR then it was done, regardless of who charted it. The CNO then stated,a nurse should not be documenting something they did not do, no nurse should chart another nurses work. Both the CRN and the CNO agreed there was the possibility that cares and wound care could not be getting done if one nurse documented what they thought another nurs[TRUNCATED]

Based on interview, observation and record review, the facility did not ensure that 4 of 68 sampled residents maintained acceptable parameters of nutritional status. Specifically, residents experienced weight loss and pressure sores without timely and appropriate interventions. This will be cited at a harm level for resident 65. In addition, residents were not provided interventions to prevent weight loss further weight loss. Resident identifiers: 16, 44, 65 and 88. Findings include: HARM 1. Resident 65 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included, spiral fracture of the left femur, type 2 diabetes, muscle weakness, and arthritis. On 7/30/23 at 8:57 AM, an interview was conducted with resident 65. Resident 65 stated that he came to the facility because he broke his femur and was now bed ridden but participated in physical therapy. Resident 65 stated that he had developed sores on his heels during the beginning of his stay at the facility. Resident 65 stated he admitted to the facility in February 2023 and ended up getting COVID-19, and once he had COVID-19 he stated he was quarantined for 27 days. Resident 65 stated staff asked how he was doing, assisted with brief changes and brought his food in, but did not perform skin checks, and no visitors were allowed. Resident 65 stated that he would try to move around in his bed but with his femur fracture he had a difficult time repositioning, and that he eventually complained of pain in his feet, and he stated that was when staff saw he had sores on both heels. Resident 65 stated that once staff saw the wound they started treating the wounds. On 8/7/23 at 12:34 a follow-up interview with resident 65 was conducted. Resident 65 stated that he felt like he had lost a lot of weight because of small meal portions. Resident 65 stated when he had COVID-19, he could tell he was losing weight. Resident 65 stated that he was given bland small meals and that he had complained about his portion sizes multiple times. Resident 65 stated that after complaining about the portion size he now gets more food. Resident 65's medical record was reviewed from 7/30/23 through 8/16/23. Resident 65's weights documented: a. On 2/3/23 weight 282.5 Lbs (pounds) b. On 2/7/23 weight 281.5 Lbs c. On 2/13/23 weight 281.2 Lbs d. On 2/20/23 weight 273.2 Lbs e. On 2/27/23 weight 264.0 Lbs f. On 3/14/23 weight 262.0 Lbs g. On 3/20/23 weight 267.0 Lbs h. On 3/28/23 weight 274.5 Lbs i. On 4/3/23 weight 260.6 Lbs j. On 4/10/23 weight 266.0 Lbs k. On 4/17/23 weight 256.0 Lbs l. On 4/24/23 weight 251.0 Lbs m. On 5/1/23 weight 237.0 Lbs n. On 5/2/23 weight 239.4 Lbs o. On 5/8/23 weight 229.0 Lbs p. On 5/15/23 weight 225.6 Lbs q. On 5/23/23 weight 223.0 Lbs r. On 5/29/23 weight 223.0 Lbs s. On 6/5/23 weight 220.0 Lbs t. On 6/12/23 weight 224.0 Lbs u. On 6/19/23 weight 223.2 Lbs v. On 6/26/23 weight 221.0 Lbs w. On 7/3/23 weight 222.5 Lbs x. On 7/10/23 weight 222.9 Lbs It should be noted resident 65 experienced a 21% weight loss from 2/3/23 until 7/10/23. Resident 65 experienced a 6.8% weight loss from 2/13/23 until 3/14/23. Resident 65 experienced a 16% weight loss from 2/3/23 until 5/8/23. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed resident 65 was 282 pounds. A MDS assessment dated [DATE] documented a swallowing/nutritional status for resident 65. The swallowing/nutritional status documented resident 65 weighed 264 pounds. The MDS revealed it was unknown or resident 65 did not have loss of 5% or more in the last month or loss of 10% in the last 6 months. [ Note: Resident 65 was admitted to the facility on [DATE] with a weight of 282 pounds. Resident 65 experienced a 6.5% weight loss from 2/3/23 until 2/2723.] A quarterly Minimum data set (MDS) assessment dated [DATE] documented a swallowing/nutritional status for resident 65. The swallowing/nutritional status documented resident 65 was 224 pounds. The MDS revealed that it was unknown or resident 65 had not had a loss of 5% or more in the last month or loss of 10% in the last 6 months. [Note: Residents previous MDS dated [DATE] documented a weight of 264 pounds.] An admission care area assessment (CAA) dated 2/9/23 documented, resident 65 has a potential risk for nutritional status and requires staff to monitor/assess daily intake, weights as ordered, and minimize risks associated with nutrition. A care plan focus dated 2/7/23 revealed, Resident is at risk for nutritional and hydration status rt [related to] impaired mobility, infection, diuretic use. The care plan had a revision dated of 8/2/23, which documented, Resident is at risk for nutritional and hydration status rt impaired mobility, diuretic use, morbid obesity. Likes to have large portions of meats. The Care plan interventions included: a. Encourage good nutrition and hydration (if not contraindicated). Provide and serve diet as ordered. Provide supplementation as ordered. RD(registered dietitian) to evaluate and make RD diet changes, recommendations PRN (as needed); educate about good food choices, caloric intake established diet, etc. Educate/reinforce importance of maintaining ordered diet PRN b. An intervention initiated on 5/10/23, documented added large protein portions, NSA [No sugar added] house shake BID [twice a day]. c. An intervention initiated on 6/28/23, documented multivitamin with minerals. A care plan dated 2/7/23 with a focus care area documented resident is at risk for impaired skin integrity rt impaired mobility, episodes of incontinence. Interventions put in place were to encourage good nutrition and hydration (if not contraindicated). Keep peri area clean and dry. Apply barrier cream PRN and with each incontinent episode. Notify wound nurse of any open areas of change in skin condition. The care plan did not address resident 65's need for assistance with repositioning in bed. A care plan dated 3/14/23 with a focus care area documented, The resident has Diabetes Mellitus with a goal of the resident will have no complications related to diabetes through the review date. Interventions were to Check all body for breaks in skin and treat promptly as ordered by doctor. Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen . Resident 65's medical record review revealed the following regarding his weight loss: A nutritional assessment dated [DATE] documented resident 65's skin was intact and had a weight of 282.5 lbs. The RD calculated resident 65's nutritional needs using his adjusted body weight. Resident 65 needed were 2362 calorie (kcals) with a 25 kcal/kg(kilogram) factor, 2362 milliliters (ml) of fluid using 1 ml/kcal, and 75-95 grams (g) of protein using 0.8 to 1.0 g/kg. The RD documented Resident tolerating reg [regular] diet well, no chew/swallow concerns. PO [oral] intake 51-100% of meals, mostly >76%. Snacks ad lib [as desired]. Energy needs est. [estimated] using adjusted body weight (94.5 kg) d/t [due to] morbid obesity. He is expected to be meeting needs at this time. CCHO [carbohydrate controlled] diet order appropriate d/t PMH [past medical history. Allergy to walnuts, kitchen aware. Sub-optimal fluid intake charted, encourage fluids with/between meals. No recent wt [weight] changes known, will monitor trends as ordered. Skin intact. No BM [bowel movement] yet, bowel regimen ordered to assist. On 2/7/23 a skin and weight review documented the reason for review was a new admission with a stable weight of 282.5 pounds. On 2/21/23 a skin and weight review documented the reason for review was weight loss with a 2% loss in 7 days. The most recent weights documented on 2/13/23, resident 65's weight was 281.2 Lbs, and on 2/20/23 weight was 273.2 Lbs. Resident has had recent weight loss, he is on diuretics which can cause weight fluctuations, he recently tested positive for COVID . no other issues noted. The summary documented Weight loss noted at 2.9% x1 week, currently with edema and on diuretics. Weight fluctuation expected with fluid shifts. Continue to monitor. On 2/28/23 a skin and weight review documented the reason for review was weight loss with a 2% loss in 7 days. The most recent weight documented on 2/20/23, resident 65's weight was 273.2 Lbs, and on 2/27/23 his weight was 267.0 Lbs. Resident has had weight loss again this week, he continues with diuretics and weight fluctuation is expected. The summary documented weight loss continues at 3.4% x1 week. He has edema and continues taking diuretics. Expect that weight loss is attributed to fluid shifts. Continue to monitor. There were no new interventions provided at this time On 3/6/23 a nutritional/dietary note documented that resident reported he was having difficulty cutting foods and decided not to eat. Spoke with family and agreed to change to NDD3 [national dysphagia diet level 3]. [Note: This diet was moist foods in bite-sized pieces. In addition, resident 65 had lost 18 pounds since admission 2/3/23.] On 3/14/23 a nutritional assessment documented resident 65's current intake may promote gradual weight loss, which is desirable . wt has been trending down, noted at 6.9% weight loss x 1 month. On 4/4/23 a skin and weight assessment documented the reason for review was weight loss with a 2% loss in 7 days. The most recent weight documented on 3/28/23, resident 65's weight was 274.5 Lbs, and on 4/3/23 his weight was 260 Lbs. Resident has had a recent weight loss, he is on diuretics that can cause fluctuations in weight. There were no new interventions provided at this time. On 4/18/23 a skin and weight assessment documented the reason for review was weight loss with a 2% loss in 7 days. The most recent weights documented on 4/10/23, resident 65's weight was 266 Lbs, and on 4/17/23 his weight was 256 Lbs. Resident has had a recent weight loss this week, he is on diuretics which can cause fluctuation in weight . no other issues noted at this time. The summary documented resident 65 was tolerated diet well . Weight fluctuations persist . overall weight loss is desired d/t elevated BMI [body mass index]. There were no new interventions provided at this time. On 4/25/23 a skin and weight assessment documented the reason for review was weight loss with a 2% loss in 7 days. The most recent weights documented on 4/17/23, resident 65's weight was 256 Lbs, and on 4/24/23 his weight was 251 Lbs. [Resident 65] has had a weight loss this week he is currently taking Lasix . There are no dietary recommendation at this time. No other concerns. The summary/comments documented resident 65 has had Some weight fluctuations, overall noted to have weight loss since admit: 6% loss x1 month or 11.2% since 2/2023. Weight loss attributed to fluid loss with edema/diuretic use. Continue to monitor wt trends as ordered. There were no new interventions provided at this time. On 4/25/23 a nutrition/dietary note documented a brief nutrition not d/t significant weight loss .continue to monitor. [Note: No interventions were implemented at this time.] On 5/2/23 a skin and weight review documented the reason for review was weight loss, with 2% loss in 7 days. The most recent weights documented on 4/24/23, resident 65's weight was 251.0 Lbs, and on 5/2/23 his weight was 239.4 Lbs. [Resident 65] has had a weight loss this week. He is currently taking Lasix . He is not taking any dietary supplements . Dietary recommendations listed below will be implemented. No other concerns at this time. A new intervention provided was to add large protein portions The summary/comments documented resident 65's Weight loss continues (noted at 4.7% x1 week, confirmed on reweigh.) He continues with edema and on diuretics . RD suggested large protein portions to augment, though rapid weight loss. good PO [by mouth] intake is likely associated with fluid shifts. On 5/8/2023 a nutrition/dietary note documented, Dietary suggested to start large protein portions. MD [Medical Doctor] approved. [Note: This is the first intervention implemented for residents continued weight loss. Resident 65 had a total weight loss of 55 lbs since his admission.] On 5/9/23 a skin and weight review documented the reason for review was weight loss, with a 2% loss in 7 days, a 5% loss in 30 days, and a 7.5% loss in 90 days. The most recent weights documented on 5/1/23, resident 65's weight was 237.0 Lbs and on 5/8/23 his weight was 229.0 Lbs. [Resident 65] has had a weight loss this week. He is currently taking Lasix . Dietary recommendation listed below have been approved by provider and will be updated. No other concerns at this time. New interventions provided were to add NSA house shake BID [twice a day]. The summary/comments documented resident 65's weight continues to decline. Noted to have 4.4% wt loss x1 week(-14% x1 month, -18.7% x3 months). He continues with edema and on diuretics; rapid wt loss attributed to fluid loss vs. sub-optimal PO intake . RD suggested NSA house shake BID to provide and additional 400 kcals [kilocalories] and 16 gm [grams] protein. Continue to monitor wt trends. On 5/10/23 a nutrition/dietary note documented dietary suggested to start NSA house shake BID. MD approved. On 6/12/23 a mini nutritional assessment screening documented resident 65 nutritional status. Resident 65 current weight was documented as 220 lbs, with a weight loss greater than 3 kg (kilograms) during the last 3 months. The nutritional status screening, resident 65 scored 8 points. Note: 8-11 points: At risk of malnutrition. On 6/27/23 a skin and weight review documented the reason for review was for wounds. Resident 65's weight change was documented as stable. [Resident 65] is on large protein portions with house supplements 2 times a day, his DTI [deep tissue injury] is stable and his weight remains stable. [Note: After the interventions were added, resident 65's weight has remained stable.] On 8/1/23 at 1:05 PM, an observation was made of resident 65. Resident 65 had a chocolate health shake on his meal tray. [Note: Resident 65's order was the NSA House supplement twice a day. The one provided was the regular sugar house shake.] On 8/7/23 at 12:43 PM, an observation of resident 65's lunch tray was made. Resident 65 had a strawberry banana house shake NSA, ham, gravy, mashed potatoes, green beans, apple juice and cake. On 8/9/23 at 11:52 AM, an interview was conducted with the wound nurse (WN). The WN stated that she was not involved in the buildings skin and weight meetings, she informed the Director of nursing (DON) of any information regarding residents wounds and any new findings. The WN stated that she was not directly involved with the dietitian in regards to communication with a residents nutrition status in aiding wound healing. The WN stated the resident 65 had poor circulation, dry skin and that he was scared to move a lot with his healing fracture, and that could be the reason his diabetic sore may have progressed to a stage III pressure ulcer. The WN stated that protein would help with stabilize blood sugar and help with wound healing. On 8/9/23 at 2:34 PM an interview with the Registered Dietitian (RD) was conducted. The RD stated that she gave the DON a list of residents she was monitoring. The RD stated that she was not involved in the skin and weight meetings, and that the DON notified her if an intervention was needed. The RD stated that for resident 65's weight loss was due to aggressive diureses and that interventions were not necessary because of his good oral intake. The RD stated that a protein will be added to a resident's diet, if they have a pressure injury and were not eating well. The RD stated that resident 65's house shakes were the ones with no sugar. The RD stated that he was on a diabetic diet and she would expect the resident to get the correct shakes ordered for him. On 8/9/23 at 3:03 PM an interview with the DON was conducted. The DON stated that for the skin and weight meetings the RD gathered information and submitted the information to the DON. The DON stated that resident 65 did not move very well in his bed when he was first admitted . When the DON was asked about resident 65's bilateral heel wounds and continual weight loss the DON stated that he was admitted to the facility on diuretics which caused his fluctuating weights. The DON stated that recommendations were documented from the RD and the MD was then notified of the recommendations. On 8/9/23 at 3:19 PM an interview was conducted with the Corporate Director of Nutrition Services (CDNS). The CDNS stated that the protein needs for a resident depended on the RD's nutrition assessment. The CDNS stated the CCHO diet provides 1800-2000 Kcals and an average of 85 to 95 grams of protein. [Note: Resident 65's admission nutritional assessment documented his calorie needs were 2362 kcals with a 25 kcal/kg and 75 to 95 g of protein using 0.8 to 1.0 g/kg. The CCHO diet provided less calories that resident 65's calculated needs.] 