Every finding on record at South Ogden Post-Acute (Cascades at South Ogden)

Based on interview and record review it was determined, for 1 of 43 sampled residents, the facility did not allow each resident the right to formulate an advance directive. Specifically, a resident did not have a Physician Order for Life Sustaining Treatment (POLST) form. Resident identifier: 76. Resident 76 was admitted to the facility on [DATE] with diagnoses which included moderate protein-calorie malnutrition, adult failure to thrive, and Alzheimer's disease.Resident 76's medical record was reviewed on 8/18/25 through 8/21/25.No orders related to a code status or a POLST form could be located in resident 76's medical records.On 8/19/25 at 10:46 AM, an interview was conducted with Registered Nurse (RN) 1, who stated that she was unable to locate any orders related to resident 76's code status. RN 1 stated that resident 76 was on hospice when she was admitted to the facility and that the hospice company could send a completed POLST form to the facility. RN 1 stated that if orders related to a code status were not in a resident's chart she reacted to situations as if the resident was full code.On 8/19/25 at 11:03 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident was admitted to the facility the admitting nurse assisted a resident, or a family member if the resident was not oriented, with filling out a POLST form. The DON stated that if a resident is on hospice the facility obtains a POLST form from the hospice company, but the facility should also fill out a POLST form for themselves. The DON was unable to locate an order related to resident 76's code status. The DON stated that nurse management verified new admissions had a POLST form completed. The DON stated that if code orders cannot be located staff are expected to react to situations as if the resident was a full code.On 8/19/25 at 1:39 PM, an additional interview was conducted with the DON. The DON stated that a POLST form for resident 76 was obtained from the hospice company on 8/19/25.

Based on interview and record review, it was determined for 1 of 43 sampled residents, the facility failed to maintain medical records on each resident that was complete, accurately documented, readily accessible, and systematically organized. Specifically, a resident had no documentation regarding an incident. Resident identifier: 36.Findings included:Resident 36 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction, heart failure, and chronic respiratory failure.Resident 36's medical record was reviewed on 8/18/25 through 8/21/25.On 8/19/25 at 8:12 AM, resident 36 stated that her eyebrows were singed when a staff member was assisting her in lighting her cigarette.An email from Licensed Practical Nurse (LPN) 1 was time stamped at 8/20/25 at 12:39 PM. LPN 1 stated that on 8/5/25 at approximately 6:30 PM she assisted resident 36 with lighting a cigarette with a lighter. LPN 1 stated that as resident 36 leaned in to light the cigarette a few strands of hair were singed, and LPN 1 immediately extinguished the lighter. LPN 1 stated that she conducted an immediate assessment of resident 36 and no evidence of burns or injury to the skin was found. LPN 1 stated that resident 36 was lighthearted and in good spirits after the incident.No documentation of this incident was located in resident 36's medical record.On 8/20/2025 at 2:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if there was an incident where a resident could have been injured the nursing staff was required to notify nurse management, the administrator, and the resident's provider. The DON stated that nursing staff was encouraged to make a progress note about the incident. The DON stated that the incident with resident 36 was a gray area because resident 36 was calm, there was no harm, and everything was resolved.

Based on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professionals standards for food safety. Specifically, there were observations of numerous flies making contact with food preparation surfaces and utensils in the kitchen, observations of kitchen staff not properly wearing hairnets, observations of staff not washing their hands after leaving the kitchen and returning, and observations of dirty ceiling tiles above food preparation areas of the kitchen. Findings Included:On 8/20/25 at 11:37 AM, an observation was made of the facility kitchen while lunch was being plated and served. There were multiple flies in the kitchen. The flies were landing on hotel pans and food preparation tables. The ceiling above the tray line area of the kitchen was dirty. On 8/20/25 at 11:44 AM, Dietary Aide (DA) 1 was observed to be wearing a hairnet. The hairnet only covered the bun on the back of her head, and not the face framing pieces of her hair. DA 1 was observed to touch her hair, then touch a resident's meal plate that was being prepared without washing her hands. On 8/20/25 at 12:12 PM, DA 2 was observed to leave the kitchen and then return. DA 2 did not wash her hands upon returning to the kitchen. DA 2 started handling food without washing her hands. On 8/21/25 at 9:24 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the kitchen does not handle pest control and that maintenance is responsible for pest control. The DM stated that all staff in the kitchen should be wearing a hairnet. The DM stated that kitchen staff should wash their hands when starting shifts, when changing gloves, when changing tasks, when using the restroom, when they leave the kitchen, and when switching between handling clean and dirty dishes.

Based on interview and record review it was determined for 2 out of 43 sampled 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, two residents laboratory results were not located in the electronic medical record. Resident identifiers: 5 and 85.Findings included:1. Resident 5 was admitted to the facility on [DATE] with diagnoses which included, obstructive and reflex uropathy, acute kidney failure, and type 2 diabetes.Resident 5's medical record was reviewed 8/18/25 through 8/21/25.A review of resident 5's medical record revealed: a. A physician's order dated 6/23/25 documented, Urinalysis with culture and sensitivity. one time only for Hematuria and increased urine sediments. for 1 day only.There was no urine culture and sensitivity laboratory results located in resident 5's medical record. b. A physician's order dated 8/8/25 documented, UA [urinalysis] with reflex to culture one time only for UTI [urinary tract infection] symptoms for 1 dayThere was no urine culture and sensitivity laboratory results located in resident 5's medical record. 2. Resident 85 was admitted to the facility on [DATE] with diagnoses which included, chronic kidney disease, lymphedema, and pulmonary hypertension.Resident 85's medical record was reviewed 8/18/25 through 8/21/25.A physician's order dated 4/30/25 documented, UA with C&S [culture and sensitivity] one time only for Follow up post UTI for 3 daysThere was no urine culture and sensitivity laboratory results located in resident 85's medical record. On 8/21/25 at 8:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Assistant Director of Nursing (ADON) 1 was the one who handled printing the labs and had the medical provider sign them. The DON stated after the results were reviewed and signed by the medical provider the results would be uploaded into the electronic medical record. The DON stated that medical records was in charge of ensuring the results got uploaded into the resident's chart. On 8/21/25 at 10:33 AM, an interview was conducted with Medical Records. Medical Records stated that he started the position about 4 months ago and at first he did not know that lab results were to be uploaded into the results section of a resident's medical record. Medical Records stated that after the DON and ADON reviewed lab results the results were placed in a folder in the copy room and he got them from there. Medical Records stated that it was hard to concentrate on uploading medical records because he was so busy with other things that he tried to find time to scan them in. Medical Records stated that he was behind on scanning records because he was the only person uploading records and he hadn't been able to keep up.

Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 43 sampled residents, a resident had a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), erythrocyte sedimentation rate (ESR), and C-Reactive Protein (CRP) collected prior to the date the physician's order stated. Resident identifier: 7.Findings included:Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, paranoid schizophrenia, acute kidney failure, and acquired absence of left leg below knee.Review of resident 7's records was completed on 8/18/25 through 8/21/25.On 7/26/2025 at 10:10 PM, a Nurses Note revealed new orders per house provider were entered. Due to highly elevated ESR and CRP and patient biting hands, internal inflammation may be the cause, steroid to be started on 7/28/25 (Monday). Draw labs on 8/4/25 (Monday) for CBC, CMP, ESR, and CRP.On 7/26/25 a physician's order was entered for labs CBC, CMP, ESR, CRP one time only for Elevated ESR, CRP for 1 Day. This is a Repeat Lab after completion of steroid treatment with a start date of 8/4/25.It should be noted that no laboratory results for 8/4/25 could be located in the medical record.On 8/21/2025 at 9:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the lab orders from 8/4/25 for CBC, CMP, ESR, and CRP were received and entered on a weekend, and the lab request form was placed in the lab binder. When lab services came on 7/30/25 the lab request was drawn prior to the completion of the steroid treatment and not on 8/4/25 as the order stated.

Based on interview and record review, it was determined the facility did not ensure residents who were continent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 43 sampled residents, a resident was not started on antibiotics for 11 days after complaining of continued dysuria. Resident identifier: 85. Findings included: Resident 85 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease stage 4, pulmonary hypertension, and chronic diastolic (congestive) heart failure.Resident 85's medical record was reviewed on 8/18/25 through 8/21/25.On 4/30/25 at 7:01 PM, a nurse's note documented, Resident complaining of continued burning with urination. Provider notified. New order to collect UA [urinalysis] with C&S [culture and sensitivity].On 4/30/25, a physician's order documented, UA C&S one time only for Follow up post UTI [urinary tract infection] for 3 days.On 5/2/25 at 5:13PM, a nurse's note documented, resident c/o [complaining of] burning/urination/frequency. ua picked up.On 5/2/25 at 6:12 PM, a nurse's note documented, per provider for urinary frequency and burning with urination; give pyridium 200mg [milligrams] po [by mouth] tid [three times daily] prn [as needed]. encourage fluids.On 5/2/25, a physician's order documented, Pyridium Oral Tablet 200 MG (Phenazopyridine HCl [hydrochloride] Give 200 mg by mouth every 8 hours as needed for voiding pain and frequency for 3 days.On 5/5/25 at 1:31 PM, a nurse's note documented, Provider notified of UA results, waiting for culture results at this time. No new orders.On 5/6/25 at 2:30 PM, a nurse's note documented, Provider notified of UA results, new order to refer to urology.On 5/7/25, a physician's order documented, Pyridium Oral Tablet 100 MG (Phenazopyridine HCl) Give 100 mg by mouth two times a day for Dysuria for 3 DaysOn 5/9/25 at 10:19 AM, an Antimicrobial Stewardship: Molecular Lab Result was reported. On 5/10/25 at 2:22 PM, a nurse's note documented, On call MD [medical doctor] notified of UA and C&S results. New order received for fosfomycin 3 gm [gram] PO X [times] 1 dose for UTI.On 5/10/25, a medication order documented, Fosfomycin Tromethamine Oral Packet 3 GM (Fosfomycin Tromethamine) Give 3 gram by mouth one time only for UTI until 05/10/2025 1600 [4:00 PM].The Medication Administration Record (MAR) was reviewed. On 5/10/25, the Fosfomycin Tromethamine 3 GM was not administered. A MAR note documented at 4:17 PM code 31. Chart code 31 indicated that the medication was held per MD orders. It should be noted that resident 85 never received the one time dose of Fosfomycin Tromethamine.On 5/11/25 at 10:33 AM, a nurse's note documented, Provider ordered to change Augmentin P.O dosing from 500-125 to 875-125 BID X7. RP [responsible party] notified.On 5/11/25, a physician's order documented, Amoxicillin-Pot Clauvulanate Tablet 875-125 MG Give 1 tablet by mouth two times a day for bacterial infection for 7 days.On 5/14/25 at 9:33 AM, a nurse's note documented, NP [Nurse Practitioner] ordered Pyridiumm [sic] 100 mg qd [daily] r/t [related to] dysuria.On 5/14/25 at 3:44 PM, a nurse's note documented, Results for Urinalysis with reflex to PCR [Polymerase Chain Reaction] collected 5/1/25. Negative for infection. Resident continues to report symptoms of uti. Provider would like her seen by urologist. Referral already in. transport to schedule.On 5/15/25, a physician's order documented, Pyridium Oral Tablet 100 MG (Phenazopyridine HCl) Give 100 mg by mouth one time a day for 7 DaysOn 8/21/25 at 9:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 85 began to complain of painful urination on 4/14/25 and started on an antibiotic on 4/18/25. The DON stated that urine culture results were received on 4/23/25 and resident 85 was kept on the antibiotic. The DON stated that resident 85 continued to complain of painful urination on 4/30/25 and a new order for a ua and urine culture was ordered and the urine was sent out on 5/2/25. The DON stated that resident 85 was started on pyridium for continued painful urination. The DON stated that on 5/9/25 the results of the urine culture were received and Fosfomycin was ordered for one dose. The DON stated that on 5/11/25 amoxicillin-clauvulanate was restarted. The DON stated she did not know why the provider changed the antibiotic to amoxicillin-clauvulanate after the Fosfomycin was administered. On 8/21/25 at 10:08 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. ADON 1 stated that she was unsure why the progress note on 5/14/25 stated that resident 85 did not have a urinary tract infection.

Based on observation and interview, the facility did not ensure that each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, surveyors sampled a test tray and found it to not be palatable, there were concerns about the palatability of the food served at the facility identified during the initial pool interviews, and there were grievances filed by residents about the food served at the facility. Resident identifiers: 2, 26, 40, 63, and 72. Findings Included: On 3/17/25 at 10:41 AM, an interview was conducted with resident 2. Resident 2 stated that most of the time the food served at the facility tasted bad. On 3/17/25 at 11:01 AM, an interview was conducted with resident 40. Resident 40 stated that sometimes the food was not so bad, but other times it was so bad he would rather not eat. Resident 40 stated that the food served at the facility was worse on the weekends. On 3/17/25 at 11:08 AM, an interview was conducted with resident 63. Resident 63 stated the food was normally good but every once in awhile it was on the yuck. On 3/17/25 at 1:20 PM, an interview was conducted with resident 26. Resident 26 stated the food served at the facility was not the best. Resident 26 stated on Christmas day she was served cold cheese pizza. Resident 26 stated that all of the soups served at the facility were watered down. On 3/18/25 at 8:38 AM, an interview was conducted with resident 72. Resident 72 stated that the potato soup served at the facility tasted like potato and water. On 11/4/24, a resident at the facility filed a Grievance/Complaint Report. The report stated, [Resident name redacted] expressed that colonial [name of unit at facility] often does not get full menu item [sic], english muffins are hard, kitchen freq. [frequently] out of coffee. On 2/10/25, two residents at the facility filed a Grievance/Complaint Report. The report stated, Residents feel that dinner has been served late and the food was cold. On 3/18/25 at 5:53 PM, surveyors sampled a test tray of the dinner served at the facility. The meal consisted of chicken tenders, onion rings, pickled beets, and a fruit cup. The onion rings were soggy. The beets were not pickled as described on the menu. The beets were very wet and beet juice had dripped onto the onion rings. On 3/19/25 at 9:35 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that food complaints were addressed in the facility food council and that she provided frequent training to the kitchen staff. The DM stated that kitchen staff should follow the instructions left on a spreadsheet to prepare meals. The DM stated that each resident had a tray card that listed their diet order, diet texture, and any other pertinent information.

Based on observation and interview, the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, surveyors observed two meals that were served late, multiple residents complained of late meals during the initial pool, and there were grievances filed by residents about late meals. Resident identifier: 2 and 44. Findings Included: The posted facility meal times posted outside of the main dining room were as follows: Breakfast: 7:30 to 8:30 AM Lunch: 11:30 AM to 12:30 PM Dinner: 4:30 to 5:30 PM The facility serves residents who eat in their rooms first and then serves residents who choose to eat in the dining room after. On 3/17/25, an observation was made of the breakfast meal service at the facility. The facility did not finish serving residents in the dining room until 8:52 AM. The last breakfast tray for the Colonial hall was not served until 8:48 AM. On 3/18/25, an observation was made of the dinner meal service at the facility. The facility did not begin plating and loading meal trays onto the delivery carts until 4:52 PM. The facility did not finish serving residents in the dining room until 5:53 PM. The last dinner dray for the Cambridge hall was not served until 5:40 PM. The last dinner tray for the Colonial hall was not served until 5:57 PM. On 3/13/25 at 8:25 AM, an interview was conducted with the Ombudsman. The Ombudsman stated there had been some continuing concerns at the facility including the quality of food and dining times. The Ombudsman stated that residents had complaints about the food quality, not enough food, and the food tasting bad. The Ombudsman stated that several residents have reported that the meals were served late, especially dinner. The Ombudsman stated that she had been told that dinner was not served to some residents until 7:00 PM. On 3/17/25 at 10:37 AM, an interview was conducted with resident 2. Resident 2 stated that the kitchen was understaffed and she had to wait until after 5:30 PM, to receive dinner. On 3/17/25 at 12:45 PM, an interview was conducted with resident 44. Resident 44 stated that she had no concerns about the food served at the facility other than the food timing. Resident 44 stated the facility was pressed to get the food out and there was not enough workers. On 9/30/24, a resident at the facility filed a Grievance/Complaint Report. The report stated, [Resident name redacted] expressed that he received a bagged lunch (sandwich and chips) for lunch on the weekend instead of a hot lunch. He was told it was due to kitchen being short handed. On 2/10/25, two residents at the facility filed a Grievance/Complaint Report. The report stated, Residents feel that dinner has been served late and the food was cold. On 2/18/25, a resident at the facility filed a Grievance/Complaint Report. The report stated, Dinner is coming out late impacting ability to attend family home evening. On 3/19/25 at 7:31 AM, an interview was conducted with the Administrator. The Administrator stated that the facility used to have three staff members working in the kitchen at night, but the facility census dropped and the extra staff had nothing to do. The Administrator stated that the facility was trying to staff the kitchen higher. The Administrator stated the facility should start plating meals 15 minutes prior to a meals starting time. On 3/19/25 at 9:35 AM, an interview was conducted with the Dietary Manager (DM). The DM stated when dietary staff at the facility were hired, they completed a three day training program with another dietary staff member. The DM stated that after the three day training was completed, the new dietary staff member completed a post training checklist. The DM explained the process the kitchen used to ensure meals that were served on time at the facility. The DM stated that the cook was responsible for following the spreadsheet on the tray table to ensure that meals were served timely. The DM stated that the facility recently lost two kitchen staff members, including one who had worked at the facility for over [AGE] years. The DM stated that staff in the kitchen had been stretched thin due to an increase in the facility census. The DM stated that after recently hiring additional evening kitchen staff, she felt that the facility had enough dietary staff. The DM stated that the facility has had difficulties with potential employees accepting job offers, but then not showing up on their start date. The DM stated that meals were served late because steps were missed in the training program for new kitchen staff. The DM stated that there was usually one cook and two dietary aides working in the kitchen in the evening. The DM stated that timeliness was the missing piece of the puzzle to ensuring that meals were served on time. On 3/20/25 at 7:29 AM, an additional interview was conducted with the Administrator. The Administrator stated that breakfast was served late on 3/17/25 because the cook scheduled to work the shift did not show up. 50200 33215

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program to prevent the development and transmission of communicable diseases. Specifically, for 1 out of 38 sampled residents, a resident's feeding tube was observed to be on the floor and not capped while not in use. Additionally, facility staff did not wear Personal Protective Equipment (PPE) while providing high contact care on Enhanced Barrier Precautions (EBP). Resident identifier: 238. Findings included: Resident 238 was admitted to the facility on [DATE] with diagnoses which included, encephalopathy, acute kidney failure, and adult failure to thrive. On 3/17/25 at 8:47 AM, an observation was made of resident 238's room. There was an EBP sign posted on the door. On 3/18/25 at 10:36 AM, an observation was made of Certified Nursing Assistant (CNA) 1 coming out of resident 238's room with a used brief in a disposable trash bag. On 3/18/25 at 10:57 AM, an observation was made of resident 238. Resident 238's tube feed was disconnected and the tubing was laying on the floor with no cap. On 3/18/25 at 5:54 PM, an observation was made of resident 238's feeding tube uncapped and hanging on an Intravenous (IV) pole. On 03/20/25 at 8:01 AM, an observation was made of resident 238's tube feed that was not running and the end of the tubing was not capped and was hanging from an IV pole. A physician's order with a start date of 3/16/25, documented that resident 238 was on EBP related to the feeding tube. On 3/18/25 at 11:04 AM, an interview was conducted with CNA 1. CNA 1 stated she had recently changed resident 238's brief before the resident went to physical therapy. CNA 1 stated she was unsure if resident 238 had EBP precautions, as she was new to the facility. CNA 1 stated the EBP sign on the door may have been for the previous resident in the room. On 3/18/25 at 11:14 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated night shift changed the tubing for tube feeds. RN 1 stated physical therapy requested that resident 238 be disconnected from her tube feed. RN 1 stated that she wore gloves when caring for the tube feed. RN 1 stated when the feeing tube was not in use she would leave the tubing with the feed because it was good for 24 hours. RN 1 stated she had not capped the feeding tube when it was disconnected. On 3/20/25 at 11:32 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a feeding tube needed to be unhooked for any reason the tube should be capped and hung up on an IV pole. The DON stated staff should be wearing PPE when providing care for feeding tubes or when changing the resident.

Based on interview and record review, the facility did not ensure that the resident assessment accurately reflected the residents' status. Specifically, for 2 out of 38 sampled residents, the facility indicated on the resident assessment that the residents did not have a serious mental illness despite the residents' Preadmission Screening and Resident Review (PASRR) level II assessments that documented the residents had a serious mental illness. Resident identifiers: 45 and 68. Findings Included: 1. Resident 45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, paranoid schizophrenia, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder recurrent moderate. Resident 45's medical record was reviewed on 3/17/25 through 3/20/25. Resident 45's admission Minimum Data Set (MDS) assessment dated [DATE], was reviewed. The response to Question A1500 on the assessment, which stated, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked as no. Resident 45's PASRR level II dated 4/22/24, was reviewed. The PASRR level II evaluator indicated that resident 45 was seriously mentally ill. 2. Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, anxiety disorder and schizoaffective disorder depressive type. Resident 68's medical record was reviewed on 3/17/25 through 3/20/25. Resident 68's admission MDS assessment dated [DATE], was reviewed. The response to Question A1500 on the assessment, which stated, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked as no. Resident 68's PASRR level II dated 11/15/24, was reviewed. The PASRR level II evaluator indicated that Resident 68 was seriously mentally ill. On 3/18/25 at 3:36 PM, an interview was conducted with the MDS Coordinator. The MDS coordinator stated that a previous MDS coordinator had completed the assessments for the two residents and that she would need to review the assessments. The MDS coordinator stated that some examples of diagnoses that would indicate for her to mark that a resident had a serious mental illness on the resident's assessment included autism and epilepsy.

Based on interview and record review, the facility did not ensure residents received the appropriate treatment and assistive devices to maintain vision and hearing abilities. Specifically, for 2 out of 38 sampled residents, a resident with impaired vision had a referral sent to the eye doctor in January and the resident had not see the eye doctor. In addition, a resident with vision and hearing concerns . Resident identifiers: 2 and 63. Findings included: 1. Resident 63 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus without complications. On 3/17/25 at 11:12 AM, an interview was conducted with resident 63. Resident 63 stated the facility told her that someone would be in for the glasses but she had not heard anything. Resident 63 stated that she hoped she did not miss them because she needed new glasses. Resident 63 stated that she told someone that she needed new glasses but could not remember who. Resident 63's medical record was reviewed on 3/18/25 through 3/20/25. On 1/28/25 at 9:21 AM, a Social Service Note documented Note Text: Referral sent to [name redacted] vision and dental. Resident declined hearing services at this time. On 2/3/25 at 8:53 AM, a Minimum Data Set (MDS) Note documented Note Text: Resident assessed today for functional abilities. Resident has impaired vision with glasses. Resident has been added to the eye doctor list per her request, and social services has been notified to provider [sic] her with new glasses. On 3/19/25 at 8:32 AM, an interview was conducted with the Resident Advocate (RA). The RA stated if a resident requested that they wanted to see vision she would present them with two options. The RA stated the resident could either see the in-house vision provider or they could make an appointment with an outside optometrist. The RA stated if the resident requested to see an outside provider Transportation would schedule the appointment. The RA stated she was unsure if resident 63 was seen for vision and would need to check with the in-house vision provider to see what the recommendation was and or if the resident was seen. On 3/19/25 at 9:50 AM, a follow up interview was conducted with the RA. The RA stated that she confirmed with the in-house vision provider that they received the referral for resident 63. The RA stated that the in-house vision provider had not updated their data census which indicated who was on dental, hearing, and vision. The RA stated that she would send the referral and the in-house vision provider would come into the building. The RA stated when the in-house vision provider came back to the facility the provider would see who wanted to be on services. The RA stated that the in-house vision provider came to the facility on ce a quarter. The RA confirmed that it was not appropriate for a resident to wait a quarter to be seen if they needed glasses. 50200 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, heart failure, dysphagia, and cognitive communication deficit. On 3/17/25 at 10:37 AM, an interview was conducted with resident 2. Resident 2 stated she did not receive a vision assessment, new glasses, hearing aid evaluation, or dental care during her stay at the facility. Resident 2's medical record was reviewed. On 1/15/25 at 12:21 PM, a Minimum Data Set Note documented, Resident assessed today for functional abilities. Resident reports she has difficulty hearing with background noise and would like hearing aids. Resident reports she has lost her glasses and would like new ones to be able to read. Social services notifiedof [sic] resident's request for hearing aids and glasses. Resident is able to speak clearly and understand others. Social services notified of request. On 3/20/25 at 8:53 AM, an interview was conducted with the RA. The RA stated that a different social worker handled referrals when resident 2 was admitted . The RA stated she was unaware of the request and had not submitted a referral for services. The RA stated that dental services visit monthly, based on resident needs, and optometry and hearing services visit quarterly. The RA stated she would look to see if resident 2 had the referrals sent in. On 3/20/25 at 9:41 AM, a follow-up interview was conducted with the RA. The RA stated resident 2 had not yet been referred. The RA stated she typically submitted referrals immediately once informed but noted the previous social worker was responsible to do this at the time. The RA stated she would now follow through to ensure resident 2 was referred for services.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 38 sampled residents, a resident that was a high fall risk did not have interventions implemented to prevent future falls. Resident identifier: 81. Findings included: Resident 81 was admitted to the facility on [DATE] with diagnoses which included, dementia, rheumatism, chronic pain syndrome, and essential hypertension. Resident 81's medical record was reviewed on 3/17/25 through 3/20/25. An admission Morse fall risk assessment was performed on 12/16/24. Resident 81's Morse score was 90. A score of 45 and higher indicated a high-risk for falling. A review of resident 81's care plan interventions for falls revealed: a. Answer call lights promptly. Date initiated: 2/15/25. b. Clean up spills immediately. Date initiated: 2/15/25. c. Educate resident to use wheelchair. Date initiated: 3/12/25. d. Encourage resident to stay in common area while during awake hours. Date initiated: 3/5/25. e. Ensure resident was in the center of bed during rounds. Date initiated: 3/15/25. f. Ensure resident was not seated too close to edge of bed prior to transfers. Date initiated: 3/17/25. g. Visible sign to the back of the door to remind resident to use his call light or call for assistance. Date initiated: 2/15/25 and revised on: 2/17/25. On 3/17/25 at 10:05 AM, an observation was made of resident 81. Resident 81 was observed ambulating in his room without a walker. His pant legs were under his shoes, and he repeatedly tried to pull up his pants while walking. No staff were observed in the hallway at the time. Resident 81 had purplish-yellow discolorations under both eyes. There was no signage indicating that the resident should use his call light for assistance. On 3/18/25 at 7:50 AM, an observation was made of resident 81 in the dining area of the unit. Resident 81 was observed to stand up out of his wheelchair and ambulate to a dining room chair without assistance. There were no staff present in the dining room. On 3/18/25 at 1:08 PM, an observation was made of resident 81 ambulating in his room without a walker. Resident 81 was observed to be wearing pants with the pant legs under his shoes. No staff were observed to be in the hallway. There was no signage indicating that the resident should use his call light for assistance. A review of the facility's incident reports revealed the following: a. On 2/15/25, an incident report documented, . Patient was in room with CNA [Certified Nursing Assistant]. CNA reports trying to organize room and prepare resident for cares. Patient's son was outside of room and prompted to keep door shut for cares. CNA reports resident was in room and wheeled over to door and tried to open the door. Resident reached to open the door and fell out of wheelchair. Patient suffered swelling and abrasion to left eyebrow and orbital area. Patient has abrasion to nose and medial part of forehead. Patient has abrasion to right tibia. Interventions put in place after the fall: Place sign reminding resident to use call light and ask for assistance. b. On 3/2/25, an incident report documented, . Resident in bedroom & [and] while standing next to his w/c [wheelchair] he reached to get the tissue box that was on the w/c seat & then lost his footing & fell down on his buttock first then on his left side and arm as went backwards to then being in laying position. No injuries noted & V/S [vital signs] stable & Neuro [neurological] check WNL [within normal limits] of baseline. Assisted by staff onto recliner chair in bedroom. States that Lt [left] lateral upper arm sore. Interventions put in place after the fall: Intervention was to keep resident in common areas while awake as able. c. On 3/12/25 an incident report documented, . Resident was found on the floor on his left side between the bed and his bedside table. He stated that he was going to turn down the temperature in his room, when he lost balance and he slipped. He complained of pain in his left forearm, it is red, but no other obvious injury. He hit his left ear, it is red and has a tear around the base of the outer ear next to the scalp. Nurse tried to clean it and apply bacitracin but he refused. VS within his normal range. Nurse was able to assist him up and back into his chair. He refused to come to the day, but the nurse then asked PT [physical therapy] to help and got him back into his chair so we can watch him better. He is not happy about staying in the dayroom. Interventions put in place after the fall: Educate the resident to use wheelchair instead of ambulating by himself. d. On 3/15/25 an incident report documented, . CNA was assisting resident getting ready for the day. Resident slid out of bed and landed on buttocks. Bed was in the lowest position possible. Patient has a small abrasion to right lower extremity by knee and hip. First aide [sic] was applied. Patient did not hit head or back. Patient rates pain 0/10 post fall. Patient's vitals were WNL. Interventions put in place after the fall: Ensure the resident was not sitting on the edge of the bed prior to transfers. On 3/19/25 at 8:55 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 81 was a fall risk and needed to be checked on often. RN 2 stated that resident 81 needed to stay in the common area, but was independent and preferred to be in his room. RN 2 stated that resident 81 walked with a shuffling gait and required assistance when he was ambulating. RN 2 stated she often walked behind resident 81 when he used his walker to ensure that he did not fall down. On 3/19/25 at 9:46 AM, an interview was conducted with CNA 2. CNA 2 stated that staff were expected to remain in the hallway to monitor resident 81 and watch for his call light. CNA 2 stated resident 81 needed checks every 5 to 10 minutes due to his high fall risk. CNA 2 stated resident 81 was unsteady and did not use his walker and had fallen multiple times. CNA 2 stated staff tried to keep resident 81 in the common area for closer supervision, but he often returned to his room on his own. On 3/20/25 at 8:13 AM, an interview was conducted with RN 3. RN 3 stated that resident 81 walked with a shuffle or like his feet overlapped. RN 3 stated that resident 81 was supposed to use a walker when walking, but liked to walk around his room without it. RN 3 stated that resident 81 should be in the common area during the day. On 3/20/25 at 11:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 81 had fallen since arriving at the facility. The DON stated he was unsteady and required a walker. The DON stated a sign in his room reminded him to use the call light for assistance. The DON stated staff encouraged resident 81 to stay in the common area during the day. The DON stated there were two CNAs on the unit but planned to increase to three due to a rise in resident falls. On 3/20/25 at 11:27 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that she had educated the CNA's on the need to monitor residents in their rooms and round frequently. ADON 1 stated that the facility had added a shift for an extra CNA for the day due to increased falls from resident 81. It should be noted that the nursing administration staff did not know that resident 81 did not have a sign hanging in his room to use his call light.

Based on interview and record review, the facility did not ensure that the resident's drug regimen was free of unnecessary drugs without adequate monitoring. Specifically, for 1 out of 38 sampled residents, nursing staff administered blood pressure lowering medications to the resident when the resident's blood pressure was outside of the parameters specified by a physician's order. Resident identifier: 40. Findings Included: Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, essential primary hypertension, type 2 diabetes mellitus with hyperglycemia, mixed hyperlipidemia, and severe morbid obesity due to excess calories. Resident 40's medical record was reviewed on 3/17/25 through 3/20/25. A physician's order with a start date of 11/26/24, stated, HydroCHLOROthiazide Oral Tablet 25 MG [milligrams] (Hydrochlorothiazide) Give 100 mg by mouth one time a day for HTN [hypertension] Hold for SBP [systolic blood pressure] < [less than ]110 or HR [heart rate] < 60. A physician's order with a start date of 1/3/25, stated, Metoprolol Succinate Oral Capsule ER [extended release] 24 Hour Sprinkle 25 MG (Metoprolol Succinate) Give 50 mg by mouth two times a day for HTN Hold for SBP <110 or HR <60. The Medication Administration Record was reviewed for March 2025. a. On 3/1/25 at 8:00 PM, the SBP was measured as 90. Resident 40 received the 50 mg dose of metoprolol succinate. b. On 3/16/25 at 8:00 PM, the SBP was measured as 101. Resident 40 received the 50 mg dose of metoprolol succinate c. On 3/16/25, the SBP was measured as 101. Resident 40 received the 100 mg dose of hydrochlorothiazide. On 3/20/25 at 8:51 AM, an interview was conducted with Registered Nurse (RN) 4 and RN 5. RN 4 and RN 5 stated that they would not administer a blood pressure lowering medication if a resident's blood pressure was below the number specified in a physician's order. RN 4 and RN 5 stated that if a resident's blood pressure was outside the parameters specified by a physician's order, they would hold the medication and notify the physician. On 3/20/25 at 2:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident's blood pressure was outside of the parameters established by a physician's order for blood pressure lowering medications, then she would expect the nurses to hold the medication and notify the physician of the blood pressure.

Based on interview and record review, the facility did not ensure the residents were free of any significant medication errors. Specifically, for 1 out of 38 sampled residents, a resident's physician order for oxycodone was transcribed to the wrong resident's Medication Administration Record (MAR) and that resident received five doses of the medication. Resident identifier: 60. Findings included: Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, osteomyelitis of vertebra, cauda equina syndrome, stimulant abuse, and discitis. On 3/17/25 at 2:45 PM, an interview was conducted with resident 60. Resident 60 stated that she had not had her pain medications since 3/4/25, because her pain medications were not available. Resident 60's medical record was reviewed on 3/18/25 through 3/20/25. The March 2025 MAR was reviewed. The following documentation was related to pain. a. A physician's order dated 3/4/25 at 4:00 PM, documented oxyCODONE HCl [hydrochloride] Oral Tablet 5 MG [milligrams] (Oxycodone HCl) Give 1 tablet by mouth every 4 hours for aching pneumonia for 5 Days. Resident 60 received four doses prior to the physician's order being discontinued on 3/5/25 at 9:13 AM. b. A physician's order dated 3/5/25 at 1200 PM, documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours for aching pneumonia for 5 Days Crush Narcotics and verify they are swallowed. Resident 60 received one dose prior to the physician's order being discontinued on 3/5/25 at 12:42 PM. On 3/20/25 at 8:20 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated the Nurse Practitioner would email the facility the physician orders. ADON 2 stated the initial oxycodone physician order on 3/4/25, was the wrong order. ADON 2 stated she spoke with the Medical Director (MD) on 3/5/25, and the physician order was discontinued. ADON 2 stated the nurse on the night of 3/4/25, called her and was worried that resident 60 was not taking the oxycodone and might be diverting the medication. ADON 2 stated that was why a crush physician order was put in place on 3/5/25. ADON 2 stated she spoke to the MD on 3/5/25, regarding changing the physician order from every four hours to three times daily (TID). ADON 2 stated the TID order was never implemented because she realized the physician orders got mixed up with another resident's physician orders. ADON 2 stated resident 60 was not supposed to be on oxycodone. ADON 2 stated that she spoke to resident 60 about the mistake when it happened. ADON 2 stated when the physician orders were emailed to the facility, herself and the other ADON would split the physician orders and enter them into the resident's MAR but now only one of them would input the physician orders to prevent mistakes. ADON 2 stated when the physician orders were emailed on the day of the mistake there were three pages and page two and three got out of order.

Based on observation, interview, and record review, the facility did not provide or obtain outside resources for routine or emergency dental services to meet the needs of the resident. Specifically, for 1 out of 38 sampled residents, a resident was not provided dental services for missing teeth. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, heart failure, dysphagia, and cognitive communication deficit. On 3/17/25 at 10:37 AM, an interview was conducted with resident 2. Resident 2 stated she had not received a vision assessment, new glasses, hearing aid evaluation, or dental care during her stay at the facility. On 1/15/25 at 12:21 PM, a Minimum Data Set Note documented, Resident assessed today for functional abilities. Resident reports she has difficulty hearing with background noise and would like hearing aids. Resident reports she has lost her glasses and would like new ones to be able to read. Social services notifiedof [sic] resident's request for hearing aids and glasses. On 3/20/25 at 8:53 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that a different social worker handled referrals when resident 2 was admitted . The RA stated she was unaware of the request and had not submitted a referral for services. The RA stated that dental services visited monthly, based on resident needs, and optometry and hearing services visit quarterly. The RA stated she would look to see if resident 2 had the referrals sent in. On 3/20/25 at 9:41 AM a follow-up interview was conducted with the RA. The RA stated resident 2 had not yet been referred. The RA stated she typically submitted referrals immediately once informed but noted the previous social worker was responsible to do this at the time. The RA stated she would now follow through to ensure resident 2 was referred for services.

Based on interview and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, a resident with food allergies to fish and shellfish was served a Krabbycake and needed Benadryl administered. Resident identifier: 66. Findings include: Resident 66 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, type 2 diabetes mellitus, anxiety disorder, hyperlipidemia, and adult failure to thrive. On 9/10/24 at 1:46 PM, an interview was conducted with resident 66. Resident 66 stated he was upset with the kitchen because they did not watch for his allergies to shellfish, which almost resulted in him having to go to the hospital. Resident 66 stated the incident happened about 2 months ago when he was served an entree that he thought what was prepared with chicken. Resident 66 stated that after he took a bite, his throat was sore and he started to break out in a rash. Resident 66 stated that Registered Nurse (RN) 3 was quick to identify what was happening and administered the anti-histamine Benadryl to him, which stopped the allergic reaction. Resident 66 stated the entree he thought had been prepared with chicken, was actually a crab cake. Resident 66's medical record was reviewed 9/9/24 through 9/16/24. Resident 66's allergies listed in the medical record were Fish, Shellfish and Tide Detergent. A care plan dated 5/1/24 revealed [Resident 66] has potential nutritional problem. The goal was [Resident 66] will maintain adequate nutritional status through review date. Interventions included Provide and serve diet as ordered and Administer medications as ordered. Monitor/Document for side effects and effectiveness. It should be noted that there was no information regarding food allergies in resident 66's care plan. A physician's order dated 7/24/24 revealed Benadryl Allergy oral tablet Give 25 mg [milligrams] by mouth every 6 hours as needed for allergic reaction for 14 days. The Benadryl was administered on 7/24/24 at 5:47 PM and on 7/27/24 at 10:30 AM. A nursing progress note dated 7/24/24 at 5:46 PM revealed, Standing order inputted following guidelines provided. Benadryl 25mg PO [orally] PRN [as needed] QID [four times a day] x [times] 14 days for allergic reaction. There were no nursing progress notes, assessment or documentation regarding what the allergic reaction was from or why the Benadryl was administered on 7/24/24 and on 7/27/24. Resident 66's Dietary Profile assessment dated [DATE] revealed food allergies to fish and shell fish. Resident 66's meal tray card was reviewed. Allergies to shellfish and fish listed in red font. A review of the facility's menu was completed. On 7/24/24, Krabbycakes were served for the evening meal. On 9/11/24 at 11:00 AM, an interview was conducted with Registered Nurse (RN) 3 regarding the allergic reaction resident 66 had experienced. RN 3 stated resident 66 had taken a bite of what the resident thought was a chicken patty. RN 3 stated it was not a chicken patty, but rather a crab cake. RN 3 stated resident 66 had an allergy to fish and shell fish and had an allergic reaction to the crab cake. RN 3 stated he administered Benadryl to resident 66. RN 3 stated he could not remember if resident 66 had issues after the Benadryl was administered. On 9/12/24 at 9:41 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated that for new admissions, resident allergies were documented in the hospital discharge information. The RD stated an admission dietary profile interview was completed for new admissions and allergies were included in the documentation of this interview. The RD stated true food allergies were listed on the resident's meal ticket. The RD stated a resident's reaction to a food item would be considered a true food allergy. The RD stated she was not aware resident 66 had food allergies. The RD looked at resident 66's medical record and affirmed the resident's allergies to shellfish and fish were listed upon admission. The RD stated she was not aware that the facility served Krabbycakes. The RD stated that due to the resident's food allergies, resident 66 should not eat Krabbycakes. On 9/16/24 at 10:44 AM, an interview was conducted with the Certified Dietary Manager (CDM). The CDM stated resident allergies were included in the admission paperwork from the hospital. The CDM stated she asked residents about food allergies when residents were admitted to the facility. The CDM stated food allergies were added to the resident's meal ticket. The CDM stated after resident 66 was served the Krabbycake, she had a meeting with the dietary staff. The CDM stated that in the staff meeting she reinforced the importance of reading and following each resident's meal ticket and ensuring residents were not served items listed as allergies. A review of the inservice dated 7/31/24 revealed Tray Cards - Everyone should be paying close attention to the tray cards. Reading their diets, allergies, dislikes and standing orders. The cooks should be reading them and then the aides should be reading them also. Sometimes the cooks may miss something, that is why having the aides double check is always good just in case. I have had many complaints about this recently.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine was not meeting the required temperature to sanitize the dishes and there were no chemical strips in the kitchen to monitor the sanitizer in the dish machine or the sanitation buckets. Additionally, food items in the freezer and dry storage room were open to air. Findings include: On [DATE] at 9:41 AM, an initial walk through was conducted in the kitchen. The Assistant Dietary Manager was asked to check the sanitation buckets. The Assistant Dietary Manager obtained a bottle of sanitizer strips and attempted to check the chlorine content of the water, but was unable to get a reading on the strip. The Assistant Dietary Manager checked the expiration date on the strips and stated they were expired. The Assistant Dietary Manager was unable to locate additional strips to test the sanitizer. On [DATE] at 9:50 AM, an observation was made of the dish machine as it was running after the breakfast meal. An attempt to check the sanitizer content was made, but again, the strips would not produce a reading. The temperature was monitored for a wash and rinse cycle for the low temperature machine. The wash temperature was 115 degrees Fahrenheit and the rinse temperature was 120 degrees Fahrenheit. An observation was made of the temperature log just outside of the dish machine area. The temperatures on the log were 120 and higher, and all chemical readings were 100 ppm [parts per million] on the log. An observation of the Assistant Dietary Manager was made putting the dish covers on the rack. At 9:52 AM, an interview was conducted with the Certified Dietary Manager (CDM). The surveyor reviewed the temperature log with the CDM and observed the chemical content was marked at 100 ppm for all entries. The CDM stated she would have to provide education to the kitchen staff tomorrow. The CDM stated the [servicing company] came every 3 months, but had come twice in the past 3 months. The CDM stated the dish machine had not been suctioning enough sanitizer up during the cycle. The CDM stated she had ordered some new chemical strips to test the machine. The CDM stated if the temperatures were not correct on the machine she would call the repair man. The CDM stated temperatures were always checked while doing the dishes for each meal. On [DATE] at 10:01 AM, a second temperature reading was conducted. The wash temperature was observed to be 113 degrees Fahrenheit and the rinse temperature was observed to be 118 degrees Fahrenheit. On [DATE] at 10:04 AM, an observation was made of the dry food storage area. A container of cold cereal was found to be open to air. At 10:08 AM, an observation of the walk-in freezer was made. Beef pattie fritters were open to air, and patties of Salisbury steak were open to air. On [DATE] at 10:13 AM, an observation was made of 2 packages of hot dogs sitting in a container in the sink. The hot dogs were sitting in water, and there was no running water being used to thaw them. On [DATE] at 8:16 AM, an observation was made of the dish machine log. The entries were as follows with the date, wash temperature and chemical reading for each meal: a. [DATE]- B: 127 130 --- L: 127 131 --- D: 120 130 --- b. [DATE]- No entries had been made. On [DATE] at 2:22 PM, a second walk through of the kitchen was conducted. In the walk-in freezer, patties for Salisbury steak was open to air, and cinnamon roll dough was open to air. On [DATE] at 2:30 PM, an observation was made of the dish machine. The washing temperature was 117 degrees Fahrenheit and 120 degrees Fahrenheit for the rinse cycle. At 2:46 PM, the CDM was asked to check the chlorine content in the dish machine. Several attempts were made to obtain a reading with the strips that she had. The CDM was observed to push the switch regulating the sanitizer several times while the dish cycles were running. After approximately 7 attempts, the CDM was able to obtain a reading of 200 ppm on the strip. The temperature log was reviewed. Additional entries were as follows: a. [DATE]- B: 128 132 100 L: 132 131 50 D: 138 130 55 b. [DATE]- B: 127 132 100 L: 130 132 100 D: No temperature logged c. [DATE]- B: 127 132 100 L: 130 129 55 D: No temperature logged d. [DATE]- B: 120 132 200 L: 122 123 200 D: No temperature logged e. [DATE]- B: No temp logged L: No temp logged D: No temp logged On [DATE] at 9:46 AM, an interview was conducted with the Registered Dietitian (RD) who stated she completed monthly inspections in the kitchen. The RD stated her inspections consisted of going through every area of the kitchen, looking at cleanliness, making sure food items were closed and off of the floor, and that the freezer and refrigerator were running at proper temperatures. The RD stated she always looked at counter tops, in the drawers and microwave. The RD stated she would check to see if the mixer was clean, if the stove, ovens and walls were clean. The RD stated she did not check the temperature on the dish machine, she would just check the temperature log. The RD stated she asked the staff to test the chemicals and temperature and/or tell her how it is done. The RD stated if the dish machine was running she would check it. The RD stated she found it was best to let the dish machine run through a couple of cycles before testing to ensure the temperatures and chemicals were correct. On [DATE] at 2:53 PM, an interview was conducted with the CDM who stated the [service company] service man came on [DATE] and said everything was working and the tubing from the sanitizer was sitting on top of a metal bar instead of going into the dish machine. The CDM stated temperatures were being checked and the staff were required to check during the breakfast, lunch and dinner dish cycles. The CDM stated the kitchen staff were supposed to be writing down the temperatures as they take them. The CDM stated if there was a problem with the dish machine temperatures the kitchen staff should be telling her so she could call to have the machine serviced. The CDM stated if the dish machine was not working the staff should be doing the dishes in the 3 sink compartment to ensure they were clean and sanitized. The CDM stated if staff were using frozen foods to prepare a meal, they usually took it out a couple of days in advance and let it thaw in the refrigerator. The CDM stated if that did not happen, the frozen food should be thawed under cold running water. The CDM stated for items in the freezer and refrigerator, the staff should be making sure an open date was on the item, that food items were wrapped up or closed tightly.

Based on observation, interview and record review, for 4 of 45 residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for the use of oxygen, and residents did not have properly labeled oxygen tubing. Resident identifiers: 6, 39, 51, and 69. Findings include: 1. Resident 39 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, morbid obesity, pulmonary hypertension, asthma, and chronic kidney disease. On 9/9/24 at 2:10 PM, an interview was conducted with resident 39 who stated she was supposed to be on oxygen 24 hours a day. Resident 39 stated that staff were not checking her oxygen levels. Resident 39's oxygen concentrator was observed to be running, while her oxygen tubing and cannula were hanging over her wheel chair. Resident 39's medical records were reviewed between 9/9/24 and 9/16/24. An admission MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 39 had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. The MDS assessment also revealed that resident 39 was not using oxygen. A baseline care plan dated 7/31/24 included, Reasons for Nursing Services .Oxygen therapy, pain management, ADL [activities of daily living] assistance, skilled nursing assessment, skilled wound care, anxiety, and depression management. An Admission review dated 7/31/24 revealed, .Admitting diagnosis: COPD, Heart failure; Reason for admission: Wound care, medication management, oxygen management. Lifestyle: current smoker, [AGE] years. A Care Conference report dated 8/1/24 revealed a care conference at 8:25 AM. The form stated resident 39 and the IDT (interdisciplinary team) were present at the meeting. Members who participated in development of resident 39's care plan were the attending physician, physician extenders, licensed nurse, certified nursing assistant (CNA), dietary manager, social services, activities director, and the administrator. Additional care areas noted were, She wears oxygen and needs some assistance with her ADL's. Resident 39's orders were reviewed. There were no orders for use of oxygen found. Resident 39's care plan revealed, [Resident 39] has altered respiratory status rt [related to] COPD, chronic respiratory failure, pulmonary HTN [hypertension], morbid obesity. The goal was, [resident 39] will have no s/sx [signs or symptoms] of poor oxygen absorption through the review date. Interventions included, Elevate the head of bed as tolerated for ease of breathing. Resident cannot tolerate lying flat due to SOB [shortness of breath]; Monitor for s/sx of respiratory distress and report to MD [medical doctor] PRN [as needed]: Increased respirations, decreased pulse oximetry, increased heart rate (tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; cough; Pleuritic pain; Assessory muscle usage; skin color changes to blue/gray. On 9/11/24 at 9:22 AM, an observation was made of resident 39's oxygen concentrator. The concentrator was running and the cannula was noted to be on the floor next to the resident's bed. On 9/11/24 at 9:35 AM, an interview was conducted with CNA 5 who stated that resident 39 used her oxygen during the night and not during the day. CNA 5 stated the oxygen tubing was changed every Tuesday night. On 9/11/24 at 9:36 AM, an interview was conducted with Registered Nurse (RN) 3 who stated he thought resident 39 was on 2 liters of oxygen. RN 3 stated most residents were on 2 to 3 liters. RN 3 began to check resident 39's orders but was unable to find an order. RN 3 stated resident 39 had COPD and chronic respiratory failure with hypoxia. On 9/11/24 at 9:38 AM, an interview was conducted with the Director of Nursing (DON) who was also unable to find an oxygen order for resident 39. The DON stated it was necessary to have a physician order for oxygen use. On 9/11/24 at 10:17 AM, a physician order for oxygen revealed, Titrate oxygen as needed to maintain SPO2 [oxygen saturation] equal or greater than 90%. On 9/11/24, an additional intervention was added to resident 39's care plan stating, Oxygen Settings: Oxygen as ordered, wean as able, check 02 sats [saturations] as ordered. On 9/16/24 at 11:47 AM, a follow-up interview was conducted with the DON who stated resident 39 was originally admitted to the facility on hospice, but hospice was retracted because resident 39 was not appropriate for hospice. The DON stated that when a resident was admitted , the floor nurse was the first to do an assessment on the resident. The DON stated the assessment that went to the MDS coordinator who completed the comprehensive admission assessment. The DON stated resident 39 must not have been on oxygen when she was admitted and then she must have been put back on oxygen but there was no physician's order. On 9/16/24 at 11:57 AM, an observation was made of resident 39's oxygen concentrator which was set at 3 Liters. 44640 2. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, adult failure to thrive, need for assistance with personal cares, hypertensive heart, chronic kidney disease stage 3, diastolic congestive heart failure, pulmonary hypertension, chronic pain, major depressive disorder, and generalized anxiety disorder. On 9/11/24 at 10:21 AM, an observation was made of the oxygen concentrator in resident 6's room. The humidifier bottle on the oxygen concentrator was empty and labeled with the date of 8/28. The nasal cannula and bag that held the nasal cannula were both labeled with the date of 8/28. Resident 6 was not in the room to interview. The Certified Nursing Assistant Coordinator was observed to enter the room and change the oxygen tubing. A new date of 9/11 was written on the oxygen tubing and the humidifier bottle. Resident 6's medical record was reviewed 9/9/24 through 9/12/24. No Physician order for changing the oxygen tubing or equipment could be located in resident 6's medical record. No documentation could be located in the medical record of the oxygen tubing being changed and dated. A care plan focus of oxygen therapy r/t CHF [congestive heart failure], COPD . was initiated on 3/6/2020, with a goal for resident 6 to have no s/sx of poor oxygen absorption through the review date. No interventions for changing the oxygen tubing were noted. 3. Resident 51 was admitted to the facility on [DATE] with diagnoses which included dysphagia following cerebral infarction, acute respiratory failure with hypoxia, gastrostomy malfunction, permanent atrial fibrillation, dependence on supplemental oxygen, hemiplegia and hemipareses affecting right dominant side, and primary hypertension. On 9/11/24 at 10:31 AM, an observation was made of resident 51's oxygen tubing and humidifier. Both were labeled with the date of 8/28. The CNAC was observed to enter the room and change the oxygen tubing. A new date of 9/11 was written on the oxygen tubing and the humidifier bottle. Resident 51's medical record was reviewed 9/9/24 through 9/12/24. Physician order dated 5/16/24 documented, O2 per nc at 1-6 L [liter]/min [minute] PRN. Check O2 sat q [every] shift. Goal to maintain O2 sats > [greater than] 90% [percent]. one time a day every Thu [Thursday]. Change nasal cannula & O2 filters on concentrator Q week and PRN; Check humidifier weekly and change humidifier when consumed. THURSDAY The September 2024 Medication Administration Record (MAR) revealed the oxygen tubing had been changed on Thursday 9/12/24 by staff. The documentation of the oxygen tubing being changed that was observed on 9/11/24 was not found in the medical record. A care plan focus of [resident 51] has altered respiratory status/difficulty breathing DX [diagnoses] chronic respiratory failure w [with]/hypoxia. was initiated on 2/12/24 with a goal for resident 51 to have no complications r/t SOB (shortness of breath) through the review date. No interventions for changing the oxygen tubing were noted. 4. Resident 69 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, severe sepsis, pneumonia, thrombocytopenia, dependence on supplemental oxygen, hyperkalemia and shortness of breath. On 9/9/24 at 10:45 AM, an observation was made of the oxygen concentrator in resident 69's room. The nasal cannula, humidifier bottle and bag that held the nasal cannula were all labeled with the date of 8/28. The CNAC was observed to enter the room and change the oxygen tubing. A new date of 9/11 was written on the oxygen tubing, bag and the humidifier bottle. Resident 69's medical record was reviewed 9/9/24 through 9/12/24. No Physician order of Change oxygen tubing weekly had a revision date of 8/27/24. The order did not have a start date. No documentation could be located in the medical record of the oxygen tubing being changed and dated. A care plan focus of [Resident 69] has altered respiratory status and requires O2 rt COPD, Pneumonia, respiratory failure, SOB, tobacco use was initiated on 8/26/24 with a goal for resident 69 to have no complications related to SOB through the review date. No interventions for changing the oxygen tubing were noted. On 9/9/24 at 11:00 AM, an interview was conducted with the CNAC. The CNAC stated she was changing out the oxygen tubing, humidifiers and bags on all the residents in the facility who were on oxygen. The CNAC stated she was the only one who changed the oxygen supplies and that she did it weekly. The CNAC stated the oxygen tubing should be changed weekly to decrease the risk of the residents getting sick from dirty oxygen supplies. On 9/12/24 at 10:03 AM, a follow up interview was conducted with the CNAC. The CNAC stated she did change all of the oxygen supplies for the residents on Monday. The CNAC stated she did not chart it anywhere, she usually just keeps track of it. The CNAC stated the nurses keep track of the resident's oxygen levels but that did not reflect when she changed the oxygen supplies. The CNAC stated the CNA's at night could change it if she was not there. The CNAC stated there was no record for CNA's to reference to know if oxygen supples needed to be changed unless they just went around to each resident and checked the date on the oxygen supplies in the rooms. The CNAC stated the CNAs had a list of responsibilities they were supposed to look at each shift to make sure things were getting done. The CNAC stated they were aware this was an issue and were working on the process with the staff to ensure oxygen tubing was changed weekly. On 9/16/24 at 2:36 PM, an interview was conducted with the Administrator and DON. The DON stated oxygen supplies were changed out weekly. The DON stated the supplies included the nasal cannula, humidifier and tubing. The DON stated all the oxygen supplies should be dated and labeled. The DON stated there should be physician's orders for oxygen to know how much the resident needed.

Based on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 9 out of 45 sampled resident, residents complained of food quality and a test tray not attractive or palatable. Resident identifiers: 8, 15, 28, 31, 34, 39, 47, 55 and 66. Findings include: 1. On 9/9/24 at 9:29 AM, an interview was conducted with resident 15 who stated the food was terrible. Resident 15 stated there was too much rice served and what they pass off as meat went right through her. Resident 15 stated she continued to be served food she had put on her dislikes list. On 9/10/24 at 1:42 PM, an interview was conducted with resident 15. Resident 15 stated the food was not good. Resident 15 stated she was sick of rice and they put rice on everything. Resident 15 stated that there was rice on sandwiches. Resident 15 stated the last sandwich she was served had cheese, chicken, rice, tomato and bread with no sauce. Resident 15 stated she needed wheat bread and was only served white bread 2. On 9/9/24 at 10:06 AM, an interview was conducted with resident 28. Resident 28 stated the food had too many carbohydrates. Resident 28 stated the vegetables were under cooked or over cooked and not palatable. Resident 28 stated when vegetables were over cooked there were no vitamins in them. Resident 28 stated the portions at dinner were not big enough and if he asked for seconds, sometimes he was able to get them. Resident 28 stated the meal tray had salt and pepper packets but most of the time the milk or water spilled onto the packets. Resident 28 stated many times the food was left at his bedside because he was sleeping and staff did not wake him up. Resident 28 stated when he woke up the food was always cold. Resident 28 stated he tried to eat in the dining room because the food was not cold in the dining room. 3. On 9/9/24 at 10:23 AM, an interview was conducted with resident 55. Resident 55 stated the food was bad. Resident 55 stated that when he cut the eggs, powder would fall out of them. 4. On 9/9/24 at 2:03 PM, an interview was conducted with resident 39. Resident 39 stated the kitchen did not serve salads. Resident 39 stated the menu had been revamped to cut down on costs and the food quality had decreased. 5. On 9/9/24 at 2:44 PM, an interview was conducted with resident 34. Resident 34 stated since getting a new Dietary Manager, the food had gone down hill. Resident 34 stated she was not able to get coffee when she wanted it at night. Resident 34 stated she was served an English muffin and 1 sausage patty for breakfast and nothing else. 6. On 9/10/24 at 7:57 AM, an interview was conducted with resident 47. Resident 47 stated some days the food was good and some days the food was bad. Resident 47 stated the egg salad sandwiches were soggy with no flavor. 7. On 9/10/24 at 10:12 AM, an interview was conducted with resident 31 who stated the food was terrible and he was not getting enough to eat. Resident 31 stated he wished he could ask for something else to eat. 8. On 9/10/24 at 1:46 PM, an interview was conducted with resident 66. Resident 66 stated the food was not good. Resident 66 stated that he was served a Krabbycake and thought it was a chicken patty. Resident 66 stated he had to have Benadryl because he had a food allergy to shell fish. 9. On 9/10/24 at 1:46 PM, an interview was conducted with resident 8. Resident 8 stated the food was horrible. Resident 8 stated fries were not cooked and were still frozen in the middle. Resident 8 stated the facility did not have a fryer. Resident 8 stated the facility was buying cheap bread. Resident 8 stated he did not usually eat the food. Resident 8 stated that he ate a lot of oatmeal. Resident 8 stated that usually he took the lid off the meal and put the lid right back on because it was not appetizing. On 9/12/24 at 12:13 PM, an observation was made of the lunch trayline. There was pork, scalloped potatoes, California vegetable blend and cookie. The last meal was plated at 12:22 PM for the main dining room. A test tray was requested at 12:22 PM. The test tray was placed in the meal cart. The first tray was served at 12:26 PM and the last try was served at 12:31 PM. The test tray was observed to have shredded pork, scalloped potatoes, dull colored California blend veggies and a cookie in a plastic bag. The vegetables were warm, mushy and bland to the taste. The shredded pork was warm, had a dry consistency, chewy and bland to the taste. The ground pork for mechanical soft diet had a dark brown gravy on it. The pork was chewy and the gravy was thick. The scalloped potatoes had a glue and grain consistency. The California blend was dull in color and mushy with excess moisture. On 9/16/24 at 10:49 AM, an interview was conducted with the Certified Dietary Manager (CDM). The CDM stated food concerns were discussed during food council each month. The CDM stated she talked to residents individually between food council. 43212 Food council notes were obtained and revealed: a. On 5/29/24: Concerns- condiments were not sent with meals and too much fish was being served. b. On 6/27/24: Concerns- residents requested more snacks at night. c. On 7/24/24: Concerns- potatoes were too hard, carrots were not cooked, soups had no flavor, the corn dogs were not hot, no condiments were sent on the trays and sugar free juices were not being offered. Residents also added that they disliked Brussels sprouts and the enchilada casserole. d. On 8/28/24: Concerns- residents wanted more pancake and french toast days, and resident requested real eggs.

Based on observation and interview, it was determined the facility did not ensure that all drugs and biologicals were stored and secured in locked compartments. Specifically, medication was left unattended in a medication cup on top of an unlocked medication cart within reach of other residents and a blue pill was observed to be on the floor during medication pass. Findings include: On 9/10/24 at 8:04 AM, an observation was made of the medication cart in the Cambridge Unit. It was observed that there were medications in a medication cup on top of the cart, the medication cart was not locked and left unattended by Registered Nurse (RN) 1. It was observed that several residents were passing by the medication cart on their way into the dining room. RN 1 was observed to be in the dining room and returned to the medication cart at 8:06 AM. On 9/11/24 at 7:17 AM, an observation was made of a blue pill on the floor near the nurses station and the south hall. It was observed that there were multiple residents in the area. On 9/11/24 at 7:30 AM, an observation was made of housekeeping picking the blue pill up off the floor and handing the pill to RN 4. RN 4 was observed to dispose of pill in the sharps container. On 9/11/24 at 9:42 AM, an interview was conducted with RN 1. RN 1 stated that when she passed medications to residents she tried not to leave the medications on top of the medication cart and if she did it was usually an emergency. RN 1 stated that she should not leave medications unattended and the medication cart should always be locked. On 9/16/24 at 10:38 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated that all medications should be stored inside of the medication cart and never left out unattended and the cart should be locked when not in use. ADON 2 stated that if a medication fell on the floor, she would verify what the medication was and what resident did not get their medication. ADON 2 stated that after she verified the medication she would waste the medication appropriately if it was on the floor. On 9/16/24 at 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that medications found on the floor should be identified and investigated to see where they came from. The DON stated that the medication should then be disposed of. The DON stated that medications should never be left on top of a medication cart unattended. The DON stated the medication cart should always be locked when a nurse left the cart.