30563 POTENTIAL FOR HARM 2. Resident 44 was admitted to the facility on [DATE] with diagnoses which included other specified disorder of brain, seizures, lack of coordination, aphasia, type 2 diabetes mellitus, ataxia, aphasia, dementia without behavioral disturbance, slurred speech, anxiety, alcohol intoxication, and personal history of traumatic brain injury. On 7/31/23 at 2:19 PM, an interview was conducted with resident 16 who was resident 44's roommate and significant other. Resident 16 stated that food was not good and resident 44 had had weight loss. Resident 44's medical record was reviewed from 7/30/23 through 8/16/23. An annual MDS assessment dated [DATE] revealed resident 44 was 70 inches tall and 158 pounds. Resident 44 had no lost weight in the last month or the last 6 months. A care plan dated 7/24/22 and revised on 4/2/23 revealed Resident is at nutritional and dehydration risk rt diabetes, deficits in self care, alcohol abuse, dementia. The goal was [Resident 44] to maintain weight [plus or minus] 10% until next review and [Resident 44] to maintain adequate hydration status; no s/s [signs and symptoms] of dehydration. Interventions included Diet as ordered; support/encourage resident to make healthy dietary choices to manage blood glucose levels.Monitor weekly weights x4 weeks, or until stable.House Supplement TID [three times a day] and Large protein portions. Resident 44's weights were: [Note: All weights were in pounds.] a. On 1/2/23 was 177.0 b. On 2/2/23 was 65.0 c. On 3/13/23 was 148.2 d. On 3/14/23 was 145.4 e. On 5/1/23 was 149.9 f. On 4/3/23 was 141.2 g. On 6/5/23 was 158.4 Resident 44 lost 10.7% weight from 1/2/23 until 6/5/23. Resident 44 lost 17.9% from 1/2/23 until 3/14/23. Resident 44 lost 15.3% weight from 1/2/23 until 5/1/23. On 3/15/23 at 9:41 AM, a Nutrition/Dietary Note revealed Nutrition note d/t [due to] significant wt change: Tolerating CCHO, NAS, large protein diet well. Good intake noted at 51-100% of meals (often >76%). Weight has been trending down, overall down 16.8% in the last month. BMI 20.9. He is not expected to be meeting energy needs at this time. RD suggested house shake TID [three times a day] to augment, for NAR [nutrition at risk] on 3/15/23. Suggest transitioning back to weekly weights until stable. Continue to monitor. Physician orders revealed that a house supplement was ordered on 5/3/23. Resident 44's diet order dated 8/2/22 revealed carbohydrate controlled and no added salt with large portions. A physician's order dated 3/17/23 revealed Mirtazapine 15 milligrams one time a day for an appetite stimulant. It should be noted resident 44 continued to lose weight and no interventions were added from 3/17/23 until 5/3/23. A Skin and Weight meeting dated 8/8/23 revealed resident 44 had gained weight and current weight was 164.2. The diet order was Large protein, NAS, CCHO. Eats 75-100%. Supplement intake percent 100% and received snacks as desires. Resident tolerating diet well, good appetite. PO [oral intake] intake 76-100% of meals. Accepting house shake as ordered. Weight gain noted at 9.9% x3 months, attributed to increased energy intake. BMI 23.6. Wt gain ideal, continue to monitor. [Resident 44] has had weight gain over the past three months. He continues to take MVI multivitamin, appetite stimulant, hydrochlorothiazide and house supplement. There are no dietary recommendations at this time and no skin issues. 3. Resident 88 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease with late onset, cerebrovascular disease, type diabetes mellitus, abnormalities of gait and mobility, sciatica of left side and hypertension. On 8/1/23 at 1:05 PM, an observation was made of resident 88. Resident 88 had a chocolate health shake on the meal tray. The chocolate shake was not a no sugar added. Resident 88's medical record was reviewed 7/30/23 through 8/16/23. An admission MDS dated [DATE] revealed resident 88's height was 64 inches and 171 pounds. Resident 88 did not have 5% or more weight loss in the last month or more than 10% in the last 6 months. A care plan dated 5/10/23 revealed [Resident 88] has Diabetes Mellitus type 2. The goal was [Resident 88] will have no complications related to diabetes through the review date. An intervention revealed Dietary consult for nutritional regimen and ongoing monitoring. A nutritional care plan dated 5/16/23 revealed [Resident 88] is at risk for altered nutritional status and dehydration r/t: impaired mobility, diabetes and Alzheimer's disease, diuretic use. The goal was [Resident 88] will eat/drink 75-100% of meals/drinks provided. Will have no s/s of dehydration. Will have no complaints of hunger or thirst. Will tolerate food/beverages without choking or aspiration. An intervention included NSA [no sugar added] House supplement TID. A physicians order dated 5/23/23 revealed a house supplement with meals for supplement no sugar added shake if available.

Based on observation, interview, and record review, it was determined for 2 of 68 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility must ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs. Specifically, facility staff transferred a resident who required a two person physical assist resulting in a femur fracture. Also, a resident who sustained a fall was not assessed by the nurse or monitored after the fall. The findings for resident 22 were determined to have occurred at a harm level. Resident identifier: 18 and 22. Findings included: HARM 1. Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Multiple Sclerosis (MS), chronic obstructive pulmonary disease, dysphagia, muscle weakness, dementia, anemia, hypertension and age related osteoporosis without pathological fracture. Resident 22's medical record was reviewed on 7/30/23 through 8/16/23. A Nurse Progress note on 2/18/23 documented, CNA [Certified Nursing Assistant] was transferring res. [resident] from power w/c [wheelchair] to bed using the gait belt around the res. CNA explained to the res. what she (sic) was going to do with transfer, she put the sheet around the thigh then lifted the feet on to bed at the very edge, cna was on res. bed halfway lifted by gait belt and moved res. towards the bed while res. held onto arm, res. moved towards the bed and heard there was a pop. Res. said she did not feel anything, she was not sure, when positioning the legs and feet CNA noticed the rt. [right] thigh did not looks right, res, denies pain, affected thigh immobilized, asked PT [Physical Therapy] to assesses, NP [Nurse Practitioner], DON [Director of Nursing], and sister [name omitted] notified. An IDT (Interdisciplinary Team) review was conducted on 2/20/23 with the following interventions documented, MD [Medical Doctor] notified, x-ray obtained of the right leg, NP notified that the leg appeared to have a fx [fracture], sent resident to the ER [emergency room ] for further evaluation. No intervention was put in place for CNA education on transferring residents. On 8/9/23 at 4:45 PM, an interview was conducted with CNA 9. CNA 9 stated on the day resident 22 broke her femur she was sitting in her wheelchair and there was not a Hoyer lift sling underneath her. CNA 9 stated she did not know why the previous aide had not left one there and stated resident 22 was anxious to get back to bed. CNA 9 stated she was not resident 22's aide but was trying to help out. CNA 9 stated she went out into the hallway to find someone to help her transfer resident 22 but could not find anyone. CNA 9 stated she then moved resident to the side of her bed, so that her wheelchair was parallel with the bed. CNA 9 stated she then lifted resident 22's legs up on the bed so that her heels were on the bed. CNA 9 then placed a sheet around both of resident 22's legs just above the knee level. CNA 9 stated she then climbed onto resident 22's bed so that she was facing resident 22. CNA 9 stated she had resident 22 put both her arms around CNA 9's neck. CNA 9 stated she them grabbed hold of the gait belt resident 22 had on with her left hand and wrapped the sheet around her right hand and tucked it under her right armpit. CNA 9 stated at that time she pulled resident 22 over onto the bed in one smooth motion, kind of like a slide board situation. CNA 9 stated the resident's legs did not get caught on anything and she did not know how this happened. CNA 9 stated she noticed something was wrong when there was an audible sound and resident 22's right thigh didn't look quite right. CNA 9 stated at that time she went out to get someone to help her and the nurse came in to assess resident 22. CNA 9 stated the resident did not appear to be in any pain and was sent to the ER for evaluation. CNA 9 stated she did not remember if there was enough staff working in the facility that day. CNA 9 stated she did not know why there were not enough Hoyer slings that day. CNA 9 she had done this maneuver many many times and stated she had seen this technique used at the facility before. CNA 9 stated the best practice would have been to wait for another staff member to help use the Hoyer lift, if there was a sling under resident 22. CNA 9 stated the next would have been, since there was no sling, to have 2 other staff help move her over to the bed, the next safest option would be to have just one staff help move her over - kind of like a fireman carry. CNA 9 stated the method she used would be that last option to use. CNA 9 stated she was taught this in training and was sure she was taught it at the facility by someone but was unsure who. CNA 9 stated, If she had the sling under her this wouldn't have happened. CNA 9 stated This was avoidable in every way if the Hoyer was used. The exhibit 358 had alleged that on 6/1/23 at 12:58 PM, the facility reported that on 2/18/23 at 11:00 AM, the resident 22 was being transferred to bed by 2 unidentified staff members. During the transfer a pop was heard and the CNA had noted the right thigh looked abnormal but resident 22 denied any pain. A STAT X-ray was ordered and per the results of the X-ray the resident was sent to [local hospital] for further evaluation. A fracture was detected. The ombudsman was notified. The investigation was completed by Administrator (Admin) 1. The allegation was Not verified: Abuse can not be verified at this time as resident is at risk for fractures related to her diagnosis of osteoporosis. Furthermore, there was no intent to cause harm. Patient is at baseline as evidence by participating in facility activities, ambulate via electric wheelchair throughout facility, and continues to participate in family events outside facility. The corrective actions taken were Education completed on correct transfer techniques. Facility ordered more slings to be available for resident use. There was an interview documented with resident 22 by the Admin 1. A form titled Interview with [Resident 22] on 6/7/23, [Resident 22] stated she was transferred by a CNA into her bed without the use of the Hoyer lift. When the aid transferred her it resulted in a fracture to her right femur. Resident stated she has no lasting pain, resident stated she feels safe at the facility. Resident 20 had signed the form by signing her initials and the form had been witnessed by the Admin 1's signature. On 8/10/23 at 1:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNA had moved resident 22 by herself and the resident was sent out with a suspected right femur fracture. The DON stated the expectation of the staff would have been for the CNA to wait to get help and use the Hoyer lift to transfer resident 22. The DON stated resident 22's femur fracture could have been avoided if the transfer was completed correctly. The DON stated on orientation physical therapy educated the staff how use the Hoyer lift and the Sit to Stand. The CNA coordinator educated staff on how to use the lifts by example and by them working on the floor with the other staff. The DON stated an inservice was completed after this incident on how to transfer residents correctly. [Note: CNA inservice information was not provided to the survey team.] On 8/16/23 at 12:03 PM, an interview was conducted with the Certified Nursing Assistance Coordinator (CNAC). The CNAC stated the expectation of the CNAs when they care for a resident who was dependent and required a 2 person assist was that there were two CNAs in the room to transfer and care for that resident. The CNAC stated CNAs were educated upon hire on how to correctly transfer residents. The CNAC stated further education was done on an as needed basis. 43212 POTENTIAL FOR HARM 2. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, conversion disorder with seizures, Todd's paralysis, morbid obesity, anxiety disorder, post traumatic stress disorder, and seizures. Resident 18's medical records were reviewed from 7/30/23 through 8/16/23. A review of resident 18's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 18 required a 1 person physical assist with transfers. Resident 18's care plan initiated on 8/9/22 and revised on 11/17/22 included that resident 18 was at risk for falls related to impaired mobility, right sided weakness, Todd's paralysis, history of repeated falls, and seizure disorder. Interventions included, follow facility fall protocol. Resident 18 had a fall risk assessment completed on 3/15/23 that concluded he was at high risk for falling. Resident 18 did not have a fall risk assessment after the reported fall on 4/17/23. Resident 18 was assessed again for fall risk on 7/18/23 and determined to be a moderate risk for falls. No documentation of neurological checks were found in resident 18's medical records for the reported fall on 4/17/23. A nurse's progress note dated 4/16/23 at 6:56 PM documented, Resident had a seizure around 5:50 PM and night nurse [nurses name] gave his prn [as needed] Ativan for seizure. Resident stopped seizing around 6:15 pm. Notified APRN [advanced practice nurse practitioner][provider's name]. On 4/21/23 at 9:52 AM, an Interdisciplinary Team (IDT) meeting was conducted. The IDT note documented,DOI (date of injury) 4/17/23 .IDT: 4/21/23 .Event: unwitnessed fall .Resident status prior to event: Stable .Risk factors: transferring without assistance, received Lorazapam prior to fall .Preventative measures prior to event: assist with ADL's [activities of daily living], call light within reach, med [medication]/treatment as ordered, anticipate needs, pain control .root cause analysis: ambulating without assistance, weakness, increased sedation .Interventions: ordered ammonia level. On 4/20/23, exhibit 358 was submitted to the State Survey Agency (SSA). The report stated that on 4/16/23 at an unknown time, resident 18 had fallen and proper procedures were not followed. The report stated resident 18 was assessed and no injuries or changes in behavior were noted. On 4/24/23, the exhibit 359 was submitted to the SSA. The investigation stated that resident 18 was interviewed and reported having 2 falls. The investigation stated that resident 18 was embarrassed at how the aids helping him had conducted themselves. The investigation stated that resident 18 could not confirm if follow-up fall procedures or neurological checks were completed. The investigation stated that the nurse on duty was interviewed and stated that resident 18 fell on ly 1 time and that facility fall protocols were not followed. Other staff interviews included 2 Certified Nursing Assistants (CNA) who attended to resident 18 after the fall. One CNA stated that the nurse was notified of the fall and did not initiate the fall protocol. The second CNA was never reached for an interview. A summary of information that may have been contributing factors included the resident's known seizure on 4/16/23, his medication administration after the seizure, and a Brief Interview for Mental Status (BIMS) score of 10. The conclusion of the investigation found the allegation of abuse or neglect not verified. The reason stated was resident 18 confirmed there was no mental harm or mental anguish because of the nurse's inaction. The conclusion also stated that the nurse was no longer employed at the facility. On 8/7/23 at 3:06 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was familiar with resident 18's care. RN 1 stated resident 18 did not have any preventative measures in place to stop his seizures. RN 1 stated resident 18 had Ativan for administration after a seizure, and that he would usually pass out after having a seizure. RN 1 stated that resident 18 used to fall frequently after having seizure, and that the Ativan caused him difficulty with mobility. RN 1 stated she did not know where resident 18 had fallen after his seizure event on 4/16/23. RN 1 stated resident 18 may have been in the bathroom. RN 1 stated that resident 18 did not always call for help. RN 1 stated if a resident sustained a fall, the CNA should notify the nurse and the nurse should assess the resident before getting up. RN 1 stated the protocol was to notify the Director of Nursing (DON), the physician, and the resident's family if applicable. RN 1 stated the fall protocol also included doing neurological checks, if the fall was unwitnessed, every 15 minutes for the first hour, then every 30 minutes for a total of 2 days. RN 1 stated the nurses assessment included doing a full set of vitals, having the resident squeeze the nurses hands, and looking at the resident's pupils. RN 1 also stated depending on the reason for the fall, the care plan might be changed. On 8/16/23 at 12:54 PM, a phone interview was conducted with Administrator (Admin) 1. Admin 1 stated that the DON had interviewed the nurse on duty during the reported fall to determine how many falls occurred. Admin 1 stated the DON interviewed resident 18's roommate at the time who did not witness any inappropriate comments by staff. Admin 1 stated she was reading through the report during the interview. Admin 1 stated she had received a phone call from an agency service supervisor about a fall that had occurred on the shift during which the fall happened. Admin 1 stated the agency CNA had reported his concerns to his supervisor at the agency. Admin 1 stated she had noticed there was not a progress note or any documentation regarding a fall on 4/17/23. Admin 1 stated she called the nurse that was on the shift and asked her to return to work and complete an incident report. Admin 1 stated the nurse was terminated. Admin 1 stated an IDT note was completed regarding the event on 4/21/23. Admin 1 stated the DON completed in-services for nurses about reporting events, and documenting neurological checks. Admin 1 also stated that a Quality Assessment and Performance Improvement (QAPI) was initiated. Admin 1 stated that resident 18 reported that he did not have any lasting effects as a result of his fall, and there was no physical harm. Admin 1 acknowledged that procedures were not followed.