Based on interview and record review, the facility failed to prevent an instance of sexual abuse between resident 269 and resident 270, and neglected to provide the supervision necessary to prevent the elopement of resident 17. The facility's failure to prevent the sexual abuse of resident 270 was determined to be noncompliant and constituted immediate jeopardy. Additionally, due to resident 17's assessed impaired cognitive status and known wandering behavior, the facility's lack of a coordinated plan to supervise the resident's whereabouts was also determined to be noncompliant and constituted immediate jeopardy. However, based on the facility's corrective actions and a review of the facility's current compliance in this regulatory area, the deficiency was determined to be past noncompliance. Resident identifiers: 17, 269, and 270. Corrective Action: Elopement: [DATE]: Resident was assessed for injury; no injuries were found. [DATE]: Facility representative spoke with family who reported that she had done this type of thing at home. [DATE]: Resident was determined to be a high risk for further elopements and would need to be moved to the secure unit. Resident was transferred to the secure unit to prevent further elopements. [DATE]: IDT reviewed the elopement Systemic Interventions: A training was conducted on [DATE] for the monthly all staff meeting. Clinical training topics included labs, abuse reporting, and elopement prevention. The training was aimed at helping facility staff understand why residents have behaviors and interventions that they could do to help residents feel more comfortable and minimize behaviors. On [DATE], Facility IDT met to review elopement process. The following interventions were implemented: Elopement binder was created for all high-risk residents on Cambridge. CNA Coordinator was given instructions to create tools for the staff, including a task sheet to alert staff of high-risk behaviors for residents and elopement sheets for the elopement binder. CNA Coordinator was given responsibility to round at least twice daily to verify the unit was running smoothly and that staff had the tools they needed to care for the residents. Monitoring: [DATE]: Administrator/Designee began holding weekly meetings with CNA coordinator regarding the flow of the unit, communication, and the competency of the supervising staff on the unit. QAPI: On [DATE], the QAPI committee reviewed the events of the month and identified the need for further interventions for elopement/abuse prevention. QAPI committee began creating care kits for memory care residents to decrease boredom, exit seeking, and help residents who were up at night. Corrective Action: Abuse: Immediate Interventions: Immediately, residents were separated, and the abuse investigation was initiated. As part of the immediate actions, the police were notified, CMS [Centers for Medicare & Medicaid Services] was notified. Actions taken to Prevent Recurrence: The resident was placed on 1:1 on [DATE] with the intention to remain until the investigation was complete and interventions could identify how to prevent recurrence. On [DATE], the IDT reviewed the situation and identified that the root cause was that the resident thought (the victim) was his wife. To prevent recurrence, the victim was moved off the unit on [DATE]. On [DATE], As the CMS-Form 359 was nearing completion, an internal meeting was held to review the investigation with the Regional Nurse Consultant, the Director of Clinical Services, the Corporate LCSW [Licensed Clinical Social Worker], the Facility Administrator, and Director of Nursing. The investigation details were reviewed and approved for completion. Systemic Action: On [DATE], the Director of Nursing conducted an in-service with facility staff on Abuse Prevention with a post-test validation. On [DATE], the perpetrator was reviewed weekly by the Behavioral Health Facility Committee to validate interventions were effective and further abuse prevented. On [DATE], Corporate LCSW provided a training with the Social Services Department on Sexual Intimacy in the LTC [Long Term Care] setting, Assessing Capacity to Consent, Care Planning, and appropriate Documentation. Monitoring: A week later, on [DATE] the Corporate LCSW came to the facility and assessed the Perpetrator and reviewed the interventions in place. The resident had been on 1:1 up to that point. Recommendations were made to adjust the interventions as he did not appear to be at high risk to repeat the behavior. CNA Coordinator was given responsibility to round at least twice daily to verify the unit was running smoothly and that staff had the tools they needed to care for the residents. Administrator/Designee held Weekly meetings with CNA Coordinator regarding the flow of the unit, communication, and the competency of the supervising staff on the unit. Camera's were set up to enhance visibility in the unit for staff. Computers in the unit were connected to be able to view halls for when CNA's were busy in rooms. QAPI [Quality Assurance and Performance Improvement]: [DATE]: QAPI Meeting, facility reviewed staffing patterns on the unit to validate that there was proper supervision on the unit. Continued Interventions: An investigation was conducted in [DATE], and found that the abuse program was not being run in accordance with facility policy and procedure. Further investigation identified the administrator was not engaged sufficiently in managing the abuse program. The administrator was terminated. A facility manager took over the facility with significant oversight of the RVP [Regional [NAME] President]/Designee. Determination of Compliance Date: [DATE] Findings included: 1. Resident 269 was admitted to the facility on [DATE] with diagnoses which included dementia, muscle weakness, abnormalities of gait and mobility, adult failure to thrive, cognitive communication deficit, Alzheimer's disease, stage 3 kidney disease, major depressive disorder, anxiety disorder, and insomnia. Resident 269 expired on [DATE]. Resident 270 was admitted to the facility on [DATE] and again on [DATE] with diagnoses which included polyneuropathy, chronic respiratory failure, protein-calorie malnutrition, intracranial injury without loss of consciousness, dementia, major depressive disorder without psychotic features, anxiety disorder, unspecified psychosis, hallucinations, insomnia, fusion of spine, and tendinitis. Resident 270 expired on [DATE]. A form titled Exhibit 358 submitted to the State Survey Agency (SSA) documented on [DATE], there was an allegation of sexual abuse. The alleged victim was identified as resident 270. The alleged perpetrator was identified as resident 269. The allegation details documented, [resident 269] was found in [resident 270's] room naked on top of her. Exhibit 358 documented, Resident were separated by [Speech Therapist (ST)] and [Physical Therapist (PT)]. [Resident 269] redirected back to room. Ethics committee met to discuss room change for [resident 270], specialized unit assessment completed. [Resident 270] moved to rm [room] ,d+[DATE] off the the [sic] locked unit. CNA [Certified Nursing Assistant] post moved to hallway to monitor [resident 269] wandering. Monitoring for psychosocial baseline initiated for [resident 270]. Behavior monitoring initated [sic] for [resident 269]. MD [Medical Director] and [resident 270's] hospice notified. Frequent visits from SS [Social Services] for both resident through out durration [sic] of investigation. A witness statement from the initial police report dated [DATE], was reviewed. The witness statement was written by the ST and documented, [The PT] and I began looking for [resident 269] to begin our initial evals [evaluations], he wasn't in his room or the common area so we started looking in empty rooms, then in occupied rooms. I peeked in [resident 270's] room and noticed something was off so I walked in further. I realized [resident 269] was on top of [resident 270] between her legs and was naked from the waist down. I told him to stop and went back to the hallway and told [the PT] and [the occupational therapist (OT)] there was a problem. [The PT] went in next and told [resident 269] to get up. I comforted [resident 270] while [the PT] and [the OT] got [resident 269] dressed and out of the room. [CNA 18] helped to get [resident 270] a new brief and we got her in new clothes. [CNA 18] changed the bedding and we transferred [resident 270] to her wheelchair. I stayed with [resident 270] while admin/DON [Administrator and Director of Nursing] were alerted and arranged for a new room for [resident 270]. A witness statement from [DATE], written by the OT was reviewed. The OT wrote, Therapists were looking for suspect to do therapy. Speech therapist found suspect on top of victim both fully unclothed from waist down. Physical and occupational therapist pulled suspect off of victim. Suspect did not appear erect. Physical and occupational therapist proceeded to help suspect get dressed while speech therapist comforted victim. Suspect kept stating 'is that my wife' Physical therapist proceeded to take suspect out of the room to continue PT evaluation. Speech therapist stayed to help aid [CNA]care for patient. A witness statement from [DATE], written by CNA 18 was reviewed. CNA 18 wrote, I was helping therapy look for [resident 269] for about 15 minutes. We ended up spreading out (4 people including myself). As I was looking I heard a woman yell that they found him and when I went into the room I saw two people talking to [resident 269] and gently pulling him off of her. My first priority was helping [resident 270]. So I helped comfort her while [resident 269] was taken out of the room. Once he left, me and the female therapist put a new brief on her, since her other one was removed and her pants were completely removed when I first entered the room ([resident 269's] clothes from his hips down were completely off and he was still in between [resident 270's] legs when I walked into the room). I did a quick wipe down around her peri area and put on a new brief. I changed all of her clothes and bedding . I sat with [resident 270] while everyone else was making phone calls, her breathing was faster than normal abut other than that I saw no signs of stress. I took her to her new room, talked with the officer, and retrieved all of the bedding and clothes from [resident 269] and [resident 270]. The form titled Exhibit 359, the follow-up investigation report was reviewed. The steps taken to investigate the allegation documented that resident 270 was nonverbal and was alert and oriented to self, and the facility was unable to collect a statement from resident 270. The document reported that resident 270 returned to baseline shortly after separation, and had continued to participate in daily routine such as attending activities and eating in the dining room throughout the duration of the investigation. The summary of the witness interviews was documented as, Per witness statements it is concluded that [resident 269] was in [resident 270's] room on top of [resident 270]. Both of their lower body dressings had been removed. When staff intervened, [resident 269] had expressed that he had believed [resident 270] was his wife. After explaining to [resident 269] that [resident 270] was not his wife, [resident 269] was easily redirected out of the room. Male staff member stayed with [resident 269] in his room. Two females stayed with [resident 270]. DON [Director of Nursing] and Abuse Coordinator notified after it was ensured that both residents were safe. A summary of interview with other residents who may have had contact with the alleged perpetrator documented, Resident interviews were conducted with resident who reside on the locked unit and may have had contact with the perpetrator. Interviews concluded that the residents feel safe at the facility and that no one has made them feel unsafe. Residents expressed that they had not witnessed anything that concerned them . The summary of interviews with staff responsible for oversight and supervision of the location where the alleged victim resides documented, Floor nurse was assisting other residents during the time of the incident and was notified by facilities rehab staff immediately. Nurse informed Abuse Coordinator and DON after ensuring the residents were safe. CNA was informed by rehab staff that [resident 269] was not in room and assisted in locating [resident 269]. Once informed of location of [resident 269], CNA came to [resident 270's] room to assist. [Resident 269] was removed from the room by staff member and CNA stayed with [resident 270]. Exhibit 359 documented that the allegation of sexual abuse was verified by the facility. Exhibit 359 documented the plan for oversight of implementation of corrective action as, [Resident 269] will remain on 1:1 [one on one] with staff member with weekly review to be conducted to assess the effectiveness of current interventions until IDT [interdisciplinary team] finds it appropriate for 1:1 to be weaned off. Interventions planned to assist resident 270 were documented as, no changes in psychosocial baseline was observed per monitoring and frequent visits from social services. [Resident 270] will continue to receive visits from SS as needed. The facility documented steps that have been taken to address the systems as, schedular [sic] notified of need for [resident 269] to have 1:1 with facility staff member. Training being completed as 1:1 comes on shift to re-fresh techniques on de-escalation, re-direction, reporting abuse, and reducing behaviors. Resident 270's medical record was reviewed. Resident 270 started on hospice services on [DATE]. Resident 270's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that a Brief Interview for Mental Status (BIMS) score was unable to be performed and the resident was noted to be cognitively severely impaired. The MDS for functional status revealed that resident 270 had impairment on both sides for upper and lower extremities. A care plan initiated on [DATE], documented, [resident 270] is at risk for unwanted attention from other residents and has difficulty getting them to go away due to cognitive impairment. The interventions stated, Observe resident's whereabouts closely and encourage resident to be in common areas. Observe whereabouts of any aggressive resident and keep away from at risk resident. Be alert to any changes in resident's mood or attitude which may indicate resident has been subject of aggression. Report any s/sx [signs or symptoms] of abuse including injuries of unknown origin to administrator and/or DON and contact personal representative to update them. Consider a room change to area with better visibility to staff if necessary. On [DATE] at 3:17 PM, an IDT Event Review Note documented, Residents involved in sexually inappropriate conduct .New assessment completed for the need for the specialized unit. Due to decreased mobility and disease progression resident was taken off specialized unit. Ethics committee, hospice and MD agreed to room change. Alert charting initiated for changes from psychosocial baseline, frequent visits from SSW [Social Service Worker] pending investigation. [It should be noted that resident 270 did not have any family or a Power of Attorney to notify of the incident.] On [DATE] at 4:18 PM, a Nurses Note documented, I assessed resident's peri area. There was no redness, swelling or injury noted. On [DATE] at 5:25 PM, a Nurses Note documented, DON called the Medical Director to get orders for the incident. After report of what happened, alert monitoring for changes from psychosocial baseline was initiated. He did not want police to do SAEK [Sexual Assault Evident Kit] d/t [due to] trauma it could cause this resident who is on hospice and no signs of distress or indication of physical incident. Monitor and notify MD of any changes. On [DATE] at 12:00 PM, a Nurses Note documented, I assessed [resident 270] today to see how she is doing in her new room. She has adapted to the change of environment well and staff states there hasn't been any issues at this time. Resident 269's medical record was reviewed. Resident 269's History and Physical Report, dated [DATE], from the hospital prior to being admitted to the facility were reviewed. The document stated, Reportedly he has becoming more and more complicated with his agitation and wandering . Now he is worsening and they [family] have to watch him around-the-clock and concerned about him around little kids due to his agitation and aggression . On [DATE], a BIMS score was completed and resident 269 scored a 0 which indicted severe impairment. Documentation revealed that the facility was aware that resident 269 frequently wandered into other resident rooms prior to the sexual abuse incident. Resident 269's care plan initiated on [DATE], documented, [Resident 269] is an elopement risk/wanderer, r/t [related to] resident tends to wander into other residents rooms. The goal stated, Residents safety will be maintained through the review date. The interventions stated, Assess for fall risk, resident requires a secured unit for safety. Resident 269's care plan initiated [DATE], documented, [Resident 269] is at risk for impaired safety related to Wandering.The goal stated, Will be free from injuries through next review date. The interventions stated, Calmly redirect and cue as needed. Encourage resident to participate in activities of interest as tolerated. Keep environment free from clutter and obstacles to reduce risk of fall or injuries. On [DATE] at 5:17 AM, a 72-Hour Charting Admission Progress Note documented, Pt [patient] needs lots of redirection due to wandering into other pt rooms. A physician's order started on [DATE] at 6:00 PM, stated, Behavior Monitoring: Wandering Document how many episodes of wandering during the shift . It was documented that resident 269 had 10+ episodes on wandering during the night shift on [DATE]. It was documented that resident 269 had 10+ episodes of wandering during the day shift on [DATE]. On [DATE] at 5:15 AM, a 72-Hour Charting Admission Progress Note documented, Pt has been wandering into pt rooms. On [DATE] at 3:17 PM, an IDT Event Review Note documented, Initial IDT to review sexually inappropriate behavior on [DATE]. Residents involved in inappropriate sexual conduct. Residents were separated immediately. The CNA post has been moved to hallway to observe activity in and out of rooms. Behavior tracking has been added. MD notified. SSW to visit resident frequently. Care plan updated. Pending investigation. Resident 269's care plan was updated on [DATE], and documented, [Resident 269] has a history of behaviors that may include: Sexually inappropriate behaviors. The goal stated, Resident will not have sexually inappropriate behaviors . The interventions stated, 1:1 during wake time hours 0600 [6:00 AM]-1800 [6:00 PM] and PRN [as needed] if awake. Administer meds [medications] as ordered, behavior monitor. A physician's order started on [DATE] at 6:15 PM, stated, FLUoxetine HCl [hydrochloride] Capsule 20 MG [milligrams] give 20 mg by mouth one time a day for sexually inappropriate behaviors. The order was discontinued on [DATE]. A physician's order started on [DATE] at 6:00 AM, stated, 1:1 monitoring every day shift. The order was discontinued on [DATE]. On [DATE] at 1:01 PM, an interview with CNA 20 was conducted. CNA 20 stated he was not here during the incident with resident 269 and resident 270. CNA 20 stated that he felt like there were enough staff working on the memory care unit to supervise the residents. CNA 20 stated that there was always someone monitoring the hallways. CNA 20 stated that if the CNAs had to complete a task that would prevent them from watching the hallway, such as a two-person physical assist with transfers or showers, then the CNAs would ask the nurse or pull a CNA from another unit to watch the memory care unit hallway until the CNAs completed their task. On [DATE] at 1:18 PM, an interview with Licensed Practical Nurse (LPN) 2 was conducted. LPN 2 stated she was not here during the incident with resident 269 and resident 270. LPN 2 stated that she believed there were enough staff on the memory care unit to monitor the residents. LPN 2 stated that there was always a CNA watching the hallway. LPN 2 stated that she assisted with watching the hallway if the CNAs had to complete a task that would take them away from watching the hallway. On [DATE] at 9:38 AM, an interview with CNA 18 was conducted. CNA 18 stated that she was working on a different hallway when the incident occurred in the memory care unit with resident 269 and 270. CNA 18 stated that she overheard the therapy team looking for resident 269, and CNA 18 joined the therapy team to search for resident 269. CNA 18 stated the incident occurred between 2:00 PM and 3:00 PM, but could not remember the exact time. CNA 18 stated that one of the therapy employees found resident 269 in resident 270's room. CNA 18 stated that she walked into resident 270's room and saw a staff member helping resident 269 off of the bed. CNA 18 stated that both residents did not have clothes on from the waist down. CNA 18 stated that she helped resident 270 get her clothes back on. CNA 18 stated that she observed resident 270's peri area and did not see any signs of injury or bodily fluid. CNA 18 stated that resident 270 appeared to have some signs of anxiety, which included heavy breathing, slight shaking, and her eyes appeared to be open wide and she looked anxious. CNA 18 stated that resident 269 thought that resident 270 was his wife, and staff helped him get dressed and escorted him out of the room. CNA 18 stated that resident 270 was nonverbal and was unable to walk or transfer out of her bed at the time of the incident. CNA 18 stated that after the incident, resident 269 was on 1:1 monitoring at all times. CNA 18 stated that the memory care unit now has a staff member always monitoring the hallway. CNA 18 stated that the memory care unit would now pull another CNA or staff member to monitor the hallway if the CNAs were too busy to monitor the hallway. CNA 18 stated that she believed there were enough staff to ensure that the memory care unit hallways were being monitored. On [DATE] at 2:58 PM, an interview with CNA 19 was conducted. CNA 19 stated that she was working on the memory care unit when the incident when resident 269 and 270 occurred. CNA 19 stated that at the time there were two CNA's, herself included, and a nurse working on the memory care unit. CNA 19 stated that the incident occurred sometime after lunch, and she, along with the other CNA, were busy cleaning up after lunch, returning items back to the kitchen, and assisting residents into their rooms so they were not monitoring resident 269 when he went into resident 270's room. CNA 19 stated that the last time she observed resident 270 was when he was eating lunch in the memory care unit's dining room, which would have been around 1:00 PM. [It should be noted that resident 269 was found in resident 270's room around 2:30 PM]. CNA 19 stated that when resident 269 arrived at the facility, he would often wander into other resident rooms, including resident 270's room. CNA 19 reported that resident 269 wandered into resident rooms during the day and at night prior to the incident with resident 270. On [DATE], the Administrator (Admin) provided a form with systemic changes completed after the sexual abuse on [DATE]. Immediate Interventions: Immediately, residents were separated, and the abuse investigation was initiated. As part of the immediate actions, the police were notified, CMS [Centers for Medicare & Medicaid Services] was notified. Actions taken to Prevent Recurrence: The resident was placed on 1:1 on [DATE] with the intention to remain until the investigation was complete and interventions could identify how to prevent recurrence. On [DATE], the IDT reviewed the situation and identified that the root cause was that the resident thought (the victim) was his wife. To prevent recurrence, the victim was moved off the unit on [DATE]. On [DATE], As the CMS-Form 359 was nearing completion, an internal meeting was held to review the investigation with the Regional Nurse Consultant, the Director of Clinical Services, the Corporate LCSW [Licensed Clinical Social Worker], the Facility Administrator, and Director of Nursing. The investigation details were reviewed and approved for completion. Systemic Action: On [DATE], the Director of Nursing conducted an in-service with facility staff on Abuse Prevention with a post-test validation. On [DATE], the perpetrator was reviewed weekly by the Behavioral Health Facility Committee to validate interventions were effective and further abuse prevented. On [DATE], Corporate LCSW provided a training with the Social Services Department on Sexual Intimacy in the LTC [Long Term Care] setting, Assessing Capacity to Consent, Care Planning, and appropriate Documentation. Monitoring: A week later, on [DATE] the Corporate LCSW came to the facility and assessed the Perpetrator and reviewed the interventions in place. The resident had been on 1:1 up to that point. Recommendations were made to adjust the interventions as he did not appear to be at high risk to repeat the behavior. CNA Coordinator was given responsibility to round at least twice daily to verify the unit was running smoothly and that staff had the tools they needed to care for the residents. Administrator/Designee held Weekly meetings with CNA Coordinator regarding the flow of the unit, communication, and the competency of the supervising staff on the unit. Camera's were set up to enhance visibility in the unit for staff. Computers in the unit were connected to be able to view halls for when CNA's were busy in rooms. QAPI [Quality Assurance and Performance Improvement]: [DATE]: QAPI Meeting, facility reviewed staffing patterns on the unit to validate that there was proper supervision on the unit. Continued Interventions: An investigation was conducted in [DATE], and found that the abuse program was not being run in accordance with facility policy and procedure. Further investigation identified the administrator was not engaged sufficiently in managing the abuse program. The administrator was terminated. A facility manager took over the facility with significant oversight of the RVP [Regional [NAME] President]/Designee. Determination of Compliance Date: The facility believes that substantial compliance from the Sexual Abuse investigation occurred on [DATE] with the completion of the investigation as timely interventions were implemented to prevent recurrence and facility education had been implemented. 30563 2. Resident 17 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance, cognitive communication deficit, unsteadiness on feet, abnormal postures, adult failure to thrive, major depressive disorder, and insomnia. A form 358 was submitted to the SAA revealed on [DATE], there was an allegation of neglect for an elopement. There was no alleged victim's name on the form. A police officer reported to the facility at approximately 11:30 AM, [Initials redacted] was brought back to the facility, full head toe assessment, and resident was moved to the secured unit for wandering, wandering behavior tracking added to electronic medical record as well as 4 x daily safety checks documented on the electronic medical record. Alert monitoring added for changes from psychosocial baseline. The form 359, the follow-up investigation report, revealed resident 17's family was notified on [DATE] at 10:35 AM, of the elopement. The steps taken to investigate the allegation revealed the Assistant Director of Nursing (ADON) interviewed resident 17 and resident 17 did not recall the incident. There were interviews with staff and no one witnessed resident 17 leaving the facility. The receptionist was helping another resident outside and believed that was when resident 17 eloped out the front door. The report further revealed there had been no reports of exit seeking behaviors were noted by staff prior to the event. Resident 17's BIMS score indicated severe cognitive impairment. The conclusion was not verified because there were no indications or reports of elopement, wandering, or exit seeking behaviors prior to the incident that would indicated resident 17 was a risk of eloping from the facility. The systemic changes were facility staff receiving daily education on abuse, specific forms of abuse and extended oversight from management. Resident 17's medical record was reviewed on [DATE] through [DATE]. Resident 17's history and physical prior to admitted d [DATE], revealed that resident had progressively worsening behavioral issues which included frequent wandering, anger outbursts, and today she tried to stab one of her caregivers with a cake icing knife. A form titled Admit Report to be completed by Nurse who puts in orders was dated [DATE]. The report details section revealed wandering, every 4 hour checks for 72 hours. An admission MDS assessment dated [DATE], revealed resident 17 had a BIMS score of 7 which indicated severe cognitive impairment. A care plan dated [DATE], revealed [Resident 17] is at risk for impaired safety related to Wandering The goal was [Resident 17] will be free from injuries through next review date. The interventions included Anticipate needs for resident as much as possible; Calmly redirect & cue as needed; Encourage resident to participate in activities of interest as tolerated; Encourage resident to use assistive devices as resident is often noncompliant; Keep environment free from clutter and obstacles to reduce risk of fall or injuries and; Monitor for significant changes in behavior. A physician's order dated [DATE], revealed Resident safety check document yes or no call nursing mngmnt [management] if any issues. four times a day for safety. According to the Treatment Medication Record for [DATE], resident 17 was checked 4 times per day, except at 4:00 PM on [DATE] and [DATE]. It should be noted the admission form revealed to check resident 17 every 4 hours for 72 hours after admission because of wandering. An Admission evaluation for wandering risk scale dated [DATE], revealed resident 17 had a score of 20. The evaluation further revealed resident 17 was able to follow instructions, ambulatory, able to communicate, had a history of wandering, and had medical diagnoses of dementia/cognitive impairment. Resident 17 had wandered within the home without leaving the grounds and had wandered within the past month since admission. Resident 17 was at high risk to wander. Resident 17's nursing progress notes revealed the following: a. On [DATE] at 2:27 AM, Resident is an [AGE] year old female who arrived to facility in a wheelchair via facility transport. Resident was living with grandson and pulled a cake knife on live in caregiver. Resident has had an increase of behaviors recently. Family took resident to hospital for evaluation and treatment. Residents' primary diagnosis for admission is dementia with behaviors. Resident appears to be well dressed and groomed. Bruises noted to BUE [bilateral upper extremities]. A&O [alert and oriented] x1 to self. Resident appears to have sundowning behaviors. She was wandering around nurses' station and hallways. Ambulation with stand by assist- has an unsteady gait. Provided walker and education. Gait improved with walker use. Resident She is very friendly and cooperative with treatment and cares. Resident took HS [at bedtime] trazodone and was able to settle down for bed and sleep well during the night. <b [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 11 out of 45 sampled residents, a resident that had several falls and did not always have preventative interventions in place after each fall sustained a closed head injury, sacral insufficiency fracture, nasal fracture, and a laceration of the nose. The resident had two additional falls and sustained a laceration that required stitches to the head and a laceration that required staples to the back of the head. In addition, a family member found medications in a resident room on the floor and the bathroom and there were hot water temperatures in resident bathrooms. Resident identifiers: 2, 14, 15, 23, 25, 31, 40, 48, 60, 62, and 170. Findings included: 1. Resident 170 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, bilateral primary osteoarthritis of knee, repeated falls, Alzheimer's disease, and dementia with other behavioral disturbance. Resident 170's medical record was reviewed on 3/14/24. A care plan Focus initiated on 11/20/18, documented [Resident 170] is at risk for falls r/t [related to] impaired gait/balance, decreased safety awareness, short term memory deficits related to Alzheimer's dementia. The care plan interventions included: a. Resident needs a safe environment with: adequate, glare-free light; a working and reachable call light, and personal items within reach. Date Initiated: 11/20/18. b. Ensure that resident 170 was wearing appropriate footwear when ambulating or mobilizing in wheelchair. Resident walks hallways in non skid socks per her preference. Date Initiated: 11/20/18. c. Physical Therapy (PT) to evaluate and treat as ordered or as needed (PRN). Date Initiated: 11/20/18. d. Anticipate and meet resident 170's needs. Date Initiated: 4/21/19. e. Follow facility fall protocol. Date Initiated: 4/21/19. f. Be sure resident 170's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 4/21/19. g. Educate the resident, family, and caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 4/21/19. h. Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date Initiated: 4/21/19. i. Physical therapy to screen resident for services. Date Initiated: 6/23/20. j. Night light to be placed in resident 170's room to help her see at night. Date Initiated: 7/31/20. k. Make sure resident 170 was not ambulating with sheets in her arms to address her fall risk. Date Initiated: 11/7/22. l. Replace resident 170's non-skid socks weekly on Wednesday and whenever needed. Be sure to throw away the old pair when placing the new pair. Date Initiated: 11/7/22. m. Assist resident in ambulating and maneuvering the halls via walking or wheelchair. Date Initiated: 1/23/23. n. Put on falling star program 3/18/23. Ensure resident 170 was positioned correctly in chair. Date Initiated: 3/12/23. o. Resident is a high fall risk. Staff to increase checks for safety. Date Initiated: 5/5/23. p. Staff to encourage rest periods in bed after meals and activities. Date Initiated: 5/5/23. q. Staff to offer assistance first with this resident in the morning getting up and ready to prevent falls. Date Initiated: 5/5/23. r. Add dycem to wheelchair. Date Initiated: 7/26/23. s. Staff to frequently check on resident and offer assistance as resident allows. Date Initiated: 7/31/23. t. Encourage frequent rest periods to prevent fatigue and falls. Date Initiated: 8/1/23. u. Staff to frequently check on resident to ensure safety. Date Initiated: 8/18/23. v. Ensure resident has non skid socks that are adequate. Date Initiated: 8/21/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 170 did not have a Brief Interview for Mental Status (BIMS) score completed due to rarely or never understood. On 9/30/23 at 6:55 AM, a Fall Incident Report documented Nursing Description: Pt [patient] was found lying on her back, tilted slightly to her right, on the floor at the foot of her roommate's bed at 0655 [6:55 AM]. Pt mumbled about going to the bathroom. The Pt was examined for injuries prior to being lifted by the RN [Registered Nurse] and the CNA [Certified Nursing Assistant] into her wheelchair. No injuries, bruising or skin tears were found. Pt was given assistance in the bathroom by the CNA and the RN started vital signs and neuro [neurological] checks immediately. Resident Description: Pt is unable to answer questions or acurately [sic] articulate what happened. [Note: No new fall interventions were implemented.] On 9/30/23 at 8:53 PM, a Fall Incident Report documented Nursing Description: Unwitnessed fall. Pt was found lying on the floor of her bedroom at the foot of her roommate's bed. The pt was in her sleeping clothes and bare feet. She mumbled that she was going to the bathroom. She was immediately examined for injuries. No injuries found. Resident Description: Pt is unable to answer questions or acurately [sic] articulate what happened. [Note: No new fall interventions were implemented.] On 9/30/23 at 9:06 PM, a Nurses Note documented Note Text: Pt had an unwitness [sic] fall in her bedroom this morning. No visible injuries were found upon examination. VS [vital signs] and neuro checks were started immediately per protocol. Pt went on to eat breakfast with no s/s [signs or symptoms] injury. On 9/30/23 at 9:13 PM, a Fall Incident Report documented Nursing Description: Pt was sitting in her wheelchair in the Day room watching a movie with the other residents at 1700 [5:00 PM]. The locks were on her wheelchair and she was wearing blue anti-skid socks. The pt suddently [sic] stood up from her wheelchair and took approx [approximately] 2 steps when she lost her balance and fell . The pt landed on the right side of her body bumping the right side of her head on the tile floor. She did not use her hands or arms to break her fall. The RN was at the nurse's cart and ran over to the pt when she saw her fall. The pt was examined and lifted back into her wheelchair by the RN and the CNA. The pt was further examined and found to have a pink swollen area on the right side of her head about the size of a silver dollar. Ice was promptly applied to the swelling area and neuro checks were started per protocol. The pt was unable to acuratley [sic] articulate what happened or if she had any pain anywhere. Resident Description: Resident Unable to give Description. On 9/30/23 at 9:39 PM, a Nurses Note documented Note Text: Pt was sitting and watching a movie in the Day room with other residents when she decided to get out of her wheelchair and ambulate independently. The RN was at the other side of the room at the nurse's cart and heard the pt. fall. RN immediately ran overto [sic] the pt. Pt was examined and lifted by the RN and the CNA into her wheelchair. THe [sic] RN further examined the pt and found her to have a pink swollen area on the right side of her head where the pt landed on the floor. An ice pack was promptly applied to the swollen area. Vital signs were taken and neuro checks were started promptly per protocol. No other injuries, skin tears or bruising were observed. Pt ate dinner without incident. Close monitoring continued. [Note: No new fall interventions were implemented.] On 10/1/23 at 3:32 PM, a Nurses Note documented Note Text: Resident had a fall near the sink in the day room. she has a severe gash that is bleeding on her nose and is bleeding from the mouth. Sending to [name of hospital redacted]. Notified MD [Medical Director]. On 10/1/23 at 4:02 PM, a Fall Incident Report documented Nursing Description: Resident was found on her stomach near the sink in the lounge. Resident Description: Resident has a gash on her nose and is bleeding from her mouth. On 10/1/23 at 9:33 PM, a Nurses Note documented Note Text: Pt returned from [name of hospital redacted] via EMS [Emergency Medical Services] @2115 [9:15 PM] on a stretcher. Pt was placed in her bed as she was very tired. Vital signs were BP [blood pressure] 156/91, RR [respiratory rate] 16, HR [heart rate] 96, 02 [oxygen] 94% on room air and temp [temperature] was 97.7 [Fahrenheit]. No concerns to be noted at this time. Pt resumed on neurochecks for head injury and fall and pt current neuro status is at baseline for this pt. On 10/2/23 at 5:30 AM, a Nurses Note documented Note Text: Pt returned from hospital ER [emergency room ] 10/1/2023 @2115 with the following diagnosis. Closed Head Injury, Sacral Insufficiency fracture, nasal fracture and a Laceration of nose. Pt has orders to follow up with her regular provider. MD was notified. On 10/2/23 at 9:14 AM, an Interdisciplinary (IDT) Event Review documented IDT Review: IDT to review fall on 9/30/23 at 0655, 2053 [8:53 PM], 2113 [9:13 PM], 10/1/23 at 1602 [4:02 PM]. Falls resulted from failed self-transfers. Interventions-Kardex updated with restlessness when sleepy. Will discuss with MD about appropriateness for hospice. A care plan Focus initiated on 10/2/23, documented [Resident 170] has nasal and sacral fracture r/t Fall. The Interventions initiated on 10/2/23, included: a. Anticipate and meet needs. Be sure call light was within reach and respond promptly to all requests for assistance. [Note: This intervention was a repeat intervention initiated on 4/21/19.] b. Specialty mattress for comfort. [Note: Two of resident 170's falls were located in the Dayroom where the resident would not have had access to a call light or the specialty mattress. No new fall interventions for safety were implemented.] On 10/9/23 at 2:55 PM, an IDT Event Review documented IDT Review: IDT to review fall with major injury on 10/1 [24] at 16:02. After completing investigation, items reviewed that staffing was found to be appropriate. Resident fell due to poor safety awareness and continuing to ambulate without assistive devices. Facility to review appropriateness for hospice. On 10/15/23 at 4:56 PM, a Nurses Note documented Note Text: Resident was found on the floor scooting away from her bed where she was laid in. Transferred to wc [wheelchair] and assessed for pain and injury. It does not appear she was injured. Started neuros. Notified ADON [Assistant Director of Nursing], MD, and family. Left VM [voicemail] for family. The care plan Interventions included: a. Ensure bed is in lowest position. Date Initiated: 10/15/23. [Note: This intervention was a repeat intervention initiated on 4/6/23.] b. Walk to dine with gait belt. Date Initiated: 10/16/23. On 10/16/23 at 9:23 AM, an IDT Event Review documented IDT Review: IDT to review unwitnessed fall on 10/15 [24] at 1654 [4:54 PM], residence found in her room on floor. Intervention: Continue with OT [Occupational Therapy]. Walk to dine with gait belt. Continue with plan of care. Least restrictive interventions in place. On 10/28/23 at 3:05 PM, a Fall Incident Report documented Nursing Description: Patient sled [sic] off the bed trying to get up. No injury observed, patient denied pain. Vitals [vital signs] within normal limit. MD and family notified. Resident Description: Resident Unable to give Description. On 10/29/23 at 12:13 PM, an Event/Alert Charting documented Type of Event: Unwitnessed fall on 10/28 [24]. Assessment /Observation: Complete neuros for this shift. No bruises/injury or pain noted this shift. Resident participated in watching movies and holding her baby doll in the day room this shift. Resident brief changed q [every] 2-3 hrs [hours]. Interventions: Resident participated in watching movies and holding her baby doll in the day room this shift. Resident brief changed q 2-3 hrs. Resident Reaction to Interventions: Residents reaction to interventions are positive evidence by breathing normal, WNL [within normal limits] for the resident. No outward or verbal expression of pain. Resident participated in watching movies and holding her baby doll in the day room this shift. Pain Management: Used PAINAD [Pain Assessment in Advanced Dementia] for monitoring pain. Frequent repositioning of the resident. Resident tolerated repositioning well evidence by no verbal outward expression of pain noted this shift. Improvement/Decline: Improvement, evidence by no verbal outward expression of pain noted this shift. Resident participated in watching movies and holding her baby doll in the day room. Resident brief changed q 2-3 hrs. Resident tolerated repositioning well evidence by no verbal outward expression of pain noted, resident remained safe this shift. Notifications:. On 10/30/23 at 9:35 AM, an IDT Event Review documented IDT Review: IDT to review unwitnessed fall on 10/28/23 at 1505 [3:05 PM] We have recently seen a decline on [resident 170]. We are unable to educate her due to decreased cognition. She is non-compliant with ambulatory devices. Intervention- Full PAIN-AD assessment by nurse management for possible residual pain from prior falls. The care plan Intervention initiated on 10/30/23, included Nurse management to assess for pain and need for pain modalities. [Note: No new fall interventions were implemented.] On 11/14/23 at 2:38 PM, a Nurses Note documented Note Text: Resident found on the floor next to the bed in her room. CNA reported to nurse. Resident was sitting up on the floor. Resident assessed for injuries. none found. vitals WNL. resident assisted into the wc. resident taken down to day room to nap in the recliner instead of her bed. neuro checks started. MD and DON [Director of Nursing] aware. POA [power of attorney] notified. On 11/15/23 at 9:12 AM, an IDT Event Review documented IDT Review: IDT to review unwitnessed fall 11/14 [24] at 1409 [2:09 PM] She was found sitting next to dresser in her room. Failed self transfer. Intervention- continue with OT, MD to assess for palliative care. The care plan Interventions initiated on 11/15/23, included activities in the day room and MD to assess for palliative care. On 11/20/23 at 8:38 AM, a Nurses Note documented Note Text: Resident found on the floor in her room. Resident was laying in between her bed and roommates bed. Nurse assessed patient for injuries, none were found. vitals WNL. patient assisted into her wc and brought into the dining room for breakfast. neuro checks started. DON and MD aware. Daughter notified. On 11/20/23 at 9:17 AM, an IDT Event Review documented 'IDT Review: IDT to review fall on 11/20/23 at 0700 [7:00 AM] Failed self transfer, unwitnessed fall. Interventions- Continue with OT, assess for appropriateness to continue OT, NSG [nursing] management to asses time she usually gets up. [Note: No new fall interventions were implemented.] On 11/20/23 at 8:17 PM, a Fall Note documented Note Text: At 1930 [7:30 PM] pt was in the television room sitting in her wheelchair at the table. CNA walked into the TV room and pt was on the floor with her head in a pool of blood. Pt was conscious and LOC [level of consciousness] was at baseline. CNA called for this Nurse and I came to assess pt. Pt was on the floor and appeared that pt had hit her head on the metal feet of the table. There was a significant amount of bleeding. We sat pt up and inspected the back of her head and applied pressure with some gauze that I grabbed from the cart that was nearby. Bleeding stopped after about 3 min [minutes] of pressure. CNA held pressure as this nurse assessed pt for further injury. No other injuries were sustained. Pt was lifted back into her wheelchair and vital signs were obtained. Vitals were all WNL But blood sugar was high at 335. Both CNAs took pt to her her [sic] room to change her brief and put clean pants on her while this nurse called EMS. We wanted to ensure pt was clean before transfer. EMS arrived at 2005 [8:05 PM] and left with pt at 2020 [8:20 PM]. Pt is being transferred to [name of hospital redacted] ER and nurse to nurse was given. Two attempts made to call her emergency contact and a message was left to contact this RN for an important update about her mother and current phone number was left. MD, DON and ADON was notified. [Note: No new fall interventions were implemented.] On 11/20/23 at 11:46 PM, a Nurses Note documented Note Text: pt returned from Hospital on stretcher via EMS A2230 [sic] [10:30 PM]. Pt had sutures in her head and CT [computed tomography] of Neck and Head were clear. Vitals were taken and BP was low at 77/41. Will continue on Neuro checks for pt. Pt is awake and orientation is at baseline. On 11/21/23 at 6:57 AM, a Fall Incident Report documented Nursing Description: pt got out of her wheelchair and fell hitting her head on feet of table. CNA came and informed this Nurse of incident. When I arrived to assess pt she was laying on her back and there was a significant amount of bleeding in the back of her head. Pressure was applied with gauze and bleeding stopped. No other injuries sustained with this fall. MD was notified that pt fell and needed stitches and MD gave the OK. Pt was sent to [name of hospital redacted] ER. On 11/21/23 at 9:14 AM, an IDT Event Review documented IDT Review: IDT to review unwitnessed fall on 11/20/21 @ 1930 Unwitnessed fall resulting in staples to back of head. Interventions- Assess for palliative care, silent alarm for bed/chair. The care plan Interventions implemented on 11/21/23, included initiate silent alarm for bed and chair to prevent falls. On 3/20/24 at 12:13 PM, an interview was conducted with RN 1. RN 1 stated if a resident had a fall there were fall packets with a checklist. RN 1 stated she would assess the situation to see where the resident was, get vital signs, and get the resident off the floor if the resident was safe. RN 1 stated if the resident was not safe she would call EMS. RN 1 stated a risk assessment in the medical record would be done after the resident was situated and safe. RN 1 stated she would them notify the DON, MD, and the nurse on call. RN 1 stated that any new orders or X-rays from the provider were put in the medical record and the resident would be sent out if the MD requested. RN 1 stated that typically the floor nurse would find out the reason for the fall and come up with an intervention. RN 1 stated It might not be an intervention the management team used but if it was something she could do to prevent a fall she would do it. RN 1 stated the intervention recommendations would go to the IDT which consisted of the ADON, DON, and PT. RN 1 stated the IDT would make the ultimate decision on interventions. RN 1 stated the interventions were put in as an order on the Treatment Administration Record (TAR) for the nurses to check off. RN 1 stated a safety check was a yes or no on the Medication Administration Record. RN 1 stated if the resident had shoes as an intervention that might be a CNA task or on the TAR. On 3/20/24 at 3:18 PM, an interview was conducted with the Director of Physical Therapy (DPT). The DPT stated that he attended the morning meeting daily and the fall IDT. The DPT stated he would check into all options and check into interventions specific to the residents fall. The DPT stated if the resident was appropriate for therapy he would pick them up. The DPT stated that some residents have a hard time following directions or they were combative. The DPT stated he would assess the resident the day of or the day after the recommendation. On 3/21/24 at 9:12 AM, an interview was conducted with RN 2. RN 2 stated that resident 170 was total assistance with all cares. RN 2 stated that resident 170 could feed herself but required a lot of prompting or resident 170 had to fed. RN 2 stated that resident 170 had a lot of falls. RN 2 stated that resident 170 used to walk a lot and then she did not but resident 170 would try to walk at times. RN 2 stated that resident 170 would get tired quickly and would lose her balance right away. RN 2 stated if a resident had a fall the floor nurse would put at least one intervention in place and the IDT might do more interventions. RN 2 stated the floor nurse was not a part of the IDT. RN 2 stated the nurse management team would determine if the interventions were appropriate or not. On 3/21/24 at 10:26 AM, an interview was conducted with CNA 8. CNA 8 stated that resident 170 was a total care with all activities of daily living (ADLs). CNA 8 stated that resident 170 was not ambulatory the last year she had been at the facility. CNA 8 stated the staff would take resident 170 to activities in her wheelchair. CNA 8 stated that resident 170 was a high fall risk. CNA 8 stated that fall interventions for resident 170 included for the CNAs to put shoes or socks on resident 170 and clothes that were resident 170's size. CNA 8 stated she needed to supervise resident 170 a lot. CNA 8 stated a lot meant to always be within eye shot because resident 170 would stand up. CNA 8 stated that resident 170 would refuse cares. On 3/21/24 at 10:38 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 170 was total assistance with ADLs and required two people for transfers because resident 170 would refuse cares. CNA 5 stated that resident 170 liked to get up and would get up by herself. CNA 5 stated when resident 170 was in her wheelchair resident 170 did not like to be changed. CNA 5 stated that resident 170 did fall a lot. CNA 5 stated that resident 170 liked to walk by herself and she enjoyed walking. CNA 5 stated that resident 170 was not stable the last few months at the facility and resident 170 would try to walk and would fall. CNA 5 stated that resident 170 had dementia and resident 170 would just get up. CNA 5 stated that most of the time staff were close to resident 170. CNA 5 stated there were only two CNAs on the memory care unit and most of the residents on the memory care unit required two staff for cares. CNA 5 stated there really needed to be one more CNA. CNA 5 stated if the staff were not busy they would make sure they had eyes on resident 170. CNA 5 stated that most of resident 170's falls were because no one was watching resident 170. CNA 5 stated when the residents go back to their rooms or if she was showering a resident it was hard to watch the residents. CNA 5 further stated the memory care unit needed another staff member to stay on the unit. On 3/21/24 at 11:01 AM, an interview was conducted with the DON. The DON stated the IDT team would go through the current fall interventions and see what had and had not worked for the resident. The DON stated they had fall meetings every morning and they would bring the fall packet, determine the root cause of the fall, and see what interventions were in place. The DON stated in the fall packet there was a spot to recommend interventions immediately and the IDT would determine if the intervention was appropriate. The DON stated when a resident had a fall the nurse would assess the resident prior to moving. The DON stated the fall packet would be followed and the staff were to notify the nurse manager, doctor, and family. The DON stated the floor nurse would assess the patient and provide any treatment as indicated. The DON stated if the fall was unwitnessed or the resident hit their head the staff would start neuro checks. The DON stated the nurses were to do the immediate interventions and recommendations for any other interventions. The DON stated the IDT would follow up the next day to determine the root cause of the fall and add any other interventions. The DON stated the fall risk assessments were done quarterly. The DON stated we talk as a group and write the IDT note in the chart with the intervention and the risk management which was the incident report. On 3/21/24 at 12:18 PM, an interview was conducted with the Director of Leadership and Development (DLD) and the Administrator (Admin). The DLD stated the day of resident 170's fall there were 15 residents on the memory care unit and staffed with two CNAs and one nurse. The Admin stated if the CNAs were giving cares there were cameras that watch both of the halls on the memory care unit and the nurse would step in. The DLD stated the fall intervention changes were initiated after the initial survey and the facility has had leadership changes. The DLD stated there were holes in the system that were working but not being followed. The DLD stated the fall committee was initiated after the original survey with the plan of correction. The Admin stated the additional information to the fall committee was tracking trends in falls. 03/21/24 at 1:26 PM, an interview was conducted with the Admin. The Admin stated they do track falls but they just started tracking fall trends including the time of day and who was on shift. The Admin stated they would put out training's to staff through the CNA Coordinator. The Admin stated they would continue to track those trends. The Admin stated there were no sign sheets for the training because it was part of the huddle. The Admin stated she would distribute interventions to the staff that day because the CNA coordinator was apart of the IDT. The Admin stated that the IDT team attended the Quality Assurance meetings. The facility policy Falls and Fall Risk, Managing was reviewed. Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Definition According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall. Fall Risk Factors 1. Environmental factors that contribute to the risk of falls include: a. wet floors; b. poor lighting; c. incorrect bed height or width; d. obstacles in the footpath; e. improperly fitted or maintained wheelchairs; and f. footwear that is unsafe or absent. 2. Resident conditions that may contribute to the risk of falls include: a. fever; g. infection; h. delirium and other cognitive impairment; i. pain; j. lower extremity weakness; k. poor grip strength; l. medication side effects; m. orthostatic hypotension; n. functional impairments; o. visual deficits; and p. incontinence. 3. Medical factors that contribute to the risk of falls include: a. arthritis; q. heart failure; r. anemia; s. neurological disorders; and t. balance and gait disorders; etc. Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 4. [sic] Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 5. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. 6. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 7. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 8. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 9. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 45470 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which include type 2 diabetes mellitus, chronic kidney disease, dementia, bipolar disorder, major depressive disorder, anxiety disorder, insomnia, hypothyroidism, and hyperlipidemia. On 3/12/24 at 12:38 PM, a family member of resident 2 brought a pill and another half pill out of resident 2's room and set it at the nurses' station. Resident 2's family member stated that he found the whole pill on the floor in resident 2's room, and the half pill was found on the floor in resident 2's bathroom. On 3/12/24 at 12:43 PM, RN 1 took the pills off the counter at the nurses' station and discarded them. On 3/12/24 at 12:47 PM, an interview with RN 1 was conducted. RN 1 stated that she identified the pills as being Tylenol and Metformin. RN 1 stated that those were medications that resident 2 received daily. RN 1 explained that nurses were supposed to give resident 2 his medication and stay in the room until resident 2 swallowed the medications. RN 1 stated that she did not know how the pills ended up on the floor. Resident 2's medical record was reviewed. Resident 2's most recent MDS assessment dated [DATE], (State Optional - other) documented that resident 2 had a BIMS score of 7 which suggested severe cognitive impairment. Resident 2's March 2024 Medication Administration Record (MAR) was reviewed. a. The MAR documented that resident 2 had an order of Tylenol Extra Strength Oral Tablet 500 Milligrams (mg) with instructions to give 1000 mg by mouth three times a day for pain. The order was started on 1/30/24. The MAR documented that the o[TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 45 sampled residents, a resident who sustained a right humerus fracture was not offered a shoulder immobilizer daily as ordered to help mitigate pain. Resident identifier: 58. Findings Included: Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include displaced fracture of surgical neck of right humerus, type 2 diabetes mellitus, alcoholic cirrhosis of liver, chronic respiratory failure, infection and inflammatory reaction due to internal left knee prosthesis, pain, hemiplegia and hemiparesis, dysphagia, difficulty in walking, pain in left hip, muscle weakness, unsteadiness on feet, repeated falls, low back pain, essential hypertension, sleep related hypoventilation, glaucoma, hemorrhoids, hyperlipidemia, anxiety disorder, and depression. On 3/11/24 at 1:23 PM, an interview with resident 58 was conducted. Resident 58 stated that she had been in a lot of pain since she broke her right arm from a fall a few months ago. Resident 58 stated that she had asked nurses multiple times for a sling and the nurses responded by telling her that they did not have a sling for her. Resident 58 stated that it was painful to move her arm and a sling would help keep it in place. An observation of resident 58 was made. Resident 58 was lying in bed without a sling on. Resident 58 had a large bruise on her upper right arm. Resident 58 stated that the bruise was from a fall. Resident 58 began to cry and stated that her arm was extremely painful, and she felt forgotten by staff at the facility. Resident 58's medical record was reviewed. On 1/11/24, a quarterly Minimum Data Set (MDS) assessment was completed. The MDS documented that resident 58 had a Brief Interview for Mental Status score of 14, which suggested that cognition was intact. Resident 58's care plan was reviewed. Resident 58 had a care plan initiated on 9/13/23 and revised on 12/18/23, that stated, [Resident 58] is resistant to cares and refuses medications at times; medications, eating, refuses to participate with therapy, refuses her shoulder immobilizer, refuses showers, refuses wound care, refuses supplements, refuses skin checks, refuses splints. The goal, initiated on 9/13/23, stated, [Resident 58] will have less occurrences of refusals of care and medications by the next review. The intervention, initiated on 9/13/23, stated, Allow the resident to make decisions about treatment regime, to provide sense of control. Resident 58 had a care plan initiated on 10/1/23, that stated, [Resident 58] has R [right] humoral [sic] fracture r/t [related to] fall. The goal initiated on 10/2/23, stated, The resident will return to prior level of function after wound healing and rehabilitation by review date. The interventions, initiated 10/2/23, stated, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Encourage deep breathing and relaxation techniques. Monitor limb for swelling and skin changes. Assess/monitor pedal pulses as needed. Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. On 9/28/23 at 3:22 PM, a Progress Note documented that resident 58 was found on the floor in the hallway near the front door of the facility. The progress note stated, .Right arm pain unable to move without hurting. Vitals were taken. 911 called at 1528 [3:28 PM] .Resident was sent to [hospital name redacted]. Provider notified. On 10/1/23 at 3:15 PM, a Progress Note documented that resident 58 was returning to the facility with a right arm fracture and had a sling. On 10/4/23 at 3:08 PM, a Progress Note documented, Orthopedics ordered for resident to wear a right shoulder immobilizer at all times. Notes state it's okay to remove for bathing. On 1/17/24 at 12:52 PM, a Social Service Note documented, Rt [resident] came to ra [Resident Advocate] office to express that she would like to be seen by the MD [Medical Director] to get a referral to a surgeon for her shoulder. Rt said that her pain has been getting really bad and that she wanted to die. Ra asked resident to clarify her feelings on wanting todie [sic]. Rt expressed that she thinks about hurting herself due to the pain she is in, but did not have a plan on how she would hurt herself and did not feel that she was going to hurt herself. Rt expressed to the ra that she felt safe at the facility and that she feels very loved. Resident 58's orders were reviewed. Resident 58 had an order that stated, Right shoulder immobilizer at all times. Okay to remove for bathing. Every shift for shoulder fracture. Start date 1/3/24. The order was discontinued on 3/13/24. a. The Treatment Administration Record (TAR) for January 2024 documented that resident 58 wore her right shoulder immobilizer every shift as scheduled. b. The TAR for February 2024 documented that resident 58 wore her right shoulder immobilizer every shift except for the day shift of February 21st and 27th. c. The TAR for March 2024 documented that resident 58 wore her right should immobilizer every shift as scheduled. Resident 58 had an order that stated, Pain Monitoring every shift for pain monitoring. Start date 1/3/24. a. The TAR for January 2024 documented that resident 58 reported a pain level of a 5 out of 10 or higher 36 times. The highest reported score was an 8 out of 10, which was reported ten times. b. The TAR for February 2024 documented that resident 58 reported a pain level of a 5 out of 10 or higher 29 times. The highest reported score was a 9 out of 10, which was reported three times. c. The TAR for March 2024 was reviewed up to 3/12/24, and documented that resident 58 reported a pain level of a 5 out of 10 or higher 13 times. The highest reported score was a 9 out of 10, which was reported one time. Resident 58's pain medications were reviewed. a. Gabapentin Capsule 300 MG [milligrams] Give 1 capsule by mouth three times a day for Pain. The order was started on 1/3/24. b. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 500 MG by mouth four times a day for pain. The order was started on 1/9/24. c. Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. The order was started on 1/9/24. On 3/12/24 at 1:30 PM, a follow-up interview was conducted with resident 58. Resident 58 was sitting on the side of her bed and was observed to have a right shoulder immobilizer on. Resident 58 stated that she now had a sling on that helped to keep her arm from moving. Resident 58 was observed smiling and stated that she was excited to go to the activities soon. On 3/12/24 at 2:15 PM, an interview with Certified Nursing Assistant (CNA) 13 was conducted. CNA 13 stated that resident 58 had a fall in September where she broke her arm. CNA 13 stated that resident 58 had a sling on for a few months after the fall, however, resident 58 had not been wearing a sling for the past two or three months, and the sling resident 58 had on today was new. CNA 13 stated that resident 58 often complained of pain in her right arm during transfers, while getting dressed, or while helping resident 58 to the bathroom. CNA 13 stated that resident 58 complained of pain anytime her right arm was moved or touched. CNA 13 stated that this made completing some of resident 13's care difficult, such as helping resident 58 put a shirt on. CNA 13 stated staff were completing these cares for the past few months while resident 58 did not have a sling on. On 3/12/24 at 3:02 PM, an interview with CNA 12 was conducted. CNA 12 stated that she did not work with resident 58 very often. CNA 12 recalled assisting resident 58 out of bed last week. CNA 12 stated that resident 58 did not have a sling on during that transfer. CNA 12 stated that resident 58 did not have a sling on at all last week. On 3/12/24 at 3:08 PM, an interview with the Therapy Recreational Technician (TRT) was conducted. The TRT stated that she was very familiar with resident 58. The TRT stated that resident 58 went to the doctor today and came back with a sling on her right arm. The TRT stated that resident 58 did not have a sling prior to her appointment today. On 3/19/24 at 2:04 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that resident 58 was supposed to always wear the right shoulder immobilizer. The DON stated that the right shoulder immobilizer would help with the pain from resident 58's fractured arm. The DON stated that resident 58 almost always refused to wear the right shoulder immobilizer. The DON stated that resident 58 told staff she did not like it and would refuse to wear it. The DON stated that the right shoulder immobilizer was in resident 58's room. The DON stated that nurses and CNA's offered the right shoulder immobilizer to resident 58 daily. The DON stated that it was care planned that resident 58 would refuse to wear the right shoulder immobilizer. Progress notes were reviewed from 9/28/23 to 3/12/24. There were no progress notes reporting resident 58 refusing to wear the right shoulder immobilizer. On 3/20/24 at 10:53 AM, an interview with Registered Nurse (RN) 8 was conducted. RN 8 stated that resident 58 sustained a humeral fracture in September of 2023 and it was inoperable. RN 8 stated that resident 58 had a sling for her right arm, but resident 58 was always losing it. RN 8 stated that resident 58 would ask staff for the sling but nobody knew where it was. RN 8 stated that resident 58 often complained of pain in her right arm. RN 8 stated that she had made a make-shift sling out of ace wrap for resident 58 because she could not find the sling. RN 8 stated that they offer resident 58 a heat pack to help with the pain in her arm.