Based on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with a mental disorder or a psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident with suicidal ideation and a Pre-Admission Screening Resident Review (PASRR) Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for resident 62 were found to have occurred at a harm level. Resident identifier: 62. Findings include: HARM Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic post-traumatic stress disorder (PTSD), anxiety disorder, insomnia and depression. On 7/30/23 at 12:00 PM, an interview was conducted with Resident 62. Resident 62 stated that she spent most of her time in her bed and that it was hard for her to get around. Resident 62 stated that she ate all meals in bed and watched TV or purchased things on amazon for her activities. Resident 62 stated that since the first day in the facility she had told multiple staff members she needed mental health. Resident 62 stated that she would like to see a psychiatrist to talk about her feeling, and to hopefully get on the right medications to help her with the anxiety and depression. Resident 62 stated that she had been having night terrors and anxiety attacks, and felt it was because she was not getting the mental health she needed. Resident 62 stated that she had suicidal ideation and often felt she would be better off dead. Resident 62 stated the last time the facility asked about her suicidal ideation was three or four months ago, but she has had those thoughts more recently. Resident 62 stated that she had been receiving mental health services since she was a teenager and that her psychiatrist retired a year ago and that she did well when she has mental health services. An observation was made during the interview with resident 62 of a registered nurse (RN) entering the room to give resident 62 medication. Resident 62 stated to the RN that she had night terrors the previous night and did not get much sleep, the RN said ok and left the room. (Which RN?) Resident 62's medical record was reviewed from 7/30/23 through 8/16/23. Resident 62 discharged from a local hospital on 3/18/23 and admitted to the facility. Resident 62's hospital care plan goals, discharge treatment orders revealed, Consult to case management- psychosocial needs (consult to social work). On 4/12/23, a level II Pre-Admission Screening Resident Review (PASRR) assessment was completed for resident 62. The assessment indicated that the evaluator's diagnostic impression was that resident 62 had major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder. The assessment also indicated that [Resident 62] reported a history of 'chronic complex PTSD' secondary to multiple traumas in her life. She reported that in 1996 she was assaulted by her boyfriend who beat, raped & strangled her and left her for dead; she stated that he 'hit me on the head with a rock like 30 times trying to break my head open'. She was able to survive this attack and rehabilitate but has suffered from severe PTSD since then. She reported about [AGE] years ago she became severely ill with sepsis, and that after this she was no longer able to concentrate enough to work, and that anytime she is in a medical setting like a hospital she goes back to the time she was severely ill with sepsis. She reports sxs [signs and symptoms] of PTSD including recurring nightmares/night terrors, flashbacks, intrusive memories, dissociative episodes in which pt [patient] reports she will 'zone out', avoidance behaviors, irritability, poor sleep, impaired concentration, heightened startle response . She has experienced sxs including depressed mood, anhedonia, loss of energy and motivation, increased eating leading to weight gain . disrupted sleep, feelings of worthlessness and hopelessness, chronic thought of being better off dead, and SI [suicidal ideation] with one past suicide attempt in 2006 when she cut her wrist with a razor . She has been involved in outpatient mental health treatment, and reported seeing a therapist/psychiatrist for 5-6 years until this psychiatrist retired in April 2022 . The Current Psychiatric Functioning section stated, .She reports chronic feelings of hopelessness and that things are not likely to get better for her. She denies active SI but endorses chronic thoughts of being better off dead/ 'it would be better if I wasn't alive' given all of her medical concerns. She is very open to a referral for mental health services as she found counseling/talk therapy to be very helpful in the past; the SNF [skilled nursing facility] social worker was advised of this. The assessment listed the following: Recommendation for Specialized Services for mental illness treatment: Pt would like to have a referral for mental health services. A review of Resident 62's Minimum Data Set (MDS) dated [DATE] revealed, a resident mood interview was conducted. The residents total severity score was 23 out of 27. [Note: A score of 20-27 would indicate severe depression.] The MDS revealed a Brief Interview for Mental Status (BIMS) score of 15. [Note: A resident that was intact cognitively would have a BIMS score of 13-15.] A care plan dated 3/29/23 revealed, a focus care area was, Resident is at risk for suicidal impulsive/ideation of self-harm A goal developed was, Resident will remain safe from self-harm by next review. Interventions were A staff member will remain with the resident until Licensed staff member arrives to assess the resident. After performing a suicide assessment, the licensed staff member shall notify the resident's attending MD [Medical Doctor] and responsible party. Immediately report to the charge nurse, nursing supervisor, and physician/NP [nurse practitioner] if resident verbalizes thoughts of hurting themselves. Licensed staff member to perform suicide assessment if suicidal ideation is identified. Assess suicidal thought by asking the resident/patient to share suicidal history, feelings, plans and behavior. Nursing personnel and other staff involved in caring for the resident shall be informed of the suicidal ideation and instructed to report changes in the resident's behavior immediately. A care plan dated 3/39/23 revealed, a focus care area was, RECREATION [Resident 62] .pain limits activity involvement; mood problem: anxiety/depression; has little interest/pleasure in doing things. A goal developed was, [Resident 62] will accept, as desired, at least 1 Therapeutic visit weekly for increasing in coping skills through next review date. Interventions were Provide 1:1 visit 1x weekly. A care plan dated 4/1/23 revealed, a focus care area was, Resident is at risk for mood impairment. A goal developed was, The resident will have improved mood state through the review date. Interventions were Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc). A review of resident 62's care plan documented a focus care area The resident uses anti-anxiety medications r/t [related to] anxiety disorder. A goal developed was the resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through review date. The interventions were administer anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness Q-shift [every shift]. A review of the Suicide/Homicide Risk Evaluation dated 3/29/23, documented, 1. Suicide/Homicide Risk Evaluation. Take the threat of suicide or homicide seriously A. Is the resident making suicidal statements? Yes 2. Determine Risk. A. Is the resident considered High or Low Risk? Low risk B. Will the resident agree to a safety plan? Yes 3. Plan. To ensure resident safety for LOW RISK A. Work with the resident on a safety plan C. Contact manager on duty, NHA (Nursing Home Administrator), DON (Director of Nursing) and Social services D. Notify MD Resident 62's progress notes revealed the following: a. On 3/19/23, a nurses note entry indicated the staff would monitor resident 62 for 72 hours upon admission. The entry documented on the first day of admission, Mental Status/Behavior: AA/Ox4 [alert and oriented to name, date, time and place]. Anxious . b. On 3/20/23, a nurses note entry indicated the staff would monitor resident 62 for 72 hours upon admission. The entry documented on the second day of admission, Mental Status/Behavior: Anxious, cooperative . c. On 3/22/23, a social services note documented, SS [social services] was informed that Pt. [patient] had a Suicidal Ideation Pt. states that she was not wanting to live any longer has no plan. ADMIN [administrator], DON, ADON [Assistant Director of Nursing], SS Consultant and MD is aware. A suicidal Ideation Assessment was done Pt. has no plan MD feels like Pt. is no harm to herself of others. staff is aware and will monitor for any signs and will report it immediately. d. On 3/22/23, a nurses note entry documented resident 62 had taken a PHQ9 [Patient Health Questionnaire 9] triggered high. We reviewed with resident. She denied suicidal ideation. She made contract for safety. e. On 3/22/23, a nurses note documented that resident 62 was Being sent to [name of local hospital] for further medical evaluation . A review of resident 62's hospital admission paperwork dated 3/22/23 the physician documented, Patient states her 'anxiety and depression are through the roof.' f. On 3/27/23, a nurses note documented the facility nurse had spoken with the nurse at the hospital to get a nurse to nurse report. The entry documented a Nurse to Nurse .Psych [psychiatric] Dx [diagnosis]: Pt c/o [complained of] anxiety. Hospital gave hydroxyzine . g. On 3/29/23, a nurses note documented during the 72 hour readmission monitoring, Mental status/Behavior: AA/O x4, anxious . h. On 3/29/23, a social service note documented, SS [social services] was informed that Pt. had a Suicidal Ideation Pt. states that she was not wanting to live any longer has no plan. ADMIN, DON, ADON, SS consultant and MD is aware. A suicidal ideation Assessment was done Pt. has no plan MD feels like Pt. is no harm to her self or others. Staff is aware and will monitor for any signs and will report it immediately. i. On 3/30/23, a physician admission note documented the reason for resident 62's hospital admission. The note revealed on 3/22/23 Transferred to [name of local hospital]- Suicidal ideations. 3/27/23: readmitted to [name of facility]. j. On 4/14/23, a nurses note documented Provider gave order to start trazodone 50 mg [milligrams] QHS [every night] for insomnia . k. On 4/18/23, a physician progress note documented a visit was conducted for the Psych IDT (Interdisciplinary team) meeting. The note revealed, Team met to review psychotropic medications .Says she doesn't sleep much .Discussed sleep hygiene. she is tearful, says 'it doesn't work for me.' Discussed sleep debt, says 'i'll try.' l. On 4/18/23, a psychotropic note documented that resident 62's,Alprazolam will end today after the 14 days m. On 5/16/23, an order note revealed an anxiety medication increase, Note Text: hydrOXYzine HCI Oral Tablet 50 MG . Give 50 mg by mouth every 6 hours as needed for itching/anxiety for 14 days . to increase hydroxyzine dose to 50 mg from 25 mg. pt c/o [complained of] heart palpitations, upset stomach, and presented with anxiety. pt explained she felt like she may have had a mild heart attack . increased dose administered. wctm [will continue to monitor] behavior and VS [vital signs] and report any changes PRN [as needed]. n. On 5/16/23, a nursing note entry documented resident 62's appointment with the infectious disease physician and during the appointment resident 62 was having, having atypical chest pain . anxiety?, MI [Myocardial infarction]?, PE [Pulmonary Embolism]? -sending to ER [emergency room ] . [Note: The emergency room notes could not be located in the residents chart.] o. On 5/17/23, a nursing note entry revealed hospital visit findings, This nurse spoke with [Resident 62] regarding her observation in the ER d/t (due to) paperwork having minimal information. [Resident 62] states that hospital completed EKG [electrocardiogram] and labs to assess for signs of a heart attack or blood clot. [Resident 62] states that the results came back all within normal limits and that's why they sent her back. She states that they believe it was anxiety associated d/t her self reporting she had had a panic attack earlier in the day . p. On 5/17/23, an IDT Event review note indicated the team discussed resident 62's most recent hospital visit. The not revealed, Event: Chest pain . Root Cause Analysis: palpitations potentially from anxiety -Intervention: Sent to ER for eval [evaluation] from clinic . No concerns were noted. Monitor for SOB [shortness of breath], recurring chest pain, anxiety symptoms . The note did not indicate what, if any, recommendations the IDT had for the residents mental health needs. q. On 5/19/23, a medication order note documented,start buspirone 10 mg TID (three times a day) for anxiety . r. On 5/26/23, a nurses note documented the MD made a change to resident 62's medication, Increase duloxetine 60 mg to BID [twice a day]- Depression. s. On 7/13/23, a physician progress note documented he saw the resident for a follow up visit. The physician documented that, Resident stated she had a panic attack and night terrors t. On 7/18/23, a Physician progress note documented that he saw the resident for a psychotropic visit. The physician documented that resident 62 . has the same complaints as usual . u. On 7/18/23, a Psychotropic note reviewing the psychotropic medication resident 62 was taking documented, Resident is taking Buspirone, Duloxetine, Trazodone, Hydroxyzine. Discussed increasing Buspirone to 20 mg TID [three times daily] for increased anxiety, Hydroxyzine will fall off 8/17/23. Resident is also asking to be seen by a therapist, will have resident advocate send request to [name removed] Behavioral health . v. On 7/18/23, a medication order note documented to, start hydroxyzine 50 q6hrs [every six hours] prn [as needed] 30 days for anxiety w. On 7/19/23, a medication order note documented another increase in anxiety medication, busPIRone HCI Oral Tablet 10 MG . Give 20 mg by mouth three times a day for Anxiety . x. On 7/24/23, a nurses note documented an increase in medication for PTSD, Prazosin from 2mg to 3 mg QHS for PTSD . y. On 7/31/23, a social services note documented, Pt application was sent in to [Behavioral Health]. [Note: Resident 62's PASRR II dated 4/13/23 recommended a referral for mental health services.] On 8/16/23 at 3:25 PM, an interview was conducted with the Corporate Resource Nurse (CRN), the CRN stated she had spoken with medical record (MR) and the administrator (Admin) 2, and could not locate the emergency room records for resident 62 indicating her visit for her anxiety attack on 5/16/23 to 5/17/23. On 8/8/23 at 12:55 PM, an interview was conducted with the Resident Advocate (RA) and the Social Services Assistant (SSA). The SSA stated that if a resident scores high on PHQ9, the resident was sent out to the therapy team. The RA stated that the facility treated the questionnaire as a serious SI. The RA stated that when the therapy consultants came to see the residents they did not have a record of when they came, the facility did not receive any notes to demonstrate when the therapy consultant met with the residents. The RA did not have a list of residents that were currently being seen for mental health services. The RA and the SSA stated that they had not personally seen the mental health representatives. The RA stated that mental health services had sent an email stating the Licensed clinical Social Worker (LCSW) was leaving. The RA provided a copy of the email sent on 2/21/23 at 2:11 PM, the email from the mental health services stated We will need to temporarily put a pause on admits from your facility. Our social workers and APRN [Advanced Practice Registered Nurse] will still be at the facility to conduct visits for emotional support and psychotropic medication consulting. If you have a resident that is needing help, please reach out to me and I will coordinate with the team to facilitate that. The SSA stated that she took over resident 62's case in May 2023. The SSA stated that she was unaware of resident 62's mental health needed when she started. The SSA stated that she was only aware of mental health needs of resident 62 beginning July 2023. The SSA stated that paperwork was sent to behavioral health services on 7/31/23, and that she was unaware of request for mental health services in resident 62's PASARR that was completed 4/12/23. On 8/8/23 at 1:43 PM, an interview with resident 62 was conducted. Resident 62 stated that she had complained of suicidal ideation, anxiety, panic attacks and night terrors to multiple staff members since her admission to the facility in march, and had not received the help she requested. Resident 62 stated that she had not seen by a mental health professional while at the facility and that she constantly felt she was on the verge of crying. On 8/8/23 at 2:00 PM, an interview conducted with a Registered Nurse (RN) 5. RN 5 stated that when a resident had suicidal ideation, the nurse completed a suicide risk assessment, then inform the DON, Admin, MD, and Social Services to come up with a plan and determine the safety of the resident. RN 5 stated the resident 62 complained of anxiety and night terrors frequently, resident 62 took medications to help with the anxiety symptoms. RN 5 stated that she had not seen metal health services and was not aware if resident 62 received services. RN 5 stated stated social services would be aware of mental health needs for resident 62. It should be noted that no indication of mental health treatment could be located in resident 62's medical record. A review of the psychotropic medication monthly review dated 4/16/23, revealed the psychotropic medications were reviewed: a. Alprazolam 0.25 mg with diagnosis/indication of anxiety. The target symptoms/behaviors tracked were anxiousness, and that the target symptoms/behaviors have: remained stable. b. Duloxetine 60 mg with diagnosis/indication of depression. The target symptoms/behaviors tracked were sadness, and that the target symptoms/behaviors have: remained stable. A psychotropic medication monthly review dated 7/17/23 revealed the psychotropic medications were reviewed: a. Buspiron 10 mg with diagnosis/indication of anxiety. The target symptoms/behaviors tracked were anxiousness, and that the target symptoms/behaviors have: remained stable. b. Duloxetine 60 mg with diagnosis/indication of depression. The target symptoms/behaviors tracked were sadness, and that the target symptoms/behaviors have: remained stable. Resident 62's ordered medications included anti-anxiety, anti-depressant and and anti-psychotic medications. A review of the April, May, June, and July 2023 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for resident 62 revealed that no behaviors had been documented from the facility nursing staff, with the exception of a 5 day period starting 3/18/23 and ending 3/23/23 to monitor behaviors. On 8/15/23 at 11:45 PM, an interview was conducted with RN 5. RN 5 stated that residents on anti-anxiety and anti-depressants had their behaviors monitored. RN 5 stated that the behaviors monitored were drowsiness, tremors, agitation, statements of sadness or anxiety. RN 5 stated that when a resident was taking medications that required monitoring, the task to indicate behaviors appeared on the list of tasks. A document listing residents that receive weekly one on one therapeutic visits documented was reviewed. Resident 62 was on the list increase in coping skills. On 8/16/23 at 11:02 AM, an interview was conducted with the Masters of Therapeutic Recreation Services (MTRS). The MTRS stated that one on ones were about building relationships, they were used to get residents to come out to activities. The MTRS stated that for resident 62 the one on one was used to increase coping skills because she had depression and anxiety. The MTRS stated the one on one for resident 62 would be for increasing her pleasure and doing things to help her find ways to decrease anxiety and depression. The MTRS stated that one one ones were note being done because there were not enough activities staff members. The MTRS stated that she made a recommendation for extra staff because there was only 1 staff member for activities.

Based on observation, interview and record review it was determined, 6 out of 68 sampled residents, that the facility did not provide an ongoing program to support resident in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the residents comprehensive assessment and care plan. Specifically, residents complained about not having activities, observations were made of less than 10 residents per activity, and one on one activities were not being provided. The findings for one resident were determined to have occurred at a harm level. Resident identifiers: 16, 20, 49, 51, 54 and 62. Findings include: HARM 1. Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic post-traumatic stress disorder, anxiety disorder, insomnia and depression. On 07/30/23 at 12:00 PM an interview was conducted with Resident 62. Resident 62 stated that she spends most of her time in her bed and that it is hard for her to get around. She stated that she eats all meals in bed and will watch TV or purchase things on amazon for her activities. Resident 62 stated that since the first day in the facility she had told multiple staff members she needed mental health services. Resident 62 stated that she would like to see a psychiatrist to talk about her feelings, and to hopefully get on the right medications to help her with the anxiety and depression. Resident 62 stated that she had been having night terrors and anxiety attacks, and felt it was because she was not getting the mental health services she needed. Resident 62 stated that she had suicidal ideation and often felt she would be better off dead. Resident 62 stated the last time the facility asked about her suicidal ideation was three or four months ago, but she has had those thoughts more recently. Resident 62 stated that she had been receiving mental health services since she was a teenager and that her psychiatrist retired a year ago and that she does well when she has mental health services. Resident 62's medical record was reviewed on 8/2/23. A review of Resident 62's MDS (minimum data set) assessment dated [DATE], MDS 3.0 section D- Mood, revealed that a resident mood interview was conducted. The residents total severity score was 23 out of 27 (Note: A score of 20-27 would indicate severe depression). A MDS assessment dated [DATE], documented resident 62 with a Brief Interview for Mental Status (BIMS) score of 15. (Note: A resident that was intact cognitively would have a BIMS score of 13-15.) A care plan dated 3/39/23 revealed, a focus care area was, RECREATION [Resident 62] .pain limits activity involvement; mood problem: anxiety/depression; has little interest/pleasure in doing things. A goal developed was, [Resident will accept, as desired, at least 1 Therapeutic visit weekly for increasing in coping skills through next review date. Interventions were Provide 1:1 visit 1x weekly. Resident 62's progress notes revealed the following: On 3/20/23 an activity progress note documented that Recreation staff will identify and engage [resident 62] in activities of interest. Recreation staff will invite and assist [resident 62] to activities of interest/importance. TRT (therapeutic recreation therapist) will provide adaptations to activities PRN (as needed) to allow for maximum participation in activities. Recreation staff will post calendar in the room and in an area accessible to [resident 62]. TRT will implement the initial recreation therapy treatment as ordered by the Therapeutic Recreation Consultant (name removed) MTRS, CTRS, including: (1) The collection of data from chart reviews, interviews, and observations for recreation assessment. (2) Inviting the resident to leisure diversionary programs of interest and observe for recreation andleisure patterns. (3) Providing leisure materials to the resident and support resident's independent leisure choices. (4) Completing the recreation therapy admission notes as seen above. A document listing residents that receive weekly 1:1 therapeutic visits was reviewed. The list documented that resident 62 was to receive 1:1 weekly visits to increase coping skills. Resident 62's activities documentation for the previous 30 days, 7/18/23 through 8/5/23, was reviewed. The activities documentation indicated that none of the following activities had occured for the resident during that 30 day period: active or passive participation in programs, 1:1 program, room visits, and activity programs included; emotional, intelletcual, physical, social, and spiritual. On 8/16/23 at 11:02 AM, an interview was conducted with the MTRS, the MTRS stated that 1:1 visits are about building relationships, and to help get residents to come out to activities. The MTRS stated that for resident 62 the 1:1's are used to increase coping skills because she has depression and anxiety. The 1:1 for resident 62 would be for increasing her pleasure and doing things to help her find ways to decrease anxiety and depression. The MTRS stated that when she was here last she looked back on the 1:1's and saw they were not getting done. The MTRS stated that she made a recommendation for extra staff because with only one staff member doing the activities the 1:1's were not being done. POTENTIAL FOR HARM 2. An activity calendar was posted at the front of the facility. There was no calendar observed in the activity room. According to the activity calendar, the following activities were scheduled for 8/14/23: a. At 9:45 AM Daily chronicles, b. At 10:00 AM Fit and Fun, c. At 10:30 AM Cards and dice, d. At 11:00 AM Lunch break, e. At 1:15 PM Scriptures study, f. At 2:00 PM, Bingo, g. At 7:00 PM, Family home evening. On 8/14/23 at 10:22 AM, an observation was made of 4 residents playing Uno with Activities Director (AD). At 11:22 AM, an observation was made of the same 4 residents playing Uno. On 8/14/23 at 1:37 PM, an observation as made of 10 residents in the activity room watching a religious video. On 8/15/23 at 1:58 PM, an activity of making fruit salad was observed. There were 6 residents in the activity. 3. Resident 16 was admitted to the facility on [DATE] with diagnoses which included chronic systolic congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes, chronic respiratory failure with hypoxia, non-rheumatic aortic stenosis, hypertension with heart disease, stimulant dependence, major depressive disorder, and sarcoidosis of skin and lungs. On 7/31/23 at 2:17 PM, an interview was conducted with resident 16. Resident 16 stated there were no activities and that's a thorn in my side Resident 16 stated that every nursing home she had lived in did van rides. Resident 16 stated the facility did not offer van rides. Resident 16 stated she gets so bored that she could spit. Resident 16's medical record was reviewed 7/30/23 through 8/16/23. An annual Minimum Data Set (MDS) dated [DATE] revealed that an interview for activity preferences was conducted. The interview revealed it was very important for resident 16 to listen to music, be around animals, keep up with the news, to do her favorite activity and get fresh air when the weather was good. A care plan dated 7/20/23 revealed RECREATION [resident 16] exhibits independence in leisure activities manifested by ability to structure own time; ability to choose activities of interest; independent hobbies/interests; mood problem: depression. Goals developed were [Resident 16] will participate in individual activities of importance/interest daily as desired, through next review date; [Resident 16] will engage, as desired, in activities of interest at least: 1 emotional activity per week for increase in mood as evidenced by making positive statements/gestures/expressions during activities through next review; and [Resident 16] will accept, as desired, at least 1 Therapeutic visit weekly for increase in self esteem/coping skills through next review date. Interventions included Check for satisfaction with leisure choices & supply with leisure materials PRN [as needed]. Post calendar in room. Encourage positive statements/feelings/gestures to decrease depressive feelings during activities. Check for diet/allergy precautions for food related activities/treats. Provide 1:1 visit 1x [time] weekly; Provide adaptations to activities PRN: physical: adapt size/height/weight of items to match physical abilities; Invite, encourage and involve in activities of importance/interest including: family/friend phone calls/visits, TV/movies, music, pets, news, outdoors, gardening (seasonal), cooking games, reminisce, &/or special events; Support and engage in social/reminisce/discussion activities in accordance to past occupation/life role as a waitress. A list of residents that needed one on one activities was provided. Resident 16 was on the list for self-esteem/coping. On 8/15/23 at 2:06 PM, an interview was conducted with CNA 7. CNA 7 stated resident 16 had not had one on one visits with activities. CNA 7 stated resident 16 did not go to activities. On 8/15/23 at 10:42 AM, an interview was conducted with Nursing Assistant (NA) 2. NA 2 stated resident 16 did not go to group activities. NA 2 stated resident 26 did not seem interested in activities. NA 2 stated resident 16 liked to be in her room and by herself. NA 2 stated she was hoping resident 16 would grow to trust NA 2 so resident 16 told her more. 4. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis (MS), disorder of central nervous system, peripheral vascular disease, and dysphagia. On 7/31/23 at 11:36 AM, an interview was conducted with resident 20. Resident 20 stated he had been asking for about activities. Resident 20 stated he got a July 2023 activities calendar that day. Resident 20 stated he had not received an activity calendar prior to today. Resident 20's medical record was reviewed 7/30/23 through 8/16/23. An annual MDS dated [DATE] revealed an interview for activity preferences. The interview revealed it was very important to have books, newspapers, and magazines; listen to music; keep up with the news; and to do his favorite activities. A care plan dated 9/28/22 revealed RECREATION [Resident 20] exhibits impaired activity patterns manifested by impaired mobility r/t MS; uses adaptive equipment to participate in leisure including: power chair; mood problem: depressive disorder/anxiety/psychotic disorder. The goals were [Resident 20] will maintain highest level of independence possible as evidenced by making choices about and participating in activities of importance/interest daily (as desired) through next review date and [Resident 20] will engage, as desired, in activities of interest at least: 1 emotional activity per week for increase in coping skills as evidenced by implementing positive coping strategies during activities; 1 social activity per week for increase in sense of community as evidenced by building meaningful relationships with staff/peers during activities through next review date. Interventions included Check for satisfaction with leisure choices; Please post the calendar in room; Provide adaptations to activities PRN [as needed] physical: adapt size/height/weight of items to match physical abilities; Encourage positive statements/affirmations to decrease depression/anxiety during activities; Engage in coping skills activities to assist with potential trauma (physical impairment) triggers as he may be triggered by discussions about his MS or discussing his current health situation; Invite and involve in activities of importance/interest including: family/friend phone calls, TV/movies, reading, 70s music, news, watching sports, &/or special events. Support and engage in social/reminisce/discussion activities in accordance to my past occupation/life role as a waiter/salesman; and Supply with independent leisure materials PRN. Support independent leisure choices. Please encourage to participate in activities of interest. On 8/14/23 at 2:18 PM, an interview was conducted with CNA 7. CNA 7 stated that resident 20 did not do any activities and the only time he gets out of bed was to work with therapy. CNA 7 stated resident 20 loved to listen to music. CNA 7 stated that every room should have an activity calendar on the bathroom door. CNA 7 stated she was not sure if resident 20 was able to see the activity calendar when his privacy curtain was closed. On 8/15/23 at 2:02 PM, a follow-up interview was conducted with CNA 7. CNA 7 stated she had not seen one on one activities with resident 20. CNA 7 stated he would benefit from one on one activities. On 8/15/23 at 11:41 AM, an interview was conducted with the AD. The AD stated that resident 20 liked the daily chronicle to be read to him so she read it to him 2 to 3 times per week. The AD stated she was unable read the daily chronicles to resident 20 every day without an assistant. The AD stated she talked to resident 20 about his family and he told her jokes. The AD stated resident 20 did not want get out of bed to go to activities. The AD stated resident 20 watched television and liked to talk on the phone. On 8/15/23 at 1:58 PM, a interview was conducted with the AD. The AD stated she did not put resident 20 on the one on one list because he was already doing the daily chronicles activity. 5. Resident 49 was admitted to the facility on [DATE] with diagnoses which included malignant neuroleptic syndrome, chronic respiratory failure with hypoxia, myalgia,, and spinal stenosis. On 7/31/23 at 11:16 AM, an interview was conducted with resident 49. Resident 49 stated he went to bingo but would like to go to more activities. Resident 49 stated there were not enough activities. Resident 49's medical record was reviewed from 7/30/23 through 8/16/23. An annual MDS dated [DATE] revealed an interview for activity preferences was not assessed. A care plan dated 5/31/23 revealed RECREATION [Resident 49] exhibits impaired mood/social interactions manifested by schizophrenia/bipolar; needs reminders, prompts/cues to choose activities. The goals were [Resident 49] will maintain highest level of independence possible as evidenced by participating in and expressing satisfaction with leisure choices daily, as desired, through next review date and [Resident 49] will engage, as desired, in activities of interest at least: 1 emotional activity per week for increase in coping skills as evidenced by implementing positive coping strategies during activities; 2 social activities per week for increase in sense of community as evidenced by building meaningful relationships with staff/peers during activities through next review date. Interventions included Invite, encourage, and involve in activities of importance/interest including: family/friend phone calls/visits, TV/movies, reading, music, pets, news, socials, outdoors, bingo, cards, games, travel discussions &/or special events. Support and engage in social/reminisce/discussion activities in accordance to past occupation/life role as a Army veteran/railroad worker; Support independent leisure and check for satisfaction with leisure choices Supply with leisure materials PRN and post calendar in room. Encourage positive coping strategies/social interactions and help uplift mood during activities. Use validation to help express feelings appropriately. Check for diet/allergy precautions for food related activities/treats and Provide adaptations to activities PRN: physical: adapt size/height/weight of items to match physical abilities & observe for signs of fatigue; Hearing: increase volume & speak clearly. On 8/15/23 at 10:45 AM, an interview was conducted with NA 2. NA 2 stated she had not noticed resident 49 going to activities. NA 2 stated resident 49 was quiet and she was not sure what he liked to do. NA 2 stated she was in the process of learning about everyone. On 8/15/23 at 2:04 PM, an interview was conducted with CNA 12. CNA 12 stated there were no one on one activities. CNA 12 stated resident 49 did not usually go to activities. CNA 12 stated resident 49 was usually just in bed sleeping. CNA 12 stated resident 49 did therapy and then went back to bed. CNA 12 stated resident 49 did not watch television. On 8/15/23 at 11:38 AM, an interview was conducted with the AD. The AD stated resident 49 went to Bingo three times a week. The AD stated resident 49 was very routine, gets up, eats breakfast. The AD stated resident 49 did not like the daily chronicle. The AD stated that resident 49 enjoyed going out with his family. The AD stated resident 49 mostly rested between meals. The AD stated there were not enough activities staff to ask all the residents if they wanted to go to activities. 6. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included seizures, dementia, diabetes, and anxiety. On 8/15/23 at 9:19 AM, an interview was conducted with resident 51. Resident 51 stated she would like an ice cold coke. Resident 51 stated she was not sure about activities and only a few people know about the activities. Resident 51 stated she did not want to go to Bingo or scripture studies. Resident 51 stated she just Sits in room all the time and smokes. Resident 51 stated she Goes nuts the rest of the time when she was not smoking. Resident 51 stated she would go to Bingo if there was an incentive like cigarettes. 7. Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, delirium, major depressive disorder, and weakness. On 7/30/23 through 8/10/23, observations were made and resident 54 did not attend activities. Resident 54's medical record was reviewed 7/30/23 through 8/17/23. Resident 54 did not have an admission MDS completed. A care plan dated 4/24/23 revealed RECREATION [Resident 54] exhibits alteration in thought process manifested by cognitive impairment; needs reminders/prompts/cues to choose activities; has communication difficulties; mood problem: depression. The goals were [Resident 54] will accept, as desired, at least 1 Therapeutic visit weekly for cognitive activity/communication through next review date; [Resident 54] participate in individual activities of importance/interest daily as desired, through next review date; and [Resident 54] will engage, as desired, in activities of interest at least: 1 emotional activity for increase in mood as evidenced by making positive statements/gestures/expressions during activities weekly through next review date. Interventions included Check for satisfaction with leisure choices & supply with leisure materials PRN. Post calendar in room. Provide with opportunities to recall long term memories during activities. Encourage positive statements/feelings/gestures to decrease depressive feelings during activities.; Check for diet/allergy precautions for food related activities/treats; Provide 1:1 visit 1x weekly; Provide adaptations to activities PRN: physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities; Invite, encourage and involve in activities of importance/interest including: family/friend visits, TV/movies, music, pets, news, socials, outdoors, sports related activities, reminisce, &/or special events. Support and engage in social/reminisce/discussion activities in accordance to past occupation/life role as a carpenter. An activity progress note dated 4/24/23 at 8:56 PM revealed, Therapeutic Recreation Assessment .[Resident 54] is able to identify and participate in activities of importance. Impaired mobility, cognitive impairment and mood are potential barriers to leisure participation. Plan Focus: Alteration in thought process care plan will focus on involving resident in activities of importance, increase in mood and retention of cognitive abilities. A list of residents that needed one on one visits was provided. Resident 54 was on the list for cognitive activity and communication. On 8/15/23 at 2:04 PM, an interview was conducted with CNA 7. CNA 7 stated resident 54 was not provided one on one activities. CNA 7 stated resident 54 smoked for her activities. CNA 7 stated resident 54 did not go to activities. On 8/16/23 at 9:44 AM, an interview was conducted with the AD. The AD stated that she did not know why resident 54 was on the one on one list. The AD stated the Master of Therapeutic Recreational Services (MTRS) created the one on one list. The AD stated residents were on the list because they did not go to group activities. The AD stated she had not been educated regarding what communication/cognitive one on one activity. The AD stated she didn't know what the services were or how to provide that service. On 8/15/23 at 11:30 AM, a follow-up interview was conducted with the AD. The AD stated her job was to plan the activities and perform the activities each month. The AD stated she usually gathered residents for activities, passed out a daily chronicle every morning to the residents that she knows that want it. The AD stated there were about 32 people who like the daily chronicle. The AD stated that daily chronicle had information regarding something that happened that day in history. The AD stated there was a calendar on every bathroom door, a calendar up front, she reminded residents to go to activities by going room to room. The AD stated she was trying to get the CNA's to help but it had been a struggle. The AD stated it helped to deliver the daily chronicles in the morning because then she knew who wanted to go to that activities that day. The AD stated resident 16 did not like to go to group activities, resident 16 had a boyfriend and they liked to go outside to smoke. The AD stated resident 16 did not go to any of the activities offered. The AD stated upon admission an assessment was done and then annually and quarterly. The AD stated the activities assistant quit in May 2023 and had been asking management for another assistant but had to wait till the census went up. On 8/14/23 at 2:06 PM, an interview was conducted with CNA 7. CNA 7 stated the activities before were really great. CNA 7 stated there was always something like cooking or music. CNA 7 stated the activities have changed in the last few year. CNA 7 stated there was an auction twice a month and now once a month. CNA 7 stated cooking class was one of their favorites. CNA 7 stated on Saturdays residents used to have something to do. CNA 7 stated residents did not have anything the last few Saturdays. On 8/15/23 at 11:41 AM, an interview was conducted with the AD. The AD stated the activities consultant completed care plans and came to the building once a month. The AD stated resident 51 benefited from one on one visits. The AD stated she spent about 10 to 15 minutes with resident 51 each time she visited him. The AD stated resident 51 was very social with people who came into his room like the nurses and CNA's. The AD stated if she had an assistant, more one on ones would be done, more residents would come to activities and she would have help with activities. The AD stated an assistant would also help with paperwork to get some of that load off. 8. Therapeutic Recreation Consultation Reports were reviewed and revealed the following: a. On 10/20/22, 1:1s have not been implemented/charted. The MTRS recommended hiring a part time assistant. The Department goals were to increase participation for isolating residents. The calendar revealed that there were no activities involving pets. b. On 11/28/22, 1:1s have not been implemented/charted. Please ensure participation is charted daily. The MTRS recommended hiring a part time assistant. A service project was recommended to be added to the calendar. c. On 12/6/22, 1:1's have not been implemented/charted. Please ensure every resident is invited to activities daily. The MTRS recommended hiring a part time assistant. The calendar revealed there was no service project, activity planning, or specialty programs. d. On 1/19/23, 1:1's had not been implemented/charted. Please ensure every resident is invited to activities daily. The MTRS recommended hiring a part time assistant. e. On 6/30/23, 1:1's have not been charted or completed. The MTRS recommended hiring a full time and part time assistant. The MTRS recommended to please ensure staff were assisting resident to activities. The MTRS recommends to follow up with concerns that were not being returned and placed in the resident council binder. Grievances were kept in a binder with social services. f. On 7/27/23, 1:1's have not been implemented or charted. The MTRS recommended hiring a full time and part time assistant, please ensure staff were assisting resident to and from activities, and please ensure the AD had enough time to completed her job duties which included assessments, resident interviews, quarterly notes, participation charting, activity planning/preparation, gathering for activities, implementing group activities, community outings, and 1:1 interventions needed to meet care plan goals. The department goal were to implement and chart 1:1's, to implement a fundraiser, to implement a leisure cart and recruit volunteers. On 8/15/23 at 11:56 AM, an interview was conducted with the MTRS. The MTRS stated she came to the facility monthly. The MTRS stated she works with TRT, did training, meet with residents, reviewed documentation, updated care plans, and observed activities. The MTRS stated she recommended hiring additional staffing. The MTRS stated one person doing activities, planning, preparation was too much. The MTRS stated she recommended additional staff for quite a few months for at least 6 months. The MTRS stated she had a list of residents that needed one on one visits and the one on one visits had not been implemented or charted. The MTRS stated the residents on the one on one visits were residents that did not come out of their rooms. The MTRS stated the challenges with not getting the therapeutic one on one visits and the residents were care plans for emotional, mental, physical health of a resident. The MTRS stated if residents were lower cognitively and not getting the one on ones, then residents declined. The MTRS stated the one on ones were for emotional help and would help improve their motivation and could cause a decline in their emotional health. On 8/16/23 11:02 AM, a follow-up phone interview was conducted with the MTRS. The MTRS stated that one on one visits were about building relationships to get residents to come out to activities. The MTRS stated self esteem and coping were to help with mental awareness and ways to identify appropriate coping. The MTRS stated an example was manicures and discuss how that made them feel. The MTRS stated art activity was used to discuss resident feelings and emotions to see their positive part of them. The MTRS stated music was used for self-esteem and discussed how music expressed out emotions and feelings. The MTRS stated the cognitive one on one activity was typically for residents with cognitive impairment with dementia or traumatic brain injury. The MTRS stated cognitive one on ones would pertain to helping cognition. The MTRS stated during the activity the staff member and resident reminisced, played games, reading to help with long term cognition. The MTRS stated the communication one on one activity was for residents having trouble with communicating. The MTRS stated during the one on one residents were encouraged to verbalize, speak and talk. The MTRS stated resident 54 was to be provided one on one for cognitive communication. The MTRS stated resident 54 was working on improving communication with socialization and short term memory recall. The MTRS stated resident 54 needed help with improving communication with staff and residents. The MTRS stated resident 20 was not listed on the one on one list. The MTRS stated she recommended resident 20 go to activities like 70s music, sport, current events, daily chronicles, reading, game shows, stuff on phone and jokes. The MTRS stated she was not sure if resident 20 was able to read it by himself. The MTRS stated she recommended that resident 20 went to social activities. The MTRS stated if resident 20 was not getting out of bed then he should be on the one on one list. The MTRS stated according to the quarterly notes, resident 20 was not going to group activities. The MTRS stated resident 16 was to receive self-esteem/coping for one on one. The MTRS stated resident 16 liked doing pet visits, pet therapy to reduce depression and improve her self -esteem and positive self expressions. The MTRS stated resident 49 went to activities like ice cream socials and bingo. The MTRS stated he went to group activities that he was interested in. The MTRS stated he was not currently getting one on one visit because he was coming to group activities to build relationships with staff and resident. The MTRS stated resident 49 had schizophrenia so working on social skills. The MTRS stated there were budget cuts with staffing in the activities. The MTRS stated she had been a big concern that one person was not sustainable to provide activities of all the residents in the facility. The MTRS stated she met with Administrator (Admin) 1 to express her concerns about activity staffing. The MTRS stated the response was We can't do it right now. The MTRS stated Admin 1 stated that she wanted to see if the AD was able to do activities by herself. The MTRS stated it was actually a job for 2 and a half staff because of the amount of residents. The MTRS stated the AD had a full time staff member until October 2022. The MTRS stated it was frustrating that she made recommendations about staff and nothing was changed. 45490 *

Based on observation, interview, and record review it was determined 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, for 1 out of 49 sampled residents, a resident that had multiple falls with injuries was not provided interventions or adequate supervision to prevent falls from occurring. In addition, the resident had a fall that resulted in a major injury and the resident was hospitalized . Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to fracture of unspecified part of neck of right femur, type 2 diabetes mellitus, [CONDITION(S)] stage 4, [CONDITION(S)], repeated falls, essential hypertension, muscle weakness, lack of coordination, difficulty in walking, acquired absence of other left toe(s), pain in left foot, acquired absence of other right toe(s), pain in right foot, [CONDITION(S)], [CONDITION(S)], other disorders of plasma-protein metabolism, vitamin D deficiency, and major depressive disorder. On 10/12/21 at 10:50 AM, an interview was conducted with resident 54. Resident 54 stated he had a fall while at the facility. Resident 54 stated he had slipped on the floor in his room and broke his hip. Resident 54 stated the call light was not within reach. Resident 54's medical record was reviewed on 10/13/21. On 3/5/21, resident 54 was categorized moderate risk for falling with a score of 40 on the Morse Fall Scale form. A Morse Fall Scoring 25 to 44 was categorized moderate risk. An Admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 54 required extensive assistance of one person for bed mobility, transfers, dressing, and toilet use. Resident 54 required supervision of one person for locomotion off unit and personal hygiene. Resident 54 required limited assistance of one person for locomotion on unit. Walk in room and walk in corridor did not occur. Resident 54 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, moving off and on the toilet, and surface to surface transfer. In addition, resident 54 had functional limitation in range of motion of the bilateral lower extremities. An Admission MDS assessment dated [DATE], documented that resident 54 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 indicates intact cognition. A care plan focus initiated on 3/18/21, documented [Resident 54] is at risk for falls s/t (secondary to) impaired mobility, altered ADL (activities of daily living) ability, assistive devices for mobility, advanced age, bowel and bladder incontinence, hx (history) of falls, med (medication) use: anti-hypertensives, clinical factors: abx (antibiotics). A care plan goal initiated on 3/18/21 and revised on 9/25/21, documented [Resident 54] shall be free from injury daily. The interventions and task initiated on 3/18/21 and revised on 9/25/21, included the following: a. Assist with ADL as needed (PRN). b. Evaluate physical abilities at least quarterly. c. Fall risk assessment upon admission, quarterly, and prn. d. Report to Medical Director (MD) and family any significant changes in condition. e. Provide cueing and supervision prn. f. Anticipate needs. g. Frequent visual checks. h. Provide a safe environment. i. Call light within reach. j. Use safety devices as ordered and prn. k. Educate the Certified Nursing Assistant (CNA) involved with cares on safe transfers. l. Transfer to hospital for evaluation. m. Educate patient to ask for help for transfers. n. Place sign in room and bathroom for reminders to ask for assistance. An additional care plan focus initiated on 3/18/21, documented [Resident 54] is at risk for altered ADL?s (sic) r/t (related to): decline in functional ADL activity such as bed mobility, transferring, walking, and bathing. A care plan goal initiated on 3/18/21 and revised on 9/25/21, documented [Resident 54] will have needs met. The interventions and task initiated on 3/18/21, included the following: a. Mobility devices as applicable for transfers, gait, and locomotion in the facility. b. Report any further deterioration in status to physician. c. Periodic rehab screens and treatments as indicated. d. Provide verbal and tactile cues as needed. Explain task during ADL care. e. Provide assistance with ADLs as needed. f. Monitor, record, and report presence of pain and intolerance during mobility. g. Assist with bed mobility, repositioning, and supporting self during care. On 3/12/21 at 11:52 AM, a Nurses Note documented [Resident 54] stood up [to] transfer to the w/c (wheelchair) when CNA was releasing the brakes he stood up and went to knee's. Denies pain, did not hit his head. His upper body was twitching as if he was experiencing a petite mal [CONDITION(S)]. Will continue to monitor. On 3/15/21 at 9:21 AM, an Interdisciplinary Team (IDT) Event Review documented . Preventative measures: Anticipate pt (patient) needs, administer meds (medications) and treatments per orders, labs per orders, assistwith (sic) ADL'S. ADL/Activity: 1-2 person assist. Response (Interventions): Educate CNA onsafe (sic) transfer, monitor for [CONDITION(S)] like activity. [Note: A fall care plan for resident 54 was not developed until 3/18/21, after resident 54 had a fall.] On 4/26/21 at 5:00 AM, an Incident Report documented CNA was taking resident to the bathroom, resident leaned forward out of the wheelchair and fell to the floor. Resident 54 had a skin tear to left eye. On 4/27/21 at 10:46 PM, an IDT Event Review documented . Preventative measures: Anticipate pt needs, administer meds and treatments per orders, labs per orders, assist with ADL'S. ADL/Activity: 1-2 person assist. Response (Interventions): Educate pt not to lean forward in wheelchair and to wait for assistance prior to attempting to transfer. [Note: Intervention was implemented on the care plan initiated 3/18/21, prior to resident 54's fall. No new fall interventions were implemented.] On 7/21/21 at 12:30 AM, an Incident Report documented Resident pushed call light and was found on the floor after trying to get into bed. Resident was conscious and talking. Alert and oriented x 4 (person, time, place, and situation). Resident said he was trying to get up and slipped and fell on to right hip and needed help getting back up. Notified NP (Nurse Practitioner) and ordered Xray for right hip. Results showed a fracture and NP wanted him to be sent to hospital. On 7/22/21 at 11:42 AM, an IDT Event Review documented . Preventative measures: Anticipate pt needs, administer meds and treatmentsper (sic) orders, labs per orders, assist with ADL's, educate CNA on safe transfer. ADL/Activity: 1-2 person assist. Response (Interventions): X-ray to left hip, upon interview, x-ray showed fracture. Send to [name of local hospital], educate pt to call for assistance with transfers. [Note: Intervention was implemented on the care plan initiated 3/18/21, prior to resident 54's fall. No new fall interventions were implemented.] On 7/22/21, resident 54 was categorized moderate risk for falling with a score of 40 on the Morse Fall Scale form. A Morse Fall Scoring 25 to 44 was categorized moderate risk. On 8/10/21 at 9:42 AM, a Fall Note documented Pt found lying on the bathroom floor. Pt states he got up to go to the bathroom and when he went to stand up he slipped out of his chair. Pt states he is not in pain and did not hit his head. Pt assessment was normal. Pt states his hip is not in pain. On 8/10/21 at 9:45 AM, an Incident Report documented Pt was lying on bathroom floor. Pt was helped up and has the dry heaves. Pt assessment WNL (within normal limits). Pt BP (blood pressure) is low at 90/58. Pt has no scrapes. Will continue to monitor pt. Pt stated he fell when his wheelchair slipped. Pt stated he did not his his head and is not in any pain. Pt was found by CNA. On 8/10/21, resident 54 was categorized high risk for falling with a score of 75 on the Morse Fall Scale form. A Morse Fall Scoring 45 or higher was categorized high risk. On 8/11/21 at 10:00 AM, an IDT Event Review documented . Preventive measuresprior (sic) to event: Anticipate needs, pain control, meds as ordered, treatments as ordered, labs as ordered, assist with ADLs, wound nurse to eval (evaluate) and treat, assist and offer to reposition pt frequently, apply LAL (low air loss) mattress, educate to call for assistance. Interventions: Place sign to use call light for assistance in room and restroom. [Note: Intervention was implemented on the care plan initiated 3/18/21, prior to resident 54's fall. No new fall interventions were implemented.] On 8/11/21, resident 54 was categorized high risk for falling with a score of 65 on the Morse Fall Scale form. A Morse Fall Scoring 45 or higher was categorized high risk. On 10/13/21 at 2:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated resident 54 was limited to extensive assistant with cares. LPN 4 stated when a resident had a fall she would alert upper management, the MD, and the resident's family. LPN 4 stated she would chart the fall in a progress note, update the Morse fall scale, update the care plans with interventions, and take care of any physician's orders. LPN 4 stated she would monitor the resident for injuries and do neurological checks if the resident hit their head. LPN 4 stated the intervention in place to keep resident 54 safe was to try and answer the call light as quickly as possible when activated by resident 54. LPN 4 stated resident 54 did not like to wait for assistance and would try to be independent. On 10/13/21 at 2:36 PM, an interview was conducted with CNA 14. CNA 14 stated resident 54 would push the call light when he was in the bathroom to get help with getting cleaned up and his brief. CNA 14 stated resident 54 would also push the call light for water, snacks, and to help him get out of bed. CNA 14 stated resident 54 would try to get out of bed on his own but he should ask for help all the time. CNA 14 stated resident 54 was a 1 person assist and was able to stand. CNA 14 further stated that resident 54 required assistance with showers and she did almost everything for him. On 10/14/21 at 10:56 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated there were fall interventions in place that the facility wanted the staff to do ahead of time. RN 2 stated neurological checks would be initiated if the resident hit their head. RN 2 stated she would assess the resident for broken bones or a broken back before they were moved. RN 2 stated if the CNA found the resident they were not to get the resident up until the nurse assessed the resident for injury. RN 2 stated if the resident had an injury she would contact the MD for orders. RN 2 stated if something appeared broken she would order a xray. RN 2 stated the nursing staff would set new interventions like moving the resident closer to the nurses station. RN 2 stated there was a risk management section of the incident report and under the orders section an alert event so other staff would know to watch the resident closer. RN 2 stated she would mainly try answering resident 54's call light as promptly as she could to keep him safe from falls. RN 2 stated resident 54 was able to use the call light and move in and out of bed a lot easier than prior and he had been approved by rehab. RN 2 stated she would ensure resident 54's wheelchair was close to the bed and the wheels were locked, check vital signs daily, temperatures every shift, make sure the call light was within reach, make sure the CNAs were educated on resident 54's cares, and make sure the CNAs knew to answer the call light quickly. On 10/14/21 at 11:13 AM, an interview was conducted with CNA 2. CNA 2 stated resident 54 did not require a lot of help. CNA 2 stated she would assist resident 54 with toilet clean up, a new brief, and help resident 54 pull up his pants. CNA 2 stated resident 54 was able to get to the bathroom on his own and she would assist with his showers. CNA 2 stated resident 54 would press the call light for help and would ask for help with transfers. CNA 2 stated resident 54 would keep the wheelchair close to him so he was able to transfer himself. On 10/19/21 at 10:37 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the staff member who identified the fall would notify the nurse and make sure there were no major injuries and then notify everyone else including the MD and family. The RNC stated the fall would be reviewed to identify the root cause of the fall. The RNC stated he would encourage floor staff to implement interventions so they were implemented timely. The RNC stated the MDS coordinator would update the care plans.

Based on observations, interviews and record reviews, , it was determined that the facility did not ensure the residents received care, consistent with professional standards of practice, to prevent pressure ulcers and would not develop pressure ulcers unless the individuals' clinical condition demonstrated the pressure ulcers were unavoidable. Specifically, the facility did not prevent pressure ulcers and did not provide treatment to promote pressure ulcer healing. This occurred for 2 of 11 sampled residents. Resident identifier: 5, 11. Findings include: 1. Resident 5 was an [AGE] year old female residing at the facility since 5/21/21. Resident 5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 at 8:45 AM, a phone interview was conducted with a family member (FM 1). FM 1 stated that resident 5 was independent when she got there, but currently is confined to wheel chair and bed. FM 1 also stated that the resident had developed a new bed sore on her coccyx. And, resident 5 was continent when she arrived at the facility but was now incontinent of bladder. On 7/26/21 at 12:00 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated, the facility had one new pressure sore. RN 4 identified that resident 5 was the resident with a new pressure sore. RN 4 stated she was informed of resident 5's pressure sore on 7/19/21, and started treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 4 stated the size of the pressure sore was 1 cm by 0.7 cm by 0.8 cm, and that the wound was unstageable because it was covered with eschar. When asked about the reason resident 5 developed the pressure sore, RN 4 stated resident 5 was not turned and was left in wet, soiled briefs due to not enough staffing. RN 4 then stated, staffing of the Certified Nursing Assistants (CNAs) was insufficient to keep up with the needs of the residents. On 7/26/21 at approximately 1:00 PM, an interview was conducted with resident 5. Resident 5's Brief Interview for Mental Status (BIMS) score was documented on the Minimum Data Set (MDS) as a 10 of 15. [Note: This BIMS score indicated moderate cognitive impairment. A BIMS score of 13 to 15 indicates intact cognition, a score of 8 through 12 indicates moderate cognitive impairment and a score of 0 to 7 indicates severe cognitive impairment.] Resident 5 stated sometimes, after using the call light she had to wait for assistance from staff. Resident 5 did not have any specifics as to how long she had waited. Resident 5 stated she had waited for staff assistance in soiled briefs, but resident 5 could not remember when or how long she had waited. On 7/27/21 at approximately 2:00 PM, RN 4 was observed performing a dressing change for resident 5. Resident 5 was observed lying flat on her back in bed prior to the dressing change. The pressure wound was located on resident 5's coccyx and measured 1.0 cm by 0.8 cm by 0.8 cm. The wound was observed to extend into the subcutaneous layer of the skin. RN 4 stated this pressure ulcer was improved since the last time RN 4 had seen it. RN 4 stated the wound was covered with black eschar on 7/19/21, and the pressure ulcer was currently beefy red colored and appeared to be starting to heal. Resident 5 was then left flat on her back following the 2:00 PM dressing change. On 7/27/21 from 2:00 PM until 3:30 PM resident 5 was observed in her room. From 2:00 PM to 3:30 PM, staff members did not check on resident 5. During that time, there were no assistive devices in place to keep resident 5 from lying flat on her back. Also, upon observation of resident 5's room, there were no assistive devices within the room to keep resident 5 from lying on her back. At 4:20 PM, resident 5 was observed to be in the same position, laying flat on her back. On 7/27/21 at 4:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility's expectation was to have residents checked on every two hours. At that time, staff should turn residents and check the residents' briefs. On 7/27/21 at 4:45 PM, a review of resident 5's chart was conducted. According to skin assessments, resident 5's pressure ulcer was first found on 7/13/21. Resident 5's last skin assessment indicating intact skin was on 7/5/21. According to the wound log for resident 5, the new wound on her coccyx was measured at 0.5 cm by 0.8 cm, and was found to be unstageable on 7/13/21. The same wound's measurements on 7/19/21 were 1.0 cm x 0.8 cm, and the wound was assessed by RN 4 as unstageable. Resident 5's Care Plan dated 5/24/21, specified that resident 5 was to be assisted with bed mobility and repositioning. The Care Plan also indicated resident 5 was at risk for impaired skin, and an intervention included, Keep peri-area clean and dry. According to the Care Plan dated 7/13/21, a pressure ulcer was identified, however at that time no direction was indicated to staff regarding resident 5's need for assistance with turning or incontinence care. 2. Resident 11 was a [AGE] year old male residing at the facility since 10/7/20. Resident 11 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 11 was on hospice care. On 7/27/21 at 1:30 PM, RN 4 was observed performing a dressing change on pressure wounds for Resident 11. According to nursing notes, resident 11 had an existing pressure ulcer on the coccyx, which had been present since admission on 10/7/20. On 7/27/21, RN 4 was made aware resident 11 had a new pressure ulcer on the left buttocks. Resident 11 was incontinent of bowel and had a Foley catheter. During observation of the wound treatment, resident 11's buttocks were clean but red throughout. Resident 11's new wound on the buttocks was 0.7 cm by 0.7 cm, and was observed as a stage 2 wound (through the cutaneous layer). Resident 11's wounds were irrigated and barrier cream was placed around the edges of the wounds. Lodosorb was applied to the interior of the wounds, and the wounds were then packed with silver agonate dressings. Following this, the wounds were dressed with two padded dressings to provide extra cushioning. On 7/27/21 at 5:00 PM, a review of resident 11 chart was conducted. Resident 11's Care Plan, revised on 5/29/21, identified resident 11 was at risk of impaired skin. The Care Plan instructed staff to keep resident 11's skin dry and clean, and to use barrier cream with each incontinence episodes as required. Resident 11's Care Plan identified a stage 2 pressure sore on the coccyx, which had been treated since admission, and this wound was indicated to be related to poor mobility. On 7/26/21 at approximately 2:00 PM, an interview was conducted with CNA 6. CNA 6 stated that there were not enough CNAs. CNA 6 stated that on 7/26/21 her patient ratio was One CNA caring for 14 residents, but she had worked with a ratio of one CNA to 25 residents. CNA 6 stated that not having enough staff meant residents' wait time for answering call lights was longer, and the ability to meet residents' care needs were delayed, until we get to them. CNA 6 stated, when the facility is short staffed, the CNAs,do what we need to do. CNA 6 stated she did not feel the residents' safety was at risk when the facility was short staffed. CNA 6 stated it was the facility's protocol for CNAs to check on residents every two hours. At that time, the CNAs were supposed to check the residents' briefs, offer trips to the bathroom, provide water and ask the residents' if they had any other needs. On 7/26/21 at approximately 2:15 PM, an interview with CNA 7 was conducted. CNA 7 was an agency CNA. CNA 7 stated there was a large staffing need at this facility, and CNA 7 stated, That's why I am here. CNA 7 stated that because the facility was short staffed, residents did not receive the attention they should. CNA 7 stated the staff really cared for the residents, but they just did not have the time to get to everything. On 7/27/21 at approximately 1:00 PM, an interview with RN 4 was conducted. When asked about the process for reporting new wounds, RN 4 stated the CNAs or RNs did skin checks during the resident's showers or during brief changes. RN 4 stated residents are scheduled to have showers three times per week. CNAs will then inform the RN on duty, and the RN will send a message to the Wound Care Nurse, either verbally of by written notes left on the Wound Care Nurse's desk. RN 4 stated that the Director of Nursing (DON) updated Care Plans based on charting and data provided by the Wound Care Nurse.