Based on observation, interview and record review, it was determined, for 2 out of 33 sampled residents, that the facility did not ensure that each resident was free from abuse, neglect, and misappropriation of resident property. Specifically, a female resident reported that a male resident had grabbed her breast without her consent. The deficiency identified was determined to be at a HARM level. Resident identifiers: 43 and 50. Findings include: HARM 1. Resident 50 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, cirrhosis of the liver, Parkinson's disease, anxiety, insomnia and major depressive disorder. On 9/11/23 at 8:34 AM, resident 50 stated, the man touched my breast, he pulled on it and it hurt. No staff were in the room with us. We were doing an activity. Resident 50 stated she feels safe and feels safe in the activity room. Resident 50 stated that the resident's name was [resident 43], the resident who touched her left breast. Resident 50 stated it happened a month ago. Resident 50 was observed to touch her left breast as she spoke. On 6/15/23, a Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 12 which indicates moderate cognitive impairment. The assessment documented resident 50 required total dependence with a two person physical assist. Review of resident 50's progress notes revealed the following: a. On 8/29/2023 at 4:11 PM, an Interdisciplinary Team (IDT) Event Review note revealed, IDT Review: Resident notified floor nurse that another resident touched her breast. Floor nurse immediately notified management. IDT initiated 1:1 with other resident. Alert charting for changes from psychosocial baseline such as not attending her favorite activity (Bingo) on a regular basis was started. Medical Director (MD) notified. b. On 8/29/2023 4:25 PM, nursing note revealed Resident had tears in her eyes when she reported to nurse that another resident touched her breast in the dining room during bingo. There were no witnesses. Resident was redirected away from her. Nurse reported to management. c. On 8/29/23 at 7:05 PM, A resident visit note documented, Summary of Visit/Conversation: When resident was asked how she was she stated she was happy to see the DON [Director of Nursing]. She stated she loved her CNA [Certified Nurse Assistant] today. Positive Comments/Experience: When asked what was happening she was tearful and stated another resident touched her breast in the bingo room. When asked when this happened she could not recall. When asked if it was today she stated no awhile ago. CNA also present during this conversation. When asked who touched her she could not say. DON asked if she felt safe resident stated she did feel safe at the facility. She thanked the DON for being her angel. She did state she attended Bingo today and she also likes passing out candy to the staff afterwards. The resident was pleasant upon DON departure. Any Suggestions for Improving Care Services by Resident?: She would like to do more walks outside in her wheelchair. DON will continue with these walks as weather permits. Grievance Completed (If Applicable)?: IDT notified and alert charting for changes in psychosocial baseline in place. Plan of Care Updated (If Applicable)? : She did state she prefers female aids care plan reflects this preference. 2. Resident 43 was admitted to the facility on [DATE] with diagnoses which consisted of intracranial injury with loss of consciousness, hemiplegia, Alzheimer's disease, osteoarthritis, major depressive disorder, insomnia, benign prostatic hypertrophy, and history of malignant neoplasm of the skin. On 8/23/23, the Quarterly MDS Assessment documented a BIMS score of 00, which would indicate a severe cognitive impairment. The assessment documented that resident 43 was an extensive 1 person assist for bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Review of the facility abuse investigation revealed that on 8/29/23 the facility reported to the State Survey Agency (SSA) an incident of sexual abuse between resident 43 and resident 50. The report documented that during an activity resident 43 touched resident 50's breast. The DON's interview with the Assistant Activities Director (AAD) documented that the AAD reported that resident 43 was with her during Bingo and was not near resident 50 during the activity. The DON's interview with CNA 4 documented that after Bingo on 8/29/23 resident 50 was at the nurse's station and became tearful and told CNA 4 he touched my breast. The interview documented that resident 50 was not able to verbalize the name of the other resident but nodded yes when asked if it was the resident wearing a tie dye shirt. The facility concluded that the allegation was inconclusive and the allegation could not be verified or refuted because there was insufficient information to determine if it had occurred. Review of the resident 43's progress notes revealed the following: a. On 9/11/2023 at 6 PM, the nurse progress note documented, Behavior notes from 1:1: Very good. A little flirty before breakfast. At lunch pt [patient] was attempting to put his hand up the CNAs shirt. Before activities was flirty again an garbed (sic) the CNAs butt, per the CNAs log. b. On 9/2/2023 at 4:17 PM, the note documented, Sexually Inappropriate behaviors Assessment /Observation: According to 1:1, Rt. [resident] exhibited inappropriate behaviors. Rt. commented on CNA's bottoms and made inappropriate sounds. Interventions: 1:1, redirection and provide distraction. Resident Reaction to Interventions: Behaviors continued throughout shift. c. On 8/31/2023 at 2:41 PM, the physician progress note documented, Pt still having some sexually inappropriate behaviors noted by staff. He is much better since starting the Depo shot but has residual issues. d. On 8/30/2023 at 1:36 AM, the nurse note documented, At around 1940 [7:40 PM] this evening this nurse was at the med cart at the nurses station when I heard a commotion, I turned and saw [resident 43] with his right hand raised in a fist and swinging it in an attempt to hit another resident. I did not see [resident 43] actually strike the other resident, but the other resident did report that [resident 43] did in fact hit his left forearm. Both resident's were sitting in the common area at the time sitting next to each other watching t.v. PT had just sat [resident 43] next to resident a few minutes prior and there were no other exchanges between residents leading up to the incident. This nurse and other med pass nurse immediately ran towards both residents and intervened. [Resident 43] was immediately removed from next to the other resident. When asked why he hit the other resident, [resident 43] stated 'I didn't hit' . [Resident 43] was then taken down to activities room by CNA where CNA reported they played basketball and did other activities before [resident 43] was then brought back to his room and put to bed. [NAME] continued on Q [every]15 minute checks. DON, POA [Power of Attorney name omitted], and MD were notified. e. On 8/26/2023 at 5:31 AM, the progress note documented, Before resident went to sleep on 8/25/23, he was touching one of the female resident's thighs and trying to fight another resident. No one was hurt during the encounter. Resident was separated from other residents and went to bed and fell asleep for the night. Will continue to monitor. f. On 8/25/2023 at 11:13 AM, the Social Service Note documented Quarterly Note Rt [resident] admitted to [name of facility] on 12/22/2022 for long term care. Primary dx [diagnosis] is Alzheimer's along with MDD [major depressive disorder]. Dx is being managed by medications. Rt is charted at being Aox1 [alert and oriented times 1] with long and short term memory deficits. Rt does have inappropriate behaviors, and is often forgetful. He needs assistnace (sic) with most ADL's [Activities of Daily Living] but is able to make wants and needs known to staff. Rt makes sexually inappropriate comments to staff members, and has been redirectable per report of staff. Monitoring shows 100+ incidents of this in the quarter. Rt's wandering had improved. 1-1 removed during the night with instructions to resume if rt gets out of bed. 1-1 continues though out (sic) the day. g. On 8/20/2023 at 5:33 PM, the progress noted documented, Type of Event: Sexually Inappropriate Behaviors Assessment /Observation: When sitting next to 1:1 aide, Rt. reached over to try and grab her thigh. Interventions: Aide quickly moved away and redirected the Rt. Resident Reaction to Interventions: Aide informed me that was the only inappropriate behavior during this shift. h. On 8/18/23 at 6:03 PM, the progress note documented, Rt. kicked activity's girl in the back. When the dentist was checking his teeth, Rt. tried to touch aide in the private area. Rt. touched activity's girl on her butt. Started pulling down pants in Dining and exposing himself. Interventions: Redirected, provided distraction, and separated from female residents. Resident Reaction to Interventions: Behaviors continued despite interventions. i. On 8/16/23 at 5:22 AM, the note documented, [Resident 43] was inappropriate with 1:1 aide. CNA reported [resident 43] stated 'Do you want me to suck your titties'. Interventions: 1:1 monitoring from 1800-2200 [6:00 PM to 10:00 PM]. 15 min checks from 2200 to 0600 [10:00 PM to 6:00 AM]. j. On 8/15/23 at 5:13 AM, the note documented, [Resident 43] had one incident of being inappropriate with female CNA. Aide reported [resident 43] asked if he could touch her genitals and attempted to expose himself to her while in the hallway. k. On 8/14/23 at 11:53 AM, the note documented, Called POA [Power of Attorney] about medroxyprogesterone IM [intramuscular] injection for inappropriate behaviors as recommended by provider. POA was thankful for the call and approves the administration of this medication for the resident. l. On 8/13/23 at 4:54 PM, the note documented, Rt. was trying to grope female staff and female residents. Interventions: Separate from females when in common areas. Provide distraction and redirect. One on one. m. On 8/11/23 at 4:55 PM, the note documented, Rt. howling at girls and asking to touch girls' parts. Interventions: Redirect or provide distraction. Resident Reaction to Interventions: Cooperative for a while. n. On 8/8/23 at 4:59 PM, the note documented, [Resident 43] had 1 episode of being inappropriate. 1:1 aide reported [Resident 43] stated 'Can I feel up your shirt. ' o. On 8/7/23 at 5:27 AM, the note documented, [Resident 43] had 2 episodes of being inappropriate earlier in the shift with female staff. 2 CNA's reported [Resident 43] stated: 'Can I touch your tits' 'Can I put my d**k in your p***y' Interventions: Monitoring, redirection, 1:1 monitoring from. p. On 8/4/23 at 3:54 PM, the note documented, Rt. made inappropriate comments to female staff and female residents. Interventions: Provide distraction and redirection. Resident Reaction to Interventions: Behaviors continued throughout the shift. q. On 8/3/23 at 3:20 AM, the note documented, Resident attempted to talk to another resident inappropriately. 1:1 redirected resident. Resident told this nurse, I want to fuck you. Interventions: redirection, 1:1, 15 minute checks from 2200-0600. r. On 8/1/23 at 5:39 AM, the note documented, [Resident 43] had attempted to expose himself to female CNA earlier in the shift and asked her if she wanted to see his genitals. No other behaviors throughout the night. s. On 7/28/23 at 5:14 PM, the note documented, At 1220 [12:20 PM] Rt. asked aide to play with me. At 1430 [2:30 PM] Aide checked Rt.'s brief and assisted him to the toilet. While assisting him, aide said the Rt. groped her and asked her if she wanted to have sex. At 1530 [3:30 PM] aide asked Rt. if he wanted a snack and drink because he has been dry (no output). Rt. told the aide he would rather have vagina. t. On 7/22/23 at 4:37 PM, the note documented, During lunch Rt. was observed asking female staff if he could stick his hand down their pants. -Asked to sleep with another resident. -Asking for girls' private parts. -Howling at girls in the dining hall. Review of resident 43's physician orders revealed the following: a. On 5/24/23, monitoring sexually inappropriate behaviors every shift was initiated. b. On 4/18/23, Depo-Provera Intramuscular suspension, inject 150 milligrams (mg) IM every 14 days for aggressive sexual behaviors was ordered. The order was discontinued on 5/4/23. c. On 7/18/23, Medroxyprogesterone Acetate IM suspension, inject 150 mg IM every Wednesday for hormone replacement was ordered. The order was discontinued on 8/31/23. d. On 8/31/23, Medroxyprogesterone Acetate IM suspension 150 mg/ml, inject 2 milliliters one time a day for behaviors was ordered. The order was discontinued on 9/2/23. e. On 9/2/23, Medroxyprogesterone Acetate IM suspension 150 mg/milliliter (ml), inject 2 ml IM every Friday for behaviors was ordered. The July 2023 Medication Administration Record (MAR) documented that resident 43 was administered the Medroxyprogesterone 150 mg injection on 7/26/23. The MAR documented that resident 43 had 116+ episodes of sexually inappropriate behaviors this month. The August 2023 MAR documented that resident 43 was administered the Medroxyprogesterone 150 mg injection on 8/1/23, 8/9/23, 816/232, 8/23/23, and 8/30/23. The MAR documented that resident 43 had 66+ episodes of sexually inappropriate behaviors this month. The September 2023 MAR documented that resident 43 was administered the Medroxyprogesterone 300 mg injection on 9/1/23 and on 9/8/23. The MAR documented that resident 43 had 11 episodes of sexually inappropriate behaviors this month. On 9/13/23, resident 43's behavior log and every 15-minute check log were reviewed. The behavior log stated that 1:1 - involves assisting residents with various activities/cares throughout their day. To provide support and to ensure the resident's comfort, safety, and engagement. The log had a section for documentation of behaviors. The patient 15-minute safety check log had time slots for a 24 hour period. The log contained a key for the resident location to indicate if they were in activities, bedroom, dining room, hallway, nurse's station, outside area, showering, or therapy. The log also contained a key for the resident behaviors to indicate if they had no behaviors, physical aggression, self harm attempt, destructive behaviors, verbally aggressive, yelling, sexually inappropriate behavior, wandering, attempting to elope, or refusing cares. The 15-minute check log had documentation from 6:00 AM to 12:15 PM and only documented the resident location. It should be noted that no other behavior logs or 15-minute check logs were found in resident 43's medical records. The facility's policy on Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures documented that the policy was in place to prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident property, to establish processes to investigate allegations, to implement staff training, and to coordinate with the Quality Assurance and Performance Improvement (QAPI) committee. The policy stated that the administrator had the overall responsibility for the coordination and implementation of the facility policy and procedures. The policy was last revised in April 2021. The facility's policy on Identifying Types of Abuse documented sexual abuse as non-consensual sexual conduct of any type with a resident. Sexual abuse included unwanted intimate touching of any kind especially of breasts or perineal area. The policy further stated that unwanted sexual touching was recognized as likely to cause psychosocial harm which may take months to years to manifest, and have long-term effects on the resident and his/her relationship with others. The policy was last revised in September 2022. On 09/11/23 at 6:48 AM, an interview was conducted with CNA 1. CNA 1 stated that she was doing 1:1 monitoring with resident 43 and that she did this 2 times per week. CNA 1 stated she was not sure how long resident 43 had been on 1:1 monitoring, but it was for sexually inappropriate behaviors. Resident 43 was observed in bed in the last room on the north hallway. All other residents residing on the north hallway were male. On 9/11/23 at 6:55 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 43 had been on 1:1 monitoring since she had been at the facility and she started on 4/24/23. RN 1 stated that when resident 43 was not in his room but in the common area outside the nurse's station they all kept an eye on him. On 9/11/23 at 8:04 AM, resident 43 was observed seated in his wheelchair in the common area by the nurse's station. Resident 43 was seated next to resident 30. Seated across from resident 43 was resident 61 and resident 47, both of which are female residents. RN 1 was in view of resident 43 at the nurse's station. On 9/11/23 at 9:02 AM, resident 43 was seated in the common area at the nurse's station and across from him was resident 47. CNA 2 was seated at the nurse's station. On 9/11/23 at 10:26 AM, resident 43 was observed in the recreation therapy room with CNA 1. Resident 43 was seated at a table with 5 other female residents. Seated on resident 43's right side was resident 5 and seated on resident 43's left side was resident 47. Both residents were within reaching distance of resident 43. The activity that was occurring was nail painting. The AAD was also present. On 9/13/23 at 9:04 AM, an interview was conducted with CNA 3. CNA 3 stated that she was assigned 1:1 with resident 43 from 6:00 AM to 6:00 PM. CNA 3 stated that she just hung out with resident 43 all day and watched for any behaviors. CNA 3 stated that resident 43's behaviors were making nasty comments about ladies bodies, and trying to grab others' butts when they walked by. CNA 3 stated that she does not keep resident 43 away from other residents, but keeps an eye on him. CNA 3 stated that she took resident 43 to the dining room and activities where he would be seated next to other residents. CNA 3 stated that today resident 43 had said, this girl has a big ass. CNA 3 stated that she was to track his behavior to see if he was getting better around other residents. CNA 3 stated that she understood that resident 43 had a history of inappropriate sexual behaviors with female residents and that was why they made his hallway male only. CNA 3 stated that resident 43 had a history of wandering into other resident's rooms. CNA 3 stated that resident 43 was a limited one person assist for transfers and toileting, and that he could take a few steps independently. CNA 3 stated that she usually filled out the behavior tracking sheet or the every 15-minute check log at the end of her shift. CNA 3 stated that they were to document resident 43's location, any refusal of cares, or any inappropriate sexual behaviors every 15-minutes. The 15-minute check log was observed empty and CNA 3 was filling in the blank spots while speaking to the State Surveyor. CNA 3 stated that after 6:00 PM they did not have any 1:1 staff monitoring resident 43. CNA 3 stated that resident 43 slept most of the night so the night shift staff just checked on him every 2 hours like they did with everyone else. CNA 3 stated that at the end of her shift she would turn in the logs to the nurse and they would discuss any behaviors that the resident had that shift. On 9/13/23 at 9:22 AM, an interview was conducted with a Licensed Clinical Social Worker (LCSW) 1 with an outside behavioral health service. LCSW stated that she was seeing resident 43 for his sexual behavior and that he was very sexual with his talking. LCSW 1 stated that when resident 43 spoke to her in a sexual manner she would ignore the behavior and redirect him to something else. The LCSW 1 stated that she was trying to make it so others could feel comfortable around resident 43. The LCSW 1 stated that resident 43 would also grope and she was nervous when getting close to him. The LCSW 1 stated that she does see some progress with the physical touching as resident 43 was attempting to touch her less. The LCSW 1 stated that the verbal comments were still present and today resident 43 said to her that he wanted her to get naked so he could f*** her. The LCSW 1 stated that resident 43 also liked to make comments on how big his genitals were. The LCSW 1 stated that she was still trying to cipher resident 43's ability to comprehend and that she had noticed that it seemed to fluctuate. The LCSW 1 stated that she had been working with resident 43 for a few months and that she was in the building every Wednesday morning. The LCSW 1 stated that resident 43 had verbalized sexual inappropriateness with other residents. On 9/13/23 at 10:13 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 50 had reported to her after bingo that someone had touched her breast. CNA 4 stated that resident 50 was pointing to her left breast while moving her hand up and down. CNA 4 stated that resident 50 could not name the individual, but when she reported this to the aide she pointed towards 2 male residents seated nearby. CNA 4 stated that she asked resident 50 if one of the males was the individual that touched her and she nodded yes. CNA 4 stated that resident 50 identified resident 43 as the individual who touched her breast. CNA 4 stated that she asked resident 50 which resident it was based on identifying the different shirts each resident was wearing and this was how resident 50 indicated it was resident 43. CNA 4 stated that afterwards she informed the nurse on shift of the allegation. CNA 4 stated that resident 50 was alert and oriented times four to person, place, situation, and time. CNA 4 stated that resident 50 had never made any allegations like this before. On 9/13/23 at 10:20 AM, a follow-up interview was conducted with RN 1. RN 1 stated that resident 43 was sexually inappropriate and could be aggressive and hit people. RN 1 stated that she had witnessed resident 43 attempting to hit other residents. RN 1 stated that resident 43 was on 1:1 monitoring on her shift and every 15-minute checks, and that the aide should be documenting any behaviors. RN 1 stated that at the end of the shift she discussed the monitoring with the aide and then wrote a progress note about any identified behaviors. RN 1 stated that she then put the monitoring paperwork in the Assistant Director of Nursing (ADON) box. RN 1 stated that resident 43 had touched her bottom in the past and just yesterday had attempted to put his hand up the aides shirt. RN 1 stated that the 1:1 aide was always instructed to sit next to resident 43 and in between any other residents to provide some distance. RN 1 stated that interventions for resident 43's behaviors were distraction, removing him from a busy environment, and 1:1 monitoring which he did well with. RN 1 stated resident 43 was not able to transfer or ambulate independent and needed a 1 person assist. RN 1 stated that she had not seen resident 43 propel himself independently in his wheelchair. RN 1 stated that resident 43 was alert and oriented times two to self and place. RN 1 stated that when they attempted to distract and educate the resident on the inappropriate behavior he would respond by smiling. RN 1 stated that sometimes the education worked and he could follow directions. On 9/13/23 at 10:33 AM, an interview was conducted with the AAD. The AAD stated that she conducted bingo on the date that resident 50 alleged resident 43 touched her. The AAD stated that day during bingo resident 50 and resident 43 were not seated next to each other. The AAD stated that she was the only staff member present during bingo and that resident 43 did not have a 1:1 aide with him. The AAD stated that after the activity she had to take residents back to the Cambridge unit and while she was gone resident 50 and resident 43 were left unattended in the dining room together. The AAD stated that when she returned to the dining room to get resident 50, resident 43 was shuffle walking in his wheelchair out of the dining room. The AAD stated that when she dropped resident 50 off at the nurse's station, resident 50 reported to her that resident 43 had touched her breast. The AAD stated that resident 50 told her in Spanish that he grabbed her breast. The AAD stated that resident 50 was crying while reporting this. The AAD stated she asked resident 50 who did this and she pointed at resident 43. The AAD stated that she asked the nurse if they were aware and they had said yes they were and that they would let management know. The AAD stated that resident 50 was alert and oriented and knows exactly what is going on. The AAD stated that resident 50 had not made allegations like this in the past. The AAD stated that resident 43 required 1:1 staffing for sexual inappropriateness, touching others and making sexual comments that made people feel uncomfortable. The AAD stated that she did not know why resident 43 did not have a 1:1 aide that day and that was the first time she had seen him without one. The ADD stated that resident 43 was able to move independently in his wheelchair and could have gotten himself within distance of resident 50 to touch her. On 9/13/23 at 11:11 AM, an interview was conducted with RN 1. RN 1 stated that she identified who was scheduled to do the 1:1 with resident 43 on the staff schedule. RN 1 stated that after 6:00 PM they did not have a 1:1 staff member with resident 43. RN 1 stated that staff were still supposed to fill out the 1:1 monitoring sheet after 6:00 PM and that they had eyes on the resident every 15-minutes. On 9/13/23 at 11:37 AM, an interview was conducted with the ADON. The ADON stated that the staff schedule showed which aide was assigned to do the 1:1 with resident 43 from 6:00 AM to 6:00 PM. The ADON stated that they did not have a CNA assigned to do 1:1 for the 2:00 PM to 10:00 PM shift or the 6:00 PM to 6:00 AM shift. The ADON stated that resident 43 did not have an aide scheduled to do 1:1 monitoring after 6:00 PM for the last couple of months. The ADON stated that staff did frequent checks on the resident after 6:00 PM and that the resident went to bed early. The ADON stated that resident 43 could not transfer himself into his wheelchair and he needed assistance being pushed. On 9/13/23 at 11:52 AM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that CNA 4 had reported to her that resident 50 had said during bingo resident 43 had touched her breast. LPN 1 stated that when she asked resident 50 who it was that touched her she could not say who it was by name. LPN 1 stated that she did not ask resident 50 to point out who the individual was. LPN 1 stated that she did not ask CNA 4 how she determined that it was resident 43 who resident 50 had allegedly said touched her breast. LPN 1 stated that resident 50's demeanor was sad, and she had tears in her eyes when she reported the incident. LPN 1 stated that resident 50 was alert and oriented to self, situation, and place. LPN 1 stated that resident 50 was sad they next day or two after the incident occurred and she would become emotional and then talk about her family. On 9/13/23 at 12:26 PM, an interview was conducted with the Medical Records (MR) staff. The MR stated that resident 43 was on 1:1 and they did not save and upload those tracking sheets anymore. The MR stated that she was not sure where they went and why they were not uploaded. On 9/13/23 at 12:38 PM, an interview was conducted with the DON and the Administrator (ADM). The DON stated that the every 15-minute monitoring forms were internal worksheets and were not uploaded into the resident's medical records. The DON stated that the 15-minute check log had an area for staff initials, time, and coding for remarks, locations, and behaviors. The DON stated that the 15-minute check log was to be completed at night and not during the daytime 1:1 monitoring. The DON stated that they were implementing the 15-minute checks at night while they did not have a 1:1 staff in place. The DON stated that in the past the aides were documenting behaviors on a different sheet, but they had discontinued this process. The DON stated that now the aides were supposed to give a verbal report to the nurse of any behaviors that were witnessed during the 1:1 monitoring, and then the nurse would document an event charting progress notes. The DON stated that resident 43 went to bed early and that was why they did not have a 1:1 monitoring at night. The DON stated that if resident 43 stayed up later then the nurse would do a 1:1 monitoring and if it was not manageable they were to call the nurse management. The DON stated that the 15-minute check flow sheet was turned into the ADON and they reviewed them in the IDT meetings and then the sheets were shredded. The DON stated that she conducted the abuse investigation for the incident between resident 50 and resident 43. The DON stated that the incident occurred the day that they conducted a trial removal of the 1:1 monitoring for resident 43. The DON stated that the residents were at bingo and resident 50 alleged that resident 43 touched her breast. The DON stated that she talked to the AAD and she stated that resident 50 was with her the entire time during bingo. The DON stated that when she interviewed CNA 4 she reported that resident 50 had told her that resident 43 had touched her breast. The DON stated that resident 43 was sitting next to resident 30 watching television at the nurse's station and resident 50 pointed towards resident 43. The DON stated that CNA 4 asked resident 50 if it was the resident in the tie dye shirt, which was resident 43, and resident 50 had said yes. The DON stated that when she spoke to resident 50 she had reported that he touched her breast but resident 50 could not identify the individual by name. The DON stated that she did not ask resident 50 to visually identify the individual who allegedly touched her. The DON stated that she asked the AAD and was told that the residents were not left alone during bingo. The DON stated that resident 43 could move his wheelchair independently. The DON stated that she did not know if any other staff were present in bingo that day. The DON stated that she would assume that there were residents that needed assistance to and from bingo, but that the AAD did not go out and return residents to their rooms. The DON stated that based on their findings in the investigation they could not substantiate the abuse allegation as it was unknown who the individual was and when it had occurred. The DON stated that once the allegation was made resident 43 was placed back on 1:1 monitoring. The DON stated that they thought that with the medication and decrease in behaviors that it was appropriate to do a trial discontinuation of the 1:1 monitoring. The ADM stated that the aides had reported a decrease in behaviors and they had said that resident 43 was easy to redirect when he did have behaviors and would stop. The ADM stated that resident 43 still propositioned staff but when he was redirected he was contrite. The DON agreed that resident 43 did not have the ability to restrain himself and to self control his behaviors. The ADM stated that was why the Medical Director had increased his medication to see if it would decrease his behaviors more. The DON stated that resident 43 had a traumatic brain injury (TBI) that had occurred in his early 20's. The DON stated that the nursing management did nurse huddles with the staff to educate them on monitoring and what to document, but that there was no documentation demonstrating what the education was and who it was provided to.

Based on observation, interview and record review it was determined, for 21 of 80 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. These findings resulted in immediate jeopardy (IJ). In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 1, 4, 7, 35, 47, 51, 54, 68, 73, 76, 77, 78, 79, 84, 85, 86, 96, 98, 209, and 357. Findings include: On 4/6/23 at 3:30 PM, an Immediate Jeopardy was identified. Notice of the IJ was given verbally and in writing to the Chief Nursing Officer (CNO) and Director of Nursing (DON) 1 and they were informed of the findings of IJ pertaining to F725 for residents. On 4/18/23, the CNO provided the following revised abatement plan for the removal of the Immediate Jeopardy effective on 4/18/2023 at 11:59 PM: F725 Sufficient Staffing It is the intent of the facility to ensure sufficient staffing. Corrective Action The Administrator/designee validated sufficient staffing levels on all units to meet the needs of current residents. The Administrator/designee notified agency companies of the requirement to provide name tags for staff agency assigned to our facility, the requirement to sign new agency orientation checklist and participate any facility training requirements. The Administrator/designee validated that current staff needs have been posted and on multiple websites and sponsoring the positions to be at the top of the list. The Director of Nursing/designee completed a change in condition assessment for Resident #73, any concerns were acted upon in accordance with professionally accepted standards of care. The Administrator/designee conducted Guardian Angel rounds to validate that Resident #73 care needs are being met; any concerns identified will be addressed. The Director of Nursing/designee completed a change in condition assessment for Resident #35 to any concerns were acted upon in accordance with professionally accepted standards of care. The Administrator/designee conducted Guardian Angel rounds to validate that Resident # 35 care needs are being met; any concerns identified will be addressed. The Director of Nursing/designee completed a change in condition assessment for Resident #1 to any concerns were acted upon in accordance with professionally accepted standards of care. The Administrator/designee conducted Guardian Angel rounds to validate that Resident #1 care needs are being me, any concerns identified will be addressed. The Director of Nursing/designee completed a change in condition assessment for Resident #98 to any concerns were acted upon in accordance with professionally accepted standards of care. The Administrator/designee conducted Guardian Angel rounds to validate that Resident #98 care needs are being met; any concerns identified will be addressed. The Director of Nursing/designee completed a change in condition assessment for Resident #51 to any concerns were acted upon in accordance with professionally accepted standards of care. The Administrator/designee conducted Guardian Angel rounds to validate that Resident #51 care needs are being met; any concerns will be addressed. Identification of Others: The Director of Nursing/designee completed a change in condition 7 day look back assessment of current residents to validate that any concerns were acted upon in accordance with professional accepted standards of care. The Administrator/designee conducted Guardian Angel rounds with current residents to validate that resident care needs were being met. Any concerns identified will be addressed. Systemic Changes: The Administrator and Director of Nursing were provided education by the RVP and CNO of Operations on staffing requirements based on census and acuity. The Administrator provided education to the Staff Coordinator and Director of Nursing regarding strategies to fill open shifts including shift and referral bonuses, agency staff, spilt shifts and coordinating department managers assisting with non-related direct care staff task. Reaching out to sister facilities. Training completed 4/10/2023 The Director of Nursing/designee will also report to the Inter-disciplinary Team in daily meeting the staffing needs as well as needs for the next 72 hours. Training completed 4/10/2023. The Inter-disciplinary Team has developed Nurse Reference and Agency Orientation Check list to validate training with agency staff, to include Licenses and Certified Nurses. Staff training started 4/10. Monitoring/QAPI The Administrator/designee will complete interviews with 5 residents three times a week for eight weeks to validate that resident care needs are being met. The Director of Nursing/designee will review the 24-hour report in daily (M-F) stand-up meetings, and as needed to validate that any changes in condition were followed up in accordance with professionally accepted standards of care. The Director of Nursing/designee will review Agency staff and validate compliance and use of new Agency Reference and Onboarding Check list 3 times a week, any concerns identified will be addressed. The Administrator/designee will report any identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. Alleged Date/Time of IJ Abatement: 4/17/2023 @ 2359 [11:59 PM]. On 4/19/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/18/23. Findings included: IMMEDIATE JEOPARDY 1. Resident 51 was admitted on [DATE] with diagnoses that included dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disorder, anxiety disorder, insomnia, and post-traumatic stress disorder. [Cross refer to F689] 2. Resident 98 was admitted on [DATE] with diagnoses that included dementia, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, hyperlipidemia, hypertension, osteoporosis, tremor, and anxiety disorder. [Cross refer to F689] 3. Resident 1 was initially admitted to the facility on [DATE] and again on 1/2/23 with diagnoses which included chronic obstructive pulmonary disease, acute respiratory failure, unspecified asthma, acute kidney failure, history of falling, muscle weakness, systolic heart failure, adult failure to thrive, hypothyroidism, lactose intolerance, insomnia, adjustment disorder, personality disorder, anxiety disorder, and bipolar disorder. [Cross refer to F689] 4. Resident 73 was admitted to the facility on [DATE] with diagnoses that included dementia with psychotic disturbance, congestive heart failure, dysphagia, mood disorder, anxiety disorder, and major depressive disorder. [Cross refer to F689] 5. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, osteoarthritis, personal history of traumatic brain injury, hemiplegia, protein-calorie malnutrition, major depressive disorder, dysphagia, and neoplasm of skin. [Cross refer to F600] 6. Resident 79 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, major depressive disorder, anxiety, altered mental status, insomnia, personal history of traumatic brain injury, and history of thrombosis and embolism. [Cross refer to F600] 7. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia with behavioral and mood disturbances, unspecified mood disorder, and diabetes mellitus. [Cross refer to F600] 8. Resident 78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia with other behavioral disturbance, unspecified psychosis, hallucinations, cognitive communication deficit, and major depressive disorder. [Cross refer to F600] 9. Resident 54 was initially admitted to the facility on [DATE] and again on 12/28/22 with diagnoses which include unspecified dementia, type 2 diabetes mellitus, obesity, acute respiratory failure, schizophrenia, sepsis, systolic heart failure, chronic kidney disease, hypertensive heart and chronic kidney disease with heart failure, metabolic encephalopathy, conversion disorder with seizures, unspecified convulsions, hyperlipidemia, hypotension, insomnia, and muscle weakness. [Cross refer to F600] 10. Resident 51 was admitted to the facility on [DATE] with diagnoses of dementia, type 2 diabetes mellitus, major depressive disorder, hypertension, anxiety disorder, insomnia, and post traumatic stress disorder. [Cross refer to F600] 11. Resident 86 was admitted to the facility on [DATE] with the following diagnoses that included but not limited to unspecified dementia, anxiety disorder, depression, and history of falling. [Cross refer to F600] 12. Resident 35 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included fibromyalgia, dysphagia, protein calorie malnutrition, cognitive social or emotional deficit, anxiety disorder, major depressive disorder, adult failure to thrive scoliosis, dysarthria, chronic pain and hypertension. [Cross refer to F689] 38031 13. Resident 76 was admitted to the facility on [DATE] with diagnoses which included esophageal obstruction, chronic obstructive pulmonary disease, emphysema, esophagitis, essential (hemorrhagic) thrombocythemia, Barrett's esophagus, gastritis, major depressive disorder, anxiety disorder, post-traumatic stress disorder, gastrostomy status, and opioid dependence. On 3/28/23 at 9:09 AM, an observation was made of resident 76. Resident 76 was in the hallway at the nurse's station and Registered Nurse (RN) 10 disconnected the resident's total parental nutrition (TPN) that was infusing in a right peripherally inserted central catheter (PICC). Resident 76 was observed to ask RN 10 for a pain pill. Resident 76 returned to his room and an immediate interview was conducted with the resident. Resident 76 stated that he had an additional tube feed that was infusing through a peg tube in addition to the TPN. Resident 76 stated that the peg tube was unhooked at 8:30 AM this morning by himself and the infusion was observed still running into the garbage can at the bedside. Resident 76 stated that he unhooked the TF himself and he waited for the nurse to come and flush the peg tube, but eventually flushed the peg tube himself. Resident 76 stated that he flushed the peg tube because the longer he had to wait the feeding would dry out and plug the tube. Resident 76 stated that the longest he has had to wait for assistance was 30 minutes, but it usually took 15 minutes before the call light was answered. Resident 76 stated that he gets aggravated that the call light was not answered because if he needed a pain pill he would have to wait. Resident 76 stated that if he had to wait longer than 10 minutes he would walk down to the nurses station to get assistance. Resident 76 stated that was what he did today. Resident 76 stated that RN 10 said she would give me my pain pill 20 minutes ago. She's forgotten already. Resident 76 stated that the pain was located in the abdomen, esophagus and ribs. Resident 76 stated that his current level of pain was a 6/10. Resident 76 stated that he did not know why RN 10 did not give him the medication at the time she unhooked the TPN. On 3/28/23 at 9:57 AM, RN 10 administered resident 76's pain medication. 14. Resident 77 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, Parkinson's disease, cirrhosis of liver, hypertension, pain in legs, edema, history of UTI, and anxiety disorder. On 3/28/23 at 1:18 PM, resident 77 was interviewed. Resident 77 stated that she had to wait when she pushed the call light awhile. Resident 77 stated that she had been having some nausea and vomiting and she has had to wait for assistance after having vomited on herself. Resident 77 was observed with contractures to all extremities and was unable to move herself independently in the bed. On 3/28/23, resident 77's medical records were reviewed. On 12/29/22, the Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, which would indicate cognitively intact, the assessment documented yes to hallucinations and no to delusions. The assessment documented the resident's functional status as total dependence one person assist for bed mobility, locomotion on and off the unit, eating, toileting, and personal hygiene and total dependence two person assist for transfers. 15. Resident 96 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, sepsis, hypertension, retention of urine, major depressive disorder, personality disorder, insomnia, anxiety disorder, and acquired absence of right leg below the knee. On 3/29/23 at 9:05 AM, an interview was conducted with resident 96. Resident 96 stated that there were not enough staff. Resident 96 stated that the staff would say they would be there and then would push things off. Resident 96 stated that when he pushed the call light the longest he had to wait was 2 hours and that was for a pain pill. On 3/29/23 at 9:15 AM, a follow-up interview was conducted with resident 96. Resident 96 stated that he did not get assistance with bathing. Resident 96 stated that he required set up assistance and then he could wash himself. Resident 96 stated that he would ask for a shower and staff would say that they would get to it, but they did not. Resident 96 stated that the facility did not have enough staff. Resident 96 stated that the staff would document that he refused his showers when he did not. Resident 96 stated that it had been awhile since his last shower. On 4/24/23, resident 96's medical records were reviewed. On 1/29/23, the Admission MDS Assessment documented a BIMS score of 13/15, which would indicate that resident 96 was cognitively intact. The assessment documented that resident 96 was a limited one person assist for transfers, dressing, and personal hygiene. The assessment documented that resident 96 required a one person extensive assist for toileting. The assessment documented that resident 96 required a one person assist with supervision for bathing. [Cross-refer F676] 16. Resident 144 was admitted to the facility on [DATE] with diagnoses which included partial traumatic amputation of left forearm, complete traumatic amputation of the right forearm, chronic obstructive pulmonary disease, diabetes mellitus type 2, congestive heart failure, and chronic pain syndrome. On 3/28/23 at 10:23 AM, an interview was conducted with resident 144. Resident 144 stated that there were not enough staff, and staff always told him they were low on help. Resident 144 stated that the longest he had to wait for assistance was 1.5 hours. Resident 144 stated that during this time he shit his pants. Resident 144 stated that with assistance he was able to use the toilet. On 3/28/23, resident 144's medical records were reviewed. On 3/10/23, resident 144's Quarterly MDS Assessment documented a BIMS score of 14/15, which would indicate that resident 144 was cognitively intact. The assessment documented resident 144's functional status was an extensive one person physical assist for bed mobility, transfers, walking in room, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. 17. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, concussion, repeated falls, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, and hypomagnesemia. On 3/28/23 at 12:33 PM, an interview was conducted with resident 357. Resident 357 was heard to tell the RN that she had not had a shower in 2 to 3 days. Resident 357 stated that she last received a bath on Saturday. Resident 357 stated that she would like a shower every other day. Resident 357 also stated that it took an hour to receive assistance with toileting, and when staff did come to help, she was saturated in urine by that point. Resident 357 stated that this made her mad. The resident stated that she started crying while toileting and told the aide who assisted with wiping the anus, it hurt because of her hemorrhoids. Resident 357 stated that the aides don't stop to ask her how she is doing and if she needed anything; they say they are busy and they will be here. Resident 357 was observed to be crying while she was talking to the surveyor. On 3/29/23, resident 357's medical records were reviewed. On 3/28/23, resident 357's Admission MDS Assessment documented a BIMS score of 15/15, which would indicate that resident 357 was cognitively intact. The assessment documented that resident 357 did not have hallucinations or delusions. Resident 357 was assessed as requiring a limited one person assist for bed mobility, transfer, locomotion off the unit, dressing, and personal hygiene; extensive one person assist for toilet use; and supervision one person assist for eating. The assessment documented that resident 357 required a one person physical assist for bathing. [Cross-refer F676 and F689] 18. Resident 84 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, protein-calorie malnutrition, liver cell carcinoma, chronic viral hepatitis C, schizophrenia, anxiety disorder, fibromyalgia, hypertension, chronic pain syndrome, and hearing loss. On 3/28/23 at 9:31 AM, an interview with resident 84 was conducted. Resident 84 stated that there were not enough staff at the facility. Resident 84 stated that he often had to wait a long time to receive medications due to the facility being short staffed. Resident 84 also stated that there were not enough staff at the facility to keep the facility clean. 19. Resident 7 was initially admitted to the facility on [DATE] and again on 4/7/23 with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. On 4/11/23 at 11:51 AM an interview with resident 7 and resident 7's Power of Attorney (POA) was conducted. Resident 7's POA stated that there were not enough staff at the facility. Resident 7's POA stated that she had waited outside the facility for hours because there were no staff to answer the door. Resident 7's POA stated that staffing was even worse on holidays. Resident 7's POA stated that she believed resident 7 was not being repositioned during the night due to short staffing. Resident 7's POA stated that resident 7 had gotten new pressure ulcers from not being repositioned during the night. [Cross refer to 686] 20. Resident 209 was admitted on [DATE] with the following diagnoses that included but not limited to weakness, cognitive communication deficit, paroxysmal atrial fibrillation, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, abnormal coagulation profile, and chronic kidney disease (CKD). On 3/28/23 at 10:12 AM an interview with resident 209 was conducted. Resident 209 stated she could not get out of bed, and would just sit in bed all day. Resident 209 stated she would tell staff she felt like she needed to have a bowel movement, but that it would be two plus hours before staff came to assist her. Resident 209 stated she often had to sit in her own feces while she waited for staff. Resident 209 stated she would press the call button, and staff would come in to turn off the call light, but then leave and not return for hours. On 4/13/23 at 8:33 AM, resident 209's call light was initiated. At 8:49 AM, 16 minutes later, Certified Nursing Assistant (CNA) 23 entered resident 209's room, and the call light was shut off. CNA 23 was observed to leave the room and return within 3 minutes to change resident 209's brief. CNA 23 was observed to change resident 23's brief by herself, and no additional staff assistance. During the brief change, CNA 23 stated that she was an agency CNA. On 3/31/23 an admission MDS was completed for resident 209. The MDS indicated that resident 209 required the assistance of two people for bed mobility for toileting. 21. On 3/28/2023 at 9:58 AM, an interview was conducted with resident 85. Resident 85 stated that he felt that the staff were inexperienced. 22. On 4/11/2023 at 11:56 AM, an interview was conducted with Resident 4. Resident 4 stated that she has lived here for [AGE] years. She feels that there is a staff shortage compared to past years. Staff Interviews 1. On 3/30/23 an interview was conducted with Staff Member (SM) 17. SM 17 stated that they usually only had 2 CNAs on the dementia unit. I don't know why they don't put 3 CNAs back here; these residents need a lot of help and attention. At night they only have 1 CNA for the entire unit. SM 17 stated that it was difficult to take care of all the residents, they needed more than 2 staff, and that they do the best they can. SM 17 stated that you need to be very alert that these patients don't fight, don't fall, that they are clothed and not walking around naked. 2. On 3/30/23 an interview was conducted with SM 16. SM 16 stated that they usually had 2 aides in the dementia unit, and that was not enough especially with resident behaviors. SM 16 stated that showers do not get done because when they have resident behaviors, they cannot watch the resident and shower them. 3. On 3/31/23, an interview was conducted with SM 3. SM 3 stated that they needed more staff on the dementia unit, and currently the facility used a lot of agency staff. SM 3 stated that a lot of the residents on the dementia unit needed a two person assist for Activities of Daily Living (ADLs) because they were combative with cares. 4. On 3/31/23 at 8:31 PM, an interview was conducted with RN 8. RN 8 stated that she would be the nurse on two halls from 10:00 PM until 6:00 AM, and the resident census would be 45 residents. 5. On 3/31/23, an interview was conducted with SM 14. SM 14 stated that she was working on the north hall and that she would be taking the whole rehab section at 10 PM. SM 14 stated that would give her a resident census of 60 residents, and she would have three aides working with her after 10 PM. SM 1 stated that resident 9 was on 15-minute checks because he yelled at staff and was abusive to peers. SM 1 stated that she had not been able to go into resident 9's room every 15 minute to check on him because she was busy with medication administration. SM 14 stated that she was checking on him approximately every 30 minutes. SM 14 stated she was not sure if the aides were also checking on resident 9. SM 14 stated that the staffing conditions were terrible. SM 14 stated that with 60 residents per nurse it created horrible patient care. You can't do 15-minute checks. It's not feasible even if the aides are helping. If they are helping with brief changes they can be in a room for 15 minutes. SM 14 stated that if she was doing a treatment or had wound care with a wound vac dressing she could be in a room for over 30 minutes. It's not possible to do 15-minute checks with this many resident. This is terrible patient care. If a patient falls on the back hall it can be awhile before we see them and if they can't get to the call light who knows how long they could be lying there. SM 14 stated that she was not aware at the beginning of the shift that she would have this many residents. SM 14 stated that the staffing was ridiculous. 6. On 4/5/23, an interview was conducted with SM 25. SM 25 stated that she had found resident 25 on multiple occassions soaking wet with their brief saturated in urine. SM 25 stated that resident 25 was a heavy wetter and should have their brief changed every 2 hours. SM 25 stated that she had noticed that resident 25 was not having her clothing changed regularly and at one point was wearing the same shirt for over 2 weeks. SM 25 stated that she had also noticed that resident 11 had been in the same clothing for 2 weeks. SM 25 stated that resident 11 would often refuse to change his clothes but that he could be convinced a couple of times a week. SM 25 stated that she had noticed that a lot of the residents were wearing the same clothing multiple days in a row or that resident's bed were soaking wet with urine. SM 25 stated that she had found resident 37 with a double brief on, not sure why. They put a tab brief with a pull up brief over the top. SM 25 stated that the staff had told her that they double brief residents so they do not have to change them often. SM 25 stated that they would also put a pad on the inside of the brief. SM 25 stated that it was not providing good care because the resident would be sitting in their urine longer and could be subjected to skin breakdown from the prolonged exposure to urine. SM 25 stated that staffing at the facility sucked. SM 25 stated that the facility used a lot of agency staff and they did not know the building or residents well and it was hard. SM 25 stated that if staff complained about this then there was the fear that they would be fired. SM 25 stated that no one does anything about the incontinence care unless the State Survey Agency (SSA) was at the facility. SM 25 stated that once the SSA left the facility everything would return to the way it was before. 7. On 4/6/23, an interview was conducted with SM 10. SM 10 stated that the residents had said on more than one occasion that they felt like cattle being herded and that there was not enough staff. SM 10 stated that she had noticed that some of the residents were not having their clothing changed, and was told that it was the agency aides that were responsible. SM 10 stated that she can see that it was not agency staff that were responsible for not changing resident clothing. SM 10 stated, we have some lazy staff. 8. On 4/13/23 at 9:17 AM, an interview was conducted with CNA 5. CNA 5 stated that she transferred resident 5 with a Hoyer lift by herself without additional staff assistance. CNA 5 stated that they were supposed to have 2 staff assist with Hoyer transfers, but everyone else was busy. CNA 5 stated that there were not enough staff to do a 2 person Hoyer lift transfer. 9. On 4/20/23 at 12:04 PM, an interview with was conducted with the Director of Nursing (DON) 3. The DON 3 state that the protocol for a Hoyer lift transfer was to utilize 2 persons. The DON 3 stated that they would need 2 staff for safety, stability, and proper body mechanics. 10. On 4/13/23 at 2:27 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated that the facility utilized a lot of agency staff. The ADM stated that they were attempting to increase facility staffing in an effort to get the agency staff use down to zero. 45470 11. On 3/30/23 an interview with SM 4 was conducted. SM 4 stated the facility was often short staffed. SM 4 stated that sometimes a hallway would be staffed with one nurse and one CNA. SM 4 stated that the facility would often send a CNA on the long term care side to the rehab side, leaving the long term care side with less CNAs. SM 4 stated that the residents did not receive proper care when the facility was short staffed. SM 4 stated that it was impossible to complete 15-minute checks for residents on top of their daily tasks. SM 4 that residents did not get their scheduled showers when there was only one CNA and one nurse. SM 4 stated that she believed if the facility had more staff, there would be less behaviors between the residents. SM 4 stated the facility had increased staff from October 2022 to December 2022, and then the facility decreased staff. SM 4 stated that behaviors seemed to increase between residents when staffing was decreased in December of 2022. 12. On 3/30/23 an interview with SM 7 was conducted. SM 7 stated she felt like the resident's did not receive proper care because the facility was short staffed. SM 7 stated that staff cannot complete 15-minute checks for the resident's who have been determined to require 15-minute checks. 13. On 4/6/23 an interview with SM 2 was conducted. SM 2 stated she was an agency staff member and she had only worked at the facility a few times. SM 2 stated she believed the facility was short staffed. SM 2 stated that the last time she worked at the facility, there were not enough staff to assist a resident to the bathroom and the resident urinated in his bed. SM 2 could not recall the resident's name. 47431 14. On 3/30/23 at 12:47 PM, an interview with RN 1 was conducted. RN 1 stated some days she was assigned to her section at the facility without any CNAs to assist her. RN 1 stated she was concerned about the safety of the residents, due to lack of staff. RN 1 stated that in her section, there were three CNAs assigned to help seventy residents, and residents never received showers. RN 1 stated there were only two nurses assigned during the night shift for the whole building. 47432 On 4/12/2023, the facility hosted a resident council meeting. Residents brought up concerns about lack of adequate staffing to provide cares and meet resident needs, and untrained agency staff. Many of these concerns had been voiced during previous resident council meetings, as indicated by the resident council notes. During the meeting, resident 357 stated, Do we have rights here? It doesn't feel like it. On paper maybe, but do we really? [Cross refer to F565] Based on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include both the number of residents and facility's resident capacity; the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population; the staff competencies that were necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plan considerations that were necessary to care for this population; and any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including but not limited to, activities and food and nutrition services. Specifically, the facility did not have an accurate facility assessment that included all of the above. [Cross refer to F838] 22992

Based on observation, interview and record review it was determined, for 11 out of 80 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident experienced 19 falls that resulted in an injury 14 times with multiple head injuries that required medical attention; a resident experienced 5 falls within 48 hours that resulted in bruising, pain, and a hip fracture; a resident experienced 17 falls that resulted in multiple fractures; a resident experienced 9 falls with head injuries that required medical attention; and a resident experienced 27 falls that resulted in lacerations that required medical attention. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, a resident eloped from the facility multiple times and sustained lacerations requiring sutures. This identified deficient practice was found to have occurred at a Harm Level. Lastly, a resident experienced repeated falls without interventions identified to prevent the falls, a resident sustained a fall after a faulty door hinge fell on top of their head, a resident residing in the dementia unit obtained a razor and cut his head, a resident sustained an injury to their foot after an improper transfer by the administrator (ADM), and hot water temperatures were measured at levels above 100 degrees Fahrenheit. Resident identifiers: 1, 11, 35, 47, 51, 73, 79, 98, 209, 258, and 357. NOTICE On 4/6/23 at 3:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents identified at risk for falls were evaluated, that interventions were identified to prevent further accidents and injuries, that interventions were re-evaluated and revised to prevent reoccurrence, and monitoring for safety was implemented. Notice of the IJ was given verbally and in writing to the Chief Nursing Officer (CNO) and Director of Nursing (DON) 1 and they were informed of the findings of IJ pertaining to F689 for residents 1, 35, 51, 73, and 98. On 4/18/23, the Chief Nursing Officer provided the following revised abatement plan for the removal of the Immediate Jeopardy effective on 4/18/2023 at 11:59 PM: F689 Free of Accident/Hazards It is the intent of the facility to ensure all residents are free from accidents and hazards. Corrective Action Resident #51 The Director of Nursing/designee re-assessed for falls including any falls that occurred in the last 14 days to validate that interventions were implemented to assist in reducing significant injury and frequency of falls, physician and resident representative notified, new orders noted, and care plan updated as applicable. On 4/18/2023 IDT [Inter-Disciplinary Team] reviewed/assessed environment and interviewed staff. Kardex updated to inform staff of specific interventions to reduce falls. Resident #98 The Director of Nursing/designee created a timeline of pts [patients] falls and root causes. Resident # 1 The Director of Nursing/designee re-assessed for falls including any falls that occurred in the last 14 days to validate that interventions were implemented to assist in reducing significant injury and frequency of falls, physician and resident representative notified, new orders noted, and care plan and Kardex updated as applicable. On 4/18/2023 IDT reviewed/assessed environment and interviewed staff. Kardex updated to inform staff of specific interventions to reduce falls. Resident # 35 The Director of Nursing/designee re-assessed for falls including any falls that occurred in the last 14 days to validate that interventions were implemented to assist in reducing significant injury and frequency of falls, physician and resident representative notified, new orders noted, and care plan updated as applicable. On 4/18/2023 IDT reviewed/assessed environment and interviewed staff. Kardex updated to inform staff of specific interventions to reduce falls. Resident # 73 The Director of Nursing/designee re-assessed for falls including any fall that occurred in the last 14 days to validate that interventions were implemented to assist in reducing significant injury and frequency of falls, physician and resident representative notified, new orders noted, and care plan and Kardex updated as applicable. On 4/18/2023 IDT reviewed/assessed environment and interviewed staff. Kardex updated to inform staff of specific interventions to reduce falls. Identification of Others Residents with falls have the potential to be affected by this alleged deficient practice. The Director of Nursing/designee conducted a review of all residents who have had falls in the last 14 days to validate that they were thoroughly reviewed, and new interventions were implemented to attempt to prevent recurrence. Care plans revised. Physician and resident representative notified. Any other concerns identified were addressed. Systemic Changes We've initiated Check-In's with each unit every two hours around the clock to identify any new falls, new injuries, negative resident interactions, and any grey area situations that need clarification. Anything newly identified is escalated to the appropriate person for follow up. This will be completed until we are able to train a Nurse Supervisor for each shift who will then assist in overseeing this process when management is not in the facility. The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) on the requirements to complete a thorough accident investigation, including determination of root cause, timely intervention of appropriate interventions, notification of physician and resident responsible party, as well as requirement to complete care plan revisions as applicable. The Inter-disciplinary Team (IDT) will review falls Monday through Friday in Morning Meeting and as needed to validate that all required components including physician/resident representative notifications are made, through investigation is conducted including root cause analysis and any identified applicable new interventions are implemented timely and noted on care plan, and Kardex. A weekly IDT meeting will be held to review the previous weeks falls to ensure appropriate interventions are in place. The residents assigned nurse will report falls via phone call or face to face timely to the DON or designee. The DON or designee will coordinate with the physician and key department heads for an abbreviated IDT. After review of the event the IDT will immediately implement applicable interventions. All nursing staff will be trained on this process prior to their next shift. We've standardized a list of investigative questions to be asked by the DON or designee upon notification of incident. This will assist in identifying the root cause to validate applicable interventions are implemented. We will obtain statements or interview staff in the vicinity of the incident. IDT will interview a random sample of staff familiar with the resident to determine other possible risks or causative factors. Monitoring/Quality Assurance The Administrator/designee will conduct a daily audit to validate that residents who have sustained a fall had the fall thoroughly investigated, a root cause determined, physician and resident responsible notified, applicable interventions implemented re [sic] have been properly investigated with applicable intervention to prevent recurrence, and that the plan of care and nursing Kardex was updated with the new intervention(s). The Administrator/designee will review daily audit findings for any identified trends and report to the Quality Assurance Performance Improvement Committee weekly and as needed until a lessor frequency is deemed appropriate. On 4/19/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/18/23. Findings included: IMMEDIATE JEOPARDY 1. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/28/23 at 2:41 PM, an interview was conducted with resident 51. Resident 51 stated that she did not have a fall recently, and did not go to the hospital to have stitches placed in the back of the head. Resident 51 was asked if she had pain in her head and she replied, ya I guess. On 3/29/23, resident 51's medical records were reviewed. On 2/10/23, resident 51's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00, which would indicate that resident 51 was severely cognitively impaired. The assessment documented that resident 51 did not have hallucinations but did have delusions. The functional status assessed resident 51 as a limited 2 person assist for bed mobility and transfers; limited one person assist for walking in the room/corridor, and locomotion on and off the unit; extensive one person for dressing; supervision one person with eating; and extensive 2 person assist for toileting and personal hygiene. The assessment documented that resident 51 was not steady, but able to stabilize without staff assistance when moving from a seated to standing position; when walking; when turning around and facing the opposite direction while walking; when moving on and off the toilet; and with surface to surface transfers. The assessment documented that resident 51 did not have any impairments to the upper or lower extremities. The assessment documented that resident 51 utilized a walker as a mobility device. On 10/24/19, resident 51's Preadmission Screening Resident Review (PASRR) Level II documented that resident 51's Transient Ischemic Attack (TIA) from 8/31/19 and cognitive impairments were most likely contributing to mental health issues. The current psychiatric functioning documented that resident 51 was feeling depressed and anxious. The assessment recommended that the nursing facility refer the resident for a neuropsychological exam to rule out other possible treatable causes of dementia symptoms. The recommendations for specialized services were for an antidepressant and urine drug tests. Review of resident 51's incident reports, progress notes, neurological assessments, and care plans revealed the following: a. On 8/17/22 at 8:30 AM, the incident report documented that resident 51 was .found sitting on bathroom floor when cna [Certified Nurse Assistant] walked, no injuries noted from what pt [patient] had said, pt refused skin check, no pain, rom [Range of Motion] at baseline. Neurological (Neuro) assessments were started every 15 minutes. The report documented injuries observed at time of incident were to the top of the scalp, and the injury type documented Unable to determine. The report documented the predisposing factors were poor lighting, resident was confused, resident was incontinent, resident had a gait imbalance, resident had impaired memory, and resident was ambulating without assist. The physician was notified on 8/17/22 at 6:35 PM. On 8/17/22 at 6:35 PM, the progress note documented, (Unwitnessed fall) pt was found sitting on bathroom floor when cna walked, no injuries noted from what pt had said, pt refused skin check, no pain, rom at baseline. Neuros started Q [every]15min [minutes] checks. It should be noted that no documentation could be found that the neurological assessments forms were initiated and completed. On 6/22/22 and again on 6/23/22, a care plan for at risk for falls was initiated for resident 51. Interventions identified were anticipate and meet the resident's needs; ensure call light was within reach and encourage the resident to use it for assistance; respond promptly to the resident's requests for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; clean up spills immediately; examine all footwear for proper fit. It should be noted that no new interventions were identified on the care plan after the fall on 8/17/22. b. On 8/26/22 at 11:55 AM, the incident report documented, Resident was found on floor at approx [approximately] 1155 [AM] by staff. Resident was sitting on her floor in the middle of her room. Resident has not c/o [complained of] pain or discomfort. The report documented that resident 51 was unable to give a description of the incident. Immediate action taken was VSS [vital signs stable] neuros started provider notified. Left message with [family member] to call back. No other problems noted at this time. The report documented no injuries were observed at the time of the incident. The report documented the predisposing factors were resident was confused and drowsy, resident was incontinent, resident had a gait imbalance, and resident had impaired memory. The physician was notified on 8/26/22 at 12:17 PM. On 8/26/22 at 12:23 PM the progress note documented, Resident had an unwitnessed fall in her room at approx 1155. She did not have any shoes on when found resident. Neuros started and VSS. Residents provider notified and also her family [representative] left a message to call facility back. Educated resident to wear footwear when ambulating. No s/s [signs and symptoms] of pain or discomfort or bruising from fall noted at this time. On 8/26/22, the neurological assessment form documented information from 12:00 PM to 6:00 PM. The neuro check schedule documented on the paper copy that checks should be performed every 15 minutes times 4, every 30 minutes time 2, every hour times 2, every 2 hours times 2, every 4 hours times 4, and every 8 hours times 6. The assessment documented that resident 51's level of consciousness was alert, her pupil response was pupil equal and reactive to light (PERL), her hand grasps were equal, and her pain response was appropriate. Resident 51's vital signs were documented with some resident refusals noted. On 8/22/22, a care plan for the resident had an actual fall with no injury was initiated for resident 51. Interventions identified were to continue interventions on the at-risk plan, frequent checks on rounds related to dementia with behaviors, implement the Falling Star Program, and offer and assist with frequent toileting as needed related to fall in bathroom. It should be noted that the all the interventions were initiated on 8/26/22, four days after the fall occurred. The care plan was resolved on 3/24/23. c. On 8/26/22 at 5:15 PM, the incident report documented, Resident was found on floor in her room at approx 1715 [5:15 PM]. She was laying on her right side when found by this nurse. Resident has a hematoma approx [sic] 2 cm [centimeters] in circ. [circumference] to the back of her head close to her neck and a 0.5 cm cut to her lip. She is alert and appropriate to self at this time. Resident provider notified and her [family representative] also called. Restarted neuros. The report documented injuries observed at the time of the incident were a hematoma to the back of the head and a small 0.5 cm cut to the lip. The report documented the predisposing factors were confusion and weakness/fainted. The physician was notified on 8/26/22 at 5:26 PM. On 8/26/22 at 5:30 PM, the progress note documented, Resident was found on floor in her room at approx 1715. She was laying on her right side when found by this nurse. Resident has a hematoma appox [sic] 2 cm in circ. to the back of her head close to her neck and a 0.5 cm cut to her lip. She is alert and appropriate to self at this time. Resident provider notified and her [family representative] also called. Restarted neuros. On 8/26/22, the neurological assessment form documented information from 12:00 PM to 6:00 PM. The 6:00 PM assessment documented that resident 51's level of consciousness was alert, her pupil response was pupil equal and reactive to light (PERL), her hand grasps were equal, and her pain response was appropriate. No documentation was noted for vital signs at 6:00 PM. It should be noted that no documentation could be found that the neurological assessments were completed after 6:00 PM on 8/26/22. Additionally, no documentation was found that a neurological assessment was completed immediately after the fall at 5:15 PM. On 8/22/22, a care plan for the resident had an actual fall with no injury was initiated for resident 51. Interventions identified were to continue interventions on the at-risk plan, frequent checks on rounds related to dementia with behaviors, implement the Falling Star Program, and offer and assist with frequent toileting as needed related to fall in bathroom. It should be noted that all the interventions were initiated on 8/26/22 after resident 51 sustained a fall that resulted in a hematoma to the head and a laceration to the lip. The care plan was resolved on 3/24/23. d. On 9/4/22 at 12:37 PM, the incident report documented, Unwitnessed fall. Resident sitting in recliner is [sic] facility hallway, watching t.v. Resident slipped down and out of recliner to floor, landing on buttocks sitting position. No injuries observed. Notified MD [Medical Doctor]. No c/o [complaints of] pain. V/S [vital signs] 130/75 [blood pressure] 64 [heart rate] 14 [respiratory rate] 97.3 [temperature] O2 [oxygen] 92% The report documented that resident 51 was unable to give a description of the incident and resident 51 was returned to sitting in the recliner. The report documented no injuries were observed at the time of the incident. The report documented the predisposing factors were resident was confused and impaired memory. The physician was notified on 9/4/22 at 12:29 PM. On 9/4/22 at 1:02 PM the progress note documented, Unwitnessed fall. Resident sitting in recliner is [sic] facility hallway, watching t.v. Resident slipped down and out of recliner to floor, landing on buttocks sitting position. No injuries observed. Notified MD. No c/o pain. V/S 130/75 64 14 97.3 O2 92%. It should be noted that no documentation could be found that the neurological assessments forms were initiated and completed. It should be noted that no new interventions were identified on the care plan after the fall on 9/4/22. e. On 9/11/22 at 9:45 PM, the incident report documented, Resident was found on floor in rm [room] this night at 1920 [7:20 PM]. She was found by another resident. She was on her back at the end of her bed. She had items from her walker all over the floor near her. She had her R [right] shoe off her foot. She didn't want any help getting off the floor. She wanted every one to get out of her room. Resident stated she was not hurt and that she did hit her head on the floor. There are no injuries visible on her person. She states she was not in pain. Two CNA [Certified Nurse Assistants]were able to convince her to get off the floor and into bed at 1927 [7:27 PM]. We laid her down to bed and started Neuro charting. She is stable. She was not on the mat by her bed at all. I contacted the MD and DON at 2028 [8:28 PM] and at 2051 [8:51 PM] I tried to call her sister with no response. Resident Description: Resident stated she wanted to be on the floor and that was why she was there and to leave her alone, she would get up when she wants. The immediate action taken was MD, DON, notified. NEURO V/S started, resident put in bed, non grippy socks taken off, Head to toe assessment no visible injury. The report documented the predisposing factors were clutter, confusion, gait imbalance, impaired memory, and ambulating without assist. The MD was notified on 9/11/22 at 9:49 PM. On 9/11/22 at 9:38 PM, the progress note documented, Resident was found on floor in rm this night at 1920. She was found by another resident. She was on her back at the end of her bed. She had items from her walker all over the floor near her. She had her R shoe off her foot. She didn't want any help getting off the floor. She wanted every one to get out of her room. Resident stated she was not hurt and that she did hit her head on the floor. There are no injuries visible on her person. She states she was not in pain. Two CNA were able to convince her to get off the floor and into bed at 1927. We laid her down to bed and started Neuro charting. She is stable. She was not on the mat by her bed at all. I contacted the MD [medical doctor] and DON at 2028 and at 2051 I tried to call her sister with no response. On 9/11/22 at 10:01 PM, the progress note documented, Reminded resident to use call light in need of help. Keep shoes or non skid socks on. Q15 min checks, v/s [vital sign] monitoring, helping resident with cares. On 9/12/22 at 9:29 PM the progress note documented, patient was sent to the hospital, due to neuro check finding. patient on neuro check and day staff found that patient's eyes were unequal and the right eye was unreactive to light. night staff assessed with the day nurse and noticed the [sic] was still same, staff notified [provider] and recommended sending pt to the hospital for further evaluation. It should be noted that no documentation could be found that the neurological assessments forms were initiated and completed. On 9/13/22 at 12:05 AM, the progress note documented, patient got back from the hospital. Staff was told that no abnormal finding from the CX [sic] of the brain and labs performed. Staff made comfortable in bed. WCTM [will continue to monitor]. It should be noted that no new interventions were identified on the care plan after the fall on 9/11/22. f. On 11/21/22 at 2: 55 PM, the incident report documented, CNA notified this nurse that during shower while whole resident was standing up, she lost her balance and fell to the floor. CNA told this nurse that resident did not hit her head. On assessment in the bathroom no apparent injuries noted. Resident denied pain. Resident refused vital signs on more than 3 attempts. MD notified by ADON [Assistant Director of Nursing]. The report documented the predisposing factors was a wet floor. The physician was notified on 11/21/22 at 3:31 PM. On 11/21/22 at 6:32 PM, the progress note documented, CNA notified this nurse that during shower while whole resident was standing up, she lost her balance and fell to the floor. CNA told this nurse that resident did not hit her head. On assessment in the bathroom no apparent injuries noted. Resident denied pain. Resident refused vital signs on more than 3 attempts. MD notified by ADON. whole body assessment done. No injury noted. refused vital signs to be checked. It should be noted that no new interventions were identified on the care plan after the fall on 11/21/22. g. On 11/24/22 at 12:23 PM, the incident report documented, Resident sitting by nurses' station and fell asleep in chair. Resident fell out of chair, to floor, onto buttocks. No contact of head to floor. Fall was witnessed by nurse. No apparent injuries observed. V/S 126/84 72 18 93.1 95. The report documented no predisposing factors to the fall. The report did not document that the physician was notified. On 11/24/22 at 2:24 PM, the progress note documented, Resident sitting by nurses' station and fell asleep in chair. Resident fell out of chair, to floor, onto buttocks. No contact of head to floor. Fall was witnessed by nurse. No apparent injuries observed. V/S 126/84 72 18 93.1 95. It should be noted that no new interventions were identified on the care plan after the fall on 11/24/22. h. On 11/24/22 at 2:25 PM, the progress note documented, Resident ambulating with FWW [forward wheeled walker] in hall. fell to right knee, supported by FWW. Redness to right knee observed. No c/o pain. v/s 132/78 [blood pressure] 88 [hear rate] 16 [respiratory rate] 98.1 [temperature] 96 [oxygen saturation] PEERL [sic] Equal grips. MD notified. It should be noted that no documentation could be found of an incident report. It should be noted that no new interventions were identified on the care plan after the fall on 11/24/22. i. On 12/1/22 at 2:03 PM, the incident report documented, Resident found on floor, lying on right side. FWW was on its side, on the floor. Assessed resident for head injuries and for physical injuries. No injuries observed. PERRL [pupils equal, round and react to light] Equal grips. V/S 148/74 80 16 96.3. Resident has been placed on Neuro checks. MD notified. The physician was notified on 12/1/22 at 2:08 PM. on 12/1/22 at 2:10 PM, the progress note documented, Resident found on floor, lying on right side. FWW was on its side, on the floor. Assessed resident for head injuries and for physical injuries. No injuries observed. PERRL Equal grips. V/S 148/74 80 16 96.3. Resident has been placed on Neuro checks. MD notified. It should be noted that no documentation could be found that the neurological assessments forms were initiated and completed. It should be noted that no new interventions were identified on the care plan after the fall on 12/1/22. j. On 12/3/22 at 2:41 PM, the incident report documented, Resident found on floor, lying on right side. FWW was on its side, on the floor. Assessed resident for head injuries and for physical injuries. Skin tear to left forearm. PERRL [pupils equal round and reactive to light] Equal grips. V/S 148/74 80 16 96.3. Resident has been placed on Neuro checks. MD notified. The physician was notified on 12/3/22 at 9:46 AM. It should be noted that no documentation could be found that the neurological assessments forms were initiated and completed. It should be noted that no new interventions were identified on the care plan after the fall on 12/3/22. k. On 12/5/22 at 5:15 PM, the incident report documented, pt called out for help and nurse found patient on floor near entrance of bedroom. nurse assisted pt into wheelchair. The immediate action taken was nurse assisted pt into wheelchair. Once in wheelchair nurse gained vital signs. Pt's vital signs were wnl [within normal limits]. Patient verbalized pain in back and buttock but would not allow nurse to assess skin. pt stated, 'that is enough'. Nurse unable to assess skin for injuries. pt is alert to baseline, pupils are not equal at baseline but are reactive to light, hand grasps equal, able to move all extremities. neuros started. provider notified. unable to reach family. The report documented resident 51's at a 4/10. The report documented the predisposing factors were gait imbalance, impaired memory and wanderer. The physician was notified on 12/5/22 at 8:04 PM. On 12/5/22 at 8:06 PM, the progress note documented, pt called out for help and nurse found patient on floor near entrance of bedroom. nurse assisted pt into wheelchair. Once in wheelchair nurse gained vital signs. Pt's vital signs were wnl. Patient verbalized pain in back and buttock but would not allow nurse to assess skin. pt stated, 'that is enough'. Nurse unable to assess skin for injuries. pt is alert to baseline, pupils are not equal at baseline but are reactive to light, hand grasps equal, able to move all extremities. neuros started. provider notified. unable to reach family. On 12/6/22 at 4:37 AM, the progress note documented the 72 Hour Event Charting for the fall on 12/5/22 at 5:15 PM. The note documented interventions as Fall mat next to bed, non-slip footwear, adequate lighting, increased frequency of rounding, neuro checks, bed in low position. It should be noted that no documentation could be found that the neurological assessments forms were initiated and completed. It should be noted that no new interventions were identified on the care plan after the fall on 12/5/22. l. On 12/12/22 at 7:31 PM, the incident report documented, upon brief change, nurse noticed bruising on left hip and right shin. The report documented the immediate action taken was notified provider. notified abuse coordinator. The report documented the predisposing factors were confused and wanderer. The physician was notified on 12/12/22 at 7:32 PM. On 12/12/22 at 7:33 PM, the progress note documented, upon brief change, nurse noticed bruising on left hip and right shin. resident unable to give description. provider notified. abuse coordinator notified. It should be noted that no documentation could be found that an abuse investigation was initiated for this incident or that any investigation into the cause of the bruises was conducted. Additionally, no documentation could be found that a complete skin assessment of resident 51 was conducted. m. On 12/18/22 at 2:30 PM, the incident report documented, CNA reported to the nurse that the resident was found in the hallway on the floor and leaning up against the wall because she had fallen. She reports the hallway was cluttered with other residents and there was not enough room for her to get by. She lost her balance and fell into the wall, hitting her R [right] cheek on the hand railing. She denies pain, unless the site is palpated, to which she states the pain is there but not bed [sic]. There were no other apparent injuries. The resident description documented, Resident states she lost her balance with all the other people around and ended up falling into the wall and hitting her R [right] cheek on the handrail. She reports being ok and denies pain. The immediate action taken was, Resident was assisted off the floor by two staff members, skin check and Neuro checks and vital sign checks were initiated per protocol. MD and family contact were called. Nurse and aides reminded the resident that she needs to use her walker at all times when ambulating and to avoid obstacles and people. She needs constant re-direction d/t [due to] dementia. Encouraged her to use her call light in her room. The physician was notified on 12/18/22 at 5:08 PM. On 12/18/22 at 5:14 PM, the progress note documented, CNA reported to the nurse that the resident was found in the hallway on the floor and leaning up against the wall because she had fallen. She reports the hallway was cluttered with other residents and there was not enough room for her to get by. She lost her balance and fell into the wall, hitting her R cheek on the hand railing. She denies pain, unless the site is palpated, to which she states the pain is there but not bed. There were no other apparent injuries. Interventions: Resident was assisted off the floor by two staff members, skin check and Neuro checks and vital sign checks were initiated per protocol. MD and family contact were called. Nurse and aides reminded the resident that she needs to use her walker at all times when ambulating and to avoid obstacles and people. She needs constant re-direction d/t dementia. Encouraged her to use her call light in her room. Resident Reaction to Interventions: Agrees, tolerates well. Needs reminders, cues, and re-direction frequently. Pain Management: Denies pain Improvement/Decline: Stable It should be noted that no documentation could be found that the neurological assessments forms were initiated and completed. It should be noted that no new interventions were identified on the care plan after the fall on 12/18/22. n. On 12/19/22 at 6:10 PM, the progress note documented, another cambridge resident got nurse's attention by screaming nurse. Nurse found pt sitting on bottom supported by resident who scr [TRUNCATED]

Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 20 of 80 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA) the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. On 4/4/23 at 3:00 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were investigated thoroughly. Notice of the IJ was given verbally and in writing to the Regional [NAME] President (RVP), Chief Nursing Officer (CNO) and Director of Nursing (DON) 1 and they were informed of the findings of IJ pertaining to F609 for residents 47, 51, 54, 68, 78, 79, and 86. On 4/18/23, the Chief Nursing Officer provided the following revised abatement plan for the removal of the Immediate Jeopardy effective on 4/18/2023 at 11:59 PM: F610: Abuse Investigation 1* It is the intent of the facility to ensure all alleged violations are thoroughly investigated. 2* Corrective Action Resident 68: A Facility Reported Incident was submitted by 4/7/2023 for incident on 3/30/2023. The 5-day investigation will be thoroughly completed within 5 Business Days. Resident 79 A Facility Reported Incident was submitted by 4/12/2023 for incident on 11/25/2022. The 5-day investigation will be thoroughly completed within 5 Business Days. A Facility Reported Incident was submitted by 4/12/2023for incident on 11/27/2022. The 5-day investigation will be thoroughly completed within 5 Business Days. A Facility Reported Incident was submitted by 4/12/2023for incident on 12/20/2022. The 5-day investigation will be thoroughly completed within 5 Business Days. A Facility Reported Incident was submitted by 4/12/2023 for incident on 12/23/2022. The 5-day investigation will be thoroughly completed within 5 Business Days. Resident 47 A Facility Reported Incident was submitted by 4/12/2023 for incident on 1/12/2022. The 5-day investigation will be thoroughly completed within 5 Business Days. Resident 78 A Facility Reported Incident was submitted by 4/12/2023for incident on 12/22/22. The 5-day investigation will be thoroughly completed within 5 Business Days. A Facility Reported Incident was submitted by 4/12/2023for incident on 3/23/23. The 5-day investigation will be thoroughly completed within 5 Business Days. A Facility Reported Incident was submitted by 4/12/2023for incident on 3/30/23. The 5-day investigation will be thoroughly completed within 5 Business Days. Resident 54 A Facility Reported Incident was submitted on 3/30/2023 for incident on 3/24/2023. The 5-day investigation will be thoroughly completed within 5 Business Days. Resident 51 A Facility Reported Incident was submitted by 4/12/2023 for incident on 3/22/23. The 5-day investigation will be thoroughly completed within 5 Business Days. A Facility Reported Incident was submitted by 4/12/2023 for incident on 3/23/23. The 5-day investigation will be thoroughly completed within 5 Business Days. Resident 86 A Facility Reported Incident was submitted for injury of unknown injury identified on 2/22/23 by 4/7/2023. The 5-day investigation will be thoroughly completed within 5 Business Days. 3* Identification of Others A facility wide audit will be completed by the Abuse Coordinator of investigations done since January 1, 2023 to be completed by 4/7/2023. Audit will look for investigations that did not include a thorough investigation, including thorough investigation of staff, medical records, resident cognition, and other factors. The facility will review the outcome of the investigation and examine if additional interventions are indicated. Starting on/after 4/13/2023, if a resident is involved as an aggressor more than one time, the facility will refer the resident to be reviewed by the Social Services Consultant (LCSW/LSW) for review of current interventions and preventative interventions. 4* Plan to prevent from recurring Training to be done by Regional [NAME] President with Abuse Coordinator on the elements of a thorough investigation. This investigation is to include statements from the perpetrator and victim, obtaining additional resident interview(s) that were not involved, and conducting staff interviews of all staff present. Training will also include on conducting interviews with residents who have cognitive deficits. Training to be done by Regional [NAME] President with Abuse Coordinator on how to use the investigation details to identify appropriate interventions to prevent recurrence. Education to be provided with Abuse Coordinator and Director of Nursing that if a perpetrator has a repeat abuse/neglect allegation, the perpetrator will be referred to the Social Services Consultant (LCSW/LSW) for review of current interventions and preventative interventions. 5* Ongoing Monitoring A focused audit of facility reported incidents will be completed by the Abuse Coordinator/Designee every weekly to ensure each incident is investigated timely. This audit shall be done three times a week x 8 weeks and then monthly until the QA committee determines a lesser frequency is indicated. 6* QAPI Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. On 4/19/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/18/23. Findings include: IMMEDIATE JEOPARDY 1. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, osteoarthritis, personal history of traumatic brain injury, hemiplegia, protein-calorie malnutrition, major depressive disorder, dysphagia, and neoplasm of skin. Resident 68's medical record was reviewed 3/28/23 through 4/25/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 68 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severely impaired cognition. Review of resident 68's progress notes, incident reports and facility reported incidents revealed resident 68 was the aggressor for multiple times as follows: a. On 1/20/23 at 2:45 PM a nursing progress note revealed resident to resident incident. No injuries observed. Residents separated. Both residents for safety. According to the incident report dated 1/20/23 at 4:49 PM, residents were slapping each other boxer style. Residents were placed on 15 minute checks for safety. The incident was not reported to the State Survey Agency (SSA). There was no abuse investigation. There was no information on who the other resident was or if injuries were sustained to the other resident. b. On 2/6/23 at 3:51 PM a nursing progress note revealed, Nurse saw pt punching other pt on left arm and chest and the pt who received the physical aggression retaliated and hit pt on the chest. Nurse stood between both patients and separated patients to assure their safety. Pt unable to give description and wastaken[sic] to room to talk with and examine. Nurse saw no injuries and pt did not c/o [complain of] pain, nurse reminded pt to ask for assistance to prevent this from occurring pt. Pt was still agitated. q [every] 15s [15 minute checks] initiated. provider notified. family notified abuse coordinator notified. The exhibit 358, initial report revealed that resident 68 punched resident 44. In the exhibit 359, resident 68 punched resident 83 on the left arm. There were 2 different resident names used in the abuse reporting versus the investigation. The facility completed an incident report for this altercation; however, only resident 68 was identified. c. On 2/13/23 at 7:28 PM a nursing progress note revealed, While in the dining room, during dinner, another resident attempted to take this residents food. This resident attempted to push the other resident away from his food. Staff intervened, stopped this resident from hitting the other resident, and stopped the other resident from taking any of this residents food. Separated these residents. Verified both residents were uninjured and safe. Assisted this resident in obtaining more food. An additional nursing progress note dated 2/13/23 at 7:46 PM revealed, While dinner was being served, this pt had food stolen from him from another pt. Pt attempted to grab food back from the pt who stole their food by pt who stole food began to call other resident names. Aides were unable to specify what names pt used. pt punched this pt who stole food on left shoulder. pt unable to give description. aides separated residents to assure their safety. no further altercations occurred. aides reported the altercation to nurse. nurse assessed pt for any injuries specifically in the [sic] left shoulder. no injuries noted. no c/o of [sic] pain. abuse coordinator notified. adon notified. attempted to call wife to notify of incident but did not answer .pt unable to give description. aides separated residentsto [sic] assure their safety. no further altercations occurred. aides reported the altercation to nurse no c/o pain The incident report dated 2/13/23 at 6:30 PM revealed the above nursing progress note and no additional information. The facility reported to the SAA on 2/13/2023 at 9:23 pm. The facility reported that the incident occurred on 02/13/2023 at 5:30 pm. d. On 3/10/23 at 3:55 PM a social service note revealed CNA reported to Housekeeping aide that [resident 58] was seen kissing and touching another residents vagina over her clothing. Housekeeping aide reported to House keeping manager. Housekeeping manager reported to resident advocate, who reported to administrator. Allegations occurred yesterday on 3/9/23 . The incident report dated 3/10/23 at 3:20 PM, was prepared by DON 1 revealed CNA reported to Housekeeping aide that [resident 68] was seen kissing and touching another residents vagina over her clothing. Housekeeping aid reported to House keeping manager. Housekeeping Manager reported to resident advocate, who reported to administrator. Allegations occurred yesterday on 3/9/23. Initial entity report being filed, ADON notifying family. both residents are being placed on 15 minute checks. D/C planner sending referrals to other memory care units. The facility reported the incident to the SAA on 3/10/23 at 4:04 PM. The facility reported the date and time of the incident were unknown. e. On 3/30/23, the facility submitted a form 358, Facility Reported Incident, to the State Survey Agency, regarding an incident in which resident 68 was observed by a facility nurse in resident 78's room. The facility nurse observed resident 68 touching resident 78 inappropriately. The incident occurred on 3/20/23. There is no nursing progress note or incident report regarding the incident. f. On 3/30/23 at 3:42 PM an Event/Alert Charting note revealed resident 68 was sexually inappropriate with an unidentified female resident. Resident 68 was touching the female resident's genitals. There has been no incident report or form 358 Facility Reported Incident, submitted regarding this incident as of 4/3/23. A nursing progress note dated 3/31/23 revealed that resident 68 was moved from the memory care unit to the North Rehabilitation Unit. For the above incidents, the facility's response was to separate the residents, conduct 15 minute checks, and to educate the resident. Note, resident 68 has a BIMS of 5 and had diagnoses that included Alzheimer's disease. On 3/30/23 at 12:58 PM, a facility department head provided the surveyors with a copy of a group text that started as concern from a CNA working on the Cambridge Unit to the CNA Coordinator, then forwarded to facility management. The message was forwarded to facility management on 3/29/23 at 6:12 PM. The text was, [Resident 68] in Cambridge has been into 20's [resident 78's] room, trying to touch her and now he's been trying to go into [resident 86]'s room. I feel like he needs to be one on one or we need to think of something because he's not gonna stop and I don't think it's fair for other residents having to go through that. On 3/31/23 at 9:30 PM, an observation was made of resident 68. Resident 68 was wheeling from the South Rehab hallway to the nurses station. Resident 68 stated Women here are grumpy and good looking. At that same time, resident 92 was observed talking to staff member (SM) 1. SM 1 was interviewed after her discussion with resident 92, and stated that resident 92 had told her that resident 68 attempted to enter her room to use the restroom. SM 1 stated that resident 92 told her that resident 68's genitals were exposed. SM 1 stated she did not need to report the incident for an abuse investigation because resident 68 did not stay in 92's room. SM 1 stated the residents were separated and resident 68 was on his way back to his room, so there was no concern. SM 1 stated there may be a process for reporting abuse, but she was unsure of what it was. On 3/31/23 at 9:33 PM, an interview was conducted with resident 92. Resident 92 stated resident 68 was in her room and that resident 68 had his penis out. Resident 92 stated that she told resident 68 to get out of her room. Resident 92 then stated she was on hospice and very ill, and wanted to get back to bed. An initial entity form exhibit 358 was sent to the state on 3/31/23. The form revealed that resident 68 used resident 92's bathroom and she was upset. However, this is in contradiction to interviews regarding what resident 92 reported to the nurse and the state surveyors. On 3/29/23 at 2:19 PM, an interview was conducted with DON 1. DON 1 stated the RA was in charge of abuse investigations and interviews. On 3/29/23 at 2:32 PM, an interview was conducted with the Resident Advocate (RA). The RA stated she started in April 2022 and became the designee for Social Services in June 2022. The RA stated she started abuse investigations in January 2023. The RA stated that she conducted the interviews regarding abuse. The RA stated she then completed a summary of the interviews and made sure residents were safe, comfortable and made sure of what happened. The RA stated she interview staff that had contact with the resident. The RA stated she did not save the actual notes. The RA stated she put the summary and the names of people interviewed on the 359 form. The RA stated if the allegation of abuse was on a certain hallway, she found out resident's who needed the same care and interviewed those residents for the investigation. The RA stated she put all the investigation information on the follow-up investigation form, exhibit 359, that was submitted to the State Survey Agency. On 3/30/23 at 4:10 PM, a follow-up interview was conducted with the RA. The RA stated that resident 68 admitted to the facility from another long term care facility. The RA stated he had behaviors towards females both sexually and physically, specifically toward resident 86 and resident 78. The RA stated the resident 68 seeked out resident 86 and 78 more than other residents. The RA stated after an incident was witnessed, interventions included 15 minute checks and actively seeking discharge to an all male facility. The RA stated there were staff members watching resident 68 closely to ensure he and other residents were safe until discharge. The RA stated resident 68 had been found touching residents on their breasts and vagina, over the clothing. The RA stated resident 68 was found in a room alone with other female residents. The RA stated that resident 68 and resident 78 had been found to be Special friends. The RA stated the residents hold hands in the main area and seek out private areas together. The RA stated that resident 78 was also going to resident 68 for contact. The RA stated that due to both residents decreased cognition, they were unable to consent. The RA stated that resident 86 was unable to consent. The RA stated that CNA's and nurses were aware of resident 68, resident 78 and resident 86's behaviors and staff were asked to keep a closer eye on them. The RA stated she was planning on having the facility contract LCSW complete a behavior contract with resident 68. The RA stated resident 68 did not have the capacity to work with a behavior contract. The RA stated if the resident was unable to have the capacity to understand a behavior contract, then she worked with the family on the behavior contract. The RA stated she was told to complete the behavior contracts with family members by the CNO. The RA stated she did not feel it was be appropriate to enter into a contract with the resident with cognitive issues or family member because they would not be able to commit to the contract. The RA stated she did not know if there were enough staff in the Cambridge unit to keep a closer eye on residents. The RA stated the facility had been working to get more activities in the Cambridge unit because there were only activities a couple days per week. The RA stated there was going to be a CNA and nurse to work on having more activities to keep the residents busy. The RA stated residents needed assistance with bathing, incontinent care and less acute care things like wounds. The RA stated the Administrator felt the CNA's and nurses had more time to complete activities since there were not wounds to be dressed in the Cambridge unit. The RA stated there needed to be more activities to keep the residents busy to avoid abuse. The RA stated that the residents with decreased cognition could have a decrease in abuse, because a lot of the abuse was from boredom. 2. Resident 79 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, major depressive disorder, anxiety, altered mental status, insomnia, personal history of traumatic brain injury, and history of thrombosis and embolism. Resident 79's medical record was reviewed from 3/28/23 through 4/25/23. Resident 79's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severely impaired cognition. Resident 79 required set up help with supervision required for locomotion on and off the unit. Review of resident 79's nursing progress notes, incident reports and facility reported incidents revealed the following: a. On 11/25/22 at 5:18 PM a nursing progress note revealed, resident 79 was yelling aggressively and threatening physical violence toward another resident. Resident required 30 minute redirection. The facility did not document an incident report and did not submit a form 358, Facility Reported Incident to the State Survey Agency. The other resident was not identified. b. On 11/27/22 at 5:18 PM a nursing progress note revealed, resident 79 reported that he was hit in his face by a peer. Resident 79 had a nail mark on the back of his right hand. Resident 79 verbally agreed to stay away from peer until a solution was made available. The facility did complete an incident report, but the other resident was not identified. There was no additional information on the incident report. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. c. On 12/12/22 at 7:16 PM a nursing progress note revealed, .Ptcan [sic] have mood swings and aggressive behavior. d. On 12/14/22 at 1:01 PM an MDS note revealed, .[resident 79] has a lot of behaviors that I talked to the nurse about in length. [Resident 79] has mood swings and can yell and be physically or verbally aggressive with residents or staff, and is a high elopement risk . e. On 12/19/22 at 6:49 PM a nursing progress note revealed, resident 79 pushed a peer and when asked why he pushed the other resident he shrugged. An incident report dated 12/19/22 at 1:15 PM revealed, immediate action taken was Nurse stated that pt can not initiate verbal or physical aggression toward others and needs to vocalize frustration to nurse. pt started yelling at nurse, 'I do not give shit you have done nothing.' Provider notified of mood swings. provider ordered one time dose of 1mg Haldol. 15 minute checks remain in place. The other resident was not identified. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. f. On 12/20/22 at 11:14 AM a nursing progress note revealed, Due to pt's increased behaviors nurse advocated for patient. Nurse stated that no pharmacological interventions are unsuccessful. Pt has aggressive repetitive vocals towards staff, elopement risk, and verbal assault towards peers, provider gave lexapro 10mg po daily new order. g. On 12/20/22 at 7:04 PM a nursing progress note revealed, Pt showed increase aggressiveness various mood swings leading to verbal aggression towards staff and peers. Pt called nurse 'bitch that doesn't do anything, fuck you and I hate you'. Nurse gave pt five minutes intervals and reapproached to redirect. Unable to redirect. asked administrator to speak with patient, patient initiated verbal aggression towards other resident. Patient said 'fuck you, I hate the people here.' Provider notified. Abuse coordinator notified q 15 minute checks continued. The other residents were not identified. There was no incident report. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. h. On 12/21/22 at 4:33 PM a nursing progress note revealed, resident 79 was verbally aggressive with staff and other residents. Resident 79 was on 15 minute checks to ensure residents interactions with others were calm and safe. The other residents were not identified. There was no incident report. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. i. On 12/23/22 at 5:50 AM an Event/Alert Charting note revealed, resident 79 was aggressive toward another resident and hit another resident. The facility completed an incident report on 12/23/22 at 1:22 AM revealed, Resident was observed hitting another resident in the arm. Resident also yelled 'fuck you' at the other resident while attempting to hit again. Aide stated that the resident also shoved the other resident while walking past. The immediate action taken was two residents were separated into different rooms and resident placed on 15-minute safety checks. The other two residents were not identified. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. j. On 1/7/23 at 4:06 PM an incident report revealed that resident 79 and another resident were arguing, and then began hitting each other. Staff are not aware as to who was the aggressor. The immediate action taken was separated residents and assisted away from each other. The other resident was not identified. There was no nurses note. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. k. On 1/8/23 at 1:04 AM an Event/Alert Charting note revealed, resident 79 aggressive outburst during the day shift with another resident. There was a female resident bothering resident 79 and he pushed her to the common area and told her not for you. The interventions were to maintain daily routine, keep resident away from residents that cause him to be frustrated. There was no incident report completed. The other resident was not identified. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. l. On 1/10/23 at 4:30 PM a nursing progress note revealed, Admissions staff pulled nurse into dining room who then found resident supine grabbing onto another resident's arm and was covered in blood. Pt refused to give details and stated reasoning 'I do not want to be reported' Nurse separated both patients. Nurse assisted patient into chair whose gait was unsteady. Pt had no c/o of [sic] pain. Nurse gained assistance from ADON [Assistant Director of Nursing] who then took over care for patient. EMS [emergency medical services] called to assess patient. PT did not go to hospital per ems assessment. Police notified. Administration notified. Family notified. Provider notified. due to no internal injuries and pt at baseline neuros not started. nurse consulted with adon. no injuries noted. An incident report dated 1/10/23 at 2:38 PM revealed the same information as the nursing progress note. Resident 47 received stitches to the back of his head. The facility submitted a form 358, Facility Reported Incident to the State Survey Agency revealed resident 79 was found bloody in the dining room. Resident 79 pushed resident 47 to the floor, hitting his head on the floor. Resident 47 sustained a 1 1/2 inch laceration to the back of his head. The interventions were the facility was looking at transferring one of the two residents to a different facility with memory care. The exhibit 358 did not have a time the incident occurred. It was reported to the SAA on 1/10/23 at 5:08 PM. m. On 1/20/23, the facility submitted a form 358, Facility Reported Incident to the State Survey Agency revealed that resident 79 was found touching resident 78's breasts. The residents were separated and placed on 15 minute checks. Request for psychotropic medication evaluation. Family, Physician, Ombudsman and Abuse Coordinator were notified. There was no incident report or nursing note regarding the incident. n. On 1/20/23, the facility submitted a form 358 which revealed a nurse reported that resident 409 was drawn to resident 79. The resident's were seen walking down the hall together smiling and resident 79 requested a shower. The nurse reported When showering [resident 409] she noticed that she had a foul smelling vaginal odor not associated with urine. The discharge planner was working on getting one of the resident's transferred to another facility. There was no nursing progress note or incident report. o. On 2/5/23 at 1:29 PM a nursing progress note revealed, Resident returning from lunch in DR. [dining room] walking down the hall. Another resident walked up to him and started hitting him. The other resident continued hitting, until nurse could get there, and separate the residents. This resident held the other residents' arm to prevent being hit further. Other resident sustained a skin tear to right forearm. Notified MD. This resident has no injuries. An incident report dated 2/5/23 at 1:22 PM revealed the same information as the nursing progress note. There was a resident description of This lady just started yelling at me about how she doesn't want to be here, and started hitting me. The facility submitted a form 358, which revealed resident 86 started hitting resident 79. Resident 79 grabbed resident 86's arm to keep her from hitting him. Resident 86 sustained a laceration on her arm where resident 79 grabbed her. The residents were separated and redirected. Resident 79 have been given as needed Lorazepam for agitation. The facility reported to the SAA on 2/6/23 at 10:43 am and the incident happened on 2/5/23 at 1:17 pm. 3. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia with behavioral and mood disturbances, unspecified mood disorder, and diabetes mellitus. On 1/7/23, an incident report indicated that resident 47 and another unidentified resident were arguing and then hit each other. This incident was not reported to the State Agency or investigated as an abuse allegation. 4. Resident 78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia with other behavioral disturbance, unspecified psychosis, hallucinations, cognitive communication deficit, and major depressive disorder. Review of resident 78's medical record indicated that since 12/22/22, resident 78 has been the victim of sexual and physical abuse that was unreported and uninvestigated as follows: On 12/22/22, resident 78 was slapped several times on her left arm by another resident. The facility completed an incident report, but the other resident was not identified. The facility did not submit a form 358 Facility Reported Incident. On 3/23/23, resident 78 had her hair pulled by an unidentified resident. This allegation was not reported to the State Survey Agency or investigated. On 3/30/23, resident 78 had sexual contact received initiated male resident. The perpetrator was unidentified. This allegation was not reported to the State Survey Agency or investigated. An interview with CNA 2 was held on 3/31/23 at 10:00 PM. CNA 2 stated resident 68 had touched resident 78 on her pelvic area, under her clothing on 3/30/23. 5. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. Review of resident 51's incident reports and facility abuse investigations revealed the following: a. On 9/27/22 at 6:15 PM, the facility reported to the State Survey Agency (SSA) an altercation between resident 51 and resident 409. The facility reported that on 9/27/22 at 4:45 PM, resident 409 was passing by resident 51 in the hallway when resident 51 called resident 409 a bitch and stupid. Resident 409 clinched and raised her fist and resident 409 struck resident 51 first. The residents exchanged one or two punches each before a Nurse was able to separate the two. Both residents were assessed for injuries and none were noted. The residents were separated and 15-minute checks were implemented. No documentation could be found that demonstrated that Adult Protective Services (APS) or local law enforcement were notified of the incident. The facility did not submit a final abuse investigation summary to the SSA. b. On 10/4/22 at 6:34 PM, the facility reported to the SSA an altercation between resident 51 and resident 460 The facility reported that on 10/4/22 at 4:30 PM, resident 51 was angry and was swearing at resident 460 and pushed a wheelchair at resident 460 that hit her foot. The Residents were separated and redirected with no further incidents. Resident 460 was assessed for injuries and nothing was noted. The facility investigation report documented that resident 51 was agitated because resident 460 was in her spot. Resident 51 used profanity and vulgarities and then pushed her wheelchair into resident 460. The report documented that the residents were educated and separated. The facility investigation documented that local law enforcement was not notified. No documentation could be found that demonstrated that APS was notified of the incident. c. On 10/4/22 at 9:38 PM, the facility reported to the SSA an altercation between resident 51 and resident 73. The facility reported that on 10/4/22 at 7:30 PM, the Residents became irritated of each other and began to verbally assault each other which lead [sic] to the Residents hitting each other on the head. The Residents were separated and assessed for injuries. The facility investigation documentation stated that resident 51 and resident 73 were i [TRUNCATED]

Based on record review and interview it was determined for 20 of 80 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79 and 86. Resident identifiers: 14, 32, 37, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 86, 87, 92, 359, 409, 459 and 460. NOTICE On 4/4/23 at 3:00 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Notice of the IJ was given verbally and in writing to the Regional [NAME] President (RVP), Chief Nursing Officer (CNO) and Director of Nursing (DON) 1 and they were informed of the findings of IJ pertaining to F609 for residents 47, 51, 54, 68, 78, 79, and 86. On 4/18/23, the Chief Nursing Officer provided the following revised abatement plan for the removal of the Immediate Jeopardy effective on 4/18/2023 at 11:59 PM: F609: Abuse Reporting 1* It is the intent of the facility to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported within the timeframes required by the law. 2* Corrective Action Resident 68: The incident on 3/30/2023 was reported to the State Agency by Administrator/Designee by 4/12/2023 and investigation is in progress. Resident 79 The incident on 11/25/2022 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. The incident on 11/27/2022 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. The incident on 12/20/2022 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. The incident on 12/23/2022 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. Resident 47 The incident on 1/7/2022 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. Resident 78 The incident on 12/22/22 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. The incident on 3/23/23 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. The incident on 3/30/23 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. Resident 54 A Facility Reported Incident was submitted on 3/30/2023 for incident on 3/24/2023 (Late). An intervention was identified and care planned by 4/13/2023. Resident 51 Social Services Director was interviewed on 4/11/2023 by Chief Nursing Officer about the incident on 3/22/23. The progress note was not referring to a new abuse incident but was a follow up from the one that happened on 3/15/2023. The incident on 3/23/23 was reported to the State Agency by Administrator/Designee by 4/13/2023 and investigation is in progress. Resident 86 A Facility Reported Incident was submitted by 4/13/23 by the Administrator for the injury of unknown injury identified on 2/22/23. 3* Identification of Others A facility record audit of residents in the facility will be completed by Director of Nursing/Designee by 4/13/2023 to identify residents who have experienced abuse or neglect in the facility since January 1, 2023. The Abuse Coordinator/Designee will report any allegations of abuse per Standard of Practice. 4* Plan to prevent from recurring Facility Abuse Coordinator to identify multiple individuals to assist with Reporting Allegations of Abuse/Neglect. These individuals will be trained by Abuse Coordinator/Designee by 4/13/2023 on how to submit entity reports and on the regulatory requirements on reporting abuse. In response to surveyor concern about urgency & abatement focus, On 4/17/2023 the facility initiated Check-In's with each unit every two hours around the clock to identify any new Abuse Allegations, New Injuries, Negative Resident Interactions, and any grey area situations that need clarification. Anything newly identified is escalated to the appropriate person for follow up. Education to be completed by Abuse Coordinator/Designee about Regulatory Reporting Requirements to facility staff by 4/13/2023. This training will be done with all available staff working 4/13/2023, and then staff who were unable to attend will be provided the training prior to working their next scheduled shift. Training to include: * If allegation is made after hours, staff must call the Abuse Coordinator, not send a text message. * Upon recognition of an abuse allegation, the first responder must identify an intervention to keep the resident safe and help to prevent recurrence. This will be shared with the abuse coordinator to be included in the initial report. * All facility staff are considered mandatory reporters, the facility leadership is willing to assist with the reporting, but each team member is responsible for ensuring abuse is prevented and reported. 5* Ongoing Monitoring A focused audit of facility reported incidents will be completed by the Abuse Coordinator/Designee three times a week to ensure each incident is reported timely. This shall be done three times a week x 8 weeks and then monthly until the QA committee determines a lesser frequency is indicated. 6* QAPI Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. On 4/19/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/18/23. Findings include: IMMEDIATE JEOPARDY 1. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, osteoarthritis, personal history of traumatic brain injury, hemiplegia, protein-calorie malnutrition, major depressive disorder, dysphagia, and neoplasm of skin. Resident 68's medical record was reviewed 3/28/23 through 4/25/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 68 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severely impaired cognition. Review of resident 68's progress notes, incident reports and facility reported incidents revealed resident 68 was the aggressor for multiple times as follows: a. On 1/20/23 at 2:45 PM a nursing progress note revealed resident to resident incident. No injuries observed. Residents separated. Both residents for safety. According to the incident report dated 1/20/23 at 4:49 PM, residents were slapping each other boxer style. Residents were placed on 15 minute checks for safety. The incident was not reported to the State Survey Agency (SSA). There was no abuse investigation. There was no information on who the other resident was or if injuries were sustained to the other resident. b. On 2/6/23 at 3:51 PM a nursing progress note revealed, Nurse saw pt punching other pt on left arm and chest and the pt who received the physical aggression retaliated and hit pt on the chest. Nurse stood between both patients and separated patients to assure their safety. Pt unable to give description and wastaken[sic] to room to talk with and examine. Nurse saw no injuries and pt did not c/o [complain of] pain, nurse reminded pt to ask for assistance to prevent this from occurring pt. Pt was still agitated. q [every] 15s [15 minute checks] initiated. provider notified. family notified abuse coordinator notified. The exhibit 358, initial report revealed that resident 68 punched resident 44. In the exhibit 359, resident 68 punched resident 83 on the left arm. There were 2 different resident names used in the abuse reporting versus the investigation. The facility completed an incident report for this altercation; however, only resident 68 was identified. c. On 2/13/23 at 7:28 PM a nursing progress note revealed, While in the dining room, during dinner, another resident attempted to take this residents food. This resident attempted to push the other resident away from his food. Staff intervened, stopped this resident from hitting the other resident, and stopped the other resident from taking any of this residents food. Separated these residents. Verified both residents were uninjured and safe. Assisted this resident in obtaining more food. An additional nursing progress note dated 2/13/23 at 7:46 PM revealed, While dinner was being served, this pt had food stolen from him from another pt. Pt attempted to grab food back from the pt who stole their food by pt who stole food began to call other resident names. Aides were unable to specify what names pt used. pt punched this pt who stole food on left shoulder. pt unable to give description. aides separated residents to assure their safety. no further altercations occurred. aides reported the altercation to nurse. nurse assessed pt for any injuries specifically in the [sic] left shoulder. no injuries noted. no c/o of [sic] pain. abuse coordinator notified. adon notified. attempted to call wife to notify of incident but did not answer .pt unable to give description. aides separated residentsto [sic] assure their safety. no further altercations occurred. aides reported the altercation to nurse no c/o pain The incident report dated 2/13/23 at 6:30 PM revealed the above nursing progress note and no additional information. The facility reported to the SAA on 2/13/2023 at 9:23 pm. The facility reported that the incident occurred on 02/13/2023 at 5:30 pm. d. On 3/10/23 at 3:55 PM a social service note revealed CNA reported to Housekeeping aide that [resident 58] was seen kissing and touching another residents vagina over her clothing. Housekeeping aide reported to House keeping manager. Housekeeping manager reported to resident advocate, who reported to administrator. Allegations occurred yesterday on 3/9/23 . The incident report dated 3/10/23 at 3:20 PM, was prepared by DON 1 revealed CNA reported to Housekeeping aide that [resident 68] was seen kissing and touching another residents vagina over her clothing. Housekeeping aid reported to House keeping manager. Housekeeping Manager reported to resident advocate, who reported to administrator. Allegations occurred yesterday on 3/9/23. Initial entity report being filed, ADON notifying family. both residents are being placed on 15 minute checks. D/C planner sending referrals to other memory care units. The facility reported the incident to the SAA on 3/10/23 at 4:04 PM. The facility reported the date and time of the incident were unknown. e. On 3/30/23, the facility submitted a form 358, Facility Reported Incident, to the State Survey Agency, regarding an incident in which resident 68 was observed by a facility nurse in resident 78's room. The facility nurse observed resident 68 touching resident 78 inappropriately. The incident occurred on 3/20/23. There is no nursing progress note or incident report regarding the incident. f. On 3/30/23 at 3:42 PM an Event/Alert Charting note revealed resident 68 was sexually inappropriate with an unidentified female resident. Resident 68 was touching the female resident's genitals. There has been no incident report or form 358 Facility Reported Incident, submitted regarding this incident as of 4/3/23. A nursing progress note dated 3/31/23 revealed that resident 68 was moved from the memory care unit to the North Rehabilitation Unit. For the above incidents, the facility's response was to separate the residents, conduct 15 minute checks, and to educate the resident. Note, resident 68 has a BIMS of 5 and had diagnoses that included Alzheimer's disease. On 3/30/23 at 12:58 PM, a facility department head provided the surveyors with a copy of a group text that started as concern from a CNA working on the Cambridge Unit to the CNA Coordinator, then forwarded to facility management. The message was forwarded to facility management on 3/29/23 at 6:12 PM. The text was, [Resident 68] in Cambridge has been into 20's [resident 78's] room, trying to touch her and now he's been trying to go into [resident 86]'s room. I feel like he needs to be one on one or we need to think of something because he's not gonna stop and I don't think it's fair for other residents having to go through that. On 3/31/23 at 9:30 PM, an observation was made of resident 68. Resident 68 was wheeling from the South Rehab hallway to the nurses station. Resident 68 stated Women here are grumpy and good looking. At that same time, resident 92 was observed talking to staff member (SM) 1. SM 1 was interviewed after her discussion with resident 92, and stated that resident 92 had told her that resident 68 attempted to enter her room to use the restroom. SM 1 stated that resident 92 told her that resident 68's genitals were exposed. SM 1 stated she did not need to report the incident for an abuse investigation because resident 68 did not stay in 92's room. SM 1 stated the residents were separated and resident 68 was on his way back to his room, so there was no concern. SM 1 stated there may be a process for reporting abuse, but she was unsure of what it was. On 3/31/23 at 9:33 PM, an interview was conducted with resident 92. Resident 92 stated resident 68 was in her room and that resident 68 had his penis out. Resident 92 stated that she told resident 68 to get out of her room. Resident 92 then stated she was on hospice and very ill, and wanted to get back to bed. An initial entity form exhibit 358 was sent to the state on 3/31/23. The form revealed that resident 68 used resident 92's bathroom and she was upset. However, this is in contradiction to interviews regarding what resident 92 reported to the nurse and the state surveyors. On 3/29/23 at 2:19 PM, an interview was conducted with DON 1. DON 1 stated the RA was in charge of abuse investigations and interviews. On 3/29/23 at 2:32 PM, an interview was conducted with the Resident Advocate (RA). The RA stated she started in April 2022 and became the designee for Social Services in June 2022. The RA stated she started abuse investigations in January 2023. The RA stated that she conducted the interviews regarding abuse. The RA stated she then completed a summary of the interviews and made sure residents were safe, comfortable and made sure of what happened. The RA stated she interview staff that had contact with the resident. The RA stated she did not save the actual notes. The RA stated she put the summary and the names of people interviewed on the 359 form. The RA stated if the allegation of abuse was on a certain hallway, she found out resident's who needed the same care and interviewed those residents for the investigation. The RA stated she put all the investigation information on the follow-up investigation form, exhibit 359, that was submitted to the State Survey Agency. On 3/30/23 at 4:10 PM, a follow-up interview was conducted with the RA. The RA stated that resident 68 admitted to the facility from another long term care facility. The RA stated he had behaviors towards females both sexually and physically, specifically toward resident 86 and resident 78. The RA stated the resident 68 seeked out resident 86 and 78 more than other residents. The RA stated after an incident was witnessed, interventions included 15 minute checks and actively seeking discharge to an all male facility. The RA stated there were staff members watching resident 68 closely to ensure he and other residents were safe until discharge. The RA stated resident 68 had been found touching residents on their breasts and vagina, over the clothing. The RA stated resident 68 was found in a room alone with other female residents. The RA stated that resident 68 and resident 78 had been found to be Special friends. The RA stated the residents hold hands in the main area and seek out private areas together. The RA stated that resident 78 was also going to resident 68 for contact. The RA stated that due to both residents decreased cognition, they were unable to consent. The RA stated that resident 86 was unable to consent. The RA stated that CNA's and nurses were aware of resident 68, resident 78 and resident 86's behaviors and staff were asked to keep a closer eye on them. The RA stated she was planning on having the facility contract LCSW complete a behavior contract with resident 68. The RA stated resident 68 did not have the capacity to work with a behavior contract. The RA stated if the resident was unable to have the capacity to understand a behavior contract, then she worked with the family on the behavior contract. The RA stated she was told to complete the behavior contracts with family members by the CNO. The RA stated she did not feel it was be appropriate to enter into a contract with the resident with cognitive issues or family member because they would not be able to commit to the contract. The RA stated she did not know if there were enough staff in the Cambridge unit to keep a closer eye on residents. The RA stated the facility had been working to get more activities in the Cambridge unit because there were only activities a couple days per week. The RA stated there was going to be a CNA and nurse to work on having more activities to keep the residents busy. The RA stated residents needed assistance with bathing, incontinent care and less acute care things like wounds. The RA stated the Administrator felt the CNA's and nurses had more time to complete activities since there were not wounds to be dressed in the Cambridge unit. The RA stated there needed to be more activities to keep the residents busy to avoid abuse. The RA stated that the residents with decreased cognition could have a decrease in abuse, because a lot of the abuse was from boredom. 2. Resident 79 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, major depressive disorder, anxiety, altered mental status, insomnia, personal history of traumatic brain injury, and history of thrombosis and embolism. Resident 79's medical record was reviewed from 3/28/23 through 4/25/23. Resident 79's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severely impaired cognition. Resident 79 required set up help with supervision required for locomotion on and off the unit. Review of resident 79's nursing progress notes, incident reports and facility reported incidents revealed the following: a. On 11/25/22 at 5:18 PM a nursing progress note revealed, resident 79 was yelling aggressively and threatening physical violence toward another resident. Resident required 30 minute redirection. The facility did not document an incident report and did not submit a form 358, Facility Reported Incident to the State Survey Agency. The other resident was not identified. b. On 11/27/22 at 5:18 PM a nursing progress note revealed, resident 79 reported that he was hit in his face by a peer. Resident 79 had a nail mark on the back of his right hand. Resident 79 verbally agreed to stay away from peer until a solution was made available. The facility did complete an incident report, but the other resident was not identified. There was no additional information on the incident report. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. c. On 12/12/22 at 7:16 PM a nursing progress note revealed, .Ptcan [sic] have mood swings and aggressive behavior. d. On 12/14/22 at 1:01 PM an MDS note revealed, .[resident 79] has a lot of behaviors that I talked to the nurse about in length. [Resident 79] has mood swings and can yell and be physically or verbally aggressive with residents or staff, and is a high elopement risk . e. On 12/19/22 at 6:49 PM a nursing progress note revealed, resident 79 pushed a peer and when asked why he pushed the other resident he shrugged. An incident report dated 12/19/22 at 1:15 PM revealed, immediate action taken was Nurse stated that pt can not initiate verbal or physical aggression toward others and needs to vocalize frustration to nurse. pt started yelling at nurse, 'I do not give shit you have done nothing.' Provider notified of mood swings. provider ordered one time dose of 1mg Haldol. 15 minute checks remain in place. The other resident was not identified. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. f. On 12/20/22 at 11:14 AM a nursing progress note revealed, Due to pt's increased behaviors nurse advocated for patient. Nurse stated that no pharmacological interventions are unsuccessful. Pt has aggressive repetitive vocals towards staff, elopement risk, and verbal assault towards peers, provider gave lexapro 10mg po daily new order. g. On 12/20/22 at 7:04 PM a nursing progress note revealed, Pt showed increase aggressiveness various mood swings leading to verbal aggression towards staff and peers. Pt called nurse 'bitch that doesn't do anything, fuck you and I hate you'. Nurse gave pt five minutes intervals and reapproached to redirect. Unable to redirect. asked administrator to speak with patient, patient initiated verbal aggression towards other resident. Patient said 'fuck you, I hate the people here.' Provider notified. Abuse coordinator notified q 15 minute checks continued. The other residents were not identified. There was no incident report. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. h. On 12/21/22 at 4:33 PM a nursing progress note revealed, resident 79 was verbally aggressive with staff and other residents. Resident 79 was on 15 minute checks to ensure residents interactions with others were calm and safe. The other residents were not identified. There was no incident report. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. i. On 12/23/22 at 5:50 AM an Event/Alert Charting note revealed, resident 79 was aggressive toward another resident and hit another resident. The facility completed an incident report on 12/23/22 at 1:22 AM revealed, Resident was observed hitting another resident in the arm. Resident also yelled 'fuck you' at the other resident while attempting to hit again. Aide stated that the resident also shoved the other resident while walking past. The immediate action taken was two residents were separated into different rooms and resident placed on 15-minute safety checks. The other two residents were not identified. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. j. On 1/7/23 at 4:06 PM an incident report revealed that resident 79 and another resident were arguing, and then began hitting each other. Staff are not aware as to who was the aggressor. The immediate action taken was separated residents and assisted away from each other. The other resident was not identified. There was no nurses note. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. k. On 1/8/23 at 1:04 AM an Event/Alert Charting note revealed, resident 79 aggressive outburst during the day shift with another resident. There was a female resident bothering resident 79 and he pushed her to the common area and told her not for you. The interventions were to maintain daily routine, keep resident away from residents that cause him to be frustrated. There was no incident report completed. The other resident was not identified. The facility did not submit a form 358, Facility Reported Incident to the State Survey Agency. l. On 1/10/23 at 4:30 PM a nursing progress note revealed, Admissions staff pulled nurse into dining room who then found resident supine grabbing onto another resident's arm and was covered in blood. Pt refused to give details and stated reasoning 'I do not want to be reported' Nurse separated both patients. Nurse assisted patient into chair whose gait was unsteady. Pt had no c/o of [sic] pain. Nurse gained assistance from ADON [Assistant Director of Nursing] who then took over care for patient. EMS [emergency medical services] called to assess patient. PT did not go to hospital per ems assessment. Police notified. Administration notified. Family notified. Provider notified. due to no internal injuries and pt at baseline neuros not started. nurse consulted with adon. no injuries noted. An incident report dated 1/10/23 at 2:38 PM revealed the same information as the nursing progress note. Resident 47 received stitches to the back of his head. The facility submitted a form 358, Facility Reported Incident to the State Survey Agency revealed resident 79 was found bloody in the dining room. Resident 79 pushed resident 47 to the floor, hitting his head on the floor. Resident 47 sustained a 1 1/2 inch laceration to the back of his head. The interventions were the facility was looking at transferring one of the two residents to a different facility with memory care. The exhibit 358 did not have a time the incident occurred. It was reported to the SAA on 1/10/23 at 5:08 PM. m. On 1/20/23, the facility submitted a form 358, Facility Reported Incident to the State Survey Agency revealed that resident 79 was found touching resident 78's breasts. The residents were separated and placed on 15 minute checks. Request for psychotropic medication evaluation. Family, Physician, Ombudsman and Abuse Coordinator were notified. There was no incident report or nursing note regarding the incident. n. On 1/20/23, the facility submitted a form 358 which revealed a nurse reported that resident 409 was drawn to resident 79. The resident's were seen walking down the hall together smiling and resident 79 requested a shower. The nurse reported When showering [resident 409] she noticed that she had a foul smelling vaginal odor not associated with urine. The discharge planner was working on getting one of the resident's transferred to another facility. There was no nursing progress note or incident report. o. On 2/5/23 at 1:29 PM a nursing progress note revealed, Resident returning from lunch in DR. [dining room] walking down the hall. Another resident walked up to him and started hitting him. The other resident continued hitting, until nurse could get there, and separate the residents. This resident held the other residents' arm to prevent being hit further. Other resident sustained a skin tear to right forearm. Notified MD. This resident has no injuries. An incident report dated 2/5/23 at 1:22 PM revealed the same information as the nursing progress note. There was a resident description of This lady just started yelling at me about how she doesn't want to be here, and started hitting me. The facility submitted a form 358, which revealed resident 86 started hitting resident 79. Resident 79 grabbed resident 86's arm to keep her from hitting him. Resident 86 sustained a laceration on her arm where resident 79 grabbed her. The residents were separated and redirected. Resident 79 have been given as needed Lorazepam for agitation. The facility reported to the SAA on 2/6/23 at 10:43 am and the incident happened on 2/5/23 at 1:17 pm. 3. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia with behavioral and mood disturbances, unspecified mood disorder, and diabetes mellitus. On 1/7/23, an incident report indicated that resident 47 and another unidentified resident were arguing and then hit each other. This incident was not reported to the State Agency or investigated as an abuse allegation. 4. Resident 78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia with other behavioral disturbance, unspecified psychosis, hallucinations, cognitive communication deficit, and major depressive disorder. Review of resident 78's medical record indicated that since 12/22/22, resident 78 has been the victim of sexual and physical abuse that was unreported and uninvestigated as follows: On 12/22/22, resident 78 was slapped several times on her left arm by another resident. The facility completed an incident report, but the other resident was not identified. The facility did not submit a form 358 Facility Reported Incident. On 3/23/23, resident 78 had her hair pulled by an unidentified resident. This allegation was not reported to the State Survey Agency or investigated. On 3/30/23, resident 78 had sexual contact received initiated male resident. The perpetrator was unidentified. This allegation was not reported to the State Survey Agency or investigated. An interview with CNA 2 was held on 3/31/23 at 10:00 PM. CNA 2 stated resident 68 had touched resident 78 on her pelvic area, under her clothing on 3/30/23. 38031 5. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. Review of resident 51's incident reports and facility abuse investigations revealed the following: a. On 9/27/22 at 6:15 PM, the facility reported to the State Survey Agency (SSA) an altercation between resident 51 and resident 409. The facility reported that on 9/27/22 at 4:45 PM, resident 409 was passing by resident 51 in the hallway when resident 51 called resident 409 a bitch and stupid. Resident 409 clinched and raised her fist and resident 409 struck resident 51 first. The residents exchanged one or two punches each before a Nurse was able to separate the two. Both residents were assessed for injuries and none were noted. The residents were separated and 15-minute checks were implemented. No documentation could be found that demonstrated that Adult Protective Services (APS) or local law enforcement were notified of the incident. The facility did not submit a final abuse investigation summary to the SSA. b. On 10/4/22 at 6:34 PM, the facility reported to the SSA an altercation between resident 51 and resident 460 The facility reported that on 10/4/22 at 4:30 PM, resident 51 was angry and was swearing at resident 460 and pushed a wheelchair at resident 460 that hit her foot. The Residents were separated and redirected with no further incidents. Resident 460 was assessed for injuries and nothing was noted. The facility investigation report documented that resident 51 was agitated because resident 460 was in her spot. Resident 51 used profanity and vulgarities and then pushed her wheelchair into resident 460. The report documented that the residents were educated and separated. The facility investigation documented that local law enforcement was not notified. No documentation could be found that demonstrated that APS was notified of the incident. c. On 10/4/22 at 9:38 PM, the facility reported to the SSA an altercation between resident 51 and resident 73. The facility reported that on 10/4/22

Based on observation, interview and record review it was determined for 24 out of 80 sample residents, that the facility failed to protect residents from abuse, neglect and misappropriation of property. Specifically, residents were repeatedly physically, verbally and sexually abused without ongoing interventions to prevent further abuse. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. NOTICE On 4/4/23 at 3:00 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that residents were free from abuse and neglect. Specifically, residents were victims of abuse by the same perpetrator on multiple occasions, and interventions to prevent further abuse were not implemented. Notice of the IJ was given verbally and in writing to the Regional [NAME] President (RVP), Chief Nursing Officer (CNO) and Director of Nursing (DON) 1 and they were informed of the findings of IJ pertaining to F600 for residents 47, 51, 54, 68, 78, 79, and 86. On 4/18/23, the Chief Nursing Officer provided the following revised abatement plan for the removal of the Immediate Jeopardy effective on 4/18/2023 at 11:59 PM: F600: Free from Abuse & Neglect 1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. 2* Corrective Action Resident 68 Was assessed by LSW (Licensed Social Worker on 4/5/23 to ensure interventions were in place to prevent abusive interactions and to ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. Medication Evaluation was completed by physician and Care Plan was updated. The incident on 1/20/2023 was reported to State Agency by Administrator/Designee and investigation is in progress. A progress note was documented for the incident that occurred on 3/20/2023. The incident on 3/30/2023 was reported to State Agency by Administrator/Designee and investigation is in progress and documentation was entered into the medical record. The incident on 3/31/2023 was reported to State Agency by Administrator/Designee and investigation is in progress. Resident was placed on a 1:1 until he is determined not to be a danger to other residents by the Interdisciplinary Team (IDT). Resident 78 Was assessed by LSW on 4/5/2023 to ensure that interventions were in place to prevent abusive interactions and ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. Room evaluation was completed on April 7, 2023 to decrease overstimulation. Plan of Care was updated. The incident on 12/22/2022 was reported to the State Agency by Administrator/Designee and investigation is in progress. The incident on 3/30/2023 was reported to the State Agency by Administrator/Designee and investigation is in progress. Resident 79 Was assessed by LSW on 4/5/2023 to ensure that interventions were in place to prevent abusive interactions and ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. The Physician completed a Medication Evaluation on April 7, 2023 and Care Plan was updated. Room evaluation was completed on April 7, 2023 to decrease overstimulation. The incident on 11/25/2022 was reported to the State Agency by Administrator/Designee and investigation is in progress. The incident on 11/27/2022 was reported to the State Agency by Administrator/Designee and investigation is in progress. The incident on 12/23/2022 was reported to the State Agency by Administrator/Designee and investigation is in progress. Resident 86 Was assessed by LSW on 4/5/2023 to ensure that interventions were in place to prevent abusive interactions and ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. Medications were reviewed by MD on April 7, 2023, Orders were entered, and Care Plan was updated. Room evaluation was completed on April 7, 2023 to decrease overstimulation. The incident on 2/22/22 was submitted to the State Agency by Administrator/Designee and investigation was initiated to determine the cause of the resident's forehead bruise and right knee sore. Resident 51 Was assessed by LSW on 4/5/2023 to ensure that interventions were in place to prevent abusive interactions and ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. Room evaluation was completed on April 7, 2023 to decrease overstimulation and care plan has been updated. Social Services Director was interviewed on 4/11/2023 by Chief Nursing Officer about the incident on 3/22/23. The progress note was not referring to a new abuse incident but was a follow up from the one that happened on 3/15/2023. Resident 54 Was assessed by LSW on 4/5/2023 to ensure that interventions were in place to prevent abusive interactions and ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. Medications were reviewed by MD on April 7, 2023, Orders were entered, and Care Plan was updated. The incident on 12/6/2022 was reviewed by Administrator/Designee and plan of care was updated with interventions the facility can do to ensure other residents safety. The incident on 3/24/2023 was reviewed by Administrator/Designee and the final investigation was completed and sent to the State Agency. The incident on 3/28/2023 and was reviewed by Administrator/Designee and resident 54 was provided Soda and a supply was ordered so he would not be needing to seek it from other residents. This was care planned. The incident on 3/29/2023 was reviewed by Administrator/Designee. The resident was moved to a room across the facility that was not adjacent to other females. Care plan was updated to minimize the risk of recurrent wandering into others room. Resident 47 Was assessed by LSW on 4/5/2023 to ensure that interventions were in place to prevent abusive interactions and ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. Medications were reviewed by MD on April 7, 2023, Orders were entered, and Care Plan was updated. The incident on 1/7/2023 was reported to the State Agency by Administrator/Designee and the investigation is in progress Resident 34 Was assessed by LSW on 4/5/2023 to ensure that interventions were in place to ensure there were no unaddressed psychological or behavioral conditions. The LSW also reviewed the investigations identified by the survey team to ensure interventions were appropriate to prevent recurrence. Resident to be rounded on weekly by social services to ensure her psychological needs have been met. 3* Identification of Others An assessment to be completed by 4/12/2023 of all facility residents by a LCSW/LSW, and a Registered Nurse. Assessment will observe for S/Sx (signs and symptoms) of Abuse and for Behavioral or Psychosocial Disturbances that are not currently being treated. The Abuse Coordinator/Designee will report any allegations of abuse to the State Survey Agency, Law Enforcement, and APS (Adult Protective Services) by 4/12/2023 The facility will assess all residents for change of condition by 4/12/2023. This will be completed by a Registered Nurse. Any change of condition identified will be addressed per standard of practice, including MD notification, Care Plan Updates, and Staff Education. A facility record audit of residents in the facility will be completed by Director of Nursing/Designee by 4/12/2023 to identify residents who have experienced abuse or neglect in the facility since January 1, 2023. The Abuse Coordinator/Designee will report any allegations of abuse to the State Survey Agency, Law Enforcement, and APS by 4/12/2023. 4* Plan to prevent from recurring Intervention for Known Aggressors: Social Services (LSW) to evaluate the identified aggressor residents (Resident 68, 79, 86, 54, 47. 51) and their plan of cares to ensure interventions are tailored to their diagnosis and behaviors. The Director of Nursing/Designee updated each resident's plan of care by 4/12/2023 with those new interventions/recommendations. Identification of New Aggressors: As a new practice, all Allegations of Abuse/Neglect will be placed on an updated Log that identifies the Perpetrator, Victim, Unit, and Time of Day. Residents with repeat Aggressive incidents to other residents will be referred to the Social Services Consultant (LCSW/LSW) for review of current interventions and preventative interventions. Abuse/Neglect Log to be brought to QAPI (Quality Assurance and Performance Improvement) committee monthly and reviewed to identify trends on Unit. Facility staffing review to be completed by Administrator & (and) Director of Nursing/Designee to review staffing and supervision on the locked unit. In response to surveyor concern about urgency & (and) abatement focus, On 4/17/2023 the facility initiated Check-In's with each unit every two hours around the clock to identify any new Abuse Allegations, New Injuries, Negative Resident Interactions, and any grey (sic) area situations that need clarification. Anything newly identified is escalated to the appropriate person for follow up. Training Plan * Initial Trainings: Facility Social Services to Initiate De-escalation Training by 4/12/2023 training from training materials provided by Social Services Consultant (LCSW). This training will be done with all available staff working 4/13/2023, and then staff who were unable to attend will be provided the training prior to working their next scheduled shift. The Director of Nursing/Designee to create an Agency Binder to provide key interventions to be in place for Behavior de-escalation. This tool will be created by 4/13/2023. *External Expert Trainer scheduled to provide training on Wednesday 4/12/2023 on Trauma care, PTSD (Post-Traumatic Stress Disorder), and De-Escalation with staff involved with resident cares. 5* Ongoing Monitoring Facility abuse environmental rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care, and that staff are interacting well with residents. This rounding will be done with each shift until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done three times weekly to ensure interventions are in place and staff are interacting appropriately with residents. In addition, random facility audit rounds will be done twice a week on weekends and/or night shift. 5 total facility rounds will be completed per week. These Audit to be done weekly x 8 weeks and then monthly until reviewed by the QA Committee to determine frequency of future audits. Abuse prohibition knowledge rounds to be completed daily by Abuse Coordinator/Designee throughout the facility on each shift until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done three times weekly to ensure interventions are in place and staff are interacting appropriately with residents. In addition, random facility audit rounds will be done twice a week on weekends and/or night shift. Audit to be done weekly x 8 weeks and then monthly until the QA Committee determines a lesser frequency is indicated. 6* QAPI Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. On 4/19/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/18/23. Findings include: IMMEDIATE JEOPARDY 1. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, osteoarthritis, personal history of traumatic brain injury, hemiplegia, protein-calorie malnutrition, major depressive disorder, dysphagia, and neoplasm of skin. Resident 68's medical record was reviewed 3/28/23 through 4/25/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 68 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severely impaired cognition. Resident 68's care plans revealed resident 68 was at risk for potential abuse related to decreased cognition, and psychological conditions. The goal was that resident 68 would not have unaddressed signs and symptoms of abuse. The interventions were to follow abuse protocol if allegations were made, medication review and observe for symptoms. Another care plan revealed resident 68 was verbally/physically aggressive; had made inappropriate sexual remarks to female staff member related to dementia, and poor impulse control. On 1/20/23, 2/6/23, 2/11/23, 2/13/23 there were altercations with another patient. The interventions developed were that resident 68 would demonstrate effective coping skills through the review date; will verbalize understanding of needing to control verbally abusive behavior; assess resident's coping skills and support system; monitor behaviors; and analyze key times, places, circumstances, triggers, and what de-escalated behavior and document. An admission nursing screening assessment dated [DATE] and locked on 12/23/22 revealed resident 68 was admitted with a diagnosis of Alzheimer's disease. Resident 68 was admitted to the secured unit for safety. Resident 68 verbalized/demonstrated the use of call bell and bed controls. Resident 68 was alert to person and situation. In addition, resident 68 had made verbal sexual content comments to caregivers. The St [NAME] University Mental Status (SLUMS) exam dated 11/1/22 revealed resident 68 had dementia with a score of 3 out of 30. A Pre-Admission Screening/ Resident Review (PASRR) dated 10/12/22 revealed a history of Traumatic Brain Injury, the level 1 screen indicated referral for level II evaluation for serious mental illness was not needed. Review of resident 68's progress notes, incident reports and facility reported incidents revealed resident 68 was the aggressor for multiple incidents as follows: a. On 1/20/23 at 2:45 PM a nursing progress note revealed resident to resident incident. No injuries observed. Residents separated. According to the incident report dated 1/20/23 at 4:49 PM, residents were slapping each other boxer style. Residents were placed on 15 minute checks for safety. The incident was not reported to the State Survey Agency (SSA). There was no abuse investigation. There was no information on who the other resident was or if injuries were sustained to the other resident. b. On 2/6/23 at 3:51 PM a nursing progress note revealed, Nurse saw pt (patient) punching other pt on left arm and chest and the pt who received the physical aggression retaliated and hit pt on the chest. Nurse stood between both patients and separated patients to assure their safety. Pt unable to give description and wastaken[sic] to room to talk with and examine. Nurse saw no injuries and pt did not c/o [complain of] pain, nurse reminded pt to ask for assistance to prevent this from occurring pt. Pt was still agitated. q [every] 15s [15 minute checks] initiated. provider notified. family notified abuse coordinator notified. The exhibit 358, initial report revealed that resident 68 punched resident 44. In the exhibit 359, resident 68 punched resident 83 on the left arm. There were 2 different resident names used in the abuse reporting versus the investigation. The facility completed an incident report for this altercation; however, only resident 68 was identified. c. On 2/11/23 at 2:58 PM a nursing progress note revealed, Nurse saw pt punching other pt on the chest and begain [sic] slapping patient in the hallway. Pt's unable to give description but yelled 'asshole' and flipped off patient. Nurse saw pt's altercation and stood in between pt'swhile [sic] aide assisted nurse by separating pt's. As soon as pt's safety was assured nurse asked pt if they have any pain. No c/o [complaints of] of pain. Nurse assessed skin for any injuries. no injuries noted. provider notified. Abuse coordinator notified. Family notified. q15 [every 15] minute checks initiated. After speaking with patient pt was understanding the actions were inappropriate and therapeutic communication was effective. An incident report dated 2/11/23 at 10:45 AM, did not have additional information from the nursing progress note. The facility reported to the SSA on 2/11/13 at 2:39 pm. The facility reported that the incident happened on 2/11/23 at 10:45 AM, according to the exhibit 358. d. On 2/13/23 at 3:44 PM a nursing progress note revealed, It was reported that the nurse working came out of a residents room and found this resident touching another resident above her clothing in her groin area. nurse immediately separated residents. Verified both residents were safe and unharmed. Educated this resident on inappropriate touch, and that he can not do that. both residents were confused as to what the nurse was talking about. Called and notified [family member] of incident. Thanked for notification. Both residents placed on 15 minute checks. Management is aware. An incident reported dated 2/13/23 at 2:20 PM, revealed the above nurses note and no additional information. There was no information regarding the who the resident that was touched was. e. On 2/13/23 at 7:28 PM a nursing progress note revealed, While in the dining room, during dinner, another resident attempted to take this residents food. This resident attempted to push the other resident away from his food. Staff intervened, stopped this resident from hitting the other resident, and stopped the other resident from taking any of this residents food. Separated these residents. Verified both residents were uninjured and safe. Assisted this resident in obtaining more food. An additional nursing progress note dated 2/13/23 at 7:46 PM revealed, While dinner was being served, this pt had food stolen from him from another pt. Pt attempted to grab food back from the pt who stole their food by pt who stole food began to call other resident names. Aides were unable to specify what names pt used. pt punched this pt who stole food on left shoulder. pt unable to give description. aides separated residents to assure their safety. no further altercations occurred. aides reported the altercation to nurse. nurse assessed pt for any injuries specifically in the [sic] left shoulder. no injuries noted. no c/o of [sic] pain. abuse coordinator notified. adon (Assistant Director of Nursing) notified. attempted to call wife to notify of incident but did not answer .pt unable to give description. aides separated residentsto [sic] assure their safety. no further altercations occurred. aides reported the altercation to nurse no c/o pain The incident report dated 2/13/23 at 6:30 PM revealed the above nursing progress note and no additional information. The facility reported to the SAA on 2/13/2023 at 9:23 pm. The facility reported that the incident occurred on 02/13/2023 at 5:30 pm. f. On 3/10/23 at 3:55 PM a social service note revealed CNA (Certified Nursing Assistant) reported to Housekeeping aide that [resident 68] was seen kissing and touching another residents vagina over her clothing. Housekeeping aide reported to House keeping manager. Housekeeping manager reported to resident advocate, who reported to administrator. Allegations occurred yesterday on 3/9/23 . The incident report dated 3/10/23 at 3:20 PM, was prepared by DON 1 revealed CNA reported to Housekeeping aide that [resident 68] was seen kissing and touching another residents vagina over her clothing. Housekeeping aid reported to House keeping manager. Housekeeping Manager reported to resident advocate, who reported to administrator. Allegations occurred yesterday on 3/9/23. Initial entity report being filed, ADON notifying family. both residents are being placed on 15 minute checks. D/C (discharge) planner sending referrals to other memory care units. The facility reported the incident to the SAA on 3/10/23 at 4:04 PM. The facility reported the date and time of the incident were unknown. g. On 3/30/23, the facility submitted a form 358, Facility Reported Incident, to the State Survey Agency, regarding an incident in which resident 68 was observed by a facility nurse in resident 78's room. The facility nurse observed resident 68 touching resident 78 inappropriately. The incident occurred on 3/20/23. There is no nursing progress note or incident report regarding the incident. h. On 3/30/23 at 3:42 PM an Event/Alert Charting note revealed resident 68 was sexually inappropriate with an unidentified female resident. Resident 68 was touching the female resident's genitals. There has been no incident report or form 358 Facility Reported Incident, submitted regarding this incident as of 4/3/23. A nursing progress note dated 3/31/23 revealed that resident 68 was moved from the memory care unit to the North Rehabilitation Unit. For the above incidents, the facility's response was to separate the residents, conduct 15 minute checks, and to educate the resident. Note, resident 68 has a BIMS of 5 and had diagnoses that included Alzheimer's disease. On 3/30/23 at 12:58 PM, a facility department head provided the surveyors with a copy of a group text that started as concern from a CNA working on the Cambridge Unit to the CNA Coordinator, then forwarded to facility management. The message was forwarded to facility management on 3/29/23 at 6:12 PM. The text was, [Resident 68] in Cambridge has been into 20's [resident 78's] room, trying to touch her and now he's been trying to go into [resident 86]'s room. I feel like he needs to be one on one or we need to think of something because he's not gonna stop and I don't think it's fair for other residents having to go through that. On 3/31/23 at 9:30 PM, an observation was made of resident 68. Resident 68 was wheeling from the South Rehab hallway to the nurses station. Resident 68 stated Women here are grumpy and good looking. At that same time, resident 92 was observed talking to staff member (SM) 1. SM 1 was interviewed after her discussion with resident 92, and stated that resident 92 had told her that resident 68 attempted to enter her room to use the restroom. SM 1 stated that resident 92 told her that resident 68's genitals were exposed. SM 1 stated she did not need to report the incident for an abuse investigation because resident 68 did not stay in 92's room. SM 1 stated the residents were separated and resident 68 was on his way back to his room, so there was no concern. SM 1 stated there may be a process for reporting abuse, but she was unsure of what it was. On 3/31/23 at 9:30 PM, an interview was conducted with resident 92 in the hallway outside of her room. Resident 92 stated that resident 68 was inside her room. Resident 92 stated that at the time she was in bed and was attempting to get up to use the bathroom and resident 68 had his penis out. Resident 92 stated she told resident 68 to get out of her room and that resident 68 knew where his room was located. Resident 92 stated that she was really sick, was on hospice and she needed to get back into bed. Resident 92 stated that she only got up to get resident 68 to leave her room. Resident 92 stated that she informed SM 1 of the incident with resident 68. An initial entity form exhibit 358 was sent to the state on 3/31/23. The form revealed that resident 68 used resident 92's bathroom and she was upset. However, this is in contradiction to interviews regarding what resident 92 reported to the nurse and the state surveyors. On 3/29/23 at 2:19 PM, an interview was conducted with DON 1. DON 1 stated the Resident Advocate (RA) was in charge of abuse investigations and interviews. On 3/29/23 at 2:32 PM, an interview was conducted with the RA. The RA stated she started in April 2022 and became the designee for Social Services in June 2022. The RA stated she started completing abuse investigations in January 2023. The RA stated that she conducted the interviews regarding abuse. The RA stated she then completed a summary of the interviews and made sure residents were safe, comfortable and made sure of what happened. The RA stated she interviewed staff that had contact with the resident. The RA stated she did not save the actual notes. The RA stated she put the summary and the names of people interviewed on the 359 form. The RA stated if the allegation of abuse was on a certain hallway, she found out residents who needed the same care and interviewed those residents for the investigation. The RA stated she put all the investigation information on the follow-up investigation form, exhibit 359, that was submitted to the State Survey Agency. On 3/30/23 at 4:10 PM, a follow-up interview was conducted with the RA. The RA stated that resident 68 admitted to the facility from another long term care facility. The RA stated he had behaviors towards females both sexually and physically, specifically toward resident 86 and resident 78. The RA stated the resident 68 seeked out resident 86 and 78 more than other residents. The RA stated after an incident was witnessed, interventions included 15 minute checks and actively seeking discharge to an all male facility. The RA stated there were staff members watching resident 68 closely to ensure he and other residents were safe until discharge. The RA stated resident 68 had been found touching residents on their breasts and vagina, over the clothing. The RA stated resident 68 was found in a room alone with other female residents. The RA stated that resident 68 and resident 78 had been found to be Special friends. The RA stated the residents would hold hands in the main area and seek out private areas together. The RA stated that resident 78 was also going to resident 68 for contact. The RA stated that due to both residents' decreased cognition, they were unable to consent. The RA stated that resident 86 was unable to consent. The RA stated that CNA's and nurses were aware of resident 68, resident 78 and resident 86's behaviors and staff were asked to keep a closer eye on them. The RA stated she was planning on having the facility contract Licensed Clinical Social Worker (LCSW) complete a behavior contract with resident 68. The RA stated resident 68 did not have the capacity to work with a behavior contract. The RA stated if the resident was unable to have the capacity to understand a behavior contract, then she worked with the family on the behavior contract. The RA stated she was told to complete the behavior contracts with family members by the CNO. The RA stated she did not feel it would be appropriate to enter into a contract with the resident with cognitive issues or family member because they would not be able to commit to the contract. The RA stated she did not know if there were enough staff in the Cambridge unit to keep a closer eye on residents. The RA stated the facility had been working to get more activities in the Cambridge unit because there were only activities a couple of days per week. The RA stated there was going to be a CNA and nurse to work on having more activities to keep the residents busy. The RA stated residents needed assistance with bathing, incontinent care and less acute care things like wounds. The RA stated the Administrator felt the CNA's and nurses had more time to complete activities since there were not wounds to be dressed in the Cambridge unit. The RA stated there needed to be more activities to keep the residents busy to avoid abuse. The RA stated that the residents with decreased cognition could have a decrease in abuse, because a lot of the abuse was from boredom. On 3/31/23, an interview was conducted with SM 12. SM 12 stated there were no residents in the Cambridge unit on 15 minute check or with 1 on 1 supervision. SM 12 stated the previous shift had passed on that resident 68 was moved to the rehab side. SM 12 stated resident 68 was transferred because of inappropriately touching resident 78. On 3/31/23, an interview was conducted with SM 13. SM 13 stated she was checking on resident 68 to make sure he was in his room. SM 13 stated that SM 12 had told her to check on resident 68 but did not tell her why. On 3/31/23, an interview was conducted with SM 14. SM 14 stated resident 68 was sexually aggressive with staff and had touched a therapy staff member's breasts. SM 14 stated resident 68 needed to be monitored and she was not supposed to leave him alone with a female resident because he would touch female residents too. On 3/31/23, an interview was conducted with SM 15. SM 15 stated there were not any residents on 15 minute checks in the rehab hallway where she was working. SM 15 stated resident 68 should be on 15 minute checks because He's wild. SM 15 stated resident 68 was Very sexually inappropriate. SM 15 stated resident 68 got physical with resident resident 78 in the Cambridge unit. SM 15 stated resident 68 put his hands down her pants. SM 15 stated resident 68 had previously said to the SM, can I grab your tits, want to see my dick. SM 15 stated resident 68 was transferred to the Rehab unit on 3/31/23. SM 15 stated there had not been an interactions with other female residents on the Rehab unit yet, but give it time. On 4/3/23 at 8:53 AM, Director of Nursing (DON) 1 stated there were no abuse allegations with resident 68 from 3/30/23 until 4/3/23. 10560 2. Resident 79 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, major depressive disorder, anxiety, altered mental status, insomnia, personal history of traumatic brain injury, and history of thrombosis and embolism. Resident 79's medical record was reviewed from 3/28/23 through 4/25/23. Resident 79's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severely impaired cognition. Resident 79 required set up help with supervision required for locomotion on and off the unit. A care plan revealed that resident 79 was verbally and physically abusive at times. The care plan revealed that there were abuse altercations on 10/13/22, 10/23/22, 10/26/22, 11/9/22, 11/27/22, 1/2/23, 1/10/23, 1/20/23, and 2/6/23. Interventions were resident would express self without becoming aggressive or abusive; seek out staff when he was feeling angry and overwhelmed; 15 minute checks initiated; resident was sent to the hospital; looking for facility to transfer to; moved to room in another hallway; monitor for signs and symptoms of anxiety and intervene if appropriate; if resident becomes upset, redirect resident to a quiet place away from others so resident can calm down, if resident rejects care plan, make sure resident was safe, then re approach later; redirect resident away from any resident who upset resident; follow abuse protocol if allegations were made; observe for symptoms; and social services visits as needed. A Social Service Note dated 9/26/22

Based on interview, observation and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. Findings include: 1. Based on observation, interview and record review it was determined, for 1 of 80 sampled residents, that the facility did not treat each resident with respect and dignity. This included the right to retain and use personal possessions. Specifically, a resident's phone and electric wheelchair were taken away. The deficient practice identified was cited at a harm level. Resident identifier: 32. [Cross refer to F557] 2. Based on observation, interview and record review it was determined for 24 out of 80 sample residents, that the facility failed to protect residents from abuse, neglect and misappropriation of property. Specifically, residents were repeatedly physically, verbally and sexually abused without ongoing interventions to prevent further abuse. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. [Cross refer to F600] 3. Based on observation, interview and record review it was determined for, 1 of 80 sampled residents, that the facility did not ensure each resident had the right to be free from abuse, neglect, misappropriate of resident property, and exploitation. This includes but was not limited to freedom from involuntary seclusion. Specifically, a resident was not assessed to determine if a locked unit was appropriate. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32. [Cross refer to F603] 4. Based on interview and record review the facility did not develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegations; Include training as required; and Establish coordination with the QAPI program. Specifically, multiple residents were repeatedly abused physically, sexually and verbally, without interventions to protect the residents, appropriate reporting, or thorough investigations. These instances were determined to have occurred at an Immediate Jeopardy level for F600, F609, and F610. [Cross refer to F607] 5. Based on record review and interview it was determined for 20 of 80 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79 and 86. Resident identifiers: 14, 32, 37, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 86, 87, 92, 359, 409, 459 and 460. [Cross refer to F609] 6. Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 20 of 80 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA) the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. [Cross refer to F610] 7. Based on interview and record review it was determined, for 7 out of 80 sampled residents, that the facility did not permit each resident to remain in the facility and not transfer or discharge the resident unless the resident's welfare and needs could not be met in the facility; or the safety of individuals in the facility was endangered due to the behavioral status of the resident. Additionally, when a facility transfers or discharges a resident under any circumstances the facility must ensure that the resident's medical record and information was communicated to the receiving health care provider. Specifically, the facility initiated a resident discharge/transfer after they suspected a resident of having a sexual relationship with another resident. There was no documentation of the facility's attempts to meet the resident's needs; the resident's Power of Attorney (POA) was not notified of the transfer; and the family representative reported that the resident was not happy in the new facility and the change in environment had caused the resident to have increasing behaviors associated with her dementia. The deficient practice identified occurred at a HARM Level. The facility initiated a resident discharge/transfer for the other resident identified in the sexual relationship and there was no documentation of the facility's attempts to meet the resident's needs, the POA was not given notice nor were the transfer options discussed with the POA. Additionally, multiple residents were transferred or discharged and no documentation was found in the medical records that demonstrated what information was communicated to the receiving provider. Resident identifiers: 2, 67, 76, 79, 86, 96 and 409. [Cross refer to F622] 8. Based on observation, interview and record review it was determined, for 4 of 80 sampled residents, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community was not provided. Specifically, there were not enough activities in the secured unit and residents with minimal cognitive impairment were unable to attend activities outside of the secured unit. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32, 79, 81 and 86. [Cross refer to F679] 9. Based on observation, interview, and record review it was determined, for 6 of 80 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident did not receive appropriate wound care or ileostomy care after a surgery, a resident with an amputated left foot was not receiving wound care, a resident with a GI (gastrointestinal) bleed was not treated timely, a resident who sustained injuries from a fall was not properly examined or followed up on, and a resident who had cellulitis did not receive proper care. These examples will be cited at a harm level. Resident identifiers: 7, 49, 86, 96, 209, and 357. [Cross refer to F684] 10. Based on observation, interview and record review it was determined, for 11 out of 80 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident experienced 19 falls that resulted in an injury 14 times with multiple head injuries that required medical attention; a resident experienced 5 falls within 48 hours that resulted in bruising, pain, and a hip fracture; a resident experienced 17 falls that resulted in multiple fractures; a resident experienced 9 falls with head injuries that required medical attention; and a resident experienced 27 falls that resulted in lacerations that required medical attention. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, a resident eloped from the facility multiple times and sustained lacerations requiring sutures. This identified deficient practice was found to have occurred at a Harm Level. Lastly, a resident experienced repeated falls without interventions identified to prevent the falls, a resident sustained a fall after a faulty door hinge fell on top of their head, a resident residing in the dementia unit obtained a razor and cut his head, a resident sustained an injury to their foot after an improper transfer by the administrator (ADM), and hot water temperatures were measured at levels above 100 degrees Fahrenheit. Resident identifiers: 1, 11, 35, 47, 51, 73, 79, 98, 209, 258, and 357. [Cross refer to F689] 11. Based on interview and record review, it was determined that the facility did not ensure, for 1 of 80 sample residents, maintained acceptable parameters of nutritional status. Specifically, a resident with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level. Resident Identifiers: 42. [Cross refer to F692] 12. Based on observation, interview, and record review it was determined, for 2 of 80 sampled residents, that the facility did not ensure pain management was provided to resident who required such services. Specifically, a resident who requested pain medications prior to a wound care treatment was not given pain medications until after the treatment was completed, and a resident on hospice was given his pain medications late and an order for pain medications was not entered into his chart for three days. These examples will be cited at a harm level. Resident identifiers: 7 and 84. [Cross refer to F697] 13. Based on observation, interview and record review it was determined, for 21 of 80 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. These findings resulted in immediate jeopardy (IJ). In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 1, 4, 7, 35, 47, 51, 54, 68, 73, 76, 77, 78, 79, 84, 85, 86, 96, 98, 209, and 357. [Cross refer to F725] 14. Based on interview and record review it was revealed that, for 1 of 80 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skills set 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. Specifically, a nurse categorized and performed wound care on a skin fold and the anus that she mistook the areas as tunneling wounds. Resident identifier: 7. [Cross refer to F726] 14. Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 80 sampled residents, a resident's vancomycin level was not monitored appropriately resulting in vancomycin toxicity. This was cited at a harm level for resident 208. Additionally, a resident's blood sugars were not monitored according to the physician's orders. Resident identifiers: 208 and 257. [Cross refer to F757] 15. Based on observations, record review, and interviews it was determined that for 7 of 80 sampled residents the facility did not ensure that its residents are free of any significant medication errors. Specifically, the facility continued to administer vancomycin without verifying trough serum levels, administering the wrong dose of insulin, and breaking open an extended-release tablet. The findings for residents 86 and 208 were determined to have occurred at harm level. Resident identifiers: 43, 50, 79, 86, 92, 208, and 457. [Cross refer to F760] 16. Based on interview and record review it was revealed that, for 6 of 80 sampled residents, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, the facility did not obtain laboratory services in a timely manner. The deficient practice for resident 208 was found to have occurred at a harm level. Resident identifiers: 7, 35, 38, 51, 79, and 208. [Cross refer to F770] 17. Based on observation, interview, and record review, the facility did not have a governing body that was legally responsible for establish and implementing policies regarding the management and operation of the facility; and did not appoint an administrator who was accountable to the governing body. Specifically, multiple instances of noncompliance were identified and determined to have occurred at an Immediate Jeopardy or harm level. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. [Cross refer to F837] 18. Based on interview, observation and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not develop and implement policies addressing how they will use a systematic approach to determine underlying causes of problems impacting larger systems; how they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and how the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Specifically multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. In addition, multiple deficiencies from recertification and complaint surveys had not been corrected. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. [Cross refer to F867]

Based on interview and record review the facility did not develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegations; Include training as required; and Establish coordination with the QAPI program. Specifically, multiple residents were repeatedly abused physically, sexually and verbally, without interventions to protect the residents, appropriate reporting, or thorough investigations. These instances were determined to have occurred at an Immediate Jeopardy level for F600, F609, and F610. Findings include: The facility was determined to be in non-compliance at an Immediate Jeopardy level with F600, F609, and F610. The facility's Abuse policy was reviewed and included the following: . The Administrator will ensure that the residents in this facility will remain free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of resident property. This will be demonstrated by providing screening of potential employees and residents, early intervention of alleged abuse, as well as identification of perpetrators and potential victims. The Administrator will also ensure that education and training are offered to the staff at this facility upon hire, annually and as needed to prevent incidents of abuse. The Administrator and Director of Nursing will be responsible for ensuring adequate staffing levels and adequately trained staff to promote a safe living environment.The facility will offer training to all staff in ways to identify potential signs and symptoms of abuse at least twice a year. Any person who suspects that abuse, neglect, or the misappropriation of property may have occurred must immediately report the alleged violation to their immediate supervisor or the Administrator of the facility, State Survey Agencies and Law Enforcement. If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual (owner, operator, employee, manager, agent or contractor), shall report the suspicion immediately, to State Survey Agencies and Law Enforcement, but no later than 2 hours after forming the suspicion. [Cross refer to F600, F609, F610, F943, and F947] 38031 45470

Based on observation, interview, and record review, the facility did not have a governing body that was legally responsible for establish and implementing policies regarding the management and operation of the facility; and did not appoint an administrator who was accountable to the governing body. Specifically, multiple instances of noncompliance were identified and determined to have occurred at an Immediate Jeopardy or harm level. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. Findings include: 1. Based on observation, interview and record review it was determined, for 1 of 80 sampled residents, that the facility did not treat each resident with respect and dignity. This included the right to retain and use personal possessions. Specifically, a resident's phone and electric wheelchair were taken away. The deficient practice identified was cited at a harm level. Resident identifier: 32. [Cross refer to F557] 2. Based on observation, interview and record review it was determined for 24 out of 80 sample residents, that the facility failed to protect residents from abuse, neglect and misappropriation of property. Specifically, residents were repeatedly physically, verbally and sexually abused without ongoing interventions to prevent further abuse. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. [Cross refer to F600] 3. Based on observation, interview and record review it was determined for, 1 of 80 sampled residents, that the facility did not ensure each resident had the right to be free from abuse, neglect, misappropriate of resident property, and exploitation. This includes but was not limited to freedom from involuntary seclusion. Specifically, a resident was not assessed to determine if a locked unit was appropriate. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32. [Cross refer to F603] 4. Based on interview and record review the facility did not develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegations; Include training as required; and Establish coordination with the QAPI program. Specifically, multiple residents were repeatedly abused physically, sexually and verbally, without interventions to protect the residents, appropriate reporting, or thorough investigations. These instances were determined to have occurred at an Immediate Jeopardy level for F600, F609, and F610. [Cross refer to F607] 5. Based on record review and interview it was determined for 20 of 80 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79 and 86. Resident identifiers: 14, 32, 37, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 86, 87, 92, 359, 409, 459 and 460. [Cross refer to F609] 6. Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 20 of 80 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA) the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. [Cross refer to F610] 7. Based on interview and record review it was determined, for 7 out of 80 sampled residents, that the facility did not permit each resident to remain in the facility and not transfer or discharge the resident unless the resident's welfare and needs could not be met in the facility; or the safety of individuals in the facility was endangered due to the behavioral status of the resident. Additionally, when a facility transfers or discharges a resident under any circumstances the facility must ensure that the resident's medical record and information was communicated to the receiving health care provider. Specifically, the facility initiated a resident discharge/transfer after they suspected a resident of having a sexual relationship with another resident. There was no documentation of the facility's attempts to meet the resident's needs; the resident's Power of Attorney (POA) was not notified of the transfer; and the family representative reported that the resident was not happy in the new facility and the change in environment had caused the resident to have increasing behaviors associated with her dementia. The deficient practice identified occurred at a HARM Level. The facility initiated a resident discharge/transfer for the other resident identified in the sexual relationship and there was no documentation of the facility's attempts to meet the resident's needs, the POA was not given notice nor were the transfer options discussed with the POA. Additionally, multiple residents were transferred or discharged and no documentation was found in the medical records that demonstrated what information was communicated to the receiving provider. Resident identifiers: 2, 67, 76, 79, 86, 96 and 409. [Cross refer to F622] 8. Based on observation, interview and record review it was determined, for 4 of 80 sampled residents, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community was not provided. Specifically, there were not enough activities in the secured unit and residents with minimal cognitive impairment were unable to attend activities outside of the secured unit. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32, 79, 81 and 86. [Cross refer to F679] 9. Based on observation, interview, and record review it was determined, for 6 of 80 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident did not receive appropriate wound care or ileostomy care after a surgery, a resident with an amputated left foot was not receiving wound care, a resident with a GI (gastrointestinal) bleed was not treated timely, a resident who sustained injuries from a fall was not properly examined or followed up on, and a resident who had cellulitis did not receive proper care. These examples will be cited at a harm level. Resident identifiers: 7, 49, 86, 96, 209, and 357. [Cross refer to F684] 10. Based on observation, interview and record review it was determined, for 11 out of 80 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident experienced 19 falls that resulted in an injury 14 times with multiple head injuries that required medical attention; a resident experienced 5 falls within 48 hours that resulted in bruising, pain, and a hip fracture; a resident experienced 17 falls that resulted in multiple fractures; a resident experienced 9 falls with head injuries that required medical attention; and a resident experienced 27 falls that resulted in lacerations that required medical attention. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, a resident eloped from the facility multiple times and sustained lacerations requiring sutures. This identified deficient practice was found to have occurred at a Harm Level. Lastly, a resident experienced repeated falls without interventions identified to prevent the falls, a resident sustained a fall after a faulty door hinge fell on top of their head, a resident residing in the dementia unit obtained a razor and cut his head, a resident sustained an injury to their foot after an improper transfer by the administrator (ADM), and hot water temperatures were measured at levels above 100 degrees Fahrenheit. Resident identifiers: 1, 11, 35, 47, 51, 73, 79, 98, 209, 258, and 357. [Cross refer to F689] 11. Based on interview and record review, it was determined that the facility did not ensure, for 1 of 80 sample residents, maintained acceptable parameters of nutritional status. Specifically, a resident with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level. Resident Identifiers: 42. [Cross refer to F692] 12. Based on observation, interview, and record review it was determined, for 2 of 80 sampled residents, that the facility did not ensure pain management was provided to resident who required such services. Specifically, a resident who requested pain medications prior to a wound care treatment was not given pain medications until after the treatment was completed, and a resident on hospice was given his pain medications late and an order for pain medications was not entered into his chart for three days. These examples will be cited at a harm level. Resident identifiers: 7 and 84. [Cross refer to F697] 13. Based on observation, interview and record review it was determined, for 21 of 80 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. These findings resulted in immediate jeopardy (IJ). In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 1, 4, 7, 35, 47, 51, 54, 68, 73, 76, 77, 78, 79, 84, 85, 86, 96, 98, 209, and 357. [Cross refer to F725] 14. Based on interview and record review it was revealed that, for 1 of 80 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skills set 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. Specifically, a nurse categorized and performed wound care on a skin fold and the anus that she mistook the areas as tunneling wounds. Resident identifier: 7. [Cross refer to F726] 14. Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 80 sampled residents, a resident's vancomycin level was not monitored appropriately resulting in vancomycin toxicity. This was cited at a harm level for resident 208. Additionally, a resident's blood sugars were not monitored according to the physician's orders. Resident identifiers: 208 and 257. [Cross refer to F757] 15. Based on observations, record review, and interviews it was determined that for 7 of 80 sampled residents the facility did not ensure that its residents are free of any significant medication errors. Specifically, the facility continued to administer vancomycin without verifying trough serum levels, administering the wrong dose of insulin, and breaking open an extended-release tablet. The findings for residents 86 and 208 were determined to have occurred at harm level. Resident identifiers: 43, 50, 79, 86, 92, 208, and 457. [Cross refer to F760] 16. Based on interview and record review it was revealed that, for 6 of 80 sampled residents, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, the facility did not obtain laboratory services in a timely manner. The deficient practice for resident 208 was found to have occurred at a harm level. Resident identifiers: 7, 35, 38, 51, 79, and 208. [Cross refer to F770] 17. Based on interview, observation and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not develop and implement policies addressing how they will use a systematic approach to determine underlying causes of problems impacting larger systems; how they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and how the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Specifically multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. In addition, multiple deficiencies from recertification and complaint surveys had not been corrected. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. [Cross refer to F867] 18. Based on interview, observation and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. [Cross refer to F835]

Based on interview, observation and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not develop and implement policies addressing how they will use a systematic approach to determine underlying causes of problems impacting larger systems; how they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and how the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Specifically multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. In addition, multiple deficiencies from recertification and complaint surveys had not been corrected. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. Findings include: 1. Based on observation, interview and record review it was determined, for 1 of 80 sampled residents, that the facility did not treat each resident with respect and dignity. This included the right to retain and use personal possessions. Specifically, a resident's phone and electric wheelchair were taken away. The deficient practice identified was cited at a harm level. Resident identifier: 32. [Cross refer to F557] 2. Based on observation, interview and record review it was determined for 24 out of 80 sample residents, that the facility failed to protect residents from abuse, neglect and misappropriation of property. Specifically, residents were repeatedly physically, verbally and sexually abused without ongoing interventions to prevent further abuse. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. [Cross refer to F600] 3. Based on observation, interview and record review it was determined for, 1 of 80 sampled residents, that the facility did not ensure each resident had the right to be free from abuse, neglect, misappropriate of resident property, and exploitation. This includes but was not limited to freedom from involuntary seclusion. Specifically, a resident was not assessed to determine if a locked unit was appropriate. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32. [Cross refer to F603] 4. Based on interview and record review the facility did not develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegations; Include training as required; and Establish coordination with the QAPI program. Specifically, multiple residents were repeatedly abused physically, sexually and verbally, without interventions to protect the residents, appropriate reporting, or thorough investigations. These instances were determined to have occurred at an Immediate Jeopardy level for F600, F609, and F610. [Cross refer to F607] 5. Based on record review and interview it was determined for 20 of 80 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79 and 86. Resident identifiers: 14, 32, 37, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 86, 87, 92, 359, 409, 459 and 460. [Cross refer to F609] 6. Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 20 of 80 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA) the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. [Cross refer to F610] 7. Based on interview and record review it was determined, for 7 out of 80 sampled residents, that the facility did not permit each resident to remain in the facility and not transfer or discharge the resident unless the resident's welfare and needs could not be met in the facility; or the safety of individuals in the facility was endangered due to the behavioral status of the resident. Additionally, when a facility transfers or discharges a resident under any circumstances the facility must ensure that the resident's medical record and information was communicated to the receiving health care provider. Specifically, the facility initiated a resident discharge/transfer after they suspected a resident of having a sexual relationship with another resident. There was no documentation of the facility's attempts to meet the resident's needs; the resident's Power of Attorney (POA) was not notified of the transfer; and the family representative reported that the resident was not happy in the new facility and the change in environment had caused the resident to have increasing behaviors associated with her dementia. The deficient practice identified occurred at a HARM Level. The facility initiated a resident discharge/transfer for the other resident identified in the sexual relationship and there was no documentation of the facility's attempts to meet the resident's needs, the POA was not given notice nor were the transfer options discussed with the POA. Additionally, multiple residents were transferred or discharged and no documentation was found in the medical records that demonstrated what information was communicated to the receiving provider. Resident identifiers: 2, 67, 76, 79, 86, 96 and 409. [Cross refer to F622] 8. Based on observation, interview and record review it was determined, for 4 of 80 sampled residents, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community was not provided. Specifically, there were not enough activities in the secured unit and residents with minimal cognitive impairment were unable to attend activities outside of the secured unit. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32, 79, 81 and 86. [Cross refer to F679] 9. Based on observation, interview, and record review it was determined, for 6 of 80 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident did not receive appropriate wound care or ileostomy care after a surgery, a resident with an amputated left foot was not receiving wound care, a resident with a GI (gastrointestinal) bleed was not treated timely, a resident who sustained injuries from a fall was not properly examined or followed up on, and a resident who had cellulitis did not receive proper care. These examples will be cited at a harm level. Resident identifiers: 7, 49, 86, 96, 209, and 357. [Cross refer to F684] 10. Based on observation, interview and record review it was determined, for 11 out of 80 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident experienced 19 falls that resulted in an injury 14 times with multiple head injuries that required medical attention; a resident experienced 5 falls within 48 hours that resulted in bruising, pain, and a hip fracture; a resident experienced 17 falls that resulted in multiple fractures; a resident experienced 9 falls with head injuries that required medical attention; and a resident experienced 27 falls that resulted in lacerations that required medical attention. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, a resident eloped from the facility multiple times and sustained lacerations requiring sutures. This identified deficient practice was found to have occurred at a Harm Level. Lastly, a resident experienced repeated falls without interventions identified to prevent the falls, a resident sustained a fall after a faulty door hinge fell on top of their head, a resident residing in the dementia unit obtained a razor and cut his head, a resident sustained an injury to their foot after an improper transfer by the administrator (ADM), and hot water temperatures were measured at levels above 100 degrees Fahrenheit. Resident identifiers: 1, 11, 35, 47, 51, 73, 79, 98, 209, 258, and 357. [Cross refer to F689] 11. Based on interview and record review, it was determined that the facility did not ensure, for 1 of 80 sample residents, maintained acceptable parameters of nutritional status. Specifically, a resident with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level. Resident Identifiers: 42. [Cross refer to F692] 12. Based on observation, interview, and record review it was determined, for 2 of 80 sampled residents, that the facility did not ensure pain management was provided to resident who required such services. Specifically, a resident who requested pain medications prior to a wound care treatment was not given pain medications until after the treatment was completed, and a resident on hospice was given his pain medications late and an order for pain medications was not entered into his chart for three days. These examples will be cited at a harm level. Resident identifiers: 7 and 84. [Cross refer to F697] 13. Based on observation, interview and record review it was determined, for 21 of 80 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. These findings resulted in immediate jeopardy (IJ). In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 1, 4, 7, 35, 47, 51, 54, 68, 73, 76, 77, 78, 79, 84, 85, 86, 96, 98, 209, and 357. [Cross refer to F725] 14. Based on interview and record review it was revealed that, for 1 of 80 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skills set 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. Specifically, a nurse categorized and performed wound care on a skin fold and the anus that she mistook the areas as tunneling wounds. Resident identifier: 7. [Cross refer to F726] 14. Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 80 sampled residents, a resident's vancomycin level was not monitored appropriately resulting in vancomycin toxicity. This was cited at a harm level for resident 208. Additionally, a resident's blood sugars were not monitored according to the physician's orders. Resident identifiers: 208 and 257. [Cross refer to F757] 15. Based on observations, record review, and interviews it was determined that for 7 of 80 sampled residents the facility did not ensure that its residents are free of any significant medication errors. Specifically, the facility continued to administer vancomycin without verifying trough serum levels, administering the wrong dose of insulin, and breaking open an extended-release tablet. The findings for residents 86 and 208 were determined to have occurred at harm level. Resident identifiers: 43, 50, 79, 86, 92, 208, and 457. [Cross refer to F760] 16. Based on interview and record review it was revealed that, for 6 of 80 sampled residents, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, the facility did not obtain laboratory services in a timely manner. The deficient practice for resident 208 was found to have occurred at a harm level. Resident identifiers: 7, 35, 38, 51, 79, and 208. [Cross refer to F770] 17. Based on interview, observation and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically multiple residents were identified to be in Immediate Jeopardy and/or have experienced harm. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. [Cross refer to F835] 18. Based on observation, interview, and record review, the facility did not have a governing body that was legally responsible for establish and implementing policies regarding the management and operation of the facility; and did not appoint an administrator who was accountable to the governing body. Specifically, multiple instances of noncompliance were identified and determined to have occurred at an Immediate Jeopardy or harm level. Resident identifiers: 1, 2, 4, 7, 9, 11, 14, 23, 32, 34, 35, 37, 38, 42, 43, 44, 47, 49, 50, 51, 54, 58, 67, 68, 73, 76, 78, 79, 81, 83, 84, 85, 86, 87, 92, 96, 98, 208, 209, 257, 258, 357, 359, 409, 457, 459 and 460. [Cross refer to F837] 19. A review of the facility ' s compliance history revealed the following: a. On 12/16/21, during a recertification survey, the facility was cited for noncompliance at F578, F584, F585, F656, F676, F684, F686, F689, F692, F744 (at a harm level), F456, F842, F880, and F882. All of these deficiencies were cited during the current recertification survey that was conducted from 3/28/23 through 4/25/23. b. On 8/26/22, during an abbreviated complaint survey, the facility was cited for noncompliance at F600 (at an immediate jeopardy level), F610 (at an immediate jeopardy level), F880, and F943. All of these deficiencies were cited during the current recertification survey that was conducted from 3/28/23 through 4/25/23. c. On 12/20/22, during an abbreviated complaint survey, the facility was cited for noncompliance at F584, F609, F684 (at a harm level), F804, and F923. All of these deficiencies were cited during the current recertification survey that was conducted from 3/28/23 through 4/25/23. 30563

Based on observation, interview, and record review it was determined, for 6 of 80 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident did not receive appropriate wound care or ileostomy care after a surgery, a resident with an amputated left foot was not receiving wound care, a resident with a GI (gastrointestinal) bleed was not treated timely, a resident who sustained injuries from a fall was not properly examined or followed up on, and a resident who had cellulitis did not receive proper care. These examples will be cited at a harm level. Resident identifiers: 7, 49, 86, 96, 209, and 357. Findings Include: HARM 1. Resident 7 was initially admitted to the facility on [DATE] and again on 4/7/23 with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. Resident 7's medical record was reviewed from 3/28/23 through 4/25/23. According to progress notes, resident 7 was sent to the hospital on 11/27/22 and was diagnosed with a small bowel obstruction at the hospital. Resident 7 returned from the hospital on 12/3/22 with a moved ileostomy, staple on midline, and a PICC line still in place. On 4/11/23 at 11:51 AM, an interview with resident 7 and resident 7's Power of Attorney (POA) was conducted. Resident 7's POA stated that when resident 7 returned from the hospital on 12/3/22, the staff were not completing any wound care or ileostomy care for resident 7's surgical site and new ileostomy. Resident 7's POA stated that the Certified Nursing Assistant's (CNA) covered the surgical site with bandages. When resident 7's POA asked to see the orders for surgical site and ileostomy, the staff were unable to show resident 7's POA any orders. Resident 7's POA stated the surgical wound looked infected because it was brown and had a strong, bad odor to it. Resident 7's POA stated that resident 7 finally received wound care orders after resident 7 had a follow up surgical appointment. Resident 7's POA stated the lack of wound care resulted in resident 7 requiring a wound vac, which was just recently removed. A review of the December 2022 Treatment Administration Record (TAR) revealed that resident 7 did not have an order for wound care on the surgical incision and no new orders for ileostomy care when resident 7 returned from the hospital on 12/3/22. A review of the December 2022 TAR revealed that resident 7 did have an order for colostomy care that was started on 7/5/22 and discontinued on 12/13/22. The order stated, Change monthly and as needed for leaking or dislodgement. One time a day starting on the 5th and ending on the 5th every month for colostomy . The December 2022 TAR revealed that the order for colostomy care was completed once, on 12/5/22. A Nurses Note from 12/10/22 at 2:20 PM stated, Wound dressing changed. Small amount of drainage and redness. A review of resident 7's medical record revealed that the physician was not notified of the drainage and redness. On 4/13/23 at 2:25, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that the nurse should have notified the doctor if there was drainage and redness because those are signs of an infection with a wound. On 12/13/22 a document from resident 7's general surgery appointment stated, Bandage unchanged, ostomy leaking [plus] appears not sealed to skin. Skin breakdown along incision appears severely neglected. A Nurses Note from 12/13/22 at 5:48 PM stated, Resident returned from her general surgery appt [appointment] . with the following note: 'Bandage unchanged, ostomy leaking and appears not sealed to skin. Skin breakdown along incision appears severely neglects. I replaced her _ and bag today. Stoma was cleansed and dried. 1/2 staples removed. No future dressing required. May shower as usual. Change ostomy bag and wafer Q [every] 2 days with Cavilon skin barrier .' Called office, spoke with [Doctor's name redacted]. Spoke with him regarding his concerns. The bandage he was referring to, this nurse changed this morning. She currently has a lot of drainage that the bandage needs changed multiple times a day upon occasion. Herileostomy [sic] wafer and bag was changed 2 days ago due to it leaking, it leaks frequently. Resident has a history of picking at her wafers and causing leakage. We have been giving her bed baths, and gently cleansing the skin around her incisions. I informedhim [sic] that we did not receive different orders regarding her ileostomy changes, wound care, or shower instructions from the hospital. I apologized that we were not following his instructions that were suppose to come with the DC [discharge] orders. We reviewed her DC orders from the hospital, and the provider was upset that there were no new ileostomy care instructions, no surgical wound instructions. New instructions received : change ileostomy wafer and bag every 2 days, use Cavilon skin barrier between wafer and skin. He stated the ileostomy secretions are more irritating on the skin, so we need to change it and wash it frequently to help protect the skin. The Cavilon skin prep will also help. He informed that shower like normal is OK now, theincision [sic] has healed enough that it will not cause any issues. He instructed to leave the sutures open to air, dry and clean until follow up appt . A review of the December 2022 TAR revealed that resident 7 had an order which started on 12/14/22 for Ileostomy Care and stated, Check ileostomy appliance each shift. Monitor and empty PRN [as needed]. Change Q2 days and as needed for leaking or dislodgement. One time a day every 2 day(s) for ileostomy care to apply new ileostomy appliance: clean site, gently pat dry, apply skin prep barrier wipe to periileostomy skin, then apply the appliance. The December 2022 TAR revealed that resident 7 had an order which started on 12/19/22 for the surgical incision. The order stated, Keep surgical incision clean and dry. OK to wash in shower and as needed, keep open to air except area of drainage. Every shift for surgical incision healing. The order was discontinued 12/22/22. It should be noted that this order was started seven days after resident 7's follow-up surgical appointment on 12/13/22, and 17 days after resident 7 returned from the hospital on 12/3/22. A new order for the surgical incision site started on 12/22/22 and stated, keep surgical incision clean and dry. Every shift for surgical incision healing. This order was discontinued on 12/28/22. A Nurses Note from 12/16/22 at 6:38 PM stated, Resident surgical incision has increased drainage and possible infection noted. Provider notified and orders received to start IV ABX [antibiotics], IV fluids, and stat labs Resident 7's Medication Administration Record (MAR) revealed that resident 7 had an order that stated, Cefepime HCL [hydrogen chloride] Solution Reconstituted 2 GM [grams] Use 2 grams intravenously two times a day for infection. with a start date of 12/16/22 and discontinue date of 12/22/22. Resident 7's MAR revealed that resident 7 also had an order that stated, Cefepime HCl Solution Reconstituted 2 GM Use 2 gram intravenously two times a day for infection . With a start date of 12/22/22 and a discontinue date of 12/28/22. A Nurses Note from 12/19/22 at 4:50 PM stated resident seen at surgeons' office, wound was opened up more. New orders for wound vac . According to resident 7's physician's orders, resident 7 had orders for a wound vac from 12/21/22 to 2/22/23. On 3/30/23 at 2:07 PM, telephone interviews were attempted with the licensed nurses who provided resident 7 cares from 12/3/22 to 12/13/22. Messages were left to those staff to return the State Survey Agency (SSA) call. It should be noted that the licensed nursing staff were either no longer working for the facility or were employed by an outside agency company. On 4/13/23 at 9:42 AM, an interview with CNA 5 was conducted. CNA 5 recalled the time when resident 7 returned from the hospital from her surgery on 12/3/22. CNA 5 stated that staff kept the incision covered with a long white bandage, and during showers, nurses would sometimes change the bandage. CNA 5 stated that there were a few times where nurses did not change the bandage, and the bandage would sometimes be unchanged for a few days. CNA 5 stated that she remembered one day that the surgical wound appeared to be more red than normal. CNA 5 stated that the nurse she was working with stated the wound was not supposed to look like that, and CNA 5 and the nurse noted that they did not know how long the current band aide was on because there was no date. CNA 5 stated she was not sure if the nurse reported the change in the wound to the doctor. On 4/13/23 at 2:31 PM an interview with the ADON was conducted. The ADON stated she did not know why resident 7 did not have wound care and ileostomy care orders when resident 7 returned from the hospital on 12/3/22. The ADON stated that nurses should have called the hospital to receive the orders for the surgical wound care and new ileostomy care when resident 7 returned from the hospital on 12/3/22. 22992 2. Resident 49 was admitted to the facility on [DATE] with diagnoses that included pneumonia, diabetes mellitus with gangrene, mild protein calorie malnutrition, acute respiratory failure with hypoxia, cognitive communication deficit, severe sepsis without septic shock, cytokine release syndrome, paranoid schizophrenia, hypertensive heart and chronic kidney disease without heart failure, partial traumatic amputation of left foot, anemia, acquired absence of right leg below the knee amputation, hypoosmolatlity and hyponatremia. Resident 49's medical record was reviewed from 3/28/23 through 4/25/23. A History and Physical (HP) report from a local hospital indicated that resident 49 was admitted to a local hospital on 3/8/23 for increased cough. The HP also indicated that resident 49 had been hospitalized from 2/25/23 through 3/7/23 for left foot gangrene requiring left forefoot amputation . Review of discharge paperwork revealed that resident 49 was discharged from a local hospital on 3/14/23. The discharge orders indicated that resident 49 had orders to change the dressing on his left foot twice a week, cleanse with puracyn, and apply adaptic touch or xeroform over site. Physician orders for resident 49 were reviewed. No orders for wound care for resident 49 were implemented until 3/31/23, approximately 24 days after resident 49 was admitted . Review of nursing progress notes revealed the following entries: a. On 3/31/23: Per physician, remove sutures, cleanse with wound cleanser, apply medihoney and absorbent bandage. Change dressing 3x [times] per week. Refer to wound nurse. b. On 4/2/23: Osteomyelitis to L. [left] foot. Assessment (S/Sx [signs and symptoms] of Infection): Sloughing and dehiscing to incision noted. Dark, discoloration noted to dorsal L. foot. Thickened, dark skin noted to plantar L. foot. The note did not indicate that either the wound nurse or the physician had been notified. c. On 4/3/23: Followed up with NP [nurse practioner] regarding pt [patient] surgical incision wound to left foot. Foot has small opening to right outer incision. NP to assess and feels a referral will be necessary. NP said she will leave orders with nurse at station when she is done with rounds. Spoke with NP and a referral to wound clinic was put in. Will continue wound care as directed until wound clinic. d. On 4/4/23: Pt's surgical amputation site presents signs of dehiscence. MD [Medical Doctor] and wound nurse notified. Waiting for orders. e. On 4/5/23: Notified Onsite wound care of dehiscence of wound. New wound orders inputed (sic). Notified infectious disease doctor of change in wound, they will address it at next appointment. Moderate dehiscence, discoloration ,tunneling, and redness noted on pt's surgical wound from amputation of left toes. NP and ADON notified. ADON confirmed that she will address orders with infectious disease doctor and that she is putting new wound care orders in the system. She added that orders should be follow (sic) until further notice. On 4/5/23 an interview was conducted with Staff Member (SM) 25. SM 25 stated that resident 49 did not have any dressing changes from the day he had surgery until 4/4/23. On 4/10/23 an interview was conducted with the ADON. The ADON stated that she was the staff member responsible for monitoring all of the residents' wounds. The ADON stated that she was not informed of resident 49's left foot wound until 4/5/23, approximately 4 weeks after resident 49 was admitted . 38031 3. Resident 96 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, sepsis, hypertension, retention of urine, major depressive disorder, personality disorder, insomnia, anxiety disorder, and acquired absence of right leg below the knee. On 4/24/23, resident 96's medical records were reviewed. On 1/29/23, resident 96's Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13/15, which would indicate that resident 96 was cognitively intact. The assessment documented that resident 96 did not have hallucinations or delusions. Resident 96 was assessed as requiring a limited one person physical assist for bed mobility, dressing, and personal hygiene; and an extensive one person physical assist for toilet use. The assessment documented that resident 96 was always incontinent of bowel and had an indwelling urinary catheter. Resident 96's Progress notes revealed the following: a. On 4/22/23 at 1:08 AM, the progress note documented, Pt stated abd [abdominal] pain beginning early in day, decreased appetite, denies N/V [nausea and vomiting], noted to have 1 episode of tarry stool by CNA [Certified Nurse Assistant]. b. On 4/22/23 at 6:30 PM, the progress note documented, Patient called the 911 asking for an ambulance because he was worried about his black tarry stool. This nurse did not see his stool and was unaware that he was going to call EMS [Emergency Medical Services]. c. On 4/23/23 at 10:45 AM, the progress note documented, This nurse called [hospital] to get an update on resident. Resident was admitted to the surgical floor. Resident will have a GI consult and EGD [Esophagogastroduodenoscopy] done today d/t [due to] stomach pain. If EGD is clear, then resident will be able to return to the facility. DON [Director of Nursing]updated on resident. On 4/22/23 at 2:56 PM, an order for a fecal occult test was entered by the ADON for resident 96. Review of the laboratory requisitions revealed no documentation or carbon copy of the order requisition for the fecal occult tests. No documentation could be found of a change in condition assessment. On 4/22/23, resident 96's hospital history of present illness documented that the resident had been experiencing abdominal bloating and abdominal pain for the past 2 days, and over the past 24 hours he had copious amounts of diarrhea. The report documented that the over the course of the afternoon the stool had turned black. A complete blood count revealed the hematocrit was 29.9 Low and the hemoglobin was 10.0 Low. The assessment documented melanotic stools with a fecal occult blood positive in the emergency room . The plan was for resident 96 to have an EGD in the morning. The assessment also documented that resident 96 complained of left lower quadrant abdominal pain as well as epigastric pain. Resident 96 tested positive for Clostridium difficile (c-diff) colitis and Vancomycin was ordered. The CT [Computed tomography] of the abdomen documented that there was diffuse thickening of the rectum and throughout the colon. The appendix was not dilated. The CT impression was pancolitis without complication. On 4/25/23, resident 96's EGD operative report documented the findings as normal with an unclear etiology of the melena. On 4/25/23 at 9:49 AM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated that the licensed nurse should have obtained vital signs and conducted an assessment for a change in condition. The CNO stated that the staff should communicate with the physician to obtain further orders. The CNO stated that they were in the process of obtaining guaiac tests to increase the speed of treatment. The CNO stated that the nurse should document a progress note or an assessment, and the assessment would be located in the e-interact form. 4. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, concussion, repeated falls, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, and hypomagnesemia. On 3/29/23, resident 357's medical records were reviewed. On 3/28/23, resident 357's Admission MDS Assessment documented a BIMS score of 15/15, which would indicate that resident 357 was cognitively intact. The assessment documented that resident 357 did not have hallucinations or delusions. Resident 357 was assessed as requiring a limited one person assist for bed mobility, transfer, locomotion off the unit, dressing, and personal hygiene; extensive one person assist for toilet use; and supervision one person assist for eating. On 3/28/23 at 10:15 AM, an observation was made of resident 357 with bruising to the face, bilateral orbits and bridge of the nose. The bruising was dark purple in coloring. At 12:34 PM, an interview was conducted with resident 357. Resident 357 stated that last night when she was exiting the door to smoke the part holding the door open fell and landed on top on her head. Resident 357 stated that the door hinge broke and when it struck her it caused her to fall out of her wheelchair. Resident 357 complained of a headache and the resident thought her nose may be broken from the hinge striking her on the head. Resident 357 stated that her nose hurt and all she had for pain control was Tylenol. Resident 357 stated that after the fall all they did was take her vitals, and she did not go to the hospital. Resident 357 stated that they did not obtain an x-ray of her nose after the incident. On 3/23/23 at 6:54 PM, the progress note documented that resident 357 was alert and oriented times 4 to person, place, time and situation. Resident 357 had a history of a stroke, falls, and weakness in the lower and upper extremities. Pt's mobility is impaired and she move slowly. She ambulates with a cane. Resident 357 required a 1 person assistance for transfers, ambulation, and pivoting was recommended. On 3/27/23 at 11:25 AM, the incident report documented, Resident began yelling and was found at the front door. Resident had fallen backwards after opening the door. Resident had no new injuries noted. Resident has a red bump to their R [right] forehead from a previous fall, and bruising under their eyes. Resident has no new bruising noted. Resident states that they were trying to go outside to smoke, and the door hinge of the front door hit them on the right side of their head, causing them to fall backwards. Resident has no c/o [complaints of] pain or discomfort. The immediate action taken was Resident had vital signs and neurological assessments completed. Resident had a head to toe assessment done to assess for any further injuries. Resident has no current c/o pain or discomfort. Res [resident] was assisted back into their bed in their room. The physician was notified on 3/28/23 at 7:14 AM. It should be noted that the physician notification was approximately 20 hours after the incident occurred. It should be noted that no documentation could be found that the neurological (neuro) assessments flowsheet was initiated after the fall at on 3/27/23 at 11:25 AM. On 3/27/23 at 10:39 PM, the progress note documented, Resident had an unwitnessed fall in her room at approximately 2220 [10:20 PM]. Resident states she was transferring self from her bed to W/C [wheelchair] and slipped as breaks were not on. Resident initially told Aid [sic] she did not hit head but then told nurse she hit the back of her head. No redness or obvious injury to head or other parts of body. Resident was assisted to feet and W/C and vitals obtained. Resident was agitated that we were assessing her and obtaining vitals. Resident initially hesitant for me to call family at this time and wanted us to call them in the morning then decided for me to call now. On 3/27/23 at 10:20 PM, the neuro checks were initiated and continued through 3/30/23. On 3/28/23 at 7:29 AM, the progress note documented, Resident had a fall at 2335 [11:35 PM] on 3/27/23. Resident was attempting to open the front door to go outside and smoke. Resident stated the hinge area of the door fell and hit their head, and caused resident to fall backwards. Resident received a head to toe assessment to determine if any new injuries were noted. Vital signs were taken: BP [blood pressure]158/90 mmHg [millimeters of mercury], HR [heart rate] 94 bpm [beats per minute], Respirations 18, oxygen saturation 96%. Resident had equal, round, and reactive pupils, and had bilateral strong hand grasps. Res had no c/o pain or discomfort. Provider was made aware of the change in condition. Resident stated they do not want their family notified during the night. Res continues to receive neurological assessments and vital signs checks. It should be noted that a previous incident report documented the incident occurred on 3/27/23 at 11:25 AM. Additionally, the Neurological Assessment Flowsheet documented resident 357's vital signs on 3/27/23 at 10:20 PM were blood pressure 158/90, heart rate 94, respirations 18, oxygen saturation 96%. Resident 357's vital signs at 10:20 PM were taken after the resident had sustained a fall inside her room. This was resident 357's second fall on 3/27/23 and not the one located at the front door with the facility door hinge. On 4/1/23 at approx. 5:35 PM, an interview was conducted with RN 1. RN 1 stated that resident 357 was on neuro checks because she slid to the floor at 5:15 AM. RN 1 stated that at 6:30 AM she found the resident on the bathroom floor laying on the side, and she had fallen and hit her head. RN 1 stated that resident 357 had no new injuries. RN 1 stated that resident 357 fell a week ago and hit her head on the corner of the dresser. RN 1 stated that resident 357 had two big black eyes. RN 1 stated that she was resident 357's nurse on Friday when she fell and hit her head and had an injury to her right temple and orbit. RN 1 stated that resident 357 did not have any imaging or treatment with the first fall. RN 1 stated that she did notify the NP immediately, and she went right in and assessed resident 357. RN 1 stated that she sent pictures to the NP later in the day as the bruising was progressing. RN 1 stated that the interventions to prevent falls were frequent checks every 2 hours and ensuring the bed was in a low position. RN 1 stated that resident 357 was a one person extensive assist for transfers. On 4/6/23 at 12:06 PM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated that the physician should be notified immediately after a fall, even if the resident did not sustain an injury. DON 1 stated that the resident representative should also be notified if the resident had a POA. DON 1 stated that the incident report and progress note would document all the parties that were informed of the fall. DON 1 stated that when a resident had a fall the staff should initiate neurological assessments, conduct a head to toe assessment prior to moving the resident, just in case something is broken in which case they should not move them at all. DON 1 stated that the licensed nurse should note any change of condition or anything unusual. On 4/19/23 at 10:17 AM, an interview was conducted with the Assistant Director of Maintenance (ADOM). The ADOM stated that they utilized What's app and the Lists app for notification of any maintenance issues or concerns. The ADOM stated that he had the back door and smoking door repaired due to the closure hinge coming off. The ADOM stated that he did not have any documentation with the date and time of the repairs. The ADOM stated that the back door was reported broken on Saturday when one of the cooks opened it and the arm broke off. The ADOM stated he did not keep a log of the facility maintenance, and that he performed repairs that were not even listed on the Lists app. On 4/20/23 at 2:46 PM, an interview was conducted with DON 3. DON 3 stated that all staff have been instructed that for any injury the staff should call her. DON 3 stated staff should remove the immediate danger, the area should be assessed for any hazards, management notified, an interdisciplinary team (IDT) meeting conducted to address the issue, and the nurses should enter a progress note. DON 3 stated that if the resident complained of pain and a possible fracture the resident should be assessed, the MD should be notified, and the resident should be sent out for an x-ray. DON 3 stated that with any suspected injury the MD and family should be notified. DON 3 stated that she and the Administrator were implementing temporary interventions to ensure that something was done immediately. 47431 5. Resident 209 was admitted on [DATE] with diagnoses that included cognitive communication deficit, paroxysmal atrial fibrillation, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, abnormal coagulation profile, and chronic kidney disease. On 3/28/23 at 10:12 AM, an interview with resident 209 was conducted. Resident 209 stated that she sustained a left foot injury when a staff member hit her foot into the door frame while being transferred into the room. Resident 209 stated her foot was sore. An observation of resident 209's left foot was immediately made. Resident 209's left foot had a baseball size hematoma on the dorsal and lateral side. On 4/5/23 at 12:26 PM, an interview was conducted with resident 209. Resident 209 was asked if the physician had assessed her foot regarding the injury on 3/24/23. Resident 209 stated, No, no one has. Resident 209's medical record was reviewed from 3/28/23 through 4/25/23. On 3/27/23 at 12:01 PM, facility staff documented in a Minimum Data Set (MDS) Progress Note as follows: Pt [patient] complains of pain all over but says her left foot hurts mostly. Left foot is bruised top and bottom. The progress note indicated that the facility Nurse Practitioner had been notified. However, no notes or orders were documented by the Nurse Practioner. On 3/28/23, the facility Medical Director (MD) assessed resident 209 as part of the admission assessment. The MD did not document that he had evaluated or been notified of resident 209's bruised and painful foot. A Nurses Progress Note on 4/13/2023 at 7:17 PM documented, this nurse was informed by another staff member that [resident 209's] left foot was accidentally hit into something during transport over a week ago. The incident was not reported at the time. This nurse assessed resident's foot; resident stated it was her inner left foot. No swelling noted, denied pain, bruising to inner and outer aspects of foot noted. Medical doctor (MD) was notified and ordered x-ray of foot. [Name of x ray company] called and placed order for x-ray. Stated they will be coming tomorrow. A review of resident 209's medical records revealed on 4/14/23 an x-ray of left foot was performed, and results of radiology findings were given at 2:45 PM. [Note: The xray of resident 209's foot was completed approximately 22 days after the injury occurred.] An interview on 4/20/23 at 2:59 PM, was conducted with DON 3. DON 3 stated that if a resident was to get hurt, for sure the physician and family needs to be notified. DON 3 stated that the event would also need to be documented in a progress note. DON 3 stated an incident report also needed to be initiated and it should be brought to the Interdisciplinary Team (IDT) meeting. DON 3 stated she would also expect further orders from the physician and an x-ray should have been done much sooner. [Cross refer to F689] 30563 6. Resident 86 was admitted to the facility on [DATE] with the following diagnoses that included but not limited to unspecified dementia, anxiety disorder, depression, and history of falling. Resident 86's medical record was reviewed 3/28/23 through 4/25/23. A form titled Hospice Nursing Clinical Note dated 2/17/23 revealed .Noted a new sore to patient's L [left] middle finger on the most distal knuckle. Slough is noted to the wound bed and the surrounding skin is red/inflamed. Brought patient back out to the nurse's station after visit and inquired about the sore on her finger. FSN [Facility Staff Nurse], [LPN 3's name removed], stated that the origin of this wound was unknown, but agreed that it appeared to be infected. Hospice RN sent a picture to [name of physician] and he messaged back within a minutes with an order for ABX [antibiotic]. Informed [LPN 3] that the Keflex would be delivered this evening and that the orders were being faxed over now . A review of resident 86's MAR for February 2023 revealed Keflex was not administered. There was no order located in resident 86's medical record for Keflex until 2/24/23 which was Keflex Oral Capsule 250 mg. Give 250 mg by mouth two times a day for wound on right middle finger for 7 days. The order was discontinued 2/24/23 after 1 dose was administered. A nursing progress note dated 2/17/23 at 6:52 PM revealed, Hospice nurse reported infection to area on right hand, between middle finger. Order for Keflex. No further details on order until received from hospice. A nursing progress note dated 2/21/23 at 5:18 AM revealed, res has skin tear to left anterior forearm, resident scratching area, skin tear cleansed with wound cleanser, patted dry, steri strips applied due to resident removing dressing, dressing applied to area also. A nursing progress note dated 2/21/23 at 5:31 AM revealed, Resident had skin tear that she was scratching, trying to rub makng [sic] skin tear longer. 3cm [centimeters] linear skin tear to left anterior forearm. Steri strips applied due to resident attempts to remove dressing, dressing applied over steri strips. A nursing progress note dated 2/23/23 at 5:45 PM revealed, Open areas to left forearm. Red, swollen, and warm to touch. S/S [signs and symptoms] of pain when accessing. Notified Hospice. Cleansed and covered .Resident continues to remove dressing and scratch, 'pick at' openings. Educated resident, but resident is confused, and not able to understand. A nursing progress note dated 2/23/23 at 10:29 PM revealed, Keflex 250 milligrams (mg) by mouth given at this time. A nursing progress note dated 2/24/23 at 5:45 PM revealed, Infection to left forearm has increased redness and cellulitis. Elbow to dorsal left hand effected (sic). Hospice notified. Keflex 250 mg BID [twice daily] discontinued. New order for Augmentin 875 BID for 10 days .New order to increase Morphine to 0.25 ml [milliliter] syringe to 2 syringes = to 0.5ml for pain. A form titled Hospice Nursing Clinical Note dated 2/24/23 revealed .Facility st [TRUNCATED]