Based on observations, interviews, and record reviews it was determined the facility did not have sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 6 of 11 sampled residents stated nursing staff failed to answer call lights for several hours, nursing staff stated due to inadequate staffing residents' care was negatively affected, and agency nursing staff were unable to state the full care needs of their residents or stated ill-prepared to care for their residents. Resident identifiers: 1, 4, 5, 8, 9, and 10. Findings included: 1. Resident 5 was an [AGE] year old female residing at the facility since 5/21/21. Resident 5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 at approximately 1:00 PM, an interview was conducted with resident 5. Resident 5 stated sometimes she had to wait for her call light to be answered. Resident 5 was unable to provide specifics as to how long she had waited. Resident 5 stated sometimes having to wait in soiled briefs. 2. Resident 9 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 at 11:57 AM, resident 9 reported the facility was under staffed. On 7/27/21 at 1:20 PM a follow-up interview was completed with resident 9. Resident 9 was asked about her Foley catheter. Resident 9 reported, I did not have trouble going to the bathroom before my surgery, and I do not have trouble going to the bathroom, but I have to go often, and resident 9 stated, It's just easier for staff. 3. Resident 10 was also admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 at 11:57 AM, resident 10 reported the facility was under staffed. Resident 10 reported, We wait a long time for help. Resident 10 stated the wait time was longest during the evenings, and resident 10 reported the wait time could be a couple hours. Resident 10 stated, most times, when using the call light at night it was due to pain and a need for medications. Upon chart review of resident 10's medical record he had orders for, Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Give 1000 mg by mouth every 8 hours as needed for pain -Start Date-07/19/2021 0630. 4. Resident 1 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 at 2:23 PM, resident 1 was interviewed. Resident 1 was interviewed regarding therapy for her contracture, and resident 1 reported, The lady who used to helping me [provide therapy] is retired, and the new lady is so busy it is hard to get therapy. Resident 1 was unable to remember the last time she had received any therapy for her contracture, but resident 1 reported the staff are good about putting her soft cast onto her contractured hand. Resident 1 reported, The call light is out of reach a lot of times, and staff will always put my phone far away, and I cannot reach it. Resident 1 reported when the call light was out of reach this made it more difficult to get help. Resident 1 reported, The facility is short staffed. Weekends are really bad for staffing. 5. Resident 8 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 at 2:35 PM, resident 8 was interviewed. Resident 8 reported, At night, staffing is a nightmare. Aides don't come for hours for call lights. There is trouble with the staff. Resident 8 also stated, This place is greatly understaffed. Especially at night. I can be waiting for hours to get help. During a follow-up interview on 7/27/21 at 1:47 PM, resident 8 stated, At night everyone is from agency and people aren't from the A-team. Resident 8 also verbalized, At night the call light can be pushed, and I wait an hour or two. I cannot think of any major issues I have had, but if I had chest pains I wouldn't be getting responsive care, and, If something was seriously wrong they wouldn't come quickly. Resident 8 also reported some night Certified Nursing Assistants (CNAs) would leave the room before finishing with the cares the CNAs were providing him, but resident 8 was unable to remember any specific aides or occurrences. 6. Resident 4 was a [AGE] year old male residing at the facility since 12/9/20. Resident 4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/26/21 at approximately 11:50 AM, an interview was conducted with resident 4. Resident 4 stated that the staff did not answer call lights. Resident 4 stated that he had watched staff pass by resident rooms while people were calling out for help. Resident 4 stated, personally he had waited 3 hours for someone to answer a call light just to get some water, and had waited up to an hour for someone to assist him with getting to the bathroom. Resident 4 reported when no help arrived, he got himself to the restroom, and resident 4 stated that had resulted in three falls between February and March. Resident 4 stated, he had waited from 10:00 PM until 6:00 AM to get assistance in getting a soiled brief changed, and the facility was so short staffed that staff did not have time to change the linens on his bed when they were soiled. Resident 4 stated, he had observed staff taking a call light from a resident because the resident had used it too much. Resident 4 would not provide specifics to that event. On 7/26/21 at approximately 11:45 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that the facility had a problem with not having enough staff to take care of residents. CNA 1 stated that there were times when she can't get to everyone when they needed us. On 7/27/21 at approximately 1:37 PM, an interview was conducted with CNA 1. CNA 1 stated that when they were short staffed that it would sometimes take 10 to 15 minutes to answer call lights when residents needed their briefs changed. On 7/26/21 at approximately 2:00 PM, an interview was conducted with CNA 6. CNA 6 stated there are not enough CNAs. CNA 6 stated that her current work load was to care for 14 residents, but CNA 6 had previously worked to care for 25 residents on her own. CNA 6 stated that being short of staff meant the residents' had to wait longer for call lights to be answered, and CNA 6 stated residents' care was delayed, until we get to them. CNA 6 stated, when the facility was short staffed, CNAs, Do what we need to do. CNA 6 stated the residents safety was at risk when they have low staffing numbers. CNA 6 stated, it was the facility's protocol to check on residents every two hours. During that time, CNAs were to check the residents' briefs, offer residents with trips to the bathroom, provide residents with water and ask the residents about any other care needs. On 7/26/21 at approximately 2:15 PM, an interview with CNA 7 was conducted. CNA 7 was an agency CNA. CNA 7 stated, there was a large staffing need at the facility, and CNA 7 stated, That's why I am here. CNA 7 stated because the facility was short staffed residents did not receive the attention that they should. CNA 7 stated the staff care for their residents, but just did not have the time to get to everything. On 7/27/21 at approximately 1:00 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated she knew the facility was short of staff, and management were stepping up to assist when the facility was short staffed. The MDS Coordinator stated, frequently she had assisted with setting up meals for residents. The MDS Coordinator stated the management team had been working on trying to get more staff. On 7/27/21 at 2:13 PM, CNA 4, an agency CNA, was observed to receive a report from the day shift CNA. The CNA who provided report to CNA 4 stated, I did not have all of your residents today, but I can go over their cares with you. CNA 4 was interviewed on 7/27/21 at 3:34 PM. CNA 4 reported this was her first time working in this facility. CNA 4 reported she felt she needed more education on her residents' transferring needs. CNA 4 stated she was unaware of her current residents' continent or incontinent level, and CNA 4 said she did not know the fall risk of her residents. CNA 4 reported, This would be helpful to keep a better eye on residents, and CNA 4 stated, There have been no issues that have come about this shift, but I could see how something could happen. On 7/27/21 at 3:15 PM, CNA 3 was interviewed. CNA 3 reported she is an agency CNA, and this is her first time working at this facility. CNA 3 reported she did receive report from the day shift CNAs regarding her residents. Within CNA 3's workload was a resident on contact precautions; this was indicated by a contact precaution sign on the resident's door. Also, the resident's chart read, Contact precautions every shift for dx [diagnosis]: Shingles to back -Start Date-07/06/2021 0600. While standing outside of the contact precaution resident's room, CNA 3 was asked if any of her residents were on contact precautions, and CNA 3 stated, No one has told me [that resident is on contact precautions]. That was not given to me during report. On 7/27/21 at 3:41 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON reported, When orienting a new aide to the unit, we do a buddy system, where a more seasoned CNA will act as a resource. The ADON was asked what occurs when all the staff are new, agency staff members, and the ADON stated, Right now we are using a lot of agency nurses, so the buddy system is not always helpful. The ADON reported that the care staff provide hand-off reports from shift to shift, and that should communicate the residents' care needs. The ADON was unaware if there were any new agency staff that felt unprepared to provide appropriate care to their residents. The ADON was also asked how a new, agency CNA would know if their residents were on contact precautions. The ADON reported, For contact precautions the sign on the door will communicate it to the aides, and the ADON stated, it is the expectation that if the resident is on contact precautions the staff will follow those precautions.

Based on interview and record review, the facility did not consult with a physician after 1 of 4 sample residents experienced a change in condition. Specifically, a resident had consistently elevated blood sugar levels without physician notification. This was found to have occurred at a harm level. Resident identifier: 2. Findings include: Resident 2 was admitted on [DATE] with diabetes mellitus, [MEDICAL CONDITION], hypertension, history of [MEDICAL CONDITION], obstructive sleep apnea, and [MEDICAL CONDITION]. Resident 2 ' s medical record was reviewed on 12/16/19. Resident 2's physician orders indicated that the resident's blood sugar levels were to be checked weekly. The physician orders did not indicate a normal range for the resident, or interventions if the resident's blood sugar levels fell outside of normal parameters. Resident 2's blood sugar summary was reviewed. The following blood sugars were entered: a. 6/25/19 111 milligrams (mg)/deciLiter (dL) b. 7/2/19 132 c. 7/9/19 144 d. 7/16/19 202 e. 7/23/19 168 f. 7/30/19 199 g. 8/6/19 212 h. 8/13/19 235 i. 8/20/19 281 j. 8/27/19 286 k. 9/3/19 319 l. 9/10/19 292 m. 9/17/19 292 n. 9/24/19 216 o. 10/1/19 234 p. 10/8/19 477 q. 10/15/19 387 r. 10/22/19 344 Nurses notes for resident 2 were reviewed. No evidence was located to indicate that resident 2's consistently abnormal blood sugar levels were reported to the physician at any time between 7/2/19 and 10/22/19. Nurses notes for resident 2 revealed the following: On 10/28/19 at 10:41 AM, Pt (patient) appears to show abnormal baseline. unresponsive to stimuli. resp (respiration) is labored. crackles and ronchi to upper (and) lower lobes of R (right) and L (left) lung. POA (Power of Attorney) determined to send pt out to hospital for further assessment. notified house MD and family, DON (Director of Nursing). There were no nurses notes prior to this to indicate any other monitoring for a change in condition. A facility transfer form dated 10/28/19 indicated that although resident 2 had been found unresponsive, her blood sugar had not been checked since 10/22/19; her blood pressure, heart rate, and oxygen saturations had not been checked since 9/21/19; her last bowel movement had been on 10/22/19, and her temperature had not been checked since 10/10/19. The History and Physical (HP) dated 10/28/19 for resident 2 indicated that upon arrival to the hospital, the resident had a Glasgow coma scale (GCS) of 3, and was emergently intubated. It sounds as if she may have been acting 'somewhat lethargic' last night but no other history was provided. she was afebrile but [MEDICAL CONDITION] to 120s and BP (blood pressure) soft 80/50s. Labs notable for leukocytosis 16 . hgb (hemoglobin) 16, plts (platelets) 296 appearing hemoconcentrated from prior. chemistry with AGMA (anion gap metabolic acidosis), gap 20, glucose 1039, K (potassium), [MEDICATION NAME] ([MEDICATION NAME]) 13, Her lactic acid was 4.7 and has positive beta-[MEDICATION NAME]-butyrate at 4.6. ABG (arterial blood gas) reveals metabolic acidosis .She has been given 3L (liters) crystalloid . A foley catheter was placed with grossly purulent drainage. Antibiotics were started. The HP also indicated that resident 2 was admitted to the Intensive Care Unit (ICU) on a ventilator and feeding tube. The HP also revealed that resident 2 . has evidence of septic shock being likely some combination of hypovolemic (and) septic, DKA/HHS (Diabetic Ketoacidosis/Hyperglycemic Hyperosmolar State) with volume depletion, evidence of UTI (urinary tract infection) with grossly purulent foley output, toxic metabolic [MEDICAL CONDITION], and possible GI (gastrointestinal) bleeding. The discharge orders from the hospital dated 11/6/19 indicated that resident 2 was diagnosed with [REDACTED]. Resident 2 was also prescribed 60 units of insulin [MEDICATION NAME] daily, with regular insulin 18 units every 6 hours. On 12/16/19 at 2:10 PM, a telephone interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she did not remember if she had contacted the physician when resident 2 ' s blood sugar level was above normal on 10/15/19. RN 1 stated that there were supposed to be blood sugar level parameters entered into the computer to indicate when the physician was supposed to be notified. On 12/16/19 at 2:40 PM, an interview was conducted with RN 2. RN 2 stated that residents with a [DIAGNOSES REDACTED]. RN 2 stated that if a blood sugar was 50 points above the resident ' s baseline, he would contact the physician. RN 2 stated that he thought the blood sugar reading of 477 was an error, but did not indicate if he rechecked it or not. RN 2 stated that he did not remember if he notified the physician for the blood sugar levels on 10/8/19 or 10/22/19 but I probably did. RN 2 stated that the DON had spoken with resident 2 ' s physician and the physician did not remember being notified of resident 2 ' s elevated blood sugar levels. On 12/16/19 at 3:05 PM, an interview was conducted with the DON. The DON stated that after resident 2 was admitted to the hospital, she had identified that resident 2 did not have blood sugar level parameters in place. The DON stated that she spoke to both RN 1 and RN 2 regarding the issue. The DON stated that she did not inservice any other staff, complete audits, speak with the medical director, or take the concern to the Quality Assurance Committee. On 12/16/19 at 3:45 PM, an additional interview was conducted with the DON. The DON stated that she had spoken with resident 2 ' s physician, who was also the medical director for the facility. The DON stated that she and the physician had determined that there were not parameters in place for blood sugar levels if a resident was on weekly blood sugar checks. The DON stated that currently, only residents receiving insulin had blood sugar parameters in place. The DON stated that she expected her nurses to contact the physician if a resident ' s blood sugar level was less than 60 or greater than 250. The DON stated that now that she had spoken with the medical director, blood sugar level parameters would now be implemented on all residents with blood sugar level checks.