Based on observation, interview and record review it was determined, for 4 of 80 sampled residents, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community was not provided. Specifically, there were not enough activities in the secured unit and residents with minimal cognitive impairment were unable to attend activities outside of the secured unit. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32, 79, 81 and 86. Findings include: 1. The March 2023 activities calendar was reviewed. The following activities were scheduled in the secured unit: a. On 3/9/23 at 4:00 PM, Cambridge craft b. On 3/11/23 at 10:30 AM, Walk and Talk c. On 3/18/23 10:30 AM Walk and Talk The April 2023 activities calendar was reviewed. There were no scheduled activities in the secured unit. On Saturdays the activity was independent activities with activity packet in day room which was outside of the secured unit. 2. On 3/28/23 from 9:15 AM until 11:59 AM, there were no activities observed. At 11:59 AM, there was an observation of residents coloring and music was playing in the secured unit dining room. Resident 86 was not observed in the activity. Resident 86 was observed to wander the hallway in the secured unit. Resident 81 was observed to wander the hallway of the secured unit. Resident 81 did not participate in the activity. Resident 79 was not observed in the activity. Resident 81 was observed to talk on the phone and wander the secured unit hallway. Resident 32 was observed in her room with the lights out and the privacy curtain pulled around her. On 4/11/23 at 10:30 AM, an observation was made of the secured unit dining room. There were 3 residents painting. The table was tipping while residents were painting. Resident 81 and resident 86 were observed to be playing cards. On 4/17/23 at 3:36 PM, an observation was made of the secured unit. There were 6 residents watching television including resident 81 and resident 86. Resident 32 was observed in her room with the lights out and the curtain closed around her bed. On 4/19/23 at approximately 11:30 AM, an observation was made of a staff member in the secured unit dining room. The staff member was observed to be reading a children's book with pictures to the residents. 3. Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, malnutrition, anxiety disorder, and age-related physical debility. Resident 86's medical record was reviewed 3/28/23 through 4/25/23. A significant Change Minimum Data Set (MDS) dated [DATE] revealed that resident 86 was not interviewed for her preferences in activities. The staff assessment of daily activity preferences revealed that resident 86 liked to listen to music, do things with groups of people, participate in their favorite activity, and be around animals such as pets. An activity care plan dated 8/23/22 revealed that resident 86 exhibited impaired activity pattern manifested by impaired mobility, need for adaptive equipment, sensory problems, poor health/pain limited activity involvement, need for reminders and assistance to/from activities. The goals were resident 86 would attend at least 1 social group per weekly, would participate in independent leisure activities, would continue life roles in accordance with preferences and maintain the highest level of independence. Interventions included to monitor for satisfaction with leisure choices; post calendar in room; supply with independent leisure choices; invite and assist to and from activities; support independent leisure choices; and provide adaptation to activities as needed for cognition, vision, and physical. An initial activities review dated 12/16/22 revealed, resident 86 liked pets, games, music, reading, relaxing, and visiting. Resident 86 wished to participate in activities while at home, group activities, and independent activities. An activity interview for daily and activity preferences dated 2/11/23 and locked on 2/16/23 revealed no information. 4. Resident 32 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, toxic encephalopathy, paroxysmal atrial fibrillation, paranoid schizophrenia, depression, anxiety, and cognitive communication deficit. On 3/28/23 at 1:01 PM, an interview was conducted with resident 32. Resident 32 stated she liked to go to BINGO, craft classes, learning classes and cooking classes. Resident 32 was observed to be in her room with the lights out, curtain drawn around her and no electronic devices. Resident 32 stated she would like to have a television. Resident 32 stated her tablet was broken and her cell phone had been taken away. On 4/13/23 at at 2:41 PM, an interview and observation was made of resident 32. Resident 32 was observed to be sitting at the locked doors inside the secured unit. Resident 32 stated she wanted to go to BINGO which was in the main dining room, outside of the secured unit. Resident 32 was observed to ask Licensed Practical Nurse (LPN) 3 about going to BINGO. LPN 3 was observed to tell resident 32 she could not go. On 4/25/23 at 10:10 AM, a follow up interview was conducted with resident 32. Resident 32 stated she had anxiety because she was unable to get out of the secured unit. Resident 32 stated she wanted to leave the secured unit for activities like BINGO. Resident 32's medical record was reviewed 3/28/23 through 4/25/23. An admission MDS dated [DATE] revealed that resident 32 was rarely or never understood to perform an interview regarding daily activities that were preferred. The staff assessed resident 32's preference or daily activities. The activities resident 32 liked were using a private phone, reading, listening to music, being around pets, keeping up with the news, doing things in groups of people, participating in favorite activities, spending time away from nursing home, spending time outdoors, and participating in religious activities. A quarterly MDS dated [DATE] revealed that resident 32 had a BIMS score of 15 out of 15 which indicated resident was cognitively intact. A care plan dated 7/29/22 and revised on 11/25/22 revealed that resident 32 exhibited impaired activity patterns manifested by: impaired mobility, need for adaptive equipment, poor health/pain limited activity involvement, need for reminders and assistant to/from activities. The goals included resident 32 would participate in independent leisure activities, continue life roles in accordance with preferences, and attend at least 1 social activity per week for 90 days. Some interventions included to monitor for satisfaction with leisure choices, post calendar in room, supply with independent leisure choices, invite and assist to/from group activities, ensure proper lights and space, and encourage and support the continuation of life roles. On 4/25/23 at 8:26 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated residents in the secured unit were able to leave unit for activities as long as the residents were supervised the whole time. RN 6 stated she was not sure if resident 32 had to be supervised the whole time when she was out of the secured unit. RN 6 stated resident 32 needed to go to activities because it got her out of her room. RN 6 stated she thought that resident 32 had a television in her room. RN 6 was observed to look in resident 32's room and asked resident 32 if she had a television. Resident 32 was observed to tell RN 6 that she did not have a television and It would be nice to have something to do. On 4/19/23 at 2:43 PM, an interview was conducted with a local mental health Licensed Clinical Social Worker (LCSW). The LCSW stated that when she visited resident 32, she was sitting in her room with the curtain pulled and the room was dark. The LCSW stated there was a future plan that She will try to participate in the activities on the unit. The LCSW stated there should be activities in the secured unit but resident 32 had higher cognition than the other residents, so she needed more stimulating activities. 5. Resident 81 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, hyperlipidemia, hypertension, major depressive disorder and anxiety. On 4/13/23 at 1:40 PM, an observation was made of resident 81. Resident 81 was observed watching a black and white television show. At 1:51 PM, resident 81 was observed to stand up and walk through the hallway. Resident 81 stated she would like things to do and it was boring around there. Resident 81 stated she liked to play cards. Resident 81's medical record was reviewed 3/28/23 through 4/25/23. An admission MDS dated [DATE] revealed it was very important for resident 81 to listen to music, to do things with groups of people, favorite activities and get fresh air when the weather was good. It was somewhat important to be around animals such as pets. Resident 81's BIMS score was a 4 out of 15 which indicated severe cognitive impairment. A care plan dated 6/11/22 revealed that resident 81 exhibited impaired activity patterns manifested by: impaired mobility, poor health/pain limits, needed reminders and assistance to and from activities, fatigue and cognitive impairment. The goals were resident 81 would attend 1 social activity per week for 90 days, would participate in independent leisure activities daily for 90 days, would continue life roles in accordance with preferences, and would maintain highest level of independence. Some interventions included to monitor for satisfaction with leisure choices, post calendar in room, supply with independent leisure choices, invite and assist to/from group activities, ensure proper lights and space, and encourage and support the continuation of life roles. An assessment titled Activities- Initial Review dated 6/9/22 revealed resident 81's past activity interests were pets, games, music, socials, reminiscing, outings, visiting, and outdoors. Resident 81 wished to participate in activities, participate in group activities, and participate in independent activities. The assessment revealed that activities were to be modified to accommodate cognitive deficit and assistance should be provided to get resident to activity. An activity interview for daily and activity preferences dated 1/13/23 revealed resident 81 was not assessed. 6. Resident 79 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, major depressive disorder, anxiety, altered mental status, insomnia, personal history of traumatic brain injury, and history of thrombosis and embolism. Resident 79's medical record was reviewed from 3/28/23 through 4/25/23. Resident 79's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severely impaired cognition. The MDS revealed that resident 79 was not assessed for activity preferences. An activity care plan dated 10/24/22 and revised on 3/21/23 revealed [Resident 79] exhibits impaired activity patterns manifested by: impaired mobility, poor health/pain limits activity involvement, need for reminders and assistance to/from activities, mood diagnosis. The goals were that resident 79 would participate in independent leisure activities daily for 90 days; would continue life roles in accordance with preferences, strengths, and functional capacity weekly for 90 days; would maintain highest level of independence possible for 90 days; and attend at least 1 social group per week for 90 days. Some interventions included to monitor for satisfaction with leisure choices, post the calendar in room, supply with independent leisure materials as needed, support independent leisure choices, invite and/or assist to/from group activities, help ensure proper lighting, sufficient space for activities both in and out of room, encourage and support the continuation of life roles, and provide adaptations to activities as needed. On 3/30/23 at 11:48 AM an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated that there were not many activities for residents. CNA 1 stated that she had only seen two or three activities a month in the secured unit. CNA 1 stated that a lot of the residents on the long-term care side of the building had behaviors, and the behaviors seemed to increase when there are no activities. On 4/13/23 at 3:28 PM, an interview was conducted with Administrator (Admin) 1. Admin 1 stated there was one full time activities staff member and a part time staff member. Admin 1 stated he was looking into hiring a full time director. Admin 1 stated he did not currently have an Activities Director. Admin 1 stated there were multiple CNA's that were trained for the Silverado program. Admin 1 stated there were activities daily for residents to attend. Admin 1 stated that CNA's should be doing the activities in the secured unit. Admin 1 stated activities in the secured unit were not happening daily. On 4/13/23, an interview was conducted with Staff Member (SM) 16. SM 16 stated the facility wanted her to do activities in the secured unit. SM 16 stated sometimes activity staff came and try to do activities with residents in the secured unit like paint, play with puzzles, and try to do things. SM 16 stated residents in the secured unit were only getting activities once in a while. SM 16 stated it was hard to do activities when there are 2 CNA's in the secured unit because there were showers and other things that had to get done. SM 16 stated some of the residents go for BINGO and some other activities outside the unit, if the residents were less aggressive. On 4/13/23 at 2:38 PM, an interview was conducted with LPN 3. LPN 3 stated resident 32 was not able to leave the unit because she had left and went onto the highway with her wheelchair. LPN 3 stated that resident 32 had a lot of behaviors and lots of medications. LPN 3 stated resident 32 was in the secured unit because she stopped taking her anti-psychotic medications. LPN 3 stated resident 32 would need one on one supervision if she left the secured unit for activities and there were not enough activity staff members. On 4/25/23, an interview was conducted with SM 26. SM 26 stated a couple weeks ago they were talking about implementing more activities to keep residents busy in the secured unit. SM 26 stated that if CNA's had time then CNA's did activities. SM 26 stated that the activities staff came over but was not sure how often they came to the secured unit. SM 26 stated activities came probably a couple times a week. SM 26 stated there were movies or westerns in the TV room or residents were able to sit at the nurses station. SM 26 stated that resident 79 liked doing games or anything with his hands. SM 26 stated that resident 79 was an educated man and liked building things. On 4/25/23, an interview was conducted with SM 20 and SM 21. SM 21 stated activities were provided twice a week in the secured unit. SM 20 stated that she was unable to provide activities in the secured unit and activities for the residents outside the secured unit. SM 20 stated there needed to be a full time activities staff member for the secured unit. SM 20 and SM 21 stated there currently was not an Activities Director. SM 20 stated in the secured unit there was nothing for residents to do and they wandered around. SM 20 and SM 21 stated when residents in the secured unit see the activity staff, the residents swarm us and ask for BINGO. SM 21 stated resident 79 liked BINGO and to visit with others. SM 21 stated when resident 79 first admitted to the facility, he was into his computer. SM 21 stated resident 79 came to music activities. SM 20 stated when resident 79 resided in the secured unit, he did not fit in because he had a TBI verses dementia. SM 20 stated the activities on the unit were geared more toward memory care. SM 20 stated the activities outside the secured unit were higher functioning and he enjoyed those. SM 21 stated resident 79 enjoyed gardening. SM 21 stated that resident 86 went to all activities. SM 21 stated that resident 86 was willing to participate in any activities and enjoyed them. SM 21 stated that all the residents in the secured unit enjoyed any activity. SM 20 stated resident 81's favorite activity was BINGO. SM 20 stated that resident 81 got irritated really easily. SM 20 stated resident 81 was able to leave the secured unit for BINGO. SM 20 stated resident 81 will come to activities and will hang back and watch the activity. SM 20 stated that resident 81 came to activities and made comments like This is what we did in 1st grade. SM 20 stated that resident 81 did not like to paint her nails. SM 20 stated that resident 32 resided on and off the secured unit. SM 20 stated that when resident 32 was off of the secured unit, she went to all the activities. SM 20 stated she did not feel like resident 32 belonged in the secured unit. SM 20 stated resident 32 did not attend activities in the secured unit because she was much higher functioning. SM 20 stated the activities on the secured unit did not meet resident 32's needs. SM 20 stated resident 32 liked to play cards and other activities that stimulated her brain. SM 20 stated if residents resided in the secured unit, that did not mean that residents had to stay there for everything. SM 20 stated LPN 3 yelled at staff and hung signs on the door in the secured unit to not let residents out. SM 20 stated that the Administrator yelled at staff for taking residents off the unit for an activity. SM 21 and SM 20 stated that last week resident 32 was able to come off the unit for activities. SM 20 stated LPN 3 tried to control everything that residents did. SM 20 stated that activities were the residents safe place. SM 20 stated that a resident with a TBI did not belong in the dementia unit. SM 20 stated a TBI resident had more cognition than a resident with dementia. SM 20 stated a resident with psychiatric diagnoses did not belong in a dementia unit. SM 20 stated We have fought this battle for 2 years. SM 20 and SM 21 stated they felt like if they left their jobs, then there was no one to fight for the residents. SM 20 stated that Administrators ignored them and Administrator 3 laughed at staff when abuse was reported. SM 20 stated staff were not able to report abuse. SM 20 stated that Administrator 1 blew us off when we brought up abuse concerns. SM 20 and SM 21 stated that Administrator 1 said that nursing and therapy were the departments that took priority. SM 20 stated a lot of abuse allegations came from lack of activities. SM 20 stated the secured unit only has a short area to walk and there were not enough CNA's to care for the residents. SM 20 stated that there were 1 to 2 CNA's staffed for the secured unit and once CNA for the Colonial hallway. SM 20 stated that corporate told staff if staff talked to state it would come back to haunt you guys. SM 20 stated after survey left after the last survey things became worse. SM 20 stated that an Master Therapeutic Recreation Specialist (MRTS) completed care plans but had not been in the building. On 4/19/23 at 2:26 PM, an interview was conducted with Administrator 2. Administrator 2 stated the MTRS was not reachable at this time. 22992 On 4/25/23 at 12:43 PM, an interview was conducted with the Consultant MTRS. The MTRS stated that she had not been consistent in providing the facility with monthly reports because we've been meeting remotely. The MTRS also stated that she had not been conducting meetings regularly with the facility activities staff. The MTRS stated that the main focus she had when she met with the facility activities staff was trying to get caught up on paperwork. The MTRS stated that facility activities staff have been overwhelmed because there were not enough activities staff to provide activities to the residents in the secured unit on a consistent basis. The MTRS stated that she and the facility activities staff had been advocating for more activities staff to meet the residents' needs but that, There's been so much turnover in administration I feel discouraged because no one is responding.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 80 sampled residents, a resident's vancomycin level was not monitored appropriately resulting in vancomycin toxicity. This was cited at a harm level for resident 208. Additionally, a resident's blood sugars were not monitored according to the physician's orders. Resident identifiers: 208 and 257. Findings Included: HARM 1. Resident 208 admitted on [DATE] with the following diagnoses that included but not limited to toxic encephalopathy, chronic obstructive pulmonary disease, methicillin resistance staphylococcus aureus infection as the cause of diseases, anemia, anxiety disorder, depression, cognitive communication deficit, muscle weakness, difficulty in walking, and unsteadiness on feet. Resident 208's medical record was reviewed from 3/28/23 through 4/25/23. Physician orders for resident 208 indicated that when the resident was admitted , he had orders for 1250 milligrams of Vancomycin twice to be administered intravenously twice daily. The electronic medical record had an alert that indicated This order is outside of the recommended dose or frequency. A review of the Medication Administration Audit Report for March 2023 revealed the following entries: a. On 3/27/2023 at 10:47 PM resident 208 was administered vancomycin. b. On 3/28/2023 at 10:08 AM resident 208 was administered vancomycin. c. On 3/28/2023 at 8:41 PM resident 208 was administered vancomycin. d. On 3/29/2023 at 10:04 AM resident 208 was administered vancomycin. e. On 3/29/2023 at 8:34 PM resident 208 was administered vancomycin. Physician orders dated 3/27/23 indicated that resident 208 was to have a vancomycin trough drawn 30 minutes prior to 3/27/23 dose. On 3/27/23 a lab requisition form was completed for resident 208. The collection time was listed as 9:50 PM. Vanco Trough was handwritten in the bottom right corner of the form. The form did not indicate that the lab was supposed to be drawn as a STAT (as fast as possible) lab. Review of laboratory results revealed that a vancomycin trough was collected from resident 208 on 3/27/23, and that the laboratory received the sample on 3/29/23, two days later. The laboratory results also listed that the lab reported the results to the facility on [DATE]. The results listed that the reference interval for the vancomycin trough was 10.0 to 15.0. The results also listed that resident 208's vancomycin level was 57.3. There was an Alert listed that stated: Toxic: Trough Vancomycin concentrations greater than 20 may be associated with the onset of nephrotoxicity . Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity. A Nursing Progress Note from 3/30/23 at 9:00 AM indicated that the facility had received the results of resident 208's vancomycin trough and had sent the resident to the local emergency room for evaluation. On 3/30/23 at 9:54 AM, an interview was conducted with Registered Nurse (RN) 10. RN 10 stated that during morning report she was notified resident 208 had high vancomycin levels. RN 10 stated during her rounds she observed resident 208 was lethargic and had noticeable twitching. RN 10 stated that the physician ordered resident 208 to be sent to hospital by ambulance. RN 10 did not indicate why resident 208 had not been sent out when the lab results were initially received. Hospital records for resident 208 dated 3/30/23 were reviewed. The records indicated that when resident 208 presented to the emergency room , his vancomycin levels were drawn and had increased to 92.7. The hospital staff documented that Patient comes in altered. We gave him Narcan 0.4 mg (milligrams) IV (intravenously). He immediately came to. He is on long-acting morphine and oxycodone for breakthrough. I think with his situation, the narcotics have probably 'stacked' is not metabolize (sic) in normally. Patient shows acute renal failure. This is new from when he left the hospital just a week ago. Also vancomycin level is quite high. Last given vancymycin 9:00 PM last night . vancomycin toxic. Patient admitted to intermediate care center. An interview at 4/17/23 at 12:09 PM was conducted with Nurse Practitioner (NP) 1. NP 1 stated they want lab results within an hour after pulling a vancomycin trough unless it was critical in which they want a phone call, not a text message. On 4/24/23 at 11:25 AMm an interview with Licensed Practical Nurse (LPN) 2 was conducted. LPN 2 stated when a resident was receiving vanco she would look for lab orders from the physician. For a vanco trough LPN 2 stated they would do the serum draw 30 minutes prior to medication administration. LPN stated for a vanco trough she would always order the lab STAT due to needing the results by the next dose, if the physician did not already order lab as STAT. On 4/18/23 at 10:10 AM an interview with RN 5 was conducted. RN 5 stated Vanco troughs should be done 30 minutes to an hour prior to the fourth dose of vancomycin. RN 5 would send vanco trough labs STAT (as soon as possible) to the lab for processing. RN 5 stated that routine labs took about 3 days. RN 5 stated she would call the lab for a pickup when it is a STAT order. RN 5 stated she would chart a progress note when the lab company picked labs up. RN 5 stated that the lab company would call when lab results were ready and alert the nurse of any lab values that were out of range. RN 5 stated the lab company would also fax over the results. RN 5 stated she would then contact the physician of lab results and follow up with any additional orders. An interview with Director of Nursing (DON) 3 on 4/20/23 at 1:34 PM was conducted. DON 3 stated that she had spoken with the physician after resident 208 was sent out to the hospital. DON 3 stated that the physician stated that the vancomycin blood draw needed to be done 30 minutes prior to administration of medication; this is so the lab results would be available prior to the next dose. DON 3 stated that the lab should call in with results and the physician needed to be notified so any changes can be noted and ordered. A call was made on 4/24/23 at 10:22 AM to the lab company customer service. The Customer Service Representative (CSR) stated they called the facility and reported results on 3/30/23 at 9:00 AM. The CSR stated that once the labs were picked up, they were sent out of state for processing. The CSR stated that resident 208's labs were sent out of state for processing on 3/29/23 at 4:47 PM. The CSR stated that the facility staff did not mark resident 208's vancomycin trough as a stat lab, and so it was processed as a routine order, which took approximately 3 days to process. According to the National Library of Medicine regarding the administration of vancomycin, Elderly patients are more prone to vancomycin toxicity with IV [intravenous] administration due to age-related changes in renal function . These patients need to be carefully monitored . and the target therapeutic serum trough concentration .typically ranges between 10 mcg/mL to 20 mcg/mL. (https://www.ncbi.nlm.nih.gov/books/NBK459263/#article-30965.s7) 47431 46232 POTENTIAL FOR HARM 2. Resident 257 was admitted to the facility on [DATE] and discharged on [DATE] with the following diagnoses but not limited to a traumatic brain compression without herniation, type 2 diabetes mellitus, end stage renal disease, gastroparesis, post traumatic seizures. On 3/28/23 at 10:23 AM, an interview was conducted with resident 257. Resident 257 stated, in the six days he had been here he had noticed it took the nurses a while to give him his medications even after he has asked for them. Resident 257 stated he had to remind the nurses to check his blood sugar and give him his insulin. Resident 257 stated on his first night here, the nurses did not check his blood sugar timely. Resident 257 stated he remember feeling weird and then the nurses finally checked his blood sugar and saw that it was high. Resident 257 stated the nurses had to chase his blood sugar down until it was finally back down in the 200's. Resident 257's medical records were reviewed on 4/11/23. Resident 257's care plan was reviewed and revealed a care area that stated Resident 257 had DM II and was managed with insulin. The documented goal was resident 257 would not have any complications related to diabetes. An intervention was identified and included as followed: Monitor/document/report PRN [as needed] compliance with diet and documented any problems. The care plan was initiated on 3/23/23 A physician's order dated 3/22/23, documented as followed: Blood glucose test ac [before meals] & has [sic] [at bedtime]. Notify MD [medical director] bs [blood sugar] above 350 or below 60 before meals and at bedtime . [Note: This meant a resident's blood sugar needed to be checked 4 times a day.] A review of the daily blood sugar summary for the months of March and April revealed the following days resident 257's blood sugar were not checked as ordered: a. On 3/23 there were no documented blood sugar checks before his 3 meals and at bedtime. b. On 3/28 there were no documented blood sugar check before his breakfast. Resident 257's progress notes were reviewed and documented the following about his blood sugars: a. On 3/24/23 at 00:59 AM, a nurses note documented, Received in report by med pass nurse that resident's BS had been reading Hi. Stated per MD orders to recheck resident throughout the night. After checking resident's BS was 545, called MD who stated to give an additional 18 units of Humalog and recheck in a couple of hours. b. On 3/24/23 at 4:17 AM, a nurses note documented, Resident BS rechecked, was 422, MD notified. Awaiting new orders. Resident is bed resting this shift, has been alert and oriented x4 and able to make needs known. c. On 3/24/23 at 5:57 AM, a nurses note documented, Rechecked resident's BS, now 327, MD notified. [Note: No documented was located to indicated that resident 257's blood sugar had been checked on 3/23/23. The progress notes documented how the nurses were chasing resident 257's blood sugar down since it had not been adequately monitored on 3/23/23.] On 4/19/23 at 1:36 PM, an interview was conducted with the Director of Nursing (DON) 3. The DON 3 stated a resident's blood sugars were checked by the registered nurse as ordered by the provider. The DON 3 stated if the blood sugar was over a certain number as set by the physician parameters, they expected the nurse to notify the provider. The DON 3 stated a progress note should be made to document that provider was notified and if any new orders were received. On 4/24/23 at 1:44 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated blood sugars were checked by the nurses and they were checked before meals and at bedtime. RN 5 stated a resident's blood sugars were found in the weight/vitals tab and it showed when the blood sugars were obtained. RN 5 stated a provider was notified about a resident's blood sugars, if it was outside of the ordered parameters. RN 5 stated normally a progress note was made to document the provider was notified and what new orders were received.

Based on observation, interview and record review it was determined for, 1 of 80 sampled residents, that the facility did not ensure each resident had the right to be free from abuse, neglect, misappropriate of resident property, and exploitation. This includes but was not limited to freedom from involuntary seclusion. Specifically, a resident was not assessed to determine if a locked unit was appropriate. The deficient practice was determined to have occurred at a harm level. Resident identifiers: 32. Findings include: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, toxic encephalopathy, paroxysmal atrial fibrillation, paranoid schizophrenia, depression, anxiety, and cognitive communication deficit. On 3/28/23 at 1:09 PM, an interview and observation was conducted of resident 32. Resident 32 was in her room in the secured unit. Resident 32 was observed to be in bed with the lights off and a curtain pulled around her bed. Resident 32 stated that she had previously resided outside of the secured unit and had an electric wheelchair. Resident 32 stated that a friend signed her out of the facility and she went to a local convenience store. Resident 32 stated while she was there she felt like her bowels were twisting so she called 911 with her cell phone. Resident 32 stated she was brought back to the facility and placed in the secured unit because facility staff said she had eloped. Resident 32 stated her electric wheelchair and cell phone were taken away. Resident 32 stated she wanted her cell phone back but no one gave her answers as to why she could not have it. Resident 32 stated that she asked staff to buy her energy drinks with her money and a nurse told her she was not allowed to have them. Resident 32 stated she wanted to move off of the secured unit. Resident 32 stated she was unable to go to activities outside of the secured unit. On 4/25/23 at 10:16 AM, a follow-up interview was conducted with resident 32. Resident 32 stated that she felt like a prisoner being in the secured unit. Resident 32 stated she signed out but staff stated she did not, so she was placed in the secured unit. Resident 32 stated it was kind of harsh that she was placed in the secured unit. Resident 32 was observed with a cell phone. Resident 32 stated she was provided her phone back and was really happy about that. Resident 32's medical record was reviewed from 3/28/23 through 4/25/23. A hospital History and Physical from a Behavioral Health facility dated 7/14/22 revealed resident 32 had aggressive behaviors and psychosis. The history of present illness revealed resident 32 was a [AGE] year old with a history of neurocognitive disorder and was recently discharged from inpatient psychiatry. Resident 32 was discharged to a nursing facility and became aggressive, hitting and kicking staff, and refused to take her medications. Resident 32 attempted to leave and fell out of wheelchair and was taken to the emergency room by emergency medical services. Resident 32 was readmitted for stabilization and evaluation. Resident 32's problem list/past medical history revealed aggressive behavior of adult, delusional disorder, generalized anxiety disorder, major depressive disorder, mood swings and patient incapable of making informed decisions. There was no diagnoses of dementia or schizophrenia. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 32 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition was intact. Resident 32 did not have inattention, disorganized thinking or altered level of consciousness. There was no care plan regarding resident 32 in the secured unit. A care plan dated 7/26/22 and updated 4/14/23 revealed that resident 32 had impaired cognitive function/dementia or impaired thought processes related to cerebral vascular accident and schizophrenia. The goal was that resident 32 would be able to communicate basic needs on a daily basis through the review date. Interventions included to ask yes/no questions; communicate with resident/family/caregivers regarding residents capabilities and needs; and communication by using resident name, identifying yourself, face the resident and make eye contact, reduce distractions and provide necessary cues to stop and return if agitated. An Admit/Readmit Screener dated 7/14/22 and was locked on 7/15/22 revealed, resident 32 was alert and oriented to person, place, time and situation. Resident 32 was verbally appropriate. An admission wander risk scale dated 7/14/22 was started by Licensed Practical Nurse (LPN) 3 but was incomplete. The section completed revealed resident 32 scored a 10 and was at risk to wander. According to the census section in the medical record, resident 32 was admitted to the secured unit on 7/14/22 until 9/15/22. Resident 32 resided outside of the secured unit from 9/16/22 until 12/31/22. Resident 32 was readmitted to the secured unit 1/1/23. There were no Evaluations for Admission to Specialized Care Unit assessments completed to determine if resident 32 required a secured unit. A nursing progress note dated 7/28/22 at 6:37 PM, revealed that resident 32 had a Power of Attorney (POA) and the POA wanted to be notified of any changes in condition and care being done. There were no nursing progress notes regarding resident 32 being from transferred from the secured unit to the non-secured unit around 9/15/22. There were no nursing progress notes from 12/29/22 until 1/4/23 regarding resident 32 being readmitted to the secured unit. An Alert note dated 2/9/23 at 9:25 PM revealed, Resident has not returned from leaving facility. She was given permission to leave on her own from her POA at the last IDT [interdisciplinary team]. Calls made to resident cell phone and calls go straight to voicemail. Message left for POA and police notified .MD [medical doctor] aware and administration aware. Other family contacted as well ex husband whose line was busy. A nursing progress note dated 2/10/23 at 12:58 AM revealed, that resident 32 returned from the hospital with emergency medical services (EMS). Resident 32 was asking EMS to take her back to the hospital. Resident 32 stated her wheelchair was at the corner store and she did not want to talk about it. Report was received by the emergency room staff that resident 32 arrived at the ER without her wheelchair asking for assistance. The hospital called the facility, family and Director of Nursing (DON) to inform them of where resident 32 was. Resident 32 was placed on 15 minute checks per the DON. A nursing progress note dated 2/10/23 at 7:59 PM revealed, the POA wanted resident 32 to remain in the facility with no unsupervised trips outside the facility until the care conference 2/13/23. A physician's progress note dated 2/11/23 at 7:22 PM revealed, Patient returned back from [local hospital] ER. She is hallucinating and will not let the nurse's approach her. She is still refusing medications. She stated she has razor blades in her wheelchair. She is in her wheelchair at the front door . DON, attempted to call POA, but it's an office number with no emergency number. At this time, for [resident 32's] safety, we will send her back to [local hospital] ER and ask them to give her a haldol injection plus invega. If they are unable do to invega, we can give iton [sic] return. I gave an order to keep her in Cambridge due to her high risk of elopement at this time. A physician's progress note dated 2/14/23 at 8:49 PM revealed, Pt last week eloped out of the building in the afternoon. She eventually returned late in the day. She was placed in the locked down Memory Care unit given her propensity to leave on her own without telling anyone . A nursing progress note dated 2/15/23 at 5:59 PM revealed, Pt is allowed to call EMS; providers do not [sic] patient to go to hospital for abd [abdominal] pain; EMS can assess pt and make their clinical decision. Please fill in EMS on the various times pt has gone to ER for abd pain. A physician's progress note dated 2/19/23 at 12:54 PM revealed I am seeing [resident 32] today about a mobility evaluation. She has limited mobility due to hemiplegia and hemiparesis, following cerebral infarction affecting the dominant right side. We discussed her need for a power mobility device to assist with her mobility related activities of daily living. She cannot safely or properly use a cane, walker, standard lightweight wheelchair, or ultra lightweight wheelchair due to muscle weakness and difficulty walking. She requires limited to extensive assistance with one person, physical assistance with her ADL's [activities of daily living] and, therefore, requires a power wheelchair to safely complete MRADL's [Mobility-Related Activities of Daily Living] in the home environment. I agree that she would benefit from using this equipment, and I am referring her to a specialty evaluation by a licensed physical or occupational therapist to make power mobility recommendations. A social service note dated 4/11/23 at 9:32 AM revealed, Sent referral for transfer to [name of long term care facility] on 4/11/2023. Guardian would like pt [patient] to go somewhere that has a wander guard because feels that pt is not a good fit for the memory care unit but is a risk of elopement based off history prior to coming to our facility. A physician's progress note dated 4/13/23 at 7:56 AM, I have met face-to-face with the patient, the primary reason for examination was to discuss power mobility. They use their wheelchair for [greater than] 12 hours per day. The endurance limitations from current condition make it difficult for them to perform activities of daily living, ex: toileting, dressing, showering and eating. They use the wheelchair for all activities throughout the day but is no longer has the strength and coordination to mobilize in the wheelchair. The patient has difficulty with mobility in all areas of her MRADL's and is unable to accomplish them without a power wheelchair. The patient is unsteady with transfers requiring 2 person transfer, and has a very unsteady gait with a high fall risk so spends most of the time in a wheelchair for mobility. Given the decreased strength in the upper extremities and easy fatigability, and poor balance further places the patient at risk of falls. A power wheelchair would preserve some of the patient's strength to use in the more important activities that the patient needs to do. The patient's mobility limitations cannot be solved with a cane or front wheel walker as the patient does not have sufficient strength in the upper and lower extremities to position themselves and they rely on the wheelchair to participate in MRADL's including toileting, bathing, grooming and dressing. I am recommending the patient to therapy to further prescribe the other items that would be needed for the patient to be best suited for the patient and their activities. On 4/11/23 at 10:41 AM, an observation was made of resident 32. Resident 32 was observed to ask Activities Assistant (AA) 1 if she was going to the store. AA 1 was observed to respond yes. Resident 32 asked AA 1 if she had gotten her money and AA 1 stated no, because she was told resident 32 did not have money. On 4/12/23 at 1:27 PM, an interview was conducted with the local mental health Licensed Clinical Social Worker (LCSW). The LCSW stated she sent a list of resident that were currently receiving services to the Resident Advocate (RA) that morning. The LCSW stated she saw residents every other week. The LCSW stated that after she visited with residents she provided a paper with any issues on it to the RA. The LCSW stated she completed psychiatric evaluations. The LCSW stated she was able to provide a copy of her notes and evaluations, if requested by the facility. The LCSW stated resident 32 was receiving services because she was having trouble with taking her medications, she was committed to the facility, had been doing well with her medications and taken her off services. The LCSW stated she saw resident 32 on 4/5/23 and 3/29/23 because she had started refusing her medications. On 4/13/23 at 2:27 PM, an interview was conducted with Administrator (Admin) 1. Admin 1 stated residents in the secured unit were provided activities in the unit. Admin 1 stated he was working on hiring a full time employee to do activities on the secured unit. Admin 1 stated that activities were provided twice a week in the secured unit. Admin 1 stated residents on the secured unit were not allowed to come out of the unit very often. Admin 1 stated resident 32 had been going to BINGO but was told no because she eloped from the facility. Admin 1 stated he was not sure if resident 32 was able to leave the unit for activities with supervision. On 4/19/23, the local LCSW's notes were reviewed and revealed on 3/29/23 from 10:45 AM until 11:08 AM the LCSW met with resident 32. The notes revealed a Goal: 'I want to figure out how to deal with my psychosis so I can live around others and they not [sic] want me to leave.' The objective section revealed 'Within the next six months, [resident 32] will work on learning coping skills to use when she feels her thoughts starting to take over as evidenced by not using coping skills to using 1-2 a day.' The Client report section revealed 'I don't know why they brought me back to this place. I think I should be able to do things with the other residents outside of this unit. They told me that I didn't follow the rules. Someone signed me out and back in and it wasn't me. My phone got broken by someone here and my tablet isn't working, either. This has me feeling down.' The therapist interventions were explored with client the reason for her move to the secure unit. Talked about her feeling depressed, things she can try to do, use light to help her feel better vs [versus] staying in a dark room with the curtains drawn around her. Discussed having some help getting her electronic devices replaced/fixed. Followed up on homework. The report of progress revealed She is making progress as seen by her talking about feeling down with the room change and more restrictions on her freedom. The future plan was She is going to talk to the staff about what it will take for her to move off the secure unit. On 4/29/23, the local LCSW's notes were reviewed and revealed on 4/5/23 from 11:17 AM until 11:33 AM the LCSW met with resident 32. The notes revealed the same goal and objectives. The Client report revealed 'I don't have any problems today. I am watching people put puzzles together.' The therapists interventions revealed Facility asked for another visit today. Discussed getting involved in activities on the unit. Explored why she wasn't doing puzzles; no interest in it today. Client was observed being pushed around in a wheelchair and was still in her pajamas. The report of progress revealed Client was moved to the secure unit a few weeks ago due to not taking her meds. She has become less active and more dependent on others. There appears to be an increase in her psychosis. The future plan was She will try to participate in the activities on the unit. On 4/19/23 at 2:05 PM, an interview was conducted with a local mental health LCSW. The LCSW stated resident 32 told her that she left the facility and when she was brought back they placed her in the secured unit. The LCSW stated there would not be a concern about her going out of the unit for activities. The LCSW stated she did not feel the activities with other residents that had decreased cognition were appropriate for resident 32. The LCSW stated resident 32 had been surrounded by residents with baby dolls and doing puzzles. The LCSW stated it would be hard to be surrounded by people who did not meet the level of impact or cognition. The LCSW stated that each resident has a future plan at the end of every visit, so that the resident had something to do. The LCSW stated she did not follow-up with residents' future plans at the next visit. The LCSW stated she did not know if resident 32 had asked about moving off of the secured unit. On 4/20/23 at 12:24 PM, an interview was conducted with DON 3. DON 3 stated she was not sure of the specific criteria to determine if a resident was appropriate for the secured unit. DON 3 stated there was an assessment titled NSG (nursing): Evaluation for Admission to Specialized Care Unit. DON 3 stated if the resident met the criteria in the assessment, then the resident was appropriate for a secured unit. On 4/25/23 at 10:56 AM, a follow-up interview was conducted with DON 3 and Chief Nursing Officer (CNO). DON 3 stated there was no assessment completed for resident 32 to determine if she required a secured unit. DON 3 stated that the assessment would document the reasons for the placement on the secured unit. DON 3 stated without the assessment and staff were no longer employed with the facility, who determined reasons for her to reside in the secured unit. DON 3 and CNA stated they were unable to speak regarding a rationale. DON 3 stated there was some misunderstanding with staff regarding resident 32 being able to leave the secured unit for activities. DON 3 stated LPN 3 prevented residents from leaving the unit. The CNO stated that there was a nurse that was upset that a resident was allowed to leave the unit and talked to him about it. The CNO stated an additional full time activity staff member for residents with decreased cognitive ability, and who would provide more activities on the secured unit would be best. CNO stated facility staff did not know why resident 32 was placed in the secured unit, why her phone was taken away, why her electric wheelchair was taken away and why she did not have a television in her room. On 4/25/23 at 8:58 AM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that resident 32 needed a wheelchair evaluation done, but the physician had not signed paperwork. The DOR stated then resident 32 started having behaviors and was unable to use an electric wheelchair. The DOR stated he did not think that electric wheelchairs were allowed in the secured unit. The DOR stated he was not sure if facility staff communicated that to resident 32 very well. The DOR stated there was a psychiatric history with resident 32. The DOR stated he thought maybe she tried to use her electric wheelchair as a weapon but did not know the details or situation. The DOR stated resident 32 knew how to use the electric wheelchair, but the DOR did not know enough about her psychiatric history. The DOR stated he did not understand why resident 32's wheelchair was taken away. The DOR stated he was working on getting an electric wheelchair in case she could have it later. The DOR stated there was a delay because of the physician's signature, then the facility took her electric wheelchair away and then the whole thing was put on ice for a while. The DOR stated he had not seen resident 32 unsafe and knew she had paranoid schizophrenia, so the facility staff must have been nervous enough to say no. The DOR stated wheelchair evaluations were outsourced to a representative. The DOR stated he would have to call and find out when the representative was contacted for a wheelchair evaluation. On 4/25/23 at 8:37 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated that when resident 32 was brought to the secured unit, she was not allowed to use an electric wheelchair. RN 6 stated resident 32 was able to mobilize to her room from the nurses station in a regular wheelchair. RN 6 stated she was not aware of therapy evaluations for electric wheelchair. RN 6 stated electric wheelchairs were not allowed on the secured unit because there were a lot of residents that wandered. RN 6 stated resident 32 had not tried to leave the facility when she was working. RN 6 stated resident 32 sat by the door in the secured unit. RN 6 stated there needed to be more activities in the secured unit and more supervision for residents to leave the unit for activities. On 4/25/23 at 11:11 AM, an interview was conducted with the RA. The RA stated there was a plan for resident 32 to transfer to another facility with a wander guard system. The RA stated that another long term care facility had agreed to come assess resident 32. The RA stated that the guardian was fine with a transfer to a facility with a wander guard system. The RA stated that resident 32 had been approved by New Choice Waiver (NCW) but the guardian was not okay with the resident not going to an assisted living facility without a secured unit because she was not taking her meds and was exit seeking. The RA stated she had not tried a behavioral contract because typically she could not do those with residents that resided in the secured unit because of dementia. The RA stated that resident 32 was appropriate for the behavioral contract and the RA needed to reach out to her contract LCSW regarding a behavioral contract. The RA stated that resident 32 would not qualify for an assisted living memory care unit. The RA stated resident 32 had not discharged with the NCW because she was exit seeking. The RA stated resident 32 resided on the secured unit because she had exit seeking behaviors. The RA stated she had been told that resident 32 stopped taking her medications, so she was exit seeking. The RA stated she was not involved in determining that resident 32 needed to reside in the secured unit. On 4/25/23 at approximately 11:30 AM, an interview was conducted with Admin 2. Admin 2 stated during quarterly psychotropic meeting resident 32 should have been evaluated for the need to reside in the secured unit. Admin 2 stated resident 32 was at risk because of her mental illness and facility staff wanted to protect her from an extreme injury. Admin 2 stated resident 32 was tough to balance because with her mental illness resident 32 had good days and bad days. Admin 2 stated that on a bad day, resident 32 could make unsafe decisions. Admin 2 stated facility staff were doing their best to keep her safe but also respect her rights. Admin 2 stated the IDT and guardian needed to drive the decision and not take away her rights. On 4/10/23 at 11:15 AM, a phone interview was conducted with Director of Nursing (DON) 2. DON 2 stated since the previous IJ, staffing had been cut because of budget reasons. DON 2 stated the receptionist position was cut. DON 2 stated I was never told that they were unlocking the front doors, and there were several residents that were elopement risks that were able to get out of the facility. DON 2 stated corporate was back and forth if we were allowed to use the wander guard system but I was told no because we had Cambridge. DON 2 stated resident 32 had a state appointed guardian and she had been mandated to take her schizophrenia medication injections. DON 2 stated resident 32 refused the second injection. DON 2 stated resident 32 was following the rules and being reasonable, and aware of medical decisions, so they decided they were not going to make her take the second shot that was due. DON 2 stated the medication wore off, and she had delusions and she left. DON 2 stated resident 32 waited until someone walked away from the front door and then she left the facility. DON 2 stated resident 32 was having delusions about having her bowels twisting, and she went to the ER and they never found anything. DON 2 stated she was placed in the Cambridge unit because of the weather in February. DON 2 stated that the rules were, if you signed out, you have to have a way to contact help, and we have to be able to contact the resident. DON 2 stated she went to the ER when she was out and gave them a false name. DON 2 stated resident 32 continued to try and leave the facility so the guardian told DON 2 to place her in the Cambridge unit for her safety. DON 2 stated resident 32 needed to be evaluated by a psychiatrist and her medications needed to be addressed.

Based on observation, interview and record review it was determined, for 1 of 80 sampled residents, that the facility did not treat each resident with respect and dignity. This included the right to retain and use personal possessions. Specifically, a resident's phone and electric wheelchair were taken away. The deficient practice identified was cited at a harm level. Resident identifier: 32. Findings include: Resident 32 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, toxic encephalopathy, paroxysmal atrial fibrillation, paranoid schizophrenia, depression, anxiety, and cognitive communication deficit. Resident 32 resided on the secured unit. On 3/28/23 at 1:09 PM, an interview was conducted with resident 32. Resident 32 stated that she had previously resided outside of the secured unit and had an electric wheelchair. Resident 32 stated that a friend signed her out of the facility and she went to a local convenience store. Resident 32 stated while she was there her bowels felt like they were twisting so she called 911 with her cell phone. Resident 32 stated she was brought back to the facility and placed in the secured unit because facility staff said she had eloped. Resident 32 stated her electric wheelchair and cell phone were taken away. Resident 32 stated she wanted her cell phone back but no one gave her answers as to why she could not have it. Resident 32 stated that she asked staff to buy her energy drinks with her money and a nurse told her she was not allowed to have them. Resident 32's medical record was reviewed 3/28/23 through 4/25/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 32 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident 32 did not have acute onset of mental status change, inattention, disorganized thinking or altered level of consciousness. Resident 32 had delusions but no hallucinations. Resident 32 did not reject evaluation or care and did not wander. Resident 32 required limited 1 person assistance with locomotion on and off the unit. Resident 32 required extensive 1 person physical assistance with transfers. The MDS further revealed that resident 32 had range of motion impairment on one side to both upper and lower extremities. Resident 32 required a manual or electric wheelchair for a mobility device. A care plan dated 11/3/22 revealed resident 32 had an Activities of daily living (ADL) self-care performance deficit related to history of cerebral vascular accident, hemiplegia and weakness. The goal was was to maintain current level of function in ADLs through the review date. Interventions were to encourage resident to participate to the fullest extent possible with each interaction and encourage the resident to use bell to call for assistance. A nursing progress note dated 9/5/22 at 1:14 PM revealed, resident 32 complained of right foot pain. Resident 32 stated she smashed her foot between the wall and wheelchair. Educated resident on safety awareness. At 9:18 PM, an x-ray was completed with no acute fracture or dislocation, no bruising, or swelling noted. A nursing progress note dated 9/16/22 at 11:02 PM revealed, Uses electric w/c [wheelchair] for mobility . A nursing progress note dated 9/26/22 at 4:30 PM revealed, SSA [Social Service Associate] spoke with POA [Power of Attorney] in regards to getting resident a phone. Due to APS [Adult Protective Services] case with kids and not having the bank account completely secured they would like to hold off to ensure resident is not taken advantage of by kids. Once account is secured ssa with helpset [sic] up phone for resident. A nursing progress note dated 10/23/22 at 6:37 PM revealed, .Uses a motorized wheelchair to get about facility . A nursing progress note dated 10/24/22 at 11:30 AM revealed, a CNA (Certified Nursing Assistant) informed the nurse that resident's motorized wheelchair was stuck in the shower and then resident 32 ran her foot into the shower wall. The physician assessed the injury and noted pain to lateral side and slight swelling. An x-ray was ordered. A nursing progress note dated 10/24/22 at 7:11 PM revealed, .Uses a motorized wheelchair to get about facility . A nursing progress note dated 10/25/22 at 3:00 PM revealed that x-ray results for the right foot revealed no acute fracture or dislocation. An MDS note dated 1/20/23 at 6:00 PM revealed, .Locomotion- has electric wheelchair that she uses to get around, able to operate herself . A nurses note dated 2/10/23 at 12:58 AM revealed that resident 32 returned from a local hospital on a gurney. Resident 32 was asked where her wheelchair was she told staff it was at the corner store and she did not want to talk about it. The nurse received report that resident arrived at the emergency room without her wheelchair asking for assistance. A nursing progress note dated 2/12/23 at 12:12 PM revealed, Resident has refused all medications, breakfast, and cares this morning. Refuses to use manual w/c [wheelchair]. States she has an electric chair. Explained that electric chairs are not permitted on the locked unit. Continues to refuse manual w/c (wheelchair). Notified MD [Medical Doctor] of refusals. A nursing progress note dated 2/15/23 at 5:59 PM revealed, Pt [patient] is allowed to call EMS [Emergency Medical Services]; providers do not patient [sic] to go to hospital for abd [abdominal] pain; EMS can assess pt and make their clinical decision. Please fill in EMS on the various times pt has gone to ER for abd pain. A physician's progress note dated 2/19/23 at 12:54 PM revealed I am seeing [resident 32] today about a mobility evaluation. She has limited mobility due to hemiplegia and hemiparesis, following cerebral infarction affecting the dominant right side. We discussed her need for a power mobility device to assist with her mobility related activities of daily living. She cannot safely or properly use a cane, walker, standard lightweight wheelchair, or ultra lightweight wheelchair due to muscle weakness and difficulty walking. She requires limited to extensive assistance with one person, physical assistance with her ADL's and, therefore, requires a power wheelchair to safely complete MRADL's [Mobility-Related Activities of Daily Living] in the home environment. I agree that she would benefit from using this equipment, and I am referring her to a specialty evaluation by a licensed physical or occupational therapist to make power mobility recommendations. On 3/1/23 at 7:45 PM, Licensed Practical Nurse (LPN) 4 documented, I was told by [name removed](our front desk receptionist) that the resident was on the phone with dispatch again and [Director of Nursing (DON) 2], DON had been notified again and we were told to take the residents cell phone away and talk to dispatch. [Front desk receptionist] and I walked down the hall and told the resident we needed her phone to talk to dispatch. She told us to get our own phone she needed hers. [Front desk receptionist] was able to undo the straps of her case and get her phone and talk to dispatch. Later the phone was broughtover [sic] and put in the top drawer of the nurse cart. Resident began yelling that her phone was taken away. She eventually calmed down. She made her way to the front desk of Csmbridge [sic] and tried to grab the phone there. Staff was sitting nearby to moved it out of [sic] her reach. On 3/23/23 at 4:46 PM, Licensed Practical Nurse (LPN) 3 documented Resident has had several behaviors this shift. Agitation and aggression toward staff. Resident called 911 and reported she was having a heart attack. Nurse was not aware of residents complaint to emergency services, and had not been notified of any symptoms. Emergency arrived. Emergency team did not find anything that would warrant transporting to ER [emergency room ] for evaluation. V/S [vital signs] wnl [within normal limits]. Resident returned to her room, and there has been no further c/o [complaints of] symptoms. Resident has new order not allowing energy drinks. Resident has impaired judgement regarding the consumption of energy drinks. It has been noted that excess intake causes Insomnia, agitation, and behaviors. A physician's progress note dated 4/13/23 at 7:56 AM revealed, I have met face-to-face with the patient, the primary reason for examination was to discuss power mobility. They use their wheelchair for >12 hours per day. The endurance limitations from current condition make it difficult for them to perform activities of daily living, ex: toileting, dressing, showering and eating. They use the wheelchair for all activities throughout the day but no longer has the strength and coordination to mobilize in the wheelchair. The patient has difficulty with mobility inall [sic] areas of her MRADL's and is unable to accomplish them without a power wheelchair. The patient is unsteady with transfers requiring 2 person transfer, and has a very unsteady gait with a high fall risk so spends most of the time in a wheelchair for mobility. Given the decreased strength in the upper extremities and easy fatigability, and poor balance further places the patient at risk of falls. A power wheelchair would preserve some of the patient's strength to use in the more important activities that the patient needs to do. The patient's mobility limitations cannot be solved with a cane or front wheel walker as the patient does not have sufficient strength in the upper and lower extremities to position themselves and they rely on the wheelchair to participate in MRADL's including toileting, bathing, grooming and dressing. I am recommending the patient to therapy to further prescribe the other items that would be needed for the patient to be best suited for the patient and their activities. On 4/25/23 08:37 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated stated that resident 32 was not allowed to have her electric wheelchair when she was admitted to the secured unit. RN 6 stated resident 32 was able to mobilize to her room from the nurses station in a manual wheelchair. RN 6 stated she was not aware of therapy evaluations for electric wheelchair. RN 6 stated she was informed that electric wheelchairs were not allowed in the locked unit because there were residents with dementia that wandered and it was unsafe. RN 6 stated resident 32 had not tried to leave the facility since the RN had started working in the secured unit. RN 6 stated resident 32 sat by the locked door and asked to go to activities. On 4/25/23 at 8:58 AM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that at one point resident 32 was leaving and needed an electric wheelchair evaluation done, but then there was no physician's signature, so the evaluation was not completed. The DOR stated then resident 32 had behaviors and was unable to use the electric wheelchair. The DOR stated resident 32 was admitted to the secured unit and electric wheelchairs were not allowed on that unit. The DOR stated he was not sure if that information was communicated to resident 32 about no electric wheelchairs in the secured unit. The DOR stated he thought resident 32 tried to use her electric wheelchair as a weapon but did not know the details. The DOR stated he was not sure why the electric wheelchair was taken away. The DOR stated he did not know that the physician had written a note to evaluate resident 32 for an electric wheelchair. The DOR stated that he had not seen resident 32 be unsafe with her wheelchair but she had paranoid schizophrenia and it must have made the facility nervous enough to say no to an electric wheelchair. The DOR stated that electric wheelchair evaluations were outsourced to a representative. The DOR stated he had contacted the outside resource. The DOR was asked to provide information of when the resource was contacted and a timeline. The DOR did not provide additional information. On 4/25/23 at 10:51 AM, an interview was conducted with the Chief Nursing Officer (CNO) and Director of Nursing (DON) 3. DON 3 stated a nurse had put resident 32's cell phone in the medication cart. DON 3 stated LPN 3 had taken resident 32's phone and put it in the nurses medication cart. DON 3 stated LPN 3 took the phone because resident 32 was calling 911 frequently. DON 3 stated she did not know why resident 32 was calling 911 frequently. DON 3 stated she gave resident 32 her phone back and told staff that they can not keep the residents' phones. The CNO stated there was no investigation into the phone being taken. On 4/25/23 at 10:16 AM, a follow-up interview was conducted with resident 32. Resident 32 was observed with a cell phone. Resident 32 stated someone brought her back her phone. Resident 32 was observed in a manual wheelchair in the hallway. Resident 32 stated she was happy to have her phone back. Resident 32 stated she felt like a prisoner in the secured unit.

Based on interview and record review it was determined, for 7 out of 80 sampled residents, that the facility did not permit each resident to remain in the facility and not transfer or discharge the resident unless the resident's welfare and needs could not be met in the facility; or the safety of individuals in the facility was endangered due to the behavioral status of the resident. Additionally, when a facility transfers or discharges a resident under any circumstances the facility must ensure that the resident's medical record and information was communicated to the receiving health care provider. Specifically, the facility initiated a resident discharge/transfer after they suspected a resident of having a sexual relationship with another resident. There was no documentation of the facility's attempts to meet the resident's needs; the resident's Power of Attorney (POA) was not notified of the transfer; and the family representative reported that the resident was not happy in the new facility and the change in environment had caused the resident to have increasing behaviors associated with her dementia. The deficient practice identified occurred at a HARM Level. The facility initiated a resident discharge/transfer for the other resident identified in the sexual relationship and there was no documentation of the facility's attempts to meet the resident's needs, the POA was not given notice nor were the transfer options discussed with the POA. Additionally, multiple residents were transferred or discharged and no documentation was found in the medical records that demonstrated what information was communicated to the receiving provider. Resident identifiers: 2, 67, 76, 79, 86, 96 and 409. Findings include: HARM 1. Resident 409 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, altered mental status, muscle weakness and cognitive communication deficit. Resident 409 was discharged on [DATE]. Resident 409's medical record was reviewed from 3/28/23 through 4/25/23. On 8/24/22, resident 409's Admission Minimum Data Set (MDS) Assessment indicated that the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. On 8/18/22, a care plan was developed for resident 409 indicating that she required long term care services. A discharge care plan was not developed. On 1/24/23, resident 409's physician documented that they had evaluated the resident that day, but did not indicate that resident 409 would be discharged soon. On 1/24/23, a nurses note indicated that resident 409 was being discharged due to Altercations with other residents. On 2/2/23, a nurses note indicated that resident 409's daughter, who was also the resident's POA, contacted the facility. The note stated Family claims that they did not receive a voice mail or call from the facility indicating why [resident 409] was moved. AIT [Administrator in Training] claims that he did leave a voice mail informing family. SSA [Social Services] did let family know location, and why resident was moved. Family was not upset, but did express concerns about [resident 409] being under the impression that we told [resident 409] it was her daughters fault that she moved. No notes prior to this date indicated that the resident had a discharge plan, that the family had been involved regarding the discharge and other possible placement options, or that the facility Interdisciplinary Team had been involved in the discharge. On 4/5/23, an interview was conducted with resident 409's POA. The POA stated that she and her family were unaware of the resident's transfer to another facility. The POA stated that she did not know where her mother, resident 409, was for several days during January 2023. The POA stated that she called the facility to check on her mother, but they told her the resident was no longer at the facility, but would not tell her where the resident had gone because it was protected information. The POA stated that she only found out where her mother had been transferred to because the new facility called to ask her some questions about her mother. The POA stated that the new facility told her that resident 409 had been sexually acting out at South [NAME] Post Acute. The POA stated that no one gave me any information with who or what was going on. I'm her POA. I was very frustrated and angry about it. they (the facility staff) were not forthcoming about things. The POA also stated that resident 409 didn't know what was happening . She hasn't been doing well since this happened (the resident was transferred). She doesn't understand why she was moved. She had gotten more comfortable there, and her friends lived in [NAME]. The POA stated that resident 409's friends would visit the resident at least once a week, but they could not visit anymore because resident 409 had been transferred to a facility in Salt Lake, which was too far for the friends to travel. The POA stated that since being transferred to the new facility, resident 409 has been physically acting out, tried to escape . it exacerbated her dementia. It has gotten bad. She now doesn't recognize my brother. She is very angry because I won't take her out of there. She doesn't have the support system that she had before. Its been a nightmare that (they transferred the resident). It was so hard on her. On 4/13/23 at 2:28 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated he did not recall being involved in resident 409's discharge planning. On 4/12/23 at 1:12 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that it was the clinical team who decided who should be discharged , and where to. The RA stated that the clinical team consisted of the Medical Director, Director of Nursing and Assistant Director of Nursing. With regard to coordinating the resident's discharge with family members, the RA stated I would prefer to notify the families first if possible. When asked about resident 409's discharge, the RA stated that it was the previous AIT who had initiated the discharge. The RA stated that the AIT had notified the family of the discharge via telephone, but had misdialed one of the numbers, so the family member did not receive the voicemail. The RA stated that both the family members and resident 409 were upset about the discharge. Neither the AIT or Director of Nursing who were present during resident 409's discharge were still employed at the facility, and therefore, not interviewed. POTENTIAL FOR HARM 46232 2. Resident 2 was admitted to the facility on [DATE] and discharged from the facility on 3/29/23 with the following diagnoses that included but not limited to Alzheimer diseases, type 2 diabetes mellitus, major depressive disorder, anxiety disorder, and muscle weakness. On 3/28/23 at 10:00 AM, an interview was conducted with resident 2. Resident 2 stated she was waiting to get into an assisted living facility close to where her family lived. Resident 2 stated she was just waiting on the facility to send over paperwork. Resident 2 stated she was unsure what the delay was in getting the paperwork sent. Resident 2's medical record was reviewed from 3/28/23 through 4/25/23 On 1/5/23, A quarterly MDS indicated that resident's BIMS score was a 10, indicating resident 2 had moderate cognitive impairment. On 4/15/22, a care plan was developed for resident 2 indicating that she required short term skilled services. A listed intervention was documented as followed, the facility will coordinate appropriate discharge environment with resident/ responsible party. Resident 2's progress notes were reviewed and documented the following entries: a. On 3/28/23, resident 2 purposefully smashed her wheelchair into another resident. b. On 3/28/23 at 1:34 PM, a nurse note documented, 1:1 CNA [certified nursing assistant] staffing initiated r/t [related to] violent and aggressive behavior. Charger to electric wheelchair confiscated. Police officer spoke with resident regarding unacceptable behavior. [Resident 2] continued to yell and use profanity with officer. c. On 3/28/23 at 3:53 PM, a social service note stated, Sent a referral for transfer to [name of nursing home removed] facilities and to [name of nursing home removed]. d. On 3/29/23 at 8:28 AM, a social service note stated, Transfer Note: Resident will be transferring to [name of nursing facility removed] on 3/29 due to aggressive behavior directed towards one specific resident. PT approves of transfer. Family notified. e. On 3/29/23 at 12:31 PM, an orders administration note stated, Resident has been agitated. She hit another resident and rammed her wheelchair into another residents and caused injuries. Pt being moved to another facility. f. On 3/29/23 at 12:34 PM, a nurse note stated, [Resident 2] discharged to [name of nursing facility removed] at 1230 [12:30 PM]. All belongings and meds [medications] sent with patient. Our facility transport driving her to new facility [sic]. [Note: No documentation was located to indicated that resident 2's discharge plan was to be transferred to another facility prior to the resident-to-resident altercation on 3/28/23.] On 3/30/23 at 12:19 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated they were unsure why resident 2 was discharged from the facility. LPN 5 stated resident 2's attitude towards other residents was a little off putting. LPN 5 stated she was unaware of resident 2 having any recent resident to resident altercations. On 4/12/23 at 11:11 AM, an interview was conducted with the Resident Advocate (RA). The RA stated a facility-initiated transfer happened when the facility was unable to provide the proper care for a resident. The RA stated a facility-initiated transfer was done when a resident was in immediate danger to themselves or to another resident. The RA stated the clinical team picked a different facility for the resident based on the resident's needs. The RA stated a facility-initiated discharge was able to happen within 24 hours. The RA stated resident 2 was discharged from the facility due to using her powered wheel chair as a weapon. The RA stated resident 2 requested to be transferred to another facility where she was allowed to use her wheelchair again since resident 2 was no longer allowed to use it at this facility. The RA stated staff witnessed what resident 2 had done with her wheelchair and stated resident 2 said she would do it again and run the resident over. On 4/13/23 at 2:57 PM, an interview was conducted with the Administrator (ADMIN) 1. ADMIN 1 stated resident 2 was transferred out to a sister facility because she was having problems with another resident. ADMIN 1 stated resident 2 was searching out a specific resident and was both verbally and physically aggressive towards them. ADMIN 1 stated the other resident was scared of resident 2 constantly looking for her. ADMIN 1 stated resident 2 was informed of the discharge and was okay with it as long as she relocated by the mountain and not south of a specific major city. On 4/17/23 at 3:50 PM, an interview was conducted with the Discharge Planner (DP). The DP stated they were unsure why resident 2 was discharged to another facility. On 4/25/23 an interview was conducted with Staff Member (SM) 20 and SM 21. SM 20 stated after the last survey residents were sent to other facilities. SM 20 stated that resident 2 was forced to leave the facility. SM 20 stated there was an allegation of abuse and the facility placed her with one on one supervision. SM 20 stated staff found resident 2 another place and it was retaliation for the resident having an abuse allegation. SM 21 agreed with SM 20. 30563 3. Resident 86 was admitted to the facility on [DATE] with diagnoses which included dementia, mild protein-calorie malnutrition, anxiety, depression, and nicotine dependence. On 4/20/23 at 10:50 AM, an interview was conducted with Hospice RN 1. Hospice RN 1 stated resident 86's family had been trying to move her with the New Choice Waiver (NCW) and the process took about 3 months. Hospice RN 1 stated that the facility told the family they were working on the NCW. Hospice RN 1 stated the family found out that nothing had been done for the NCW. Hospice RN 1 stated the family worked on the NCW and got her approved. Resident 86's medical record was reviewed 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed that resident 86 had a BIMS score of 1 which revealed severe cognitive impairment. There was no care plan regarding discharge plans. An Admission discharge planning review dated 8/18/22 revealed unknown for anticipated length of stay. An Admission discharge planning review dated 11/12/22 revealed resident 86 was anticipated to stay at the facility long term. On 4/20/23 at 1:41 PM, an interview was conducted with the RA. The RA stated the discharge planning started when residents admitted . The RA stated that the discharge goals were discussed. The RA stated to apply for the NCW, medicaid required a 60 day waiting period prior to applying. The RA stated the resident had to be in the facility for 90 days. The RA stated the DON, physician and herself worked together to determine a safe discharge or the need for the NCW application. The RA stated there were forms on-line to be completed with the resident. The RA stated since starting the on-line system, she was not sure how long the process was. The RA stated previously it was a month or 3 to get approval. The RA stated resident 86's family initiated the NCW process on their own. The RA stated she provided paperwork that the family needed for the application. The RA stated if she remembered correctly, the MD or DON did not see an assisted living as a good fit. The RA stated it was still the residents right to do the NCW, even if the DON or physician did not think it was a good for the resident. The RA stated the discharge plan upon admission was in the social service admission progress notes. The RA stated resident 86's discharge plan was not documented in social service admission note. The RA stated she did not complete the NCW forms because the previous DON or physician said no. 4. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, altered mental status, history of traumatic brain injury (TBI) and intertrochanteric fracture of right femur. On 3/29/23 at 10:30 AM, a phone interview was conducted with resident 79's family member. Resident 79's family member stated that he wanted resident 79 discharged to a TBI speciality facility. Resident 79's family member stated that the facility was unable to care for resident 79 with a TBI. Resident 79's family member stated the facility was warehousing residents and unable to care for the residents. Resident 79's medical record was reviewed 3/28/23 through 4/25/23. A care plan dated 9/27/22 and updated on 12/28/22 revealed resident 79 required long term care services related to diagnoses of dementia, altered mental status and major depression. The goals were that resident would adjust to daily activities in the long term care facility and resident 79 would receive services as necessary to meet his individualized needs. Interventions were to engage assistance from ombudsman as needed; monitor for adjustment to long term care; provide care conference for residents and family; and review plan of care quarterly and as needed. On 10/27/22 at 11:05 PM, a social services note revealed a referral was sent to another long term care facility. On 10/28/22 at 4:10 PM, a social service note revealed a referral was sent to another long term care facility. On 11/9/22 at 12:25 PM, a nursing progress note revealed resident 79 was aggressive toward staff, resident 79 was expressing frustration when he hit the lounge door and slammed door on nurse, the nurse entered the lounge room and calmed resident down with the assistance of the administrator. On 11/9/22 at 1:06 PM, a social service note revealed a referral was sent to another long term care facility. On 12/2/22 at 11:52 AM, an MD note revealed that resident 79 had dementia and had the ability to be aggressive. Resident 79 was his own power of attorney and needed a guardian. Resident 79's past medical history revealed a TBI from a car accident and communication deficits. Resident 79 had a psychiatric referral pending and needed TBI specialty follow up. On 1/9/23 at 8:09 PM, a physician's progress notes revealed resident 79 had been having increased episodes of aggression toward staff and others. Resident 79 has had increased agitation. On 1/10/23 at 4:30 PM, a nursing progress note revealed that admissions staff pulled the nurse into the dining room who found resident supine grabbing onto another resident's arm and was covered in blood. On 1/10/23 at 5:32 PM, a social service note revealed a referral was sent to two long term care facilities. On 1/10/23 at 5:36 PM, a social service note revealed that resident 79 got in a physical altercation with another resident. On 1/13/23 at 11:21 AM, a physician's progress note revealed that resident 79 was involved in an altercation last night with another resident. On 1/17/23 at 5:39 PM, a social services note revealed there was a referral to be wait listed for a special program for TBI injuries. On 1/20/23 at 9:03 AM, a social services note revealed a referral was sent to another long term care facility for a transfer. On 2/10/23 at 11:19 AM, a social service progress note revealed Spoke to intake specialist at [local disability specialist] about application for this pt. received the application and will follow up with an additional paperwork that will be needed. On 2/24/23 at 12:58 PM, a social service progress note revealed a referral was sent to another long term care facility for transfer. On 2/27/23 at 11:32 AM, a social service progress note revealed the facility denied the referral. On 3/19/23 at 10:39 PM, a nursing progress note revealed Pt returned from [local] hospital ER at around 7:30 pm, blue sheet was cleared. Upon return pt was calm cooperative, took night medications. Pt came back with new orders. On 3/20/23 at 4:05 PM, a social service note revealed referrals were sent to multiple long term care facilities in the state. On 3/21/23 at 10:40 AM, a social service note revealed a quarterly note that resident 79 had several behavioral problems resulting in abuse allegations when he was first admitted . Staff were working with resident 79's and his behaviors had decreased significantly. Resident 79 seamed to get along better with other residents, and could be seen laughing and joking with others in the lobby area. The discharge planner was working with family to get resident 79 into a facility that specialized in TBI care. On 3/24/23 at 3:47 PM, a physician's progress note revealed a psychiatric Interdisciplinary Team (IDT) was the reason for the visit. The action was that it was inappropriate to have a gradual dose reduction due to active hallucinations. The physician ordered a psychiatric consult for schizophrenia diagnosis confirmation when able. On 3/28/23 at 10:45 AM, a social service note revealed the Department of Health and Human Services came to complete an assessment with resident 79 for TBI disability. Resident 79 refused to participate. On 3/28/23 resident 79 fell and sustained a right femur fracture. Resident 79 readmitted to the facility on [DATE]. Resident 79 was admitted to a room outside of the secured unit. On 4/3/23 at 4:57 PM, a nursing progress note revealed that resident 79's family member called. The nurse informed family member that resident 79 had declined since the fall and hit his head when he fell . On 4/10/23 at 12:55 PM, a social service note revealed that there was a facility initiated transfer/IDT meeting due to facility not being able to meet the needs of the resident. Facility initiated transfer was arranged for resident to discharge to another facility in Price, Utah. Resident 79's family member was present at time of an IDT meeting.RA explained to the family that due to us not having a wander guard and [resident 79] being determined to not be a good candidate for memory care we are no longer able to meet the residents needs. Family and [resident 79] were understanding of reasoning for transfer. They did mention concern that the progress of getting [resident 79] into the specialized TBI center in [city] would stop. RA and discharged planner are going to coordinate with [name of facility] to ensure that the progress withcontinue [sic] as that is the end goal that family and [resident 79] given a copy of the paper work for facility transfer. On 4/11/23 at 1:22 PM, a physician discharge summary revealed that resident 79 would not be safe to go back to the memory care unit and he was a wander risk and would require a wander guard which the facility did not have. The summary also indicated that resident 79 would benefit going to a wander guard equipped facility for his safety. A form titled Notice of discharge date d 4/10/23 revealed that The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. The discharge was to be effective 4/14/23. The discharge was necessary because the resident's welfare and the resident's need(s) could not be met, the facility attempted to meet the resident's needs, and the services available at the receiving facility to meet the resident's need(s). The form further revealed 2 signatures at the bottom of the form. On 4/13/23 at 1:03 PM, a social service note revealed that resident 79 was notified of facility initiated discharge being canceled. On 4/13/23 at 2:56 PM, an interview was conducted with Admin 1. Admin 1 stated he did not know about resident 79 discharging and had not been involved in discussing discharges for the previous 2 weeks. On 4/12/23 at 11:11 AM, an interview was conducted with the RA. The RA stated there were two different ways residents were transferred to another facility. The RA stated if the facility was unable to care for the resident, like if there was no wander guard system. The RA stated she had heard there was a system at the facility but it was broken or not working. The RA stated the Cambridge unit was the secured memory care unit in the facility. The RA stated there were residents that needed to be monitored but not in the memory care unit. The RA stated if the resident's cognition was not low enough to need a locked unit, then the staff looked at their cognitive ability to determine if they qualify for the locked unit. The RA stated if a resident needed a different setting then other facilities were contacted to determine who had a wander guard system. The RA stated the clinical team decided if the resident needed a wander guard. The RA stated she would rather notify families prior to calling other facilities. The RA stated when there was no guardianship and the resident was not cognitively intact, then she communicated with the resident. The RA stated she worked with the MD and the clinical team on what to do. The RA stated she Would prefer to get them [family members] involved as soon as possible. The RA stated resident 79's discharge was initiated by the facility. The RA stated resident 79 was in the secured care unit and had higher cognitive function but had trouble expressing himself. The RA stated resident 79 was able to have full conversations. The RA stated Administrator 4 and the discharge planner were working on getting resident 79 into a specialized TBI center. The RA stated since the facility did not have a wander guard system, then the facility was unable to meet his needs. The RA stated the the decision was made by the physician, clinical team and herself. The RA stated a facility with a wander guard system would be more appropriate for resident 79. The RA stated resident 79 would be better off surrounded by people who he could converse with because memory care residents had very low cognition. The RA stated resident 79 needed to be in a facility with residents that had a higher cognitive status. The RA stated he was moved off of the unit because of his hip fracture. The RA stated she was planning on calling the family regarding discharge to Price, Utah but the family came in so she did a quick IDT with the family and DON. The RA stated the family was okay with the temporary move until he was accepted into the TBI program. The RA stated they expressed a little concern about him going all the way down to Price but they lived in California. The RA stated that resident 79's family member said that the new facility was quite far away. The RA stated currently resident 79 was not ambulatory but he needed to discharge because he would be ambulatory soon and needed a wander guard system. The RA stated resident 79 had to work with a case management team to get him to TBI center. The RA stated she talked to the medical director about her concerns about the resident. The RA stated the concern was not having a locked/non-memory care unit for him. The RA stated DON 1 expressed her concerns that resident 79 was abusive and would not go back to the secured unit when he was ambulatory again. The RA stated she had contacted multiple facilities in the area. On 4/12/23 at 10:50 AM, a phone interview was conducted with resident 79's family member. Resident 79's family member stated the move to another facility created an additional hardship on the family. Resident 79's family member stated it was a long drive to the other facility in Price, Utah. Resident 79's family member stated the facility was not able to handle him and the facility did not want the liability of having him in the secured unit. Resident 79's family member stated he had been informed that resident 79 had been aggressive, and that was why some of the people in the region would not take him. Resident 79's family member stated some of the aggression was caused by being in the memory care unit, and he was just being warehoused and not getting treatments. Resident 79's family member stated he was working with a staff member at the speciality center for TBIs and were waiting for state approval. Resident 79's family member stated the facility wanted to move him before he was able to be admitted to the TBI center. Resident 79's family member stated he feared that when the resident moved he would be more aggressive. Resident 79's family member stated the facility said they tried all other facilities with wander guards and no one would take him close by. Resident 79's family member stated he received a stack of papers but did not sign anything. Resident 79's family member stated it would be less problematic if he stayed at the facility until he was moved to the TBI facility. Resident 79's family member stated it was a long drive and there was no family support in Price. Resident 79's family member stated I wouldn't have known that he was being transferred Friday except we stopped last night and the staff told me that he was discharging on Friday. Resident 79's family member stated resident 79 did not have a POA and he did not think he could sign a legal document with his mental state. On 4/13/23 at 7:43 AM, an interview was conducted with Chief Nursing Officer (CNO). The CNO stated that the company had been laterally transferring residents from one facility to the next. The CNO stated that he did not know about a transfer for resident 79 to another facility and did not know why he needed a wander guard. On 4/13/23 10:00 AM, an interview was conducted with the MD. The MD stated he was contacted via phone call, text or verbally when he was in the facility regarding discharges. The MD stated he completed discharge orders and signed the orders. The MD stated when a resident was transferring to another facility he completed paperwork for the transfer. The MD stated resident 79 was having issues with behaviors and wandering. The MD stated resident 79 had issues with other residents in the secured unit and was constantly getting in fights despite him being redirected. The MD stated the other facility had a wander guard system and resident 79 was at risk for wandering with his mental issues. The MD stated he had not been informed of concerns from family regarding transfer to another facility. On 4/17/23 at 3:50 PM, an interview was conducted with the Discharge Planner (DP). The DP stated she had been working with the Department of Health and Human Services to get resident 79 into a special TBI program facility. The DP stated resident 79 was assigned a case worker and needed the second part of his assessment completed. The DP stated she would try to be there and convince him to not refuse the assessment. The DP stated Administrator 1, the RA and herself talked about not sending resident 79 anywhere and see how he was doing outside the secured unit. The DP stated the team felt he was a risk to himself and other residents in the secured unit because he was wandering and he got irritated. The DP stated he was younger than a lot of the residents over there. The DP stated DON 1 wanted to transfer him out because of his behaviors. The DP stated DON 1 wanted to send him to any place that would take him. The DP stated she had talked to resident 79's family member a lot but did not think that DON 1 had reached out the family or anyone. The DP stated she was not involved in IDT meeting when resident 79's family member was informed of the discharge to Price. The DP stated she was not sure who made the decision. The DP stated stated the External Consultant said that the facility needed to make sure We were sending him to a situation where he got services he needed based on his needs and not to a place that offers the same services available here. 38031 5. Resident 67 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included cerebral infarction, type 2 diabetes mellitus, morbid obesity, hemiplegia and hemiparesis, dysarthria, unspecified dementia, hypertensive heart disease, chronic kidney disease stage 3, hyperlipidemia, gastro-esophageal reflux disease, major depressive disorder, hypothyroidism, and a history of urinary tract infections. On 3/29/23 at 8:36 AM, an interview was conducted with resident 67. Resident 67 stated that they were transferred to the hospital recently but could not recall why. On 3/29/23, resident 67's medical records were reviewed. On 2/7/23, resident 67's Quarterly MDS Assessment documented a BIMS score of 12/15, which would indicate that resident 67 had a moderate cognitive impairment. The assessment documented that resident 67 did not have hallucinations or delusions. Resident 67 was assessed as requiring an extensive 2 person physical assist for bed mobility, dressing, toilet use, and personal hygiene; total dependence with a two person physical assist for transfers; supervision with one person physical assist for locomotion on and off the unit; and supervision with setup help for eating. On 3/21/23 at 3:30 PM, resident 67's progress note documented, Pt [patient] was brought back to nurse station by activities coordinator. Activities coordinator reported that during the activity, pt had an episode of unresponsiveness, hyperventilation, drooling, and confusion. Upon examination VS [vital signs] 117/73 [blood pressure], 24 [respiratory rate], 65 [heart rate], 92% RA [Room Air oxygen saturation], 96.7 [temperature]. Pt was able to answer questions and follow basic commands. Neuros [neurological assessment] limited per baseline. MD [Medical Doctor] and pt's daughter notified. Pt's daughter requested pt to be sent to [hospital] ER [emergency room ] for further evaluation. MD approved. While waiting for EMS [emergency medical services], pt had a second event of hypervent [TRUNCATED]

Based on interview and record review, it was determined that the facility did not ensure, for 1 of 80 sample residents, maintained acceptable parameters of nutritional status. Specifically, a resident with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level. Resident Identifiers: 42. Findings include: Resident 42 was admitted to the facility on [DATE] with the following diagnoses that included vascular dementia, apraxia following cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and history of falling. Resident 42's medical record was reviewed on 4/12/23. A Quarterly Minimum Data Set (MDS) dated [DATE] and 2/7/23 documented resident 42 had lost 5% or more body weight in the last month or 10% or more in last 6 months and was not a prescribed weight loss regimen. The MDS further revealed resident 42 required set up assistance with supervision when eating. Resident 42 weights from December 2022 to April 2023 were documented as followed: a. 12/2/2022: 167.2 pounds (Lbs) b. 12/14/2022: 169.8 Lbs c. 12/19/2022: 170.4 Lbs d. 1/16/2023: 154.0 Lbs e. 2/20/2023: 148.0 Lbs f. 4/4/2023: 156.2 Lbs g. 4/11/2023: 150.8 Lbs [Note: Weekly weights were not obtained after 12/19/22. From January 2023 to February of 2023, resident 42 had lost 22.4 lb which was a 13.15% weight loss. Weekly weights were resumed on April 4.] Resident 42's dietary orders were reviewed and documented the following interventions: a. Fortified diet with double portions had an order start date of 1/18/23. b. House supplement for weight loss had an order start date of 4/12/23. c. Mirtazapine Tablet 7.5 milligrams (mg) for appetite stimulant had an order date of 4/12/23. [Note: No other weight loss interventions were initiated after January 18. The interventions started on 4/12/23 were after the facility was made aware of resident 42's significant weight loss.] A mini nutritional assessment dated [DATE], documented resident 42 was at risk for malnutrition. A mini nutritional assessment dated [DATE] documented resident 42 was at risk for malnutrition and included resident 42 had a weight loss greater than 3 kilograms during the last 3 months. A care plan focus area documented resident 42 had nutritional problem or potential nutritional problem r/t (related to) h/o (history of) dysphagia, alcohol abuse; dx (diagnoses) of DM (diabetes), HTN (hypertension), dementia. A goal was resident 42 will maintain adequate nutritional status as evidenced by maintaining weight with no change over 5% per month. Documented interventions included: 1. Monitor/record/report to MD (medical director) PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. 2. RD (Registered Dietitian) to evaluate and make diet change recommendations PRN. The care plan was initiated on 6/16/22. Resident 42's progress notes were reviewed and documented as follows: a. On 4/4/23, a RD note documented, Weight is back up to 156.2 this week He is eating 75-100% of most meals on a Fortified diet Reg [regular] texture with double portions. Staff state that he also eats a lot of snacks. He walks back and forth to the smoking area and around facility multiple times during the day. He was not able to express any preferences for other foods or snack items due to difficulty with communicating. Staff think that he will accept and eat and extra half PBJ [peanut butter and jelly] sandwich (diet jelly) with lunch and dinner. Weekly wt to be monitored. b. On 4/12/23, two nursing note documented, Spoke with RD about weight loss, her recommendation was for House supplement TID [three times a day] between meals and an appetite suppressant. Notified MD of weight loss and RD recommendations .[Resident 42] has lost weight over the last 4 months. Spoke to the MD and received order to start Sugar Free/ Low Sugar House supplement TID 240 mL TID between meals. Remeron 7.5mg PO [by mouth] Q [every] HS [night]. Spoke to [resident 42] about new orders, he acknowledged that he understood but will have to monitor if he will accept supplement and/or medication as ordered. [Resident 42] is his own responsible party. [Note: The new interventions were put into place after the nurse was made aware of resident 42's weight loss.] Review of resident 42's nursing progress notes indicated that no notes had been entered regarding resident 42's weight loss from December 2022 to April 2023. On 4/12/23 at 2:22 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated they were not aware of resident 42's weight loss. LPN 5 stated resident 42's weight loss should have been addressed at the weekly skin and weight meetings. LPN 5 stated the only weight loss intervention that had been ordered for resident 42 was a diet change on 1/18/23. LPN 5 stated that resident 42 had steadily lost weight since reviewing his documented weights in his medical record. LPN 5 stated something needed to be done about resident 42's weight loss since it was not a planned weight loss. LPN 5 identified weight loss interventions such as fortifying a diet, have weights be monitored more often, offer supplements and snacks. LPN 5 stated resident 42 weight loss was dramatic enough that the MD needed to be notified for an appetite stimulant. LPN 5 stated resident 42's weight loss needed to be acknowledged by adding some kind of weight loss intervention. On 4/13/23 at 2:03 PM, an interview was conducted with the RD. The RD stated her responsibilities included doing a nutritional assessment, conducting the weekly skin and weight meetings and assessing a resident's nutritional status when staff are concerned. The RD stated during the skin and weight meetings, residents' weights, skin issues, meal intakes, and medication changes were reviewed. The RD stated if a resident had a significant weight loss such a 5% weight change in a month or if they had a progressive downward trend in weight, they resident needed to be on weekly weights. The RD listed resident who needed weekly weights included any residents with pressure sores, tube feeds and significant weight loss. The RD stated preventable weight loss interventions included a fortified diet and supplements. The RD stated they also checked resident food preferences, any barriers to nutrition such as trouble chewing and/or swallowing. The RD stated if a resident had intake issues, something was done to improve intake. The RD stated resident 42 had not had his weight done for a while. The RD stated they recently looked at his weight and was unsure why he had lost so much weight. The RD stated the most recent intervention for resident 42 was PB&J sandwiches which were started last week. The RD stated in January they implemented a fortified diet and double portions and had not had other interventions placed since last week. The RD stated resident 42's weight had been stable when they stopped the weekly weights. The RD stated resident 42 needed to be put back on weekly weights after they had obtained his weight on January 16. The RD stated the MD should have been notified of his 16 lb weight loss in January. The RD stated it was not their responsibility to notify the MD. The RD stated it was not the nurse's responsibility to inform the RD of a resident's weight loss. The RD stated resident 42's weight loss was overlooked and they needed to have put interventions in place sooner for his weight loss.

Based on observation, interview, and record review it was determined, for 2 of 80 sampled residents, that the facility did not ensure pain management was provided to resident who required such services. Specifically, a resident who requested pain medications prior to a wound care treatment was not given pain medications until after the treatment was completed, and a resident on hospice was given his pain medications late and an order for pain medications was not entered into his chart for three days. These examples will be cited at a harm level. Resident identifiers: 7 and 84. Findings include: HARM 1. Resident 7 was initially admitted to the facility on [DATE] and again on 4/7/23 with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. On 4/13/23 at 10:20 AM an interview with resident 7 was conducted. Resident 7 stated that she had wounds on her backside for a long time and the staff changed the dressing twice a week. Resident 7 stated that the wounds caused discomfort and pain. Resident 7 stated that her pain level was an 8 out of 10. Resident 7 stated that she did not believe that she had been given a pain pill today. Resident 7 stated that she normally takes hydrocodone for pain relief. At 10:35 AM Registered Nurse (RN) 7 entered the room. An observation of wound care treatment for resident 7 began at 10:35 AM. Resident 7 asked RN 7 if she had taken a pain pill this morning and RN 7 responded, I'll check. RN 7 asked what the pain level was and where the pain was located. Resident 7 stated her pain was an 8 out of 10 and it was on her bottom. Resident 7 asked RN 7 for pain medication. The Director of Nursing (DON) entered the room at 10:47 AM to assist RN 7 with repositioning resident 7. RN 7 began wound care treatment. After the wound care treatment was completed, resident 7 asked again for her pain medication. Resident 7's Medication Administration Record (MAR) was reviewed. Resident had an order that stated, Norco Tablet 5-325 MG (hydrocodone-acetaminophen) give 1 tablet by mouth every 4 hours as needed for pain with a start date of 12/6/22. It was revealed that resident 7 was given this pain medication at 11:50 PM, which was after RN 7 completed the wound care treatment for resident 7. The pain score was documented on the MAR at 11:50 PM as a 7 out of 10. 22992 2. Resident 84 was admitted to the facility on [DATE] with diagnoses that included liver cell carcinoma, chronic pain syndrome, chronic viral hepatitis C, anxiety, protein calorie malnutrition, and schizophrenia. On 4/7/23 at 8:05 PM, an observation was made of resident 84. Resident 84 was seated in a chair just across from the nurses station in the Colonial hall. Resident 84 was observed to be seated in the chair until 8:40 PM, at which time he approached the surveyor and stated he was upset about his medications. Resident 84 was immediately accompanied to his room by the surveyor, at which time he was interviewed. Resident 84 stated that he had a lot of pain in his back from having a stove dropped on him, and from being hit by a truck. Resident 84 stated that at 7:55 PM that evening, he had gotten up out of bed and had asked the nurse on duty for his pain pills because he was in pain. Resident 84 stated that at that time, he was at a pain level of 8 out of 10. Resident 84 stated that he stood by the medication cart and watched her (the nurse) go from room to room, and she's giving medications to every one else. Resident 84 stated that his eye, feet, neck and lumbar area were hurting him, and that the pain in his back goes up to my neck like a [NAME]. Resident 84 stated that the nurse on duty asked his name four different times. Resident 84 stated that he stood by the medication cart until 8:35 PM, at which time his legs gave out from the pain and he slid down the wall. Resident 84 stated that when his legs gave out, the nurse on duty helped him into a chair, but still did not administer his pain medications. Resident 84 stated that there had been problems with getting his pain medications correctly, and that his hospice nurse had to intervene multiple times in order for the facility to get his medication order correct. Resident 84 stated that medications were routinely not provided in a timely manner. Resident 84 further stated that there was a resident down the hall who was upset earlier that week that her medications were not administered in a timely manner so she tore up her room and threw multiple items in the hallway, and it was a mess. On 4/7/23 at 8:58 PM, the nurse on duty, Registered Nurse (RN) 13, was observed to enter resident 84's room, and administer medication. RN 13 did not ask what the resident's pain level was. RN 13 was observed to tell resident 84 that the medications she brought included resident 84's pain medication. [Note: This was approximately 1 hour after the resident reported he had asked for pain medication.] On 4/7/23 at 9:15 PM, an interview was conducted with RN 13. RN 13 stated that she was an agency nurse, and had been scheduled to work from 6:00 PM to 10:00 PM, as a medication pass nurse. RN 13 stated that at 8:58 PM, she had provided resident 84 with morphine, hydromorphone, gabapentin and xanax. When asked why she had not provided resident 84 with his medications earlier, RN 13 stated that the hydromorphone was only scheduled every 4 hours and the other medications were only scheduled to be given at bedtime, and did not have a specific administration time listed. RN 13 stated that she did not know when the previous dose of hydromorphone was administered. RN 13 confirmed that resident 84 was standing by the medication cart earlier, but that the resident decided he wanted to sit on the floor at which time RN 13 assisted the resident to a chair. Resident 84's medical record was reviewed from 3/28/23 through 4/25/23. Resident 84's nursing admission assessment dated [DATE] was reviewed. The portion of the assessment regarding resident 84's pain was left blank. No other pain assessments were located in resident 84's medical record. Resident 84's pain care plan dated 11/16/22 was reviewed. The care plan indicated that the resident was receiving pain medication due to his diagnoses of chronic pain and liver cell carcinoma. The care plan indicated that staff were to administer pain medications per the physician orders, anticipate the resident's need for pain relief, and monitor complaints of pain. Resident 84's physician orders were reviewed. On 3/24/23, resident 84's hospice physician wrote an order for resident 84 to receive Hydromorphone 6 milligrams scheduled at 8:00 PM, 12:00 AM, and 4:00 AM. In addition resident 84's physician indicated that the as needed dose of hydromorphone should be continued. Resident 84's March 2023 Medication Administration Record (MAR) was reviewed. The MAR indicated that resident 84 did not receive the scheduled hydromorphone as prescribed until 3/27/23 at 8:00 PM. On 4/10/23 at 10:27 AM, an interview was conducted with resident 84's hospice nurse, hospice nurse 2 (HN 2). HN 2 stated that resident 84 had a chronic complaint that facility staff were not giving him his medications on time. HN 2 stated that the facility has a lot of agency, so I have to make sure the order gets put in because there had been errors in the past. When asked about the physician order for the scheduled hydromorphone, HN 2 stated that she had sent the order via fax to the facility on Friday, 3/24/23. HN 2 stated that she confirmed with facility staff that they had received the fax on 3/24/23. HN 2 stated that the next week, she noticed that the order had not been implemented yet. HN 2 stated that the order was written for additional pain medication because resident 84 had not been sleeping well due to the pain, and had been repeatedly asking for additional pain medications. HN 2 stated that the facility staff had also reported to her that resident 84 was having a hard time getting up in the morning because he was in so much pain, so we scheduled his pain meds (medications) throughout the night. On 4/20/23 at 1:00 PM, an interview was conducted with Director of Nursing (DON) 3. DON 3 stated that when a nurse received a fax that included a physician's order, that nurse was responsible for entering the order into the electronic health record. DON 3 stated then when a resident asked for pain medication, the facility expectation was that facility staff should administer the pain medication as soon as possible.

Based on interview and record review it was revealed that, for 6 of 80 sampled residents, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, the facility did not obtain laboratory services in a timely manner. The deficient practice for resident 208 was found to have occurred at a harm level. Resident identifiers: 7, 35, 38, 51, 79, and 208. Findings include: HARM 1. Resident 208 admitted on [DATE] with the following diagnoses that included but not limited to toxic encephalopathy, chronic obstructive pulmonary disease, methicillin resistance staphylococcus aureus infection as the cause of diseases, anemia, anxiety disorder, depression, cognitive communication deficit, muscle weakness, difficulty in walking, and unsteadiness on feet. Resident 208's medical record was reviewed from 3/28/23 through 4/25/23. Physician orders for resident 208 indicated that when the resident was admitted , he had orders for 1250 milligrams of Vancomycin twice to be administered intravenously twice daily. The electronic medical record had an alert that indicated This order is outside of the recommended dose or frequency. A review of Medication Administration Audit Report for March 2023 revealed the following entries: a. On 3/27/2023 at 10:47 PM resident 208 was administered vancomycin. b. On 3/28/2023 at 10:08 AM resident 208 was administered vancomycin. c. On 3/28/2023 at 8:41 PM resident 208 was administered vancomycin. d. On 3/29/2023 at 10:04 AM resident 208 was administered vancomycin. e. On 3/29/2023 at 8:34 PM resident 208 was administered vancomycin. Physician orders dated 3/27/23 indicated that resident 208 was to have a vancomycin trough drawn 30 minutes prior to 3/27/23 dose. On 3/27/23 a lab requisition form was completed for resident 208. The collection time was listed as 9:50 PM. Vanco Trough was handwritten in the bottom right corner of the form. The form did not indicate that the lab was supposed to be drawn as a STAT (as fast as possible) lab. Review of laboratory results revealed that a vancomycin trough was collected from resident 208 on 3/27/23, and that the laboratory received the sample on 3/29/23, two days later. The laboratory results also listed that the lab reported the results to the facility on [DATE]. The results listed that the reference interval for the vancomycin trough was 10.0 to 15.0. The results also listed that resident 208's vancomycin level was 57.3. There was an Alert listed that stated: Toxic: Trough Vancomycin concentrations greater than 20 may be associated with the onset of nephrotoxicity . Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity. A Nursing Progress Note from 3/30/23 at 9:00 AM indicated that the facility had received the results of resident 208's vancomycin trough and had sent the resident to the local emergency room for evaluation. On 3/30/23 at 9:54 AM, an interview was conducted with Registered Nurse (RN) 10. RN 10 stated that during morning report she was notified resident 208 had high vancomycin levels. RN 10 stated during her rounds she observed resident 208 was lethargic and had noticeable twitching. RN 10 stated that the physician ordered resident 208 to be sent to hospital by ambulance. RN 10 did not indicate why resident 208 had not been sent out when the lab results were initially received. Hospital records for resident 208 dated 3/30/23 were reviewed. The records indicated that when resident 208 presented to the emergency room , his vancomycin levels were drawn and had increased to 92.7. The hospital staff documented that Patient comes in altered. We gave him Narcan 0.4 mg (milligrams) IV (intravenously). He immediately came to. He is on long-acting morphine and oxycodone for breakthrough. I think with his situation, the narcotics have probably 'stacked' is not metabolize (sic) in normally. Patient shows acute renal failure. This is new from when he left the hospital just a week ago. Also vancomycin level is quite high. Last given vancymycin 9:00 PM last night . vancomycin toxic. Patient admitted to intermediate care center. An interview at 4/17/23 at 12:09 PM was conducted with Nurse Practitioner (NP) 1. NP 1 stated they want lab results within an hour after pulling a vancomycin trough unless it was critical in which they want a phone call, not a text message. On 4/24/23 at 11:25 AM an interview with Licensed Practical Nurse (LPN) 2 was conducted. LPN 2 stated when a resident was on vanco she would look for lab orders from the physician. For a vanco trough LPN 2 stated they would do the serum draw 30 minutes prior to medication administration. LPN stated for a vanco trough she would always order STAT due to needing the results by the next dose, if the physician did not already order lab as STAT. On 4/18/23 at 10:10 AM an interview with RN 5 was conducted. RN 5 stated Vanco troughs should be done 30 minutes to an hour prior to the fourth dose of vancomycin. RN 5 would send vanco trough labs STAT (as soon as possible) to the lab for processing. RN 5 stated that routine labs took about 3 days. RN 5 stated she would call the lab for a pickup when it is a STAT order. RN 5 stated she would chart a progress note when the lab company picked labs up. RN 5 stated that the lab company would call when lab results were ready and alert the nurse of any lab values that were out of range. RN 5 stated the lab company would also fax over the results. RN 5 stated she would then contact the physician of lab results and follow up with any additional orders. An interview with Director of Nursing (DON) 3 on 4/20/23 at 1:34 PM was conducted. DON 3 stated that she had spoken with the physician after resident 208 was sent out to the hospital. DON 3 stated that the physician stated that the vancomycin blood draw needed to be done 30 minutes prior to administration of medication; this is so the lab results would be available prior to the next dose. DON 3 stated that the lab should call in with results and the physician needed to be notified so any changes can be noted and ordered. A call was made on 4/24/23 at 10:22 AM to the lab company customer service. The Customer Service Representative (CSR) stated they called the facility and reported results on 3/30/23 at 9:00 AM. The CSR stated that once the labs were picked up, they were sent out of state for processing. The CSR stated that resident 208's labs were sent out of state for processing on 3/29/23 at 4:47 PM. The CSR stated that the facility staff did not mark resident 208's vancomycin trough as a stat lab, and so it was processed as a routine order, which took approximately 3 days to process. According to the National Library of Medicine regarding the administration of vancomycin, Elderly patients are more prone to vancomycin toxicity with IV [intravenous] administration due to age-related changes in renal function . These patients need to be carefully monitored . and the target therapeutic serum trough concentration .typically ranges between 10 mcg/mL to 20 mcg/mL. (https://www.ncbi.nlm.nih.gov/books/NBK459263/#article-30965.s7) POTENTIAL FOR HARM 2. Resident 7 was initially admitted to the facility on [DATE] and again on 4/7/23 with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. A Physician Admission Note from 12/6/22 at 5:16 PM stated, 65yo [year old] LTC [long term care] resident who had no ostomy output for several days with a distended abdomen. She was sent to the ED [emergency department] and found to have SBO [small bowel obstruction] and underwent surgical intervention including moving her ostomy site. She has been sent to skilled nursing for ongoing medical care and rehab . Today pt [patient] is says [sic] she is having hallucinations when she gets her Norco or any pain med. Reviewed options . Check stat labs including UA [urinalysis] . A review of resident 7's physician orders revealed that resident 7 did not have stat labs ordered on 12/6/22. On 12/8/22 at 3:41 PM a Nurses Note stated, due to pt's [patient's] increasing sob [shortness of breath] and congestion provider ordered duoneb [inhaler] qid [four times a day] x 10 days, cxr [chest x-ray] stat, cbc [complete blood count], bmp, covid, rapid flu poa [power of attorney] notified. Son notified. A document labeled Patient Report Ordered Items: CBC with Differential/Platelet; Comp. Metabolic Panel; STAT revealed that the labs were collected on 12/10/22 and reported on 12/11/22. It should be noted that this was four days after the physician ordered the labs on 12/6/22 and two days after the labs were ordered again on 12/8/22. On 4/13/23 at 2:28 PM an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that nurses were supposed to pull the labs as soon as the labs are ordered, and generally nurses completed this before the end of their shift. The ADON stated that if nurses were unable to obtain the labs, the nurses should message the physician, ask another nurse to try, or contact the mobile diagnostic service company to pull the labs. The ADON stated that if the resident was declining and staff were unable to pull labs then the resident should be sent to the hospital. The ADON stated that staff should not wait four days before obtaining stat labs. 30563 3. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, altered mental status, history of traumatic brain injury and intertrochanteric fracture of right femur. Resident 79's medical record was reviewed 3/28/23 through 4/25/23. Physician's orders revealed the following laboratory orders: a. On 9/25/22, CBC, CMP, A1C one time only for admission. There were no laboratory results. b. On 9/26/22, CBC and CMP one time only for admission. There were no laboratory results. c. On 12/13/22, CBC, BMP, TSH, free t4 and hydroxyvitamin D one time only for increased confusion for 2 days. Review of the laboratory values revealed a CBC was completed on 12/16/22. There was no serum received so the BMP, free T4, TSH and Vitamin D were not performed. There was a comment on the form We are unable to process this transfer tube for testing. All transfer tubes must be clearly marked/labeled as serum, type specific plasma or urine. d. On 1/7/23, CBC, CMP, TSH, Free T4, 25-hydroxy Vitamin D one time only for increased confusion for 3 days. There were no laboratory results. e. On 4/11/23, collect blood sample for stat CBC and CMP. One time only for UTI, infection symptoms for 2 days. There were no laboratory results. A nursing progress note dated 4/12/23 at 5:39 PM revealed, Made several attempts to collect blood as ordered unsuccessful. Notified MD. Received order to try again in the morning. A nursing progress note dated 4/13/23 at 5:09 PM revealed, Two unsuccessful attempts were made to draw blood and several to collect urine. Pt was cooperative and tolerated well. SN encouraged oral fluids. Night nurse will be informed to keep trying. f. On 4/11/23, collect a urine sample for UA and C&S one time only for UTI symptoms for 2 days. There were no sample results. A nursing progress note dated 4/13/23 at 8:00 PM revealed, resident refused to have labs drawn, and UA. On 4/20/23 at 11:31 AM, an interview was conducted Administrator (Admin) 2. Admin 2 stated that there were not other laboratory values completed except the ones in resident 79's medical record. Admin 2 stated the facility was working on changing laboratory companies. 38031 4. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. Review of resident 51's laboratory orders revealed the following: a. On 8/4/22, valproic acid and ammonia level drawn every 3 months for Depakote were ordered. The order had a start date of 10/3/22. b. On 8/26/22, a Creatinine (CR) and Glomerular Filtration Rate (GFR) were ordered. c. On 10/10/22, a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and an ammonia were ordered. Results were obtained for the CMP only. d. On 10/20/22, an ammonia level was ordered. e. On 12/19/22, a CBC, CMP, Depakote, and 25 hydroxy vitamin D were ordered. It should be noted that no documentation could be found in resident 51's medical records of the laboratory results for the above mentioned orders. On 4/10/23 at 1:04 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that it had taken days to get lab results back from the laboratory, but usually the CMP and CBC would be available the next day. RN 5 stated that stat or immediate lab orders they would get the results within 2-3 hours. RN 5 stated that was if the laboratory picked up the specimens on time, which sometimes they don't. On 4/13/23 at 11:14 AM, the Chief Nursing Officer (CNO) stated that if they did not have the documentation then it did not exist. 46232 5. Resident 38 was admitted to the facility on [DATE] with the following diagnoses that included but not limited to Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, anxiety disorder, post-traumatic stress disorder, obsessive compulsive personality disorder and restless leg syndrome. Resident 38 medical records were reviewed on 4/5/23 Resident 38's Lab tab documented the following blood work results: a. On 4/8/23, a STAT (as soon as possible) ammonia was collected but could not be resulted. The lab report stated, Test(s) not performed. Testing of the specimen could not be completed due to a specimen identification problem. No patient identification on container. Resident 38's progress notes were reviewed and documented as followed: a. On 4/9/23, a nurse note documented, .STAT ammonia level sent this shift due to hallucinations and confusion. b. On 4/10/23 at 10:59 AM, a nurse note documented, Fax received from [name of lab company] regarding STAT ammonia that was sent yesterday. Comments stated that lab was rejected due to no identifiers. This nurse notified provider and received new order to redraw STAT Ammonia level. c. On 4/19/23 at 6:43 PM, a nurse note documented, STAT Ammonia results received, which were 40(High) Provider notified of results . On 4/19/23 at 10:28 AM, an interview was conducted with the Director in Training (DIT). The DIT stated the lab courier had certain days they came for lab pickups. The DIT stated when blood works was drawn, the lab tube needed to be labeled with the lab requisition label. The DIT stated the person that drew the blood labeled the blood tube with lab labels. The DIT stated the lab label needed to have the residents name and birthdate as well as what time the blood was drawn and the person's initials who drew it. The DIT stated the lab came and picked up the stat labs once they have been notified of them. On 4/19/23 at 1:36 PM, an interview was conducted with the Director of Nursing (DON) 3. The DON 3 stated the nurses had to fill out a lab requisition form that they had to label with the resident's name, the date and time at which the blood was drawn and their initials and credentials. The DON 3 stated every blood specimen needed to be labeled and present on the tube. 47431 47432 6. Resident 35 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included fibromyalgia, dysphagia, protein calorie malnutrition, cognitive social or emotional deficit, anxiety disorder, major depressive disorder, adult failure to thrive scoliosis, dysarthria, chronic pain and hypertension. Resident 35's medical record was reviewed from 3/28/23 through 4/25/23. Review of Resident 35's electronic physician orders revealed the following orders dated 2/4/23: a. Doxycycline Hyclate Oral Tablet 100 MG. Give 100 mg by mouth one time only for infection for 1 day. b. Chest xray STAT for R/O (Rule out) respiratory infection. C. CBC (Complete Blood Count), CMP (Complete Metabolic Panel), CRP (C-reactive protein), BNP (B-type natriuretic peptide) STAT(immediately) for sepsis workup. A nursing progress note documented that a sample of blood was taken from Resident 35 on 2/4/2023 to run the ordered tests. Review of the lab report indicated that Resident 35's blood sample was sent to an outside laboratory and received on 2/8/23. The laboratory report indicated that the company was unable to process the sample due the blood sample being hemolyzed upon arrival. No indication could be found in the resident's medical record that the facility obtained another sample and/or completed the labs as ordered.

Based on observations, record review, and interviews it was determined that for 7 of 80 sampled residents the facility did not ensure that its residents are free of any significant medication errors. Specifically, the facility continued to administer vancomycin without verifying trough serum levels, administering the wrong dose of insulin, and breaking open an extended-release tablet. The findings for residents 86 and 208 were determined to have occurred at harm level. Resident identifiers: 43, 50, 79, 86, 92, 208, and 457. Findings include: HARM: 1. Resident 208 admitted on [DATE] with the following diagnoses that included but not limited to toxic encephalopathy, chronic obstructive pulmonary disease, methicillin resistance staphylococcus aureus infection as the cause of diseases, anemia, anxiety disorder, depression, cognitive communication deficit, muscle weakness, difficulty in walking, and unsteadiness on feet. Resident 208's medical record was reviewed from 3/28/23 through 4/25/23. Physician orders for resident 208 indicated that when the resident was admitted , he had orders for 1250 milligrams of Vancomycin twice to be administered intravenously twice daily. The electronic medical record had an alert that indicated This order is outside of the recommended dose or frequency. A review of Medication Administration Audit Report for March 2023 revealed the following entries: a. On 3/27/2023 at 10:47 PM resident 208 was administered vancomycin. b. On 3/28/2023 at 10:08 AM resident 208 was administered vancomycin. c. On 3/28/2023 at 8:41 PM resident 208 was administered vancomycin. d. On 3/29/2023 at 10:04 AM resident 208 was administered vancomycin. e. On 3/29/2023 at 8:34 PM resident 208 was administered vancomycin. Physician orders dated 3/27/23 indicated that resident 208 was to have a vancomycin trough drawn 30 minutes prior to 3/27/23 dose. On 3/27/23 a lab requisition form was completed for resident 208. The collection time was listed as 9:50 PM. Vanco Trough was handwritten in the bottom right corner of the form. The form did not indicate that the lab was supposed to be drawn as a STAT (as fast as possible) lab. Review of laboratory results revealed that a vancomycin trough was collected from resident 208 on 3/27/23, and that the laboratory received the sample on 3/29/23, two days later. The laboratory results also listed that the lab reported the results to the facility on [DATE]. The results listed that the reference interval for the vancomycin trough was 10.0 to 15.0. The results also listed that resident 208's vancomycin level was 57.3. There was an Alert listed that stated: Toxic: Trough Vancomycin concentrations greater than 20 may be associated with the onset of nephrotoxicity . Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity. A Nursing Progress Note from 3/30/23 at 9:00 AM indicated that the facility had received the results of resident 208's vancomycin trough and had sent the resident to the local emergency room for evaluation. On 3/30/23 at 9:54 AM, an interview was conducted with Registered Nurse (RN) 10. RN 10 stated that during morning report she was notified resident 208 had high vancomycin levels. RN 10 stated during her rounds she observed resident 208 was lethargic and had noticeable twitching. RN 10 stated that the physician ordered resident 208 to be sent to hospital by ambulance. RN 10 did not indicate why resident 208 had not been sent out when the lab results were initially received. Hospital records for resident 208 dated 3/30/23 were reviewed. The records indicated that when resident 208 presented to the emergency room , his vancomycin levels were drawn and had increased to 92.7. The hospital staff documented that Patient comes in altered. We gave him Narcan 0.4 mg (milligrams) IV (intravenously). He immediately came to. He is on long-acting morphine and oxycodone for breakthrough. I think with his situation, the narcotics have probably 'stacked' is not metabolize (sic) in normally. Patient shows acute renal failure. This is new from when he left the hospital just a week ago. Also vancomycin level is quite high. Last given vancymycin 9:00 PM last night . vancomycin toxic. Patient admitted to intermediate care center. An interview at 4/17/23 at 12:09 PM was conducted with Nurse Practitioner (NP) 1. NP 1 stated they want lab results within an hour after pulling a vancomycin trough unless it was critical in which they want a phone call, not a text message. On 4/24/23 at 11:25 AM an interview with Licensed Practical Nurse (LPN) 2 was conducted. LPN 2 stated when a resident was on vanco she would look for lab orders from the physician. For a vanco trough LPN 2 stated they would do the serum draw 30 minutes prior to medication administration. LPN stated for a vanco trough she would always order STAT due to needing the results by the next dose, if the physician did not already order lab as STAT. On 4/18/23 at 10:10 AM an interview with RN 5 was conducted. RN 5 stated Vanco troughs should be done 30 minutes to an hour prior to the fourth dose of vancomycin. RN 5 would send vanco trough labs STAT (as soon as possible) to the lab for processing. RN 5 stated that routine labs took about 3 days. RN 5 stated she would call the lab for a pickup when it is a STAT order. RN 5 stated she would chart a progress note when the lab company picked labs up. RN 5 stated that the lab company would call when lab results were ready and alert the nurse of any lab values that were out of range. RN 5 stated the lab company would also fax over the results. RN 5 stated she would then contact the physician of lab results and follow up with any additional orders. An interview with Director of Nursing (DON) 3 on 4/20/23 at 1:34 PM was conducted. DON 3 stated that she had spoken with the physician after resident 208 was sent out to the hospital. DON 3 stated that the physician stated that the vancomycin blood draw needed to be done 30 minutes prior to administration of medication; this is so the lab results would be available prior to the next dose. DON 3 stated that the lab should call in with results and the physician needed to be notified so any changes can be noted and ordered. A call was made on 4/24/23 at 10:22 AM to the lab company customer service. The Customer Service Representative (CSR) stated they called the facility and reported results on 3/30/23 at 9:00 AM. The CSR stated that once the labs were picked up, they were sent out of state for processing. The CSR stated that resident 208's labs were sent out of state for processing on 3/29/23 at 4:47 PM. The CSR stated that the facility staff did not mark resident 208's vancomycin trough as a stat lab, and so it was processed as a routine order, which took approximately 3 days to process. According to the National Library of Medicine regarding the administration of vancomycin, Elderly patients are more prone to vancomycin toxicity with IV [intravenous] administration due to age-related changes in renal function . These patients need to be carefully monitored . and the target therapeutic serum trough concentration .typically ranges between 10 mcg/mL to 20 mcg/mL. (https://www.ncbi.nlm.nih.gov/books/NBK459263/#article-30965.s7) 2. Resident 86 was admitted to the facility on [DATE] with the following diagnoses that included but not limited to unspecified dementia, anxiety disorder, depression, and history of falling. Resident 86's medical record was reviewed 3/28/23 through 4/25/23. A form titled Hospice Nursing Clinical Note dated 2/17/23 revealed .Noted a new sore to patient's L [left] middle finger on the most distal knuckle. Slough is noted to the wound bed and the surrounding skin is red/inflamed. Brought patient back out to the nurse's station after visit and inquired about the sore on her finger. FSN [Facility Staff Nurse], [LPN 3's name removed], stated that the origin of this wound was unknown, but agreed that it appeared to be infected. Hospice RN sent a picture to [name of physician] and he messaged back within a minutes with an order for ABX [antibiotic]. Informed [LPN 3] that the Keflex would be delivered this evening and that the orders were being faxed over now . A review of resident 86's Medication Administration Record (MAR) for February 2023 revealed Keflex was not administered. There was no order located in resident 86's medical record for Keflex until 2/24/23 which was Keflex Oral Capsule 250 mg. Give 250 mg by mouth two times a day for wound on right middle finger for 7 days. The order was discontinued 2/24/23 after 1 dose was administered. A nursing progress note dated 2/17/23 at 6:52 PM revealed, Hospice nurse reported infection to area on right hand, between middle finger. Order for Keflex. No further details on order until received from hospice. A nursing progress note dated 2/21/23 at 5:18 AM revealed, res [resident] has skin tear to left anterior forearm, resident scratching area, skin tear cleansed with wound cleanser, patted dry, steri strips applied due to resident removing dressing, dressing applied to area also. A nursing progress note dated 2/21/23 at 5:31 AM revealed, Resident had skin tear that she was scratching, trying to rub makng [sic] skin tear longer. 3cm [centimeters] linear skin tear to left anterior forearm. Steri strips applied due to resident attempts to remove dressing, dressing applied over steri strips. A nursing progress note dated 2/23/23 at 5:45 PM revealed, Open areas to left forearm. Red, swollen, and warm to touch. S/S [signs and symptoms] of pain when accessing. Notified Hospice. Cleansed and covered .Resident continues to remove dressing and scratch, 'pick at' openings. Educated resident, but resident is confused, and not able to understand. A nursing progress note dated 2/23/23 at 10:29 PM revealed, Kelfex 250 milligrams (mg) by mouth given at this time. A nursing progress note dated 2/24/23 at 5:45 PM revealed, Infection to left forearm has increased redness and cellulitis. Elbow to dorsal left hand effected. Hospice notified. Keflex 250 mg BID [twice daily] discontinued. New order for Augmentin 875 BID for 10 days .New order to increase Morphine to 0.25 ml [milliliter] syringe to 2 syringes = to 0.5ml for pain. A form titled Hospice Nursing Clinical Note dated 2/24/23 revealed .Facility staff aide had just assisted her to the toilet-states patient has not attended meals and has been in bed most of the day. Patient is drowsy, yet agitative [sic]. She is resistant to assessment and repeated [sic] tells RN to 'get out' and 'Leave!'. Patient's L hand and arm are quite red, swollen, hot, and painful. Facility nurse, [LPN 3], had just placed a new bandage over the wound to patient's L forearm, but was able to show hospice RN a picture from earlier today. It is clear that the infection has spread. Patient is confused and usable to follow direction. She will frequently pick at her sore and frequent removes dressings when placed. This along with patient missing her Keflex that was ordered 1 week ago has likely contributed to her developing cellulitis. Discussed findings with hospice MD and new orders were received. Coordinated care with FSN, [LPN 3], and reached out to family to discuss findings as well. Family expressed frustration with the situation and feel the cellulitis could have been avoided - family plans to meet with facility administration on Monday to further express their frustration and see what changes can be made. Hospice team updated with family concerns as well. A physician's order dated 2/24/23 revealed Augmentin Oral Tablet 875-125 MG. Give 1 tablet by mouth two times a day for infection to left forearm until 3/5/23. The February 2023 MAR revealed the Augmentin was administered. On 4/13/23 at 2:10 PM, an interview was conducted with LPN 3. LPN 3 stated that resident 86 had a skin tear that became infected. LPN 3 stated she thought it was the left hand but did not remember the details. LPN 3 stated there were a lot of agency nurses and an agency nurse missed the inputting the order for Keflex into resident 86's medical record. LPN 3 stated there was some confusion with hospice and facility staff were unable to input the physician's order in until hospice faxed orders to the facility. LPN 3 stated she was not sure if the medication was delivered. LPN 3 stated the Kelfex was started the next week. LPN 3 stated that happened a lot that the agency staff did not follow up. On 4/13/23 at 3:50 PM, an interview was conducted with hospice Registered Nurse (RN) 1. Hospice RN 1 stated during a visits, resident 86 had a wound on her finger that was red and she was picking at it. Hospice RN 1 stated she sent a picture to the hospice physician and received an order for Kelfex. Hospice RN 1 stated that she talked to LPN 3 that orders were being faxed to the facility. Hospice RN 1 stated that 6 days later, resident 86 got another wound on the same arm. Hospice RN 1 stated that resident 86's family member sent a picture of resident 86's arm to hospice RN 1. Hospice RN 1 stated resident 86's finger was massively worse and had cellulitis. Hospice RN 1 stated she realized the Keflex was order was not done. Hospice RN 1 stated they Had to pull out the big guns and order Augmentin because of the infection. Hospice RN 1 stated that the skin tears to resident 86's forearm looked like finger nails that torn the skin. Hospice RN 1 stated that she sent an email to Director of Nursing (DON) 2. Hospice RN 1 stated she did not hear back from DON 2 regarding the email. The email was provided on 4/13/23 at 4:16 PM. The email was sent to DON 2 on 2/28/23 at 1:04 PM. The email revealed I wanted to touch base with you about [resident 86's] wound infection. On Friday 2/17/23, I noticed she had a small wound on the distal knuckle of her L middle finger. I sent the picture to our hospice MD [Medical Doctor] and received an order right away for Keflex 250mg BID. I discussed this with the nurse on staff at this time, [LPN 3]. I informed her that the medication would be delivered that very evening and that I was faxing the order over. I asked her let me know if she did not receive the order. When [resident 86's] son visited the following Thursday, he let me know [resident 86's] hand was red and that she was complaining of pain in her middle finger and thumb. When he asked the nurse on staff, [LPN 3], about it, she said his mom 'got in a fight yesterday' then pulled up her sleeve and showed him a new wound on her L forearm. He said that [LPN 3] then 'got after' [resident 86] for taking the bandage off that she had just placed. [Resident 86's family] explained that he felt the tone of voice [LPN 3] used with his mother was disrespectful. [Resident 86's family], let me know that [LPN 3] took a picture and sent it to the facility doctor for new ABx orders and then left as it was the end of her shift. I reminded [resident 86's family] that all orders should go through the hospice MD and that we had already ordered Keflex last week. I called [facility] and spoke with the nurse who started her shift at 1800 [6:00 PM] and ended up discovering that the Keflex was, in fact, delivered on 2/17/23, but was never started . I asked the nurse to make sure it was started STAT and that I would be out again tomorrow to follow up. By, Friday 2/24/23, [resident 86's] arm was red, hot, and swollen, up to her elbow. I sent new pictures to [hospice MD] and he set orders for Augmentin 875mg BID x 10 days for cellulitis. [LPN 3] was the nurse on staff again that night and I asked her if she remembered our discussion the week prior about the Keflex being delivered. She said that she did, but was gone before it arrived and had not been there for several days afterward. Informed her that the Augmentin would be delivered this evening, but [LPN 3] went ahead and administered the first dose from the facility stock -along with a PRN [as needed] dose of morphine d/t [due to] [resident 86] being in significant pain. I called [resident 86's family], after the visit with an update. He is understandably upset and feels the cellulitis could have been avoided if the Keflex would have been started when it was originally ordered by hospice. My hope is that we can find out how the Keflex order was missed and how we can better avoid a situation like this in the future. On 4/13/23 at 11:14 AM, an interview was conducted with the CNO. The CNO stated if the information was not in the medical record, then the facility did not have it. POTENTIAL FOR HARM: 3. Resident 50 was admitted on [DATE] with diagnoses which included fluency disorder following unspecified cerebrovascular disease, hemiplegia and hemiparesis affecting right dominant side, dysphagia, bipolar II disorder, type 2 diabetes mellitus (DM), impulse disorder, and major depressive disorder. On 4/17/23 at 8:50 AM, RN 3 was observed to prepare and administer medications to resident 50. On 4/17/23 Resident 50's medical record was reviewed for the reconciliation of medications. According to physician's orders, resident 50 was to receive the following: a. Insulin glargine solution inject (Lantus) 11 units subcutaneously one time a day for DM. b. Multiple vitamin one tablet by mouth one time day for supplementation. During the medication pass, RN 3 was observed omitting resident 50's multiple vitamin tablet. RN 3 was observed to administer vitamin D 5,000 units and only 4 units of Lantus. No order for vitamin D could be located in resident 50's physician orders. An interview with RN 3 at 9:13 AM was conducted regarding resident 50. RN 3 stated that the multiple vitamin tablet and additional units of Lantus were unavailable either on the medication cart or in the medication storage room, so she was unable to administer them. On 4/17/23 at 11:49 AM a follow up interview with RN 3 regarding resident 50 was conducted. RN 3 stated she spoke with Nurse Practitioner (NP) 1 about the unavailable 7 units of Lantus and only administering 4 units. RN 3 stated NP 1 told her that the resident should be fine until the prescription arrived later that day from the pharmacy, and to administer the remaining dose once Lantus arrived. As of 3:15 PM on 4/17/23 surveyors were not made aware that pharmacy had supplied the remaining Lantus nor witnessed the administration of the seven remaining units. 22992 4. Resident 92 was admitted to the facility on [DATE] with diagnoses that included lupus, end stage heart failure, ischemic cardiomyopathy, history of malignant neoplasm of ovary, hypertensive heart disease with heart failure, rheumatic disorders of both mtiral and aortic valves, anxiety disorder, and chronic respiratory failure with hypoxia. Resident 92's medical record was reviewed from 3/28/23 through 4/25/23. On 4/4/23 at 10:05 AM, an interview was conducted with resident 92. Resident 92 stated that she had been prescribed two different kinds of pain pills, but that they were supposed to be administered on an alternating schedule, every two hours. Resident 92 stated that the pain pills were not supposed to be administered together. Resident 92 stated that many times, the facility nurses were behind during the medication pass and would administer her pain pills together, every 4 hours. Resident 92 stated that the facility nurses were not bringing her pills to her on time and that could kill me. Resident 92's Medication Administration Record (MAR) for April 2023 revealed the following orders: a. 3/30/23 Hydromorphone Hcl (Dilaudid) 6 milligram (mg) tablet by mouth six times a day for increased anxiety and comfort measures. The MAR indicated that the Dilaudid should be administered at 2:00 AM, 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM. b. 2/28/23 Morphine Sulfate 15 mg tablet by mouth every for hours for pain DO NOT GIVE DILAUDID WITHIN TWO HOURS OF RECEIVING MORPHINE. The MAR indicated that the morphine should be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Review of the Medication Administration Audit Report for April 2023 (through 4/17/23 for two of the three shifts) revealed the following entries: a. On 4/1/23 at 8:30 AM, resident 92 was administered both the Dilaudid and the Morphine. b. On 4/1/23 at 3:00 PM, resident 92 was administered both the Dilaudid and the Morphine. c. On 4/3/23 at 3:22 PM, resident 92 was administered Dilaudid, and at 4:44 PM was administered Morphine. d. On 4/4/23 at 2:53 AM, resident 92 was administered Dilaudid, and at 3:22 AM was administered Morphine. e. On 4/5/23 at 1:02 PM, resident 92 was administered Morphine, and at 2:41 PM was administered Dilaudid . f. On 4/5/23 at 7:01 PM, resident 92 was administered Dilaudid, and at 7:48 PM was administered Morphine. g. On 4/5/23 at 11:41 PM, resident 92 was administered Morphine, and on 4/6/23 at 1:16 AM was administered Dilaudid. h. On 4/6/23 at 11:35 AM, resident 92 was administered Dilaudid, and at 12:30 PM was administered Morphine. At 2:11 PM, resident 92 was again administered Dilaudid. i. On 4/6/23 at 6:32 PM, resident 92 was administered Dilaudid, and at 7:42 PM was administered Morphine. j. On 4/6/23 at 11:32 PM, resident 92 was administered Morphine, and on 4/7/23 at 1:05 AM was administered Dilaudid. k. On 4/7/23 at 11:19 AM, resident 92 was administered both the Dilaudid and the Morphine. l. On 4/7/23 at 10:57 PM, resident 92 was administered Dilaudid, and on 4/8/23 at 12:34 AM was administered Morphine. m. On 4/8/23 at 9:56 AM, resident 92 was administered both the Dilaudid and the Morphine. n. On 4/8/23 at 1:43 PM, resident 92 was administered both the Dilaudid and the Morphine. o. On 4/8/23 at 10:11 PM, resident 92 was administered Dilaudid, and at 11:39 PM was administered Morphine. p. On 4/10/23 at 3:17 PM, resident 92 was administered Dilaudid, and at 4:46 PM was administered Morphine. q. On 4/10/23 at 7:28 PM, resident 92 was administered both the Dilaudid and the Morphine. r. On 4/11/23 at 1:46 PM, resident 92 was administered both the Dilaudid and the Morphine. s. On 4/11/23 at 7:40 PM, resident 92 was administered Dilaudid, and at 9:11 PM was administered Morphine. t. On 4/12/23 at 1:20 AM, resident 92 was administered Morphine, and at 2:50 AM was administered Dilaudid. At 4:30 AM, resident 92 was again administered Morphine. u. On 4/12/23 at 6:26 AM, resident 92 was administered Dilaudid, and at 7:58 AM was administered Morphine. v. On 4/12/23 at 12:50 PM, resident 92 was administered both the Dilaudid and the Morphine. w. On 4/12/23 at 3:24 PM, resident 92 was administered Dilaudid, and at 4:05 PM was administered Morphine. At 5:22 PM, resident 92 was again administered Dilaudid. x. On 4/12/23 at 10:49 PM, resident 92 was administered Dilaudid, and at 11:57 PM was administered Morphine. y. On 4/13/23 at 12:50 PM, resident 92 was administered both the Dilaudid and the Morphine. z. On 4/14/23 at at 2:25 AM, resident 92 was administered Dilaudid, and at 3:14 AM was administered Morphine. aa. On 4/14/23 at 1:45 PM, resident 92 was administered Morphine, and at 3:10 PM was administered Dilaudid. bb. On 4/14/23 at 10:53 PM, resident 92 was administered Dilaudid, and at 11:21 PM was administered Morphine. cc. On 4/15/23 at 12:17 PM, resident 92 was administered both the Dilaudid and the Morphine. dd. On 4/15/23 at 8:32 PM, resident 92 was administered Morphine, and at 9:51 PM was administered Dilaudid. At 11:32 PM, resident 92 was again administered Morphine. ee. On 4/16/23 at 1:27 AM, resident 92 was administered Dilaudid, and at 3:02 AM was administered Morphine. ff. 4/16/23 at 1:13 PM, resident 92 was administered Morphine, and at 1:52 PM was administered Dilaudid. gg. On 4/17/23 at 12:15 AM, resident 92 was administered Morphine, and at 1:52 AM was administered Dilaudid. hh. On 4/17/23 at 10:57 AM, resident 92 was administered Dilaudid, and at 12:38 PM was administered Morphine. At 1:48 PM, resident 92 was again administered Dilaudid. ii. On 4/17/23 at 9:40 PM, resident 92 was administered Morphine, and at 11:05 PM was administered Dilaudid. On 4/18/23 at 12:40 AM, resident 92 was again administered Morphine. According to drugs.com, Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including respiratory distress, coma, and even death. (https://www.drugs.com/drug-interactions/dilaudid-with-morphine-1294-768-1656-0.html#:~:text=HYDROmorphone%20morphine&text=Using%20narcotic%20pain%20or%20cough,have%20any%20questions%20or%20concerns.) On 4/20/23 at 12:05 PM, an interview was conducted with Director of Nursing (DON) 3. DON 3 stated that before administering medications, she would check what the doctor had stated. DON 3 stated that narcotic medications should be spaced at least 2 hours apart because it can decrease their respirations. 5. Resident 457 was admitted on [DATE] with diagnoses that included malignant neoplasm of pelvic bones, sacrum and coccyx; moderate protein calorie malnutrition; secondary malignant neoplasm of bone; major depressive disorder; anxiety disorder; and mild cognitive impairment of uncertain or unknown etilogy. Resident 457's medical record was reviewed from 3/28/23 through 4/25/23. Resident 457's Hospice Medication Profile was reviewed. The medication profile indicated that resident 457 was to receive Meloxicam 15 mg once daily. Review of resident 457's MAR indicated that the resident was administered Meloxicam 30 mg twice daily, from 11/28/22 through 12/30/22. This dosage was four times the prescribed amount. Per the manufacturer of Meloxicam, the maximum dose is 15 mg once daily. The manufacturer also indicated that non-steroidal anti-inflammatory drugs, such as Meloxicam, can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the esophagus, stomach, small intestine, or large intestine, which can be fatal. (https://content.boehringer-ingelheim.com/DAM/d412031b-97c4-4b5e-8f21-af1e011fa491/mobic-us-pi.pdf) On 4/20/23 at 2:45 PM, an interview was conducted with the DON. The DON stated that when a resident was admitted , the orders were entered by the DON. The DON stated that before the orders were implemented, they were double checked by the DON or the ADON. 30563 6. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, altered mental status, history of traumatic brain injury (TBI) and intertrochanteric fracture of right femur. Resident 79's medical record was reviewed 3/28/23 through 4/25/23. Resident 79's pharmacy review from April 2023 revealed on 4/7/23, This resident has an order for Eliquis 5 mg BID [twice daily]. This was started at a previous facility on August 31 for an acute, provoked DVT [deep vein thrombosis], with no prior history of DVT noted. It was documented that only six months of treatment was needed, and this treatment duration has been met. However, the patient also suffered a femur fracture recently, and is at risk of VTE [Venous thromboembolism], so the preventive dose is indicated until the functional status returns, and the risk of VTE is resolved. This fits criteria for a pre approved recommendation for the following: 1. Decrease Elliquis to 2.5 mg BID. A current physician's order dated 12/14/22 revealed Eliquis tablet 5 mg. Give 1 tablet by mouth two times a day for DVT. On 4/13/23 at 11:14 AM, an interview was conducted with the CNO and Regional Nurse (RN). The CNO stated if the information was not in the medical record, then the facility did not have it. The RN stated that the pharmacy book had to be recreated. The RN stated not all of the recommendations had been followed up on. 46232 7. Resident 43 was admitted to the facility on [DATE] with the following diagnoses but not limited to chronic obstructive pulmonary disease, type 2 diabetes mellitus, bipolar disorder, borderline personality disorder, and anxiety disorder. On 3/28/23 at 11:25 AM, an interview was conducted with resident 43. Resident 43 stated they were getting a lot of agency nurses that were not giving out the right medication. Resident 43 stated she had to argue with the agency nurses to get her right dose of potassium. Resident 43 stated she was supposed to get 2 potassium pills 4 times a day but stated it was not always happening. Resident 43 stated she had a history of low potassium and has been to the emergency room because of it. Resident 43 showed this surveyor a letter from her nurse practitioner that stated resident 43 has consistently been getting the wrong dose of potassium. please make sure she gets: 40 milliequivalents (mEq) of potassium 4 times (x) a day (sometimes the med card is only 20 mEq, so she needs 2 pills), it stated to call the np if there were any questions. Resident 43 stated she had showed agency nurses this letter in hopes of getting her right dose of potassium but still continued to get her wrong dose. Resident 43 stated since she was the patient and they were the nurse, she always lost. On 3/28/23 at 11:35 AM, an observation was made of Registered Nurse (RN) 9. RN 9 was observed to enter resident 43's room with her morning pills. Resident 43 examined her pill cup with her pills and then told RN 9 that she was only able to find one potassium pill. Resident 43 told RN 9 that she was missing a potassium pill. Before leaving the room, RN 9 stated she needed to double check the medication orders at the medication cart. RN 9 was observed to come back with one more potassium pill. A follow up interview was immediately conducted with RN 9. RN 9 stated most potassium med cards package the potassium dose together. RN 9 stated that resident 43's med card was not that way. RN 9 stated resident 43's medication card did state to give 2 tablets. Resident 43's medical records were reviewed on 4/11/23. A Quarterly MDS dated [DATE], documented resident 43 had a BIMS score of 9. This indicated that resident 43 was moderately impaired. Resident 43's lab work was reviewed from September 2022 - March 2023 with the following reported low potassium levels: a. On 12/1/22, the potassium level was 3.4 b. On 1/4/23, the potassium level was 3.3 c. On 1/9/23, the potassium level was 3.4 [Note: Normal potassium levels range from 3.5 - 5.2. A value of 3.4 to 2.5 was considered a low potassium level. A level of 2.4 or lower was considered to be critically low on potassium and life threatening. A low potassium level is known as hypokalemia.] Resident 43's orders were reviewed and the following potassium order was documented: a. An order of Potassium Chloride ER [extended release] Oral Tablet with a start date of 4/1/23 read as followed, Give 40 mEq by mouth four times a day for hypokalemia Resident 43's progress notes were reviewed and documented as followed: a. On 12/2/22, a medical director note state, .She has chronic diarrhea which is the source of her potassium loss b. On 1/1/23, a nursing note documented, Pt [patient] c/o [complaining of] of muscle and general tiredness. Pt had a history of potassium imbalance c. On 1/4/23, a nursing note stated, Pt's blood test and UA [urinalysis] results received. The following abnormal values noted: Potassium 3.3. [Note: A result of 3.3 meant resident 43 was low in potassium which is hypokalemic.] d. On 2/8/23, a physician progress note stated, .She reports feeling weak, shaky. States she just doesn't feel right. She stated she feels like she used to feel when her potassium was low On 4/19/23 at 10:28 AM, an interview was conducted with the Director in [NAME] [TRUNCATED]

Based on interview and record review it was revealed that, for 1 of 80 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skills set 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. Specifically, a nurse categorized and performed wound care on a skin fold and the anus that she mistook the areas as tunneling wounds. Resident identifier: 7. Findings include: 1. Resident 7 was initially admitted to the facility on [DATE] and again on 4/7/23 with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. Resident 7's medical record was reviewed. A wound care note from 10/10/22 was reviewed. The note from Family Nurse Practitioner (FNP) 1 stated, there is breakdown bilateral mostly on left buttock. However, there are now two small areas one distal and one proximal on her left buttocks that is tunneling. The proximal tunnel is 3.5cm [centimeters] and the distal is 9 cm, measured with Qtip. I cleansed these areas well with puracyn and packed with Maxorb Extra Alginate Wound Dressing. I applied skin prep to peri area then applied barrier cream to peri area and medihoney to the wound bed then applied a foam pad without border. Pt [patient] tolerated well. The wound care note from 10/10/22 included an order to, pack the two tunneling areas of left buttock with alginate or Iodosorb. Apply medihoney or silva kollagen gel to breakdown areas and then apply pink optifoam pad to help with pressure and exudate . Change every Thursday and Saturday. Provider will see Tuesday. A review of resident 7's Treatment Administration Record (TAR) from October 2022 revealed that staff completed the wound care orders on the two tunneling areas on resident 7's buttock on 10/13/22 and 10/15/22. A wound care note from 10/18/22 was reviewed. The note from FNP 1 stated, There is breakdown bilateral mostly on left buttock. The two small areas seen recently, one distal and one proximal on her left buttocks through to be tunneling are not wounds. Cleansed well with puracyn. With a better position of the patient and better evaluation of the folds the proximal opening is in fact her anus. She has a colostomy and the anus is not functioning. The distal opening was also a skin fold on evaluation today. Multiple attempts were made to reach FNP 1. Messages were left to those staff to return the SSA call and as of the completion of the 2567 report, the SSA was unable to contact FNP 1.