Based on interview and record review, the facility did not ensure that 1 of 4 sample residents who experienced a change in condition was monitored for the change. Specifically, a resident had consistently elevated blood sugar levels without physician notification, and the resident was subsequently hospitalized . This was found to have occurred at a harm level. Resident identifier: 2. Findings include: Resident 2 was admitted on [DATE] with diabetes mellitus, [MEDICAL CONDITION], hypertension, history of [MEDICAL CONDITION], obstructive sleep apnea, and [MEDICAL CONDITION]. Resident 2 ' s medical record was reviewed on 12/16/19. Resident 2's physician orders indicated that the resident's blood sugar levels were to be checked weekly. The physician orders did not indicate a normal range for the resident, or interventions if the resident's blood sugar levels fell outside of normal parameters. Resident 2's blood sugar summary was reviewed. The following blood sugars were entered: a. 6/25/19 111 milligrams (mg)/deciLiter (dL) b. 7/2/19 132 c. 7/9/19 144 d. 7/16/19 202 e. 7/23/19 168 f. 7/30/19 199 g. 8/6/19 212 h. 8/13/19 235 i. 8/20/19 281 j. 8/27/19 286 k. 9/3/19 319 l. 9/10/19 292 m. 9/17/19 292 n. 9/24/19 216 o. 10/1/19 234 p. 10/8/19 477 q. 10/15/19 387 r. 10/22/19 344 Nurses notes for resident 2 were reviewed. No evidence was located to indicate that resident 2's consistently abnormal blood sugar levels were reported to the physician at any time between 7/2/19 and 10/22/19. Nurses notes for resident 2 revealed the following: On 10/28/19 at 10:41 AM, Pt (patient) appears to show abnormal baseline. unresponsive to stimuli. resp (respiration) is labored. crackles and ronchi to upper (and) lower lobes of R (right) and L (left) lung. POA (Power of Attorney) determined to send pt out to hospital for further assessment. notified house MD and family, DON (Director of Nursing). There were no nurses notes prior to this to indicate any other monitoring for a change in condition. A facility transfer form dated 10/28/19 indicated that although resident 2 had been found unresponsive, her blood sugar had not been checked since 10/22/19; her blood pressure, heart rate, and oxygen saturations had not been checked since 9/21/19; her last bowel movement had been on 10/22/19, and her temperature had not been checked since 10/10/19. The History and Physical (HP) dated 10/28/19 for resident 2 indicated that upon arrival to the hospital, the resident had a Glasgow coma scale (GCS) of 3, and was emergently intubated. It sounds as if she may have been acting 'somewhat lethargic' last night but no other history was provided. she was afebrile but [MEDICAL CONDITION] to 120s and BP (blood pressure) soft 80/50s. Labs notable for leukocytosis 16 . hgb (hemoglobin) 16, plts (platelets) 296 appearing hemoconcentrated from prior. chemistry with AGMA (anion gap metabolic acidosis), gap 20, glucose 1039, K (potassium), [MEDICATION NAME] ([MEDICATION NAME]) 13, Her lactic acid was 4.7 and has positive beta-[MEDICATION NAME]-butyrate at 4.6. ABG (arterial blood gas) reveals metabolic acidosis .She has been given 3L (liters) crystalloid . A foley catheter was placed with grossly purulent drainage. Antibiotics were started. The HP also indicated that resident 2 was admitted to the Intensive Care Unit (ICU) on a ventilator and feeding tube. The HP also revealed that resident 2 . has evidence of septic shock being likely some combination of hypovolemic (and) septic, DKA/HHS (Diabetic Ketoacidosis/Hyperglycemic Hyperosmolar State) with volume depletion, evidence of UTI (urinary tract infection) with grossly purulent foley output, toxic metabolic [MEDICAL CONDITION], and possible GI (gastrointestinal) bleeding. The discharge orders from the hospital dated 11/6/19 indicated that resident 2 was diagnosed with [REDACTED]. Resident 2 was also prescribed 60 units of insulin [MEDICATION NAME] daily, with regular insulin 18 units every 6 hours. On 12/16/19 at 2:10 PM, a telephone interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she did not remember if she had contacted the physician when resident 2 ' s blood sugar level was above normal on 10/15/19. RN 1 stated that there were supposed to be blood sugar level parameters entered into the computer to indicate when the physician was supposed to be notified. On 12/16/19 at 2:40 PM, an interview was conducted with RN 2. RN 2 stated that residents with a [DIAGNOSES REDACTED]. RN 2 stated that if a blood sugar was 50 points above the resident ' s baseline, he would contact the physician. RN 2 stated that he thought the blood sugar reading of 477 was an error, but did not indicate if he rechecked it or not. RN 2 stated that he did not remember if he notified the physician for the blood sugar levels on 10/8/19 or 10/22/19 but I probably did. RN 2 stated that the DON had spoken with resident 2 ' s physician and the physician did not remember being notified of resident 2 ' s elevated blood sugar levels. On 12/16/19 at 3:05 PM, an interview was conducted with the DON. The DON stated that after resident 2 was admitted to the hospital, she had identified that resident 2 did not have blood sugar level parameters in place. The DON stated that she spoke to both RN 1 and RN 2 regarding the issue. The DON stated that she did not inservice any other staff, complete audits, speak with the medical director, or take the concern to the Quality Assurance Committee. On 12/16/19 at 3:45 PM, an additional interview was conducted with the DON. The DON stated that she had spoken with resident 2 ' s physician, who was also the medical director for the facility. The DON stated that she and the physician had determined that there were not parameters in place for blood sugar levels if a resident was on weekly blood sugar checks. The DON stated that currently, only residents receiving insulin had blood sugar parameters in place. The DON stated that she expected her nurses to contact the physician if a resident ' s blood sugar level was less than 60 or greater than 250. The DON stated that now that she had spoken with the medical director, blood sugar level parameters would now be implemented on all residents with blood sugar level checks.

Based on interview and medical record review it was determined for 1 of 3 sample residents that the facility did not permit the resident to remain in the facility without transferring or discharging the resident. Specifically, the facility discharged the resident from the facility with no documentation to show the facility could not meet the needs of the resident, the safety of individuals in the facility was endangered, or that the discharge was necessary for the resident's welfare. Resident Identifier: 2 Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's abuse investigations revealed an abuse investigation dated 12/9/10. It was documented on the investigation that the staff observed an incident with resident 2 on 12/7/10. It was documented on the abuse investigation that resident 2 had placed his hand on a female resident's upper thigh. The female resident removed resident 2's hand and resident 2 then placed his hand on the female resident's thigh again. The Social Service Worker (SSW) documented that the residents were separated and resident 2 was moved to a different unit within the facility. On 7/14/11 resident 2's closed medical record was reviewed. On 12/30/10 facility staff initiated a Behavioral Care Plan for resident 2 regarding, "impaired social interaction and coping related to poor judgement, cognitive loss, lack of awareness, thought disorder, and disordered thinking manifested by inappropriate grabbing of others and grabs female's (sic)". Facility staff documented on the care plan that resident 2 would, "stop grabbing others when cued per episode". The following goals were to be accomplished by facility staff: a.) "not seating resident 2 next to vulnerable residents" b.) "if resident makes sexual comments remind residents politely and in neutral tone of voice 'we don't talk that way'' c.) "resident 2 was put on 15 minute checks" d.) "if resident 2 tried to hold hands or put his arm around other affectionate approaches (sic), assist resident to relocate away from the person who is receiving attentions, if resident is unwilling to move, then remove the 'object of affection'" e.) "offer individual activities..." f.) "remove from others if negative behavior occurs and cannot be redirected." Review of facility documentation revealed that resident 2 was placed on hourly checks by facility staff on 12/8/10 and 12/9/10. No documentation could be found to show that resident 2 was placed on 15 minutes checks on 12/8/10 - 12/30/10 nor after 12/30/10 when the care plan was implemented. On 3/10/11 an abuse investigation was initiated by the facility SSW for an incident involving resident 2 that occurred on 3/9/11. It was documented on the abuse investigation that resident 2 was seen grabbing a female resident's breast. Resident 2 was removed from the situation with no other incidents documented. No documentation could be found in the investigation regarding the female resident's response to the attention or her feelings about the attention received from resident 2. No documentation could be found in resident 2's medical record to show that facility staff updated resident 2's care plan regarding the "inappropriate behavior" or that facility staff discussed the possibility of discharge with resident 2. On 3/14/11 an abuse investigation was initiated by the facility SSW for an incident involving resident 2 that occurred on 3/14/11. According to documentation the abuse investigation was completed on 3/16/11. It was documented on the abuse investigation that resident 2 was observed by staff to be touching a female resident by her "crouch (sic)." It was documented on the abuse investigation that a facility nurse stated that she had seen resident 2 place his hand on the female resident's inner knee and not the "crouch (sic)." The facility SSW documented that resident 2 would have a medication adjustment and a referral for a psychologist to help with behavior management. The facility Administrator documented, "It was decided to place (resident 2) on 15 minutes checks for 72 hrs. (hours). A medication change was made to see if it would help (resident) control his predatory behavior. IDT (Interdisciplinary Team) will assess in 10 - 14 days the effect of the increase (sic) medication. At that time we will re-visit our plan of care or possibility of a discharge for the resident. (on) (March 30th 2011)." No documentation could be found in the investigation regarding the female resident's response to the attention or her feelings about the attention received from resident 2. No documentation could be found to show facility staff updated resident 2's care plan regarding the "inappropriate behavior" or what new approaches staff were to use to dissuade future episodes of the "inappropriate behavior." No documentation could be found to show facility staff made a referral to a psychologist for resident 2's behavior. Review of the facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No other documentation could be found to show that facility staff adjusted resident 2's medication. On 3/17/11 an abuse investigation was initiated by the facility SSW for an incident involving resident 2 that occurred on 3/16/11. It was documented on the abuse investigation that resident 2 was observed to touch a female resident on her leg and the Certified Nursing Assistant (CNA) told the resident to stop. Resident 2 then attempted to slide his hand up the female resident's thigh to her peri-area. No documentation could be found in the investigation regarding the female resident's response to the attention or her feelings about the attention received from resident 2. Review of physician's orders [REDACTED]. On 3/17/11 a physician's orders [REDACTED]. No documentation could be found to show that resident 2 received the new medication. On 7/14/11, the facility SSW was interviewed. The SSW stated that she "forgot", during her investigations, to ask the female residents about the attention received from resident 2 and whether or not the female residents were okay with resident 2's attention. The SSW further stated that she had contacted the family about resident 2's discharge after she had arranged for resident 2 to be transferred to another facility. The SSW stated that resident 2 was upset about the discharge and did not understand why he was being discharged . The SSW further stated that a 30 day notice should have been given to resident 2 but the facility Administrator had wanted resident 2 discharged . The SSW stated that since the Administrator wanted resident 2 discharged she had discharged him. On 714/11, the facility Social Work Consultant (SWC) was interviewed. The SWC stated that she was not consulted regarding the discharge of resident 2. The SWC stated that the definition of sexually inappropriate behavior consisted of the behavior occurring daily or 2-3 times weekly, not just a couple of times. The SWC stated that with sexually inappropriate behavior if a medication change was made as an intervention, the medication should be given 2-3 weeks to show an outcome or decrease in the behavior. The SWC stated that the usual process for sexually inappropriate behavior was to place the resident on supervision, implement a care plan and behavior program and monitor the victim and perpetrator. The SWC stated that even if she had been consulted about the discharge it would not have mattered. The SWC stated that when the facility Administrator wanted the residents discharged they were discharged . On 3/24/11, the state survey agengy received a letter from resident 2. It was documented in the letter that, "I am writing because I am angry and frustrated about what (the facility) did to me. ... I was sitting in my room on March 17th, when some of the care center staff came into my room and started packing up my belongings. I asked them what they were doing and they told me that I was moving to another facility. I asked them why and they said they didn't know. Then I got a call on my phone; a woman at the facility (I didn't get her name), told me that I had been inappropriately touching women, and that I was being shipped out. I was so flabbergasted, I didn't know what to say or do. I can't believe that I was treated like that. I had to leave about 20 minutes later, when I was placed in a van from the other facility. (the facility) has been my home for the last three years, and I wasn't even given a chance to say goodbye to my friends. (the facility) treated me with no respect and dignity. ... I don't like the way I was treated. They treated me worse than a dog. ..." On 7/14/11 resident 2's Power of Attorney (POA) was interviewed. The POA stated that resident 2 cried after being discharged and made the statement to his family, "That a dog wouldn't be treated that way." The POA stated that resident 2 had told his family that he did not understand why he was discharged and that he did not get to say good-bye to his friends at the facility. The POA stated that resident 2 had experienced a decline in his status since the discharge and that resident 2 was depressed. The POA further stated that the family did not discuss the incident regarding the discharge with resident 2 because it just "upsets him." The POA stated that she did not want survey staff to interview resident 2 about the incident for fear he would have a further decline in status.