Based on observation, interview, and record review it was determined, for 2 of 8 sampled residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, a resident experienced a change in condition with decreased oxygen levels and mental status change without interventions and physician notification. Additionally, a resident had received wound care without a physician order or any documentation. Resident Identifiers: 1 and 4. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's, bipolar disorder, schizoaffective disorder, dementia, and depression. On 12/20/22 at 11:05 AM, a phone interview was conducted with resident 4's power of attorney (POA). The POA stated that resident 4 was severely dehydrated when she got to the hospital. The POA stated that she was told multiple times by staff that they were pushing fluids down resident 4. The POA stated that she did not believe the staff had encouraged resident 4 to drink anything because of the condition resident 4 arrived to the hospital in. The POA stated that resident 4 was not able to tell staff when she was thirsty but stated if she was given a glass of water she would have drank it. The POA stated that she did not understand how resident 4 was so dehydrated if staff were pushing fluids and after she got the bag of intravenous fluids before she went to the hospital. The POA stated that two to three days before resident 4 went to the hospital, she was told resident 4 had a headache and congestion. The POA stated that when she called for updates, she was not always given the right information on resident 4's condition. Resident 4's medical records were reviewed on 12/20/22. A nursing monthly summary date 8/21/22 documented resident 4's level of conscious was alert. On 8/27/22, progress notes revealed that resident 4's family was called and notified of positive COVID-19 cases within the facility. On 8/28/22, resident 4 had oxygen saturation (O2) vitals documented of 82% on room air at 6:42 AM and at 3:12 PM O2 of 88 % on room air. [It should be noted that no interventions were documented and no documentation could be found indicating the physician had been notified.] A respiratory systems evaluation dated 8/28/22; which evaluated for COVID-19 symptoms such as new onset or worsening cough, shortness of breath, congestion or runny nose, fatigue, etc .; documented Resident 4 had not exhibited any of the listed symptoms even though her oxygen saturation level for that day was documented to be 82% and 88% on room air. [It should be noted that resident 4 was not tested for COVID-19 on this day even though she exhibited symptoms of increased oxygen demand.] On 8/29/22 at 10:21 AM, resident 4 vitals were check once throughout the day and revealed an O2 level of 88%. [It should be noted that no interventions and documentation were located to indicate staff had notified the physician.] A respiratory systems evaluation dated 8/29/22 documented that resident 4 had no COVID-19 symptoms even though her oxygen saturation level was 88% on room air. On 9/1/22, a progress note revealed that resident 4 was put on airborne precautions due to a positive COVID-19 test result and started to monitor resident 4 for shortness of breath (SOB) and difficulty breathing. Resident 4's September 2022 Treatment Administration Record (TAR) revealed no documented occurrences of SOB. The September 2022 Medication Administration Record (MAR) documented that resident 4 had received a dose of Guaifenesin ER (extended release) 600 mg (milligrams) at 3:02 PM for congestion and Tylenol 500 mg for a headache. The respiratory systems evaluation dated 9/1/22 had no symptoms documented even though resident 4 had received the Guaifenesin for congestion and Tylenol for a headache. A nursing skilled daily review dated 9/1/22 at 2:41 PM, documented resident 4's level of consciousness as lethargic and that resident 4 had a dry non-productive cough present. [It should be noted that no interventions or physician notification was located regarding resident 4's mental status change from 8/21/22.] Resident 4's oxygen saturation vitals were documented as 90% and 91%. On 9/2/22, a nursing progress note stated that resident 4's decline in mental status was due to her co-morbidities. Resident 4's oxygen saturation vitals were 92% and 91% on room air. The September 2022 TAR had no documented occurrences for SOB for 9/2/22. The September 2022 MAR documented that resident 4 had received 500 mg of Tylenol for a headache at 6:10 AM. The respiratory systems evaluation dated 9/2/22 had no documented symptoms even though resident 4 received medication for a headache. On 9/4/22, a nursing skilled daily review with a time stamp of 12:41 AM documented resident 4's level of consciousness as lethargic and that resident 4 had a dry non-productive cough present. Resident 4's oxygen saturation at 1:09 AM was documented as 94% on room air. A late entry nursing progress note at 12:00 PM stated that resident 4 was lethargic, color of skin was ashy and pale, resident was non-responsive to verbal stimuli but responsive to physical stimuli, elevated temperature noted. [It should be noted that the highest temperature documented for 9/4/22 was 98.3]. The progress note stated that the doctor was notified of change in resident condition and interventions were ordered such as intravenous (IV) fluids and an acetaminophen suppository. [It should be noted that no documentation was located for the administration of the IV fluids and acetaminophen suppository on the September 2022 MAR.] The POA was notified and she decided to try the interventions before the resident needed to be sent to the emergency room . Resident 4's oxygen saturation level at 1:59 PM was documented to be at 94% while on oxygen. The September 2022 TAR documented that resident 4 had an occurrence of SOB and/or difficulty breathing while she laid flat; the oxygen saturation documented was 86%. At 2:57 PM, a progress note stated that resident 4 was, lethargic and color of skin was pale and ashy. Non-responsive to verbal commands/questions. Temp 99.1 O2 sats 86%. Notified MD (medical doctor). Orders for one time IV NS (normal saline) 200 ml (milliliters)/hr (hour) for hydration, and acetaminophen suppository. Acetaminophen effective. Resident is afebrile 96.0 tympanic temp. Residents v/s (vital signs) stable yet does not look good. Notified MD. Order to send resident out to hospital. Noted. Per Discharge summary note at 3:24 PM, resident 4 was transported to local hospital via ambulance due to COVID-19 complications. The local hospital history and physical (H&P) dated 9/6/22 documented that resident 4 was admitted to the hospital on 9/4/22 and diagnosed with severe encephalopathy, sepsis from a UTI (urinary tract infection), and severe dehydration with hypernatremia. The H&P document that resident 4 met intensive care (ICU) criteria due to her severity of illness but resident 4's code status was changed from a full code to a do not resuscitate and do not intubate (DNR/DNI) and was admitted to the hospital for a trial for antibiotics and fluids as well as a palliative consultation in hopes that resident 4 was to be discharged back to the facility on hospice. On 12/20/22 at 12:58 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when a resident tested positive for COVID-19, they were isolated to their room for 10 days and were not allowed to leave their room. RN 1 stated the policy was to test every resident in the building if someone had tested positive for COVID-19. RN 1 stated that some COVID-19 symptoms were fever, cough, body aches, loss of taste and smell, and increased oxygen demands. RN 1 stated that they checked COVID-19 positive residents' oxygen saturations once or twice a day to check for decreased oxygen saturation. RN 1 stated if a resident present with decreased oxygen, first he made sure the machine was working correctly. Then he positioned the resident appropriately and listened to their lungs to assess if the resident was oxygenating well. Lastly, RN 1 stated he contacted the doctor and applied oxygen to the resident with decreased oxygen. RN 1 stated that if a resident had a change of condition, they were suppose to document it in the progress notes. RN 1 stated that if a resident was COVID-19 positive looked rough, they transferred the resident to the emergency room . On 12/20/22 at 1:18 PM, an interview was conducted with RN 2. RN 2 stated if a resident had COVID-19 symptoms, they were tested for COVID-19. RN 2 stated if there were multiple residents with COVID-19, the facility protocol was to test every resident in the building every 2 days for 3 times. RN 2 stated that COVID-19 symptoms included a cough, fever, runny nose, gastrointestinal distress, headaches, change in mental status, shortness of breath, and increased oxygen demand. RN 2 stated that if a resident had SOB or an increase in their oxygen demand, she called the doctor and administered oxygen. RN 2 stated that normally when a resident had a low oxygen, the doctor ordered a chest x-ray and wanted laboratory work done. RN 2 stated that a change of condition was any symptom or vitals sign that was not their base line. RN 2 stated that when they contacted the doctor they were suppose to put in a progress note but stated she was not sure it was always completed. On 12/20/22 at 2:26 PM, an interview was conducted with RN 3. RN 3 stated she was familiar with resident 4. RN 3 stated that resident 4 was dependent on staff for all cares. RN 3 stated that resident 4 was alert and oriented only to herself and needed guidance on how to do things. RN 3 stated that resident 4 needed to be reminded to eat her food or else she played with it. RN 3 stated that resident 4 was hospitalized because of COVID-19. RN 3 stated that symptoms of COVID-19 were coughing, a fever, behavioral changes and temperature. RN 3 stated that once a resident had a cough, nursing staff completed a lung assessment, a respiratory assessment and checked their oxygen levels. RN 3 stated that in the respiratory assessment, nursing staff looked to see if a resident had a fever and decreased oxygen. RN 3 stated nursing staff documented any other COVID-19 symptoms and what was done to prevent the spread of COVID-19. RN 3 stated that they had standing orders for oxygen and the provider was notified if a resident was put on oxygen since that was a change in their condition. RN 3 stated interventions for low oxygenation included frequent checks, oxygen administration, elevate the head of the bed and notify the provider. RN 3 stated if nursing staff notified the doctor, they added a progress note that stated what was identified and any new orders received. RN 3 stated if any interventions were done to help increase a resident oxygen, they were supposed to document it. On 12/20/22 at 1:29 PM, an interview was conducted with Assistant Director of Nursing (ADON). The ADON stated the policy for COVID-19 testing was when a resident tested positive, they had to test every resident in the facility and proceeded to have follow-up testing at 48-hours and 96-hours. The ADON stated when a resident was COVID-19 positive, the resident was isolated to their room and were placed on droplet and contact precautions. The ADON stated nurses monitored for symptoms such as shortness of breath and made sure the residents had good oxygen saturations. The ADON stated that vitals were taken on all resident at least twice a day. The ADON stated she had an infection control log from when she became the infection preventionist at the beginning of September where she documented positive COVID-19 cases and the date the resident tested positive. [It should be noted that the ADON was unable to provide a list of positive COVID-19 cases for the beginning of September 2022.] The ADON stated that if a resident had been tested for COVID-19 there was a progress note completed regarding the results and a physician order for a COVID-19 test. [It should be noted that no COVID-19 test was ordered for resident 4.] A follow up interview was conducted at 3:20 PM, the ADON stated if a resident had a change of condition, there were standing physician orders for a COVID-19 test to be done. The ADON stated the COVID-19 symptoms they looked for were coughs, fevers, body aches, headaches, any temperature greater than 100.4 and decreased oxygen saturation. The ADON stated that if a resident had any of those symptoms, the nursing staff documented the symptoms in the daily respiratory assessment. The ADON stated she remembered that at the end of August they had a COVID-19 outbreak in the memory care unit and basically the whole unit became positive. The ADON stated they tried to keep all the residents in their rooms but that only went so well. The ADON stated she did not have access to the COVID-19 tracking for the end of August 2022 because the previous Director of Nursing was the only one who had access to the excel sheet. The ADON stated that resident 4 had been doing well up until the day she went to the hospital. The ADON stated that resident 4 was alert and oriented to herself and she was hard to understand due to her word salad. The ADON stated that the night of 9/3/22 resident 4 hadn't had any brief changes when she normally had at least 2-3 wet briefs since she was incontinent. The ADON stated that resident 4 had been drinking very little fluid prior to 9/4/22. The ADON stated that the morning of 9/4/22, a Certified Nursing Assistant (CNA) approached her because the CNA was concerned about resident 4. The ADON stated that she was not resident 4's nurse that day but was approached by the CNA because resident 4's nurse at the time had not expressed concern about resident 4's condition. The ADON stated that resident 4's oxygen had started to drop and she developed a fever. The ADON stated that the doctor was notified of resident 4's change in condition and had ordered for resident 4 to receive Tylenol, IV fluids and to be placed on oxygen. The ADON stated she called and notified resident 4's POA about her status and had her decide the course of action she wanted the nursing facility to take. The ADON stated, the POA wanted to see how effective the IV fluids were before resident 4 was sent to the hospital. The ADON stated that the IV fluids were ordered for hydration. The ADON stated she remembered she started the IV but didn't remember the rate at which it was ordered. The ADON was then asked why the IV fluids and the Tylenol were not documented in the September 2022 MAR and she stated she must have forgotten to do it in the computer but stated she had received a verbal order from the doctor. The ADON was also asked why resident 4 received a Tylenol suppository when she did not have a documented fever. The ADON's response was that she recalled resident 4 being febrile and stated they did not document her temperature. The ADON stated that resident 4 was given the suppository because she felt resident 4 was not able to safety swallow pills at the time and resident 4 was barely responding to her name. The ADON stated that resident 4 was not completely unresponsive any of the time and stated that she had to do a painful stimuli for resident 4 to respond. The ADON stated she had to do a light sternal rub and resident 4 responded with swatting her hands away. The ADON stated she reassessed resident 4's condition after she had administered the Tylenol and started the fluids. The ADON stated that resident 4 had not improved, proceeded to call the POA and doctor and resident 4 was sent to the hospital. 38031 2. Resident 1 was admitted to the facility on [DATE] with diagnoses which included sepsis, presence of hear-valve replacement, ebstein's anomaly, history of malignant neoplasm of the thyroid and esophagus, cognitive communication deficit, cardiac pacemaker, hypertension, colitis, hypothyroidism, delusional disorder, post-traumatic stress disorder, personality disorder, and chronic pain syndrome. On 12/20/22 at 12:13 PM, an interview was conducted with resident 1. Resident 1 stated that he was in excruciating pain in his left leg because it was infected. Resident 1 stated that he had a wound on the left leg and he had hurt his foot the other day. Resident 1 stated that the facility started doing dressing changes to the leg wound on 12/19/22. Resident 1 stated that the infection in the left leg wound had spread. Resident 1 stated that the wound care consisted of changing the bandage only, but he thought one nurse may have applied some treatment to the wound. Resident 1 stated that he was receiving an antibiotic for the infection, but believed it was not working due to the intensity of the pain in the wound. Resident 1 stated that the physician assessed the wound on 12/19/22. Resident 1's physician orders revealed the following: a. On 12/11/22, a laboratory order for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and C-Reactive Protein (CRP) for suspected cellulitis to the left leg was initiated. b. On 12/14/22, an order for Doxycycline Tablet 100 milligrams by mouth two times a day for 10 days due to infection was initiated. It should be noted that no orders were found for wound care or treatment. Resident 1's Treatment Administration Record (TAR) for December 2022 revealed no documentation for wound care. Resident 1's progress notes revealed the following: a. On 12/6/22 at 3:37 PM, the nursing note documented no skin breakdown noted at this time. b. On 12/11/22 at 2:11 PM, the nursing note documented, .has a laceration on the front of the left shin and a foam dressing over it. Rt. [resident] states he feel burning and throbbing. Area feels warm to touch. DON [Director of Nursing] and physician notified. Physician ordered labs; CBC, CMP, CRP for tomorrow. c. On 12/13/22 at 3:24 PM, the nursing note documented, Pt [patient] does have a wound on his left LE [lower extremity], approx [approximately] 5 cm [centimeters] long nad [sic] 2-3 cm wide, the wound is fairly superficial and does have some yellow slough tissue associated with it as well as some purulent drainage, woundwas [sic] cleaned and redressed, pt informed that we are still waiting on results from blood drawn yesterday, 12-12-22. the wound itself does not look bad bu [sic] the peri wound is red and warm to touch, does have a cellulitic appearance. d. On 12/14/22 at 11:48 PM, the nursing note documented, Wound to LLE [left lower extremity], purulent drainage noted, redness and warmth noted around periwound. Wound cleansed and dressed. e. On 12/15/22 at 11:25 PM, the nursing note documented, Resident has wound to LLE, being treated with doxycycline, wound is dressed. f. On 12/16/22 at 11:41 PM, the nursing note documented, Resident has wound to LLE, being treated with doxycycline, wound is dressed. g. On 12/19/22 at 4:49 PM, the nursing note documented, Pt has been started on doxycycline for infection in LLE, pt has been on ABX [antibiotic] for approx 5 days now and wound is almost healed and entire leg looks much better, less swelling, less redness, pt states pain has only gotten worse, NP [Nurse Practitioner] ordered a CBC on pt today but pt refused to allow his blood to be drawn for this test. On 12/14/22 at 1:29 PM, resident 1's skin assessment documented that the resident had a small wound on left front center shin, this is not a new problem and was being treated with antibiotics for the issue. No other weekly skin assessments documented resident 1's left lower extremity wound. On 12/16/22, the provider note documented that resident 1 reported that the lower extremity left leg is getting more painful. The wound is healing even though patient states he does not feel it is healing. The discoloration to the area around his wound is returning from red to normal skin color. The drainage now is minimal. Patient would like increase in his pain medication. Increased his Tramadol from 1 to 2 tabs every six hours, but set a limit for five days only. Patient refused blood culture and patient refused wound culture. Referred Patient to wound nurse who will be here on Tuesday. The assessment for skin documented, Left lower wound shows improvement. It has minimal drainage out, 100% slough tissue that is slight and can be seen through. No foul smell to wound. Patient is high risk for infection or sepsis, so wound to be monitored frequently. Antibiotics appear to be working. The provider documented the plan for the wound care was to, Continue tubigrips to left lower extremity. Daily dressing change: Cleanse with NS [normal saline] or wound cleanser, pat dry, absorbent bandage with border or tape to secure. It should be noted that resident 1 did not have any orders for wound care. On 12/19/22, the provider note documented, Patient's left lower shin wound is healing. Has gone from 13 cm length, 8 cm width to 12 cm length, 7.2 cm width. Wound bed yellow, scabbed, thin slough on shin present. No redness around the wound bed. Increased edema present. Patient refused to increase his diuretics. Will continue compression. The provider documented the plan for the wound care was to CBC to assess infectious process, continue daily nursing assessment and dressing change, continue compression stockings to left lower leg with elevation when patient in bed. On 12/20/22 at 1:17 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the facility had an outside agency provide wound care and the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) would round with them. RN 1 stated that resident 1 had a wound on the left shin and that it looked like cellulitis a week ago. RN 1 stated that the he contacted Nurse Practitioner (NP) 1 a couple of days later to notify of redness to the surrounding wound. RN 1 stated that resident 1's CBC showed that his white blood cell count (WBC) was 7.1, so the physician felt comfortable with oral doxycycline to treat. RN 1 stated that they did not obtain any wound cultures. RN 1 stated that resident 1's dressing change to the left shin wound was completed at least one time per shift if the resident allowed. RN 1 stated that the dressing change was a 4 x [by] 4 foam Mepilex dressing, and that he thought they still had orders for a compression wrap to reduce the fluid. RN 1 stated that resident 1 often refused medications and treatments. RN 1 was observed to review resident 1's TAR and stated that he did not see any wound orders. I swear it says Mepilex with compression wrap. RN 1 stated that documentation of the dressing changes should be in the TAR. RN 1 stated that he was instructed to document dressing changes in a narrative progress note. RN 1 stated that charting in the progress notes would sometimes go into an ether and could not be located. RN 1 stated that he was instructed by the ADON and DON to document dressing changes in a progress note instead of the TAR. RN 1 stated that if they had an order in the TAR they could document in there. RN 1 stated that resident 1 did not have any orders for dressing changes that he could locate. RN 1 stated that he was not sure how the other nursing staff were aware of the dressing change if there was not an order, other than receiving the information during change of shift nurse-to-nurse report. RN 1 stated that the last time he completed resident 1's dressing change was on 12/19/22. It should be noted that the progress note for 12/19/22 did not document that wound care was provided or that the dressing was changed. On 12/20/22 at 2:39 PM, an interview was conducted with the ADON. The ADON stated that the facility had a contract with a wound care company that provided services to the facility. The ADON stated that the wound care NP would do rounds with her or the DON weekly. The ADON stated that if they identified any wounds that needed more involvement then she or the DON would refer that resident to the wound care team. The ADON stated that the facility NP 1 had assessed resident 1's wound and started him on antibiotics, and wound care daily. The ADON stated that she had provided resident 1 with wound care this morning. The ADON stated that she performed a dressing change and used wound cleanser to clean the wound, applied antibiotic ointment and placed a silicone dressing on top. The ADON stated that ted hose were applied over the top of the dressing. The ADON stated that the wound care was documented as a progress note. The ADON stated that she had been working on where to document the treatment in the electronic medical records. The ADON stated that she thought resident 1 had an order for wound care but did not verify the order in the chart prior to completing the treatment. The ADON stated that she had discussed the wound care with NP 1 yesterday. The ADON stated that resident 1 had been receiving dressing changes and wound care since the start of the antibiotic. It should be noted that the antibiotic was ordered on 12/14/22. The ADON stated that she did not enter a verbal order for the silicone dressing with wound cleanser and antibiotic ointment because NP 1 had stated to continue with the dressing order, and it should have already been in the TAR. The ADON stated that the frequency of the dressing change order was daily unless the dressing was soiled. The ADON stated that the licensed nurses should be documenting in the TAR when the dressing change was completed. The ADON stated that in addition to the TAR documentation she also wanted a narrative progress note with more wound details, and the expectation was that the nursing staff were completing this with every dressing change. The ADON stated that she was trying to figure out how the nurses could document a better narrative of the wound characteristics. The ADON stated that she was informed that resident 1 did not have wound care orders, treatment in the TAR and did not have consistent documentation that care was being provided. The ADON stated that she had not consulted with the contracted wound care company regarding resident 1's wound nor requested any treatment orders for the wound care. The ADON stated that staff should have orders for treatments and medications prior to the administration of the treatment being provided.

Based on interview, observation, and record review, it was determined for 4 of 17 sample residents, that the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment that the allegations were thoroughly investigated, and that staff prevented further potential abuse while the investigation was in process. Specifically, one nurse responded to a resident throwing water on him by approaching the resident, and pinning the resident against a wall by placing his fingers around the neck and clavicle area of the resident. The allegation was not thoroughly investigated by administrative staff, and no actions were taken to prevent further incidents of potential abuse. This incident was found to have occurred at an Immediate Jeopardy level. Additionally, sexual and physical interactions occurred between residents with no thorough investigations completed, and no interventions put into place These incidents were found to have occurred at a harm level. Resident identifiers: 1, 7, 8, and 10. On 8/23/22 at 11:45 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to investigation and prevent further abuse while the investigation was being conducted. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), Clinical Resource Nurse (CRN) 1, the Director of Leadership Development (DLD), and the Regional [NAME] President of Operations (RVPO). On 8/25/22, CRN 2 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 8/25/22 at 5:00 PM. The facility seeks to ensure that each alleged violation of abuse, neglect, exploitation or mistreatment is thoroughly investigated, and the facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and take appropriate corrective action, as a results of investigation findings. Immediate Interventions Resident physical abuse allegation with Nurse * 8/23/2022: Investigation reopened and all staff that were on shift at 2026 on 8/9/2022 were reinterviewed by corporate staff (See Exhibit 16). Nurse 1 was terminated on 8/24/2022. When investigation is completed, will be submitted to CMS per protocol. * Corrective action taken: Nurse 1 was suspended pending investigation. Other interventions described in F600: Allegation of abuse between resident 1 and nurse was reported to CMS on 8/9/2022 and investigation initiated. (See Exhibit 1) Resident was sent to ER, blue sheeted by MD on 8/9/2022 Nurse was suspended 8/23/22 pending completion of further investigation. Skin check completed on resident 1 8/23/2022 with no signs of latent injury. (See Exhibit 2) 8/10/2022 Returned from hospital, provided different room on other side of facility. Resident not happy with new room and was moved back to his old room per his request. [Resident 1] to be evaluated by Licensed Social worker on 8/24/25 (sic) for psychosocial status post incident (See Exhibit 3) * Additional interventions put in place to prevent further abuse, neglect, exploitation and mistreatment from occurring: Facility Plan to Abate Immediate Jeopardy Facility Education Abuse Policy and Procedure reviewed by IDT on August 23, 2022, prior to initiating raining (sic) for nursing staff. Initial Training started 8/23/2022 Training was completed by Nursing Home Administrator (NHA)/ Designee and Regional [NAME] President (RVP) starting on August 23, 2022. (See Exhibit 4). Training was done using specific real-life examples of what type of situations constitute abuse and included the following topics: Types/Definitions of Abuse Abuse must be stopped before the staff leaves the resident Immediate interventions to put in place to prevent recurrence of the abuse When abuse is suspected to Notify Abuse Coordinator (NHA) immediately Notification guidelines (Police, APS, Utah State) This training will be ongoing until all facility staff are in-serviced Facility educated on their responsibility as mandatory reporters. This training was initiated on 8/24/2022 (See Exhibit 5) Additional Training to be provided to facility staff, initiated on 8/25/2022. Behavior De-escalation and abuse prevention. Training materials to be reviewed by Licensed Social Worker before training is completed. Recognizing employee burnout and steps to do when burnout is identified (get out of the situation, step outside, etc). Interventions staff can take if they do not feel comfortable reporting abuse/neglect to abuse coordinator. Training materials to be reviewed by Licensed Social Worker before training is completed. Staff who were unable to attend the training on 8/25/2022 will have access to an audiovisual recording of the training and do a post training test to validate understanding of the material (See Exhibit 6) Training to be provided to Resident Population: Resident Council to be done on 8/25/2022 with education about how to contact the ombudsman and how to report grievances/concerns to facility staff (See Exhibit 7) Information Flyer to be posted in resident's rooms about who to contact in the facility to report concerns (facility social worker/resident advocate/Ombudsman). (See Exhibit 8) Additional Training: Administrator was educated on the abuse policy procedure on 8/23/2022 by Regional Nurse Consultant. (See Exhibit 9) Agency Staff to receive abuse training prior to the start of their shift starting 8/24/2022. Training to include the policy/protocol of identifying abuse and how to respond when abuse is suspected (See Exhibit 10) Facility Audit by Licensed Social Worker Licensed Social Worker Consultant(s) to perform evaluation of all facility residents to identify residents at increased risk for abuse, identify residents who are exhibiting signs or symptoms of abuse and make recommendations for addressing any concerns. (See Exhibit 11) The facility will take the recommendations and update the resident's plan of care to manage identified behaviors/deficits (See Exhibit 11). Any findings of abuse/neglect that are found doing rounds will be reported per facility protocol and investigated per federal guidelines. Facility Interventions to Monitor Abuse Program Going Forward NHA/Designee to Post signage in high visibility areas of facility that NHA/Designee is the abuse coordinator and is to be contacted if abuse is suspected at any time by 8/23/2022 (See Exhibit 12) Social Worker to maintain roster of residents at risk for abuse related to Altered Cognition or Behavioral Complex Status. Licensed Caregiver to do focused wellness rounds on these residents monthly and as needed. Frequency of audits will be adjusted by IDT (See Exhibit 13) Educational Huddles and focused rounding to be done with staff at least 3x/week to evaluate staff awareness of abuse and know what to do when abuse is identified until the QAPI team determines a lesser frequency is indicated. (See Exhibit 14) Facility Abuse Coordinator to reinforce at all times that there will be no retaliation or punitive action against staff for reporting abuse. QAPI committee to determine length and frequency of these huddles ongoing. Ad-Hoc QAPI on Abuse Prevention completed on 8/23/2022 (See Exhibit 15). Facility interventions were documented and will be discussed in the monthly QAPI meetings until a lesser frequency is deemed necessary. Regional Nurse Consultant (RNC) and RVP to evaluate the facility abuse program at least monthly and as needed to ensure abuse prevention interventions are in place. IMMEDIATE JEOPARDY 1. A Facility Reported Incident (FRI) report was reviewed after it was submitted to the State Survey Agency. The FRI indicated that on 8/9/22 resident 1 became agitated and started punching and hitting [Licensed Practical Nurse (LPN) 1]. While [LPN 1] was trying to defend himself CNA (Certified Nursing Assistant) [CNA 1] got hit as well while trying to break up the fight. The fight was broken up and [resident 1] was separated from [LPN 1]. The police were called and are taking [resident 1] to the hospital for psych (psychological) eval (evaluation). A review of the facility's recent abuse investigations was completed on 8/22/22. The facility ' s abuse investigation for the incident between resident 1 and LPN 1 on 8/9/22 was reviewed. The investigation included the following: a. A statement by LPN 1 that indicated that Patient came up to me at the nurse station while I was charting said nothing and threw a glass of water on me. I went to the patient to see why he did this; he came towards me and started throwing his raised fists at me. After throwing the water at me, he started a fist fight with me at the nurse station. I defended myself against the patient, other staff entered the action pulling us from each other. The patient was escorted to his room by staff. b. A nurses note by LPN 2 indicating that This evening had just given resident [1] his meds (medications) and resident was calm and compliant and then when done had his glass of water and walked around the corner. This nurse busy [with] other things and then witnessed resident and staff member pushing against each other. Ran and tried to separate and pulled resident away from staff member. Walked resident down to his room and police were called. Resident telling police that the staff member was asking girls for sexual favors and then not paying them for it. Resident sent to hospital for eval (evaluation). Hospital sending him back. No other statements by staff or residents were located in the abuse investigation documentation provided by ADM. The facility ' s final abuse investigation for the incident between resident 1 and LPN 1 was reviewed and documented the following: Description of Incident: Resident [1] walked up to nurse [LPN 1] and threw a glass of water at [LPN 1]. As [LPN 1] asked [resident 1] why he did that he started attacking [LPN 1] and punching him repeatedly. [LPN 1] was trying to defend himself and [CNA 1] came into help pull [resident 1] off [LPN 1] and she was also hit. [Resident 1] was pulled off of [LPN 1] and calmed down and was escorted back to his room. The police were called, and they took [resident 1] to the hospital for a psych evaluation because of the way he was acting and because he was so agitated. Patient has since returned with no further incidents. Pertinent Patient History and chart review: [Resident 1] is a [AGE] year-old male who admitted to us with a diagnosis of Dementia with behaviors, type 2 diabetes, chronic pain, adjustment disorder, cognitive communication deficit, and insomnia. Description of Action Taken: [Resident 1] was escorted back to his room and the police were called and [resident 1] was taken to the hospital for a psychological evaluation. Interview with Resident: [Resident 1] said he attacked [LPN 1] because he thought [LPN 1] was asking women for sexual favors and not paying them. [Resident 1] also says many odd things and is often making up bizarre stories. Interview with Staff: Staff confirmed the incident and also confirmed that [LPN 1] just defended himself and did not hit [resident 1]. Staff also confirmed that [LPN 1] was not propositioning female staff for sexual favors. [LPN 1] is openly homosexual. Interventions at conclusion of investigation: [Resident 1] spent the night at the hospital and returned the next day without incident. Conclusion: Substantiated. Event was witnessed by several residents and staff members. [Note: The final abuse investigation did not indicate which staff the ADM had spoken with, did not include an interview with CNA 1 or other staff on duty who might have witnessed the incident, did not include an interview with other residents, did not indicate what measures had been taken to prevent further potential abuse to residents during the investigation, nor which staff he had spoken to.] On 8/22/22 at 10:10 AM, an interview was conducted with resident 1. Resident 1 was unable to recall any physical aggression or altercations between staff and residents, including himself. Resident 1 stated that there was an employee working at the facility that would tell female residents if I do this for you will you do this sexual thing to me? Resident 1 then stated that when the employee was in the exercise room, he would have one of the ladies lay down and then tell female residents he would take care of them if they had sex with him. I was a couple of feet away when I heard it. I will file a complaint. I know what I heard. I was standing right there when he said that. Then he told me he would make a deal with me not to talk. He claims to be a doctor. On 8/22 at 11:22 AM, an interview was conducted with the ADM. The ADM stated that he had not completed abuse investigations as an Administrator prior to being employed at the current facility. The ADM stated that he submitted all abuse reports to his corporate officers each evening, and that Clinical Resource Nurse (CRN) 1 reviewed all of his abuse investigations when she came to the facility. The ADM was asked about documentation regarding previous abuse investigations completed at the facility prior to 5/23/22. The ADM stated that he did not have those investigations because the previous administrator had taken those with him when he was transferred to another facility. On 8/22/22 at 2:00 PM, an interview was conducted with the facility ADM regarding the incident with resident 1 and LPN 1 on 8/9/22. The ADM stated that he had received a call that resident 1 had approached LPN 1 and threw a glass of water at him, and [LPN 1] asked why he did that, and then [resident 1] started punching [LPN 1] and going crazy, and there was a brawl in the hall. The ADM stated that there was a CNA who got hit during the incident, but that he couldn ' t remember the CNAs name. The ADM stated that facility staff called the police because resident 1 was freaking out . he was super belligerent and going crazy saying [LPN 1] was going around propositioning females for sex and not paying them, but [LPN 1] is openly gay so . We just think he (resident 1) doesn ' t like [LPN 1]. The ADM stated that when resident 1 returned from the hospital, the resident acted like it never happened. The ADM stated that resident 1 has done other things like that, such as claiming another resident took his shoes. The ADM stated that resident 1's stories were all fabricated. He will seem normal at first, and then he goes into random bizarre things. And then you realize he ' s not normal. When asked if there were any other witnesses to the incident besides resident 1 and LPN 1, the ADM stated that he was not sure, but he could ask LPN 1 who was there. The ADM stated that for the abuse investigation he had only interviewed LPN 1 and LPN 2 via telephone. The ADM stated that LPN 2 had reported being hit during the incident, and then stated maybe it was CNA 1 who was hit. The ADM then stated that he had not interviewed LPN 2. When asked what statement LPN 1 provided to the ADM, the ADM stated that LPN 1 ' s assertion was he just had his arms up protecting himself. He was super shaken up. The ADM then stated that he did not talk to resident 1 regarding the incident because when you talk to him it ' s pretty much nonsense. [Note: The ADM documented in the abuse investigation that he had spoken with resident 1]. On 8/22/22 at 3:21 PM an interview was conducted with CNA 1. When asked about the incident between resident 1 and LPN 1 on 8/9/22, CNA 1 stated that at about 9:30 PM, she was charting at the nurses station in the rehabilitation hall. CNA 1 stated that she saw resident 1 approach LPN 2 so that LPN 2 could administer resident 1 ' s medications. CNA 1 stated that she returned to her charting, and then saw some scuffling. CNA 1 stated that she did not see the beginning of the incident between LPN 1 and resident 1, but when she looked up from her charting she saw [LPN 1] pin [resident 1] against the door to the shower room. CNA 1 also stated that it looked like he (LPN 1) had him (resident 1) by the throat and pinned against the door. CNA 1 stated that LPN 1 was pushing resident 1 with one of his forearms, while the other hand had resident 1 by the throat. CNA 1 stated resident 1 was pushing LPN 1 away with his hands on LPN 1 ' s upper arm/bicep area. CNA 1 stated that it also looked like they were slapping each other. CNA 1 further stated, I didn ' t see anyone hit, but they were pushing each other. [LPN 2] ran over and got between them. Then I got in between them, and grabbed [LPN 1] ' s arms from behind. CNA 1 stated that she had grabbed LPN 1 ' s arms in an attempt to stop LPN 1 from continuing to pin the resident to the wall, and get them away from [resident 1]. CNA 1 stated that when she grabbed LPN 1 ' s arms, he squeezed my arms and said ' get the fuck off me, ' and then hit me in the chest. He raised his arm again and was getting ready to hit me again so I moved away. CNA 1 stated that the incident last for a couple of minutes. CNA 1 stated that she was very upset and crying, so she went to the memory care area of the facility to speak with other staff. CNA 1 stated that she did not think there were other residents present at the nurses station at the time. CNA 1 stated that after the incident, resident 1 was taken to the hospital for an evaluation, but subsequently returned to the facility, at approximately 2:00 AM. CNA 1 stated that when resident 1 returned from the hospital later that evening, LPN 1 and LPN 2 took resident 1 and his belongings over to the memory care area of the facility. CNA 1 stated that resident 1 was upset and repeatedly asked, Why do I have to leave?, Can I please go back to my room?, and Can I sign a paper that says I won ' t touch him (LPN 1) again? CNA 1 stated that resident 1 was offered a room in which another resident was residing, but resident 1 refused, so resident 1 sat in the hallway of the common area of the memory care area of the facility. CNA 1 stated that after the incident, LPN 1 should have gone home. You don ' t put your hands on a resident. I ' ve never seen a nurse hit a resident, and then the nurse gets to stay and work? . I went over to (the nurses station) to get my stuff but I didn ' t want to be around [LPN 1]. [Resident 1] isn ' t safe in his home. Even if [the resident] is the aggressor, you can ' t hit him. When asked about the investigation into the incident, CNA 1 stated that on the night of the incident, the DON spoke with her and told her she could leave work if she needed to. CNA 1 stated that she reported to the DON that she had been struck by LPN 1. CNA 1 stated that the DON told her that LPN 1 had blacked out and said he didn ' t realize he had hit CNA 1. CNA 1 also stated that the DON told her that LPN 1 feels bad and he ' s crying. CNA 1 stated that no one else in administration had spoken with her regarding the incident, including the ADM. CNA 1 stated that she reported the details of the incident to the DON, the same way she explained them to the surveyors. On 8/23/22 at 9:00 AM, a follow up interview was conducted with CNA 1. When asked if she was injured during the incident between LPN 1 and resident 1, CNA 1 stated that she was not injured but it hurt a little. It was more traumatic for me than physical. CNA 1 stated that when resident 1 was in the memory care area of the facility, which was locked, his voice was never raised, and he repeatedly stated I don ' t understand why I can ' t go back in the room. CNA 1 stated that she was never asked for a written statement. CNA 1 stated that after the incident, she requested not to work with LPN 1. CNA 1 stated that other staff encouraged her to report the incident to management or other government agencies, but she did not know who to contact. On 8/23/22 at 1:49 PM, an interview was conducted with CNA 2 regarding the incident between LPN 1 and resident 1. CNA 2 stated that on 8/9/22 at approximately 10:00 PM, she was seated at the nurses station while completing her charting. CNA 2 stated that she saw LPN 1 stand up from where he was seated on one end of the nurses station, and walk to the other end of the nurses station. CNA 2 stated that she then looked up to see resident 1 and LPN 1 fist fighting. CNA 2 stated that she saw resident 1 hit LPN 1 in the temple area of the head, and LPN 1 hit resident 1 twice in the cheeks. CNA 2 stated that LPN 1 used both hands, which were curled into fists, to hit resident 1. CNA 2 stated that LPN 2 and CNA 1 intervened and were able to get between LPN 1 and resident 1. CNA 2 stated that at one point during the incident, LPN 1 turned and hit CNA 1 in the chest, while saying Get off me, get off me, stop to CNA 1. CNA 2 stated that resident 1 told LPN 2 he wanted to press charges against LPN 1. CNA 2 stated that LPN 1 repeatedly told resident 1 that he was going to press charges because this was assault. CNA 2 stated that LPN 1 and LPN 2 later walked with resident 1 down to the memory care area of the facility. CNA 2 stated that LPN 2 was walking between resident 1 and LPN 1, but that LPN 1 repeatedly stated to resident 1 You know the cops are going to come, at which point resident 1 tried to reach around LPN 2 and hit LPN 1. CNA 2 stated that after the incident, CNA 1 looked at me, and said ' I ' m going home. I can ' t take this. ' CNA 2 stated that CNA 1 then went over to the memory care area of the facility to finish her shift. CNA 2 stated that both herself and LPN 2 contacted the DON to tell her about the incident. CNA 2 stated that the DON subsequently came to the facility, and spoke with both LPN 1 and resident 1. CNA 2 stated that the DON tried to relieve LPN 1 of his shift, but that LPN 1 didn ' t feel the need to go home, so he ended up staying . and worked until 6:00 AM. CNA 2 stated that after the incident, resident 1 was sent out to the hospital, but returned to the facility at approximately 2:00 AM. CNA 2 stated that resident 1 was sent to sleep in another room because things were still hostile that night. I don ' t know if [LPN 1] was still upset but we wanted to be safe more than sorry. We moved [resident 1 ' s] recliner to the other side of the facility. When asked if work assignments had been changed, CNA 2 stated that there were no adjustments, and that from 10:00 PM to 6:00 AM on the nights that LPN 1 worked, LPN 1 was the only nurse on the side of the facility were resident 1 currently resided, so if resident 1 needed anything, he would have to ask LPN 1. When asked if she had been interviewed or asked to provide a statement of the incident, CNA 2 stated that on the night of the incident, the DON asked CNA 2 what happened, but that that was the only time she was interviewed regarding the incident, and had not provided a written statement. CNA 2 stated that the ADM never spoke with her regarding the incident. On 8/22/22 at 6:52 PM, an interview was conducted with LPN 2. LPN 2 stated that she was assigned to work the 6:00 PM to midnight shift. LPN 2 stated that on 8/9/22, she was standing on the outside portion of the nurses station, in the center area of the station. [Note: This particular nursing station desk is large and situated at the intersection of four halls. It is shaped like a letter L. From the center of the desk, to exit the nursing station, on either end, is approximately 8-10 feet.] LPN 2 stated that resident 1 was walking in the hallway near the nurses station, and LPN 2 offered to give him his evening pills. LPN 2 stated that resident 1 agreed. LPN 2 stated that after resident 1 took his pills, he walked behind her and to the left side of the nurses station (from her point of view) and threw a glass of water on LPN 1, who was seated on the inside portion of the nurses station. LPN 2 stated that resident 1 then turned and walked behind her again and around to the other end of the nurses station, on her right, but stayed on the outside of the nurses station. LPN 2 stated that LPN 1 stood up from the inside portion of the nurses station where he had been seated, and she heard scuffling to her right. LPN 2 stated that at that time she observed that resident 1 had his hands on LPN 1 ' s arms, holding onto the bicep area. LPN 2 stated that LPN 1 had his left hand up to his (resident 1 ' s) neck. LPN 2 then demonstrated what she observed. LPN 2 demonstrated to surveyors that LPN 1 ' s right hand was on resident 1 in a manner that his thumb was on one side of the resident ' s neck and his fingers were pressed in the area of the resident ' s clavicle. LPN 2 stated that resident 1 was taller than LPN 1, and they were pushing against each other. LPN 2 stated that when the altercation was over, she told resident 1, Let ' s go to your room. LPN 2 stated that resident 1 did not resist or have any behaviors at that time and was fine once I intervened. LPN 2 stated that while she was walking the resident to his room, LPN 1 was telling the resident that he was going to press charges because he was assaulted. LPN 2 stated that she told LPN 1 to go away. When describing the incident, LPN 2 stated that something snapped with LPN 1 and that I don ' t think [resident 1] was going to do anything else. So the water may have been the end of it. there was a look like he (LPN 1) was just not right. He was so upset. It was like a seizure look in [LPN 1 ' s] eyes. I think he (LPN 1) overreacted. LPN 2 further stated that CNA 1 reported to her that she had tried to separate LPN 1 and resident 1, but that LPN 1 had snapped and said get the f away and hit her and she was quite upset. LPN 2 stated that both she and CNA 1 reported what happened to the DON. LPN 2 stated that she didn ' t feel safe leaving LPN 1 alone with resident 1 during the remainder of the shift, so they moved resident 1 ' s recliner over to the other side of the facility. LPN 2 stated that resident 1 agreed to move over to the other side, when she told him it was just for tonight. On 8/23/22 at 9:11 AM, a follow up interview was conducted with LPN 2. LPN 2 stated that she didn ' t see if resident 1 or LPN 1 were hit. LPN 2 stated that during the incident she was facing the resident, and tried to distract him. LPN 2 stated that she had her back to LPN 1. LPN 2 stated that she kept telling him (LPN 1) to stop . [LPN 1] was shook up and upset and saying ' I ' m going to press charges ' but [resident 1] wasn ' t really saying anything. LPN 2 stated that after the incident, she walked resident 1 to his room, and LPN 1 came up to resident 1 during that time and repeatedly told resident 1 he was going to press charges. LPN 2 stated that she told LPN 1 to just go back to the desk. LPN 2 stated that resident 1 remained in his room until the police arrived at the facility. LPN 2 stated that when the DON arrived at the facility, she told the DON that LPN 1 and resident 1 were pushing against each other and that LPN 1 was freaked. I ' ve never seen him like that. LPN 2 stated that she heard CNA 1 tell the DON about the incident also, including that CNA 1 had been struck. LPN 2 stated that CNA 1 was pretty shook up by the incident. LPN 2 stated that after she told the DON about the incident, there was no other follow up by either the DON or the ADM. On 8/22/22 an interview was conducted with Staff Member (SM) 1. SM 1 stated that he/she wanted to remain anonymous due to fears of retribution. SM 1 stated that he/she was working at the facility on the night of 8/9/22 when the incident occurred between resident 1 and LPN 1. SM 1 stated that CNA 1 approached him/her and was crying, stating that LPN 1 had hit her. SM 1 stated that he/she was able to visualize a mark on CNA 1 ' s arm, where CNA 1 stated that LPN 1 had squeezed her arm. SM 1 stated that CNA 1 reported that the nurse (LPN 1) had [resident 1] up by his neck and holding him against the wall, and they were swinging at each other. SM 1 stated that CNA 1 told him/her that CNA 1 thought LPN 1 had purposely hit her because LPN 1 was looking at her when he hit her. SM 1 stated that CNA 1 reported that the DON had been contacted, was aware of the situation, but allowed LPN 1 to finish his shift. SM 1 stated that CNA 1 now refused to work with LPN 1, and had asked to exclusively work in the memory care area of the facility. SM 1 stated that CNA 1 reported that LPN 2 had also witnessed the incident. SM 1 stated You ' re not supposed to hit a resident. they sent [resident 1] out (to the hospital), and when he came back, [LPN 1] wouldn ' t let him (resident 1) stay in his room. SM 1 stated that when resident 1 returned from the hospital, he/she saw LPN 1 and LPN 2 take resident 1 down to the memory care area of the facility because LPN 1 took things into his own hands. SM 1 stated that LPN 2 stated that resident 1 has to stay over here because [LPN 1] won ' t have him there in his assigned area. SM 1 stated that LPN 1 was stating he refused to take care of resident 1. SM 1 stated that resident 1 sat in his recliner in the hallway of the locked memory care area for the rest of the night. On 8/22/22, resident 1 ' s medical records were reviewed. On 8/9/22, the physician attending to resident 1 in the emergency room documented that the patient is a [AGE] year-old male with history of dementia . Nursing staff were concerned because of his altercation and the patient was struck in the upper back. At this point time (sic) the patient complains of no significant anger or agitation. He does have some mild upper back pain. He is quite calm and was transported to the hospital and in route he was quite calm as well. at this point time (sic) this patient does not meet any criteria for involuntary hold and he should be able to be discharged home to the facility. He is not a risk of harm to himself or others. The patient has been calm and cooperative in the ER (emergency room ). As discussed, please try to avoid any altercations at the facility. The physician documented that his/her clinical impression was that resident 1 was Agitated and had a Back contusion. On 8/22/22 at 6:07 PM, an interview was conducted with LPN 1. LPN 1 stated that prior to 8/9/22,he had only worked with resident 1 on two occasions. LPN 1 stated that on 8/9/22 he was told during shift change by another nurse that resident 1 was having delusions and was stating that a Mr. White was propositioning women at the facility and not paying them. LPN 1 stated that later that evening he was seated on one end of the nurses station completing some charting, when resident 1 walked up and chucks a glass of water at me. So I went around to the end of the nurses station to see what ' s happening. He (resident 1) had his fists up and is swinging. I attempted to block him . and hold him away. [Note: This particular nursing station desk is large and situated at the intersection of four halls. It is shaped like a letter L. From the center of the desk to exit the nursing station, on either end, is approximately 8-10 feet.] LPN 1 stated that he had bruises on his right upper chest and neck from where resident 1 had hit him. LPN 1 stated that we got pulled away from each other and that LPN 2 and LPN 1 got him (resident 1) down to his room, at which point LPN 1 called the police and told them that he had just been assaulted. When asked to describe the incident in more detail, LPN 1 stated that resident 1 walked to the area of the nurses station where LPN 1 was seated and threw a glass of water on him. LPN 1 stated that he did not say anything to the resident but that he did stand up, walked to the end of the nurses station and confronted resident 1 to determine why the resident had thrown water at him. LPN 1 stated that the resident started walking toward him and both fists were coming at me . I was trying to deflect and get him away, and he ' s deflecting. I ' m trying to get him off to the wall. There ' s thr [TRUNCATED]

Based on interview, observation, and record review, it was determined for 7 of 17 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, one nurse responded to a resident throwing water on him by approaching the resident, and pinning the resident against a wall by placing his fingers around the neck and clavicle area of the resident. This incident was found to have occurred at an Immediate Jeopardy level. Additionally, sexual and physical interactions occurred between residents with no interventions put into place. These incidents were found to have occurred at a harm level. Resident identifiers: 1, 2, 3, 7, 8, 9, and 10. On 8/23/22 at 11:45 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), Clinical Resource Nurse (CRN) 1, the Director of Leadership Development (DLD), and the Regional [NAME] President of Operations (RVPO). On 8/25/22, CRN 2 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 8/25/22 at 5:00 PM. The facility seeks to ensure that each resident is free from abuse, neglect, misappropriation of resident property, and exploitation Immediate Interventions Resident physical abuse allegation with Nurse Allegation of abuse between resident 1 and nurse was reported to CMS on 8/9/2022 and investigation initiated. (See Exhibit 1) Resident was sent to ER, blue sheeted by MD on 8/9/2022 Nurse was suspended 8/23/22 pending completion of further investigation. Skin check completed on resident 8/23/2022 with no signs of latent injury. (See Exhibit 2) 8/10/2022 Returned from hospital, provided different room on other side of facility. Resident not happy with new room and was moved back to his old room per his request. [Resident 1] evaluated by Licensed Social worker on 8/24/25 (sic) for psychosocial status post incident (See Exhibit 3) Facility Plan to Abate Immediate Jeopardy Abuse Policy and Procedure reviewed by IDT on August 23, 2022, prior to initiating raining for nursing staff. Initial Education started 8/23/2022 Training was completed by Nursing Home Administrator (NHA)/ Designee and Regional [NAME] President (RVP) starting on August 23, 2022. (See Exhibit 4). Training was done using specific real-life examples of what type of situations constitute abuse and included the following topics: Types/Definitions of Abuse Abuse must be stopped before the staff leaves the resident Immediate interventions to put in place to prevent recurrence of the abuse When abuse is suspected to Notify Abuse Coordinator (NHA) immediately Notification guidelines (Police, APS, Utah State) This training will be ongoing until all facility staff are in-serviced Facility educated on their responsibility as mandatory reporters. This training was initiated on 8/24/2022 (See Exhibit 5) Additional Education to be provided to facility staff, initiated on 8/25/2022. Behavior De-escalation and abuse prevention. Training materials to be reviewed by Licensed Social Worker before training is initiated. Recognizing employee burnout and steps to do when burnout is identified (get out of the situation, step outside, etc). Training materials to be reviewed by Licensed Social Worker before training is initiated. Interventions staff can take if they do not feel comfortable reporting abuse/neglect to abuse coordinator. Training materials to be reviewed by Licensed Social Worker before training is initiated. Staff who were unable to complete the training on 8/25/2022 will have access to an audiovisual recording of the training and do a post training test to validate understanding of the material (See Exhibit 6). Training to be provided to Resident Population: Resident Council to be done on 8/25/2022 with education about how to contact the ombudsman and how to report grievances/concerns to facility staff (See Exhibit 7) Information Flyer to be posted in resident's rooms about who to contact in the facility to report concerns (facility social worker/resident advocate/Ombudsman). (See Exhibit 8) Additional Training: Administrator was educated on the abuse policy procedure on 8/23/2022 by Regional Nurse Consultant. (See Exhibit 9) Agency Staff to receive abuse training prior to the start of their shift starting 8/24/2022. Training to include the policy/protocol of identifying abuse and how to respond when abuse is suspected (See Exhibit 10) Facility Audit by Licensed Social Worker Licensed Social Worker Consultant(s) to perform evaluation of all facility residents to identify residents at increased risk for abuse, identify residents who are exhibiting signs or symptoms of abuse and make recommendations for addressing any concerns. (See Exhibit 11) The facility will take the recommendations and update the resident's plan of care to manage identified behaviors/deficits (See Exhibit 11). Any findings of abuse/neglect that are found doing rounds will be reported per facility protocol and investigated per federal guidelines. Facility Interventions to Maintain Abuse Program Going Forward NHA/Designee to Post signage in high visibility areas of facility that NHA/Designee is the abuse coordinator and is to be contacted if abuse is suspected at any time by 8/23/2022 (See Exhibit 12) Social Worker to maintain roster of residents at risk for abuse related to Altered Cognition or Behavioral Complex Status. Licensed Caregiver to do focused wellness rounds on these residents monthly and as needed. Frequency of audits will be adjusted by IDT (See Exhibit 13) Educational Huddles and focused rounding to be done with staff at least 3x/week to evaluate staff awareness of abuse and know what to do when abuse is identified until the QAPI team determines a lesser frequency is indicated. (See Exhibit 14) Facility Abuse Coordinator to reinforce at all times that there will be no retaliation or punitive action against staff for reporting abuse. Facility Resident Advocate signed up on 8/25/2022 to obtain Elder Abuse Certification that is Accredited by ASWB of Utah. This will be completed by 8/31/2022. QAPI committee to determine length and frequency of these huddles ongoing. Ad-Hoc QAPI on Abuse Prevention completed on 8/23/2022 (See Exhibit 15). Facility interventions were documented and will be discussed in the monthly QAPI meetings until a lesser frequency is deemed necessary. Regional Nurse Consultant (RNC) and RVP to evaluate the facility abuse program at least monthly and as needed to ensure abuse prevention interventions are in place. On 8/26/22, while completing the partial extended survey and the abbreviated complaint survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/25/22 at 5:00 PM. Findings include: IMMEDIATE JEOPARDY 1. A Facility Reported Incident (FRI) report was reviewed after it was submitted to the State Survey Agency. The FRI indicated that on 8/9/22 resident 1 became agitated and started punching and hitting [Licensed Practical Nurse (LPN) 1]. While [LPN 1] was trying to defend himself CNA (Certified Nursing Assistant) [CNA 1] got hit as well while trying to break up the fight. The fight was broken up and [resident 1] was separated from [LPN 1]. The police were called and are taking [resident 1] to the hospital for psych (psychological) eval (evaluation). A review of the facility's recent abuse investigations was completed on 8/22/22. The facility's abuse investigation for the incident between resident 1 and LPN 1 on 8/9/22 was reviewed. The investigation included the following: a. A statement by LPN 1 that indicated that Patient came up to me at the nurse station while I was charting said nothing and threw a glass of water on me. I went to the patient to see why he did this; he came towards me and started throwing his raised fists at me. After throwing the water at me, he started a fist fight with me at the nurse station. I defended myself against the patient, other staff entered the action pulling us from each other. The patient was escorted to his room by staff. b. A nurses note by LPN 2 indicating that This evening had just given resident [1] his meds (medications) and resident was calm and compliant and then when done had his glass of water and walked around the corner. This nurse busy [with] other things and then witnessed resident and staff member pushing against each other. Ran and tried to separate and pulled resident away from staff member. Walked resident down to his room and police were called. Resident telling police that the staff member was asking girls for sexual favors and then not paying them for it. Resident sent to hospital for eval (evaluation). Hospital sending him back. No other statements by staff or residents were located in the abuse investigation documentation provided by ADM. The facility's final abuse investigation for the incident between resident 1 and LPN 1 was reviewed and documented the following: Description of Incident: Resident [1] walked up to nurse [LPN 1] and threw a glass of water at [LPN 1]. As [LPN 1] asked [resident 1] why he did that he started attacking [LPN 1] and punching him repeatedly. [LPN 1] was trying to defend himself and [CNA 1] came into help pull [resident 1] off [LPN 1] and she was also hit. [Resident 1] was pulled off of [LPN 1] and calmed down and was escorted back to his room. The police were called, and they took [resident 1] to the hospital for a psych evaluation because of the way he was acting and because he was so agitated. Patient has since returned with no further incidents. Pertinent Patient History and chart review: [Resident 1] is a [AGE] year-old male who admitted to us with a diagnosis of Dementia with behaviors, type 2 diabetes, chronic pain, adjustment disorder, cognitive communication deficit, and insomnia. Description of Action Taken: [Resident 1] was escorted back to his room and the police were called and [resident 1] was taken to the hospital for a psychological evaluation. Interview with Resident: [Resident 1] said he attacked [LPN 1] because he thought [LPN 1] was asking women for sexual favors and not paying them. [Resident 1] also says many odd things and is often making up bizarre stories. Interview with Staff: Staff confirmed the incident and also confirmed that [LPN 1] just defended himself and did not hit [resident 1]. Staff also confirmed that [LPN 1] was not propositioning female staff for sexual favors. [LPN 1] is openly homosexual. Interventions at conclusion of investigation: [Resident 1] spent the night at the hospital and returned the next day without incident. Conclusion: Substantiated. Event was witnessed by several residents and staff members. [Note: The final abuse investigation did not indicate which staff the ADM had spoken with, did not include an interview with CNA 1 or other staff on duty who might have witnessed the incident, did not include an interview with other residents, did not indicate what measures had been taken to prevent further potential abuse to residents during the investigation, nor which staff he had spoken to.] On 8/22/22 at 10:10 AM, an interview was conducted with resident 1. Resident 1 was unable to recall any physical aggression or altercations between staff and residents, including himself. Resident 1 stated that there was an employee working at the facility that would tell female residents if I do this for you will you do this sexual thing to me? Resident 1 then stated that when the employee was in the exercise room, he would have one of the ladies lay down and then tell female residents he would take care of them if they had sex with him. I was a couple of feet away when I heard it. I will file a complaint. I know what I heard. I was standing right there when he said that. Then he told me he would make a deal with me not to talk. He claims to be a doctor. On 8/22 at 11:22 AM, an interview was conducted with the ADM. The ADM stated that he had not completed abuse investigations as an Administrator prior to being employed at the current facility. The ADM stated that he submitted all abuse reports to his corporate officers each evening, and that Clinical Resource Nurse (CRN) 1 reviewed all of his abuse investigations when she came to the facility. The ADM was asked about documentation regarding previous abuse investigations completed at the facility prior to 5/23/22. The ADM stated that he did not have those investigations because the previous administrator had taken those with him when he was transferred to another facility. On 8/22/22 at 2:00 PM, an interview was conducted with the facility ADM regarding the incident with resident 1 and LPN 1 on 8/9/22. The ADM stated that he had received a call that resident 1 had approached LPN 1 and threw a glass of water at him, and [LPN 1] asked why he did that, and then [resident 1] started punching [LPN 1] and going crazy, and there was a brawl in the hall. The ADM stated that there was a CNA who got hit during the incident, but that he couldn ' t remember the CNAs name. The ADM stated that facility staff called the police because resident 1 was freaking out . he was super belligerent and going crazy saying [LPN 1] was going around propositioning females for sex and not paying them, but [LPN 1] is openly gay so . We just think he (resident 1) doesn ' t like [LPN 1]. The ADM stated that when resident 1 returned from the hospital, the resident acted like it never happened. The ADM stated that resident 1 has done other things like that, such as claiming another resident took his shoes. The ADM stated that resident 1's stories were all fabricated. He will seem normal at first, and then he goes into random bizarre things. And then you realize he ' s not normal. When asked if there were any other witnesses to the incident besides resident 1 and LPN 1, the ADM stated that he was not sure, but he could ask LPN 1 who was there. The ADM stated that for the abuse investigation he had only interviewed LPN 1 and LPN 2 via telephone. The ADM stated that LPN 2 had reported being hit during the incident, and then stated maybe it was CNA 1 who was hit. The ADM then stated that he had not interviewed LPN 2. When asked what statement LPN 1 provided to the ADM, the ADM stated that LPN 1 ' s assertion was he just had his arms up protecting himself. He was super shaken up. The ADM then stated that he did not talk to resident 1 regarding the incident because when you talk to him it ' s pretty much nonsense. [Note: The ADM documented in the abuse investigation that he had spoken with resident 1]. On 8/22/22 at 3:21 PM an interview was conducted with CNA 1. When asked about the incident between resident 1 and LPN 1 on 8/9/22, CNA 1 stated that at about 9:30 PM, she was charting at the nurses station in the rehabilitation hall. CNA 1 stated that she saw resident 1 approach LPN 2 so that LPN 2 could administer resident 1 ' s medications. CNA 1 stated that she returned to her charting, and then saw some scuffling. CNA 1 stated that she did not see the beginning of the incident between LPN 1 and resident 1, but when she looked up from her charting she saw [LPN 1] pin [resident 1] against the door to the shower room. CNA 1 also stated that it looked like he (LPN 1) had him (resident 1) by the throat and pinned against the door. CNA 1 stated that LPN 1 was pushing resident 1 with one of his forearms, while the other hand had resident 1 by the throat. CNA 1 stated resident 1 was pushing LPN 1 away with his hands on LPN 1 ' s upper arm/bicep area. CNA 1 stated that it also looked like they were slapping each other. CNA 1 further stated, I didn ' t see anyone hit, but they were pushing each other. [LPN 2] ran over and got between them. Then I got in between them, and grabbed [LPN 1] ' s arms from behind. CNA 1 stated that she had grabbed LPN 1 ' s arms in an attempt to stop LPN 1 from continuing to pin the resident to the wall, and get them away from [resident 1]. CNA 1 stated that when she grabbed LPN 1 ' s arms, he squeezed my arms and said ' get the fuck off me, ' and then hit me in the chest. He raised his arm again and was getting ready to hit me again so I moved away. CNA 1 stated that the incident last for a couple of minutes. CNA 1 stated that she was very upset and crying, so she went to the memory care area of the facility to speak with other staff. CNA 1 stated that she did not think there were other residents present at the nurses station at the time. CNA 1 stated that after the incident, resident 1 was taken to the hospital for an evaluation, but subsequently returned to the facility, at approximately 2:00 AM. CNA 1 stated that when resident 1 returned from the hospital later that evening, LPN 1 and LPN 2 took resident 1 and his belongings over to the memory care area of the facility. CNA 1 stated that resident 1 was upset and repeatedly asked, Why do I have to leave?, Can I please go back to my room?, and Can I sign a paper that says I won ' t touch him (LPN 1) again? CNA 1 stated that resident 1 was offered a room in which another resident was residing, but resident 1 refused, so resident 1 sat in the hallway of the common area of the memory care area of the facility. CNA 1 stated that after the incident, LPN 1 should have gone home. You don ' t put your hands on a resident. I ' ve never seen a nurse hit a resident, and then the nurse gets to stay and work? . I went over to (the nurses station) to get my stuff but I didn ' t want to be around [LPN 1]. [Resident 1] isn ' t safe in his home. Even if [the resident] is the aggressor, you can ' t hit him. When asked about the investigation into the incident, CNA 1 stated that on the night of the incident, the DON spoke with her and told her she could leave work if she needed to. CNA 1 stated that she reported to the DON that she had been struck by LPN 1. CNA 1 stated that the DON told her that LPN 1 had blacked out and said he didn ' t realize he had hit CNA 1. CNA 1 also stated that the DON told her that LPN 1 feels bad and he ' s crying. CNA 1 stated that no one else in administration had spoken with her regarding the incident, including the ADM. CNA 1 stated that she reported the details of the incident to the DON, the same way she explained them to the surveyors. On 8/23/22 at 9:00 AM, a follow up interview was conducted with CNA 1. When asked if she was injured during the incident between LPN 1 and resident 1, CNA 1 stated that she was not injured but it hurt a little. It was more traumatic for me than physical. CNA 1 stated that when resident 1 was in the memory care area of the facility, which was locked, his voice was never raised, and he repeatedly stated I don ' t understand why I can ' t go back in the room. CNA 1 stated that she was never asked for a written statement. CNA 1 stated that after the incident, she requested not to work with LPN 1. CNA 1 stated that other staff encouraged her to report the incident to management or other government agencies, but she did not know who to contact. On 8/23/22 at 1:49 PM, an interview was conducted with CNA 2 regarding the incident between LPN 1 and resident 1. CNA 2 stated that on 8/9/22 at approximately 10:00 PM, she was seated at the nurses station while completing her charting. CNA 2 stated that she saw LPN 1 stand up from where he was seated on one end of the nurses station, and walk to the other end of the nurses station. CNA 2 stated that she then looked up to see resident 1 and LPN 1 fist fighting. CNA 2 stated that she saw resident 1 hit LPN 1 in the temple area of the head, and LPN 1 hit resident 1 twice in the cheeks. CNA 2 stated that LPN 1 used both hands, which were curled into fists, to hit resident 1. CNA 2 stated that LPN 2 and CNA 1 intervened and were able to get between LPN 1 and resident 1. CNA 2 stated that at one point during the incident, LPN 1 turned and hit CNA 1 in the chest, while saying Get off me, get off me, stop to CNA 1. CNA 2 stated that resident 1 told LPN 2 he wanted to press charges against LPN 1. CNA 2 stated that LPN 1 repeatedly told resident 1 that he was going to press charges because this was assault. CNA 2 stated that LPN 1 and LPN 2 later walked with resident 1 down to the memory care area of the facility. CNA 2 stated that LPN 2 was walking between resident 1 and LPN 1, but that LPN 1 repeatedly stated to resident 1 You know the cops are going to come, at which point resident 1 tried to reach around LPN 2 and hit LPN 1. CNA 2 stated that after the incident, CNA 1 looked at me, and said ' I ' m going home. I can ' t take this. ' CNA 2 stated that CNA 1 then went over to the memory care area of the facility to finish her shift. CNA 2 stated that both herself and LPN 2 contacted the DON to tell her about the incident. CNA 2 stated that the DON subsequently came to the facility, and spoke with both LPN 1 and resident 1. CNA 2 stated that the DON tried to relieve LPN 1 of his shift, but that LPN 1 didn ' t feel the need to go home, so he ended up staying . and worked until 6:00 AM. CNA 2 stated that after the incident, resident 1 was sent out to the hospital, but returned to the facility at approximately 2:00 AM. CNA 2 stated that resident 1 was sent to sleep in another room because things were still hostile that night. I don ' t know if [LPN 1] was still upset but we wanted to be safe more than sorry. We moved [resident 1 ' s] recliner to the other side of the facility. When asked if work assignments had been changed, CNA 2 stated that there were no adjustments, and that from 10:00 PM to 6:00 AM on the nights that LPN 1 worked, LPN 1 was the only nurse on the side of the facility were resident 1 currently resided, so if resident 1 needed anything, he would have to ask LPN 1. When asked if she had been interviewed or asked to provide a statement of the incident, CNA 2 stated that on the night of the incident, the DON asked CNA 2 what happened, but that that was the only time she was interviewed regarding the incident, and had not provided a written statement. CNA 2 stated that the ADM never spoke with her regarding the incident. On 8/22/22 at 6:52 PM, an interview was conducted with LPN 2. LPN 2 stated that she was assigned to work the 6:00 PM to midnight shift. LPN 2 stated that on 8/9/22, she was standing on the outside portion of the nurses station, in the center area of the station. [Note: This particular nursing station desk is large and situated at the intersection of four halls. It is shaped like a letter L. From the center of the desk, to exit the nursing station, on either end, is approximately 8-10 feet.] LPN 2 stated that resident 1 was walking in the hallway near the nurses station, and LPN 2 offered to give him his evening pills. LPN 2 stated that resident 1 agreed. LPN 2 stated that after resident 1 took his pills, he walked behind her and to the left side of the nurses station (from her point of view) and threw a glass of water on LPN 1, who was seated on the inside portion of the nurses station. LPN 2 stated that resident 1 then turned and walked behind her again and around to the other end of the nurses station, on her right, but stayed on the outside of the nurses station. LPN 2 stated that LPN 1 stood up from the inside portion of the nurses station where he had been seated, and she heard scuffling to her right. LPN 2 stated that at that time she observed that resident 1 had his hands on LPN 1 ' s arms, holding onto the bicep area. LPN 2 stated that LPN 1 had his left hand up to his (resident 1 ' s) neck. LPN 2 then demonstrated what she observed. LPN 2 demonstrated to surveyors that LPN 1 ' s right hand was on resident 1 in a manner that his thumb was on one side of the resident ' s neck and his fingers were pressed in the area of the resident ' s clavicle. LPN 2 stated that resident 1 was taller than LPN 1, and they were pushing against each other. LPN 2 stated that when the altercation was over, she told resident 1, Let ' s go to your room. LPN 2 stated that resident 1 did not resist or have any behaviors at that time and was fine once I intervened. LPN 2 stated that while she was walking the resident to his room, LPN 1 was telling the resident that he was going to press charges because he was assaulted. LPN 2 stated that she told LPN 1 to go away. When describing the incident, LPN 2 stated that something snapped with LPN 1 and that I don ' t think [resident 1] was going to do anything else. So the water may have been the end of it. there was a look like he (LPN 1) was just not right. He was so upset. It was like a seizure look in [LPN 1 ' s] eyes. I think he (LPN 1) overreacted. LPN 2 further stated that CNA 1 reported to her that she had tried to separate LPN 1 and resident 1, but that LPN 1 had snapped and said get the f away and hit her and she was quite upset. LPN 2 stated that both she and CNA 1 reported what happened to the DON. LPN 2 stated that she didn ' t feel safe leaving LPN 1 alone with resident 1 during the remainder of the shift, so they moved resident 1 ' s recliner over to the other side of the facility. LPN 2 stated that resident 1 agreed to move over to the other side, when she told him it was just for tonight. On 8/23/22 at 9:11 AM, a follow up interview was conducted with LPN 2. LPN 2 stated that she didn ' t see if resident 1 or LPN 1 were hit. LPN 2 stated that during the incident she was facing the resident, and tried to distract him. LPN 2 stated that she had her back to LPN 1. LPN 2 stated that she kept telling him (LPN 1) to stop . [LPN 1] was shook up and upset and saying ' I ' m going to press charges ' but [resident 1] wasn ' t really saying anything. LPN 2 stated that after the incident, she walked resident 1 to his room, and LPN 1 came up to resident 1 during that time and repeatedly told resident 1 he was going to press charges. LPN 2 stated that she told LPN 1 to just go back to the desk. LPN 2 stated that resident 1 remained in his room until the police arrived at the facility. LPN 2 stated that when the DON arrived at the facility, she told the DON that LPN 1 and resident 1 were pushing against each other and that LPN 1 was freaked. I ' ve never seen him like that. LPN 2 stated that she heard CNA 1 tell the DON about the incident also, including that CNA 1 had been struck. LPN 2 stated that CNA 1 was pretty shook up by the incident. LPN 2 stated that after she told the DON about the incident, there was no other follow up by either the DON or the ADM. On 8/22/22 an interview was conducted with Staff Member (SM) 1. SM 1 stated that he/she wanted to remain anonymous due to fears of retribution. SM 1 stated that he/she was working at the facility on the night of 8/9/22 when the incident occurred between resident 1 and LPN 1. SM 1 stated that CNA 1 approached him/her and was crying, stating that LPN 1 had hit her. SM 1 stated that he/she was able to visualize a mark on CNA 1 ' s arm, where CNA 1 stated that LPN 1 had squeezed her arm. SM 1 stated that CNA 1 reported that the nurse (LPN 1) had [resident 1] up by his neck and holding him against the wall, and they were swinging at each other. SM 1 stated that CNA 1 told him/her that CNA 1 thought LPN 1 had purposely hit her because LPN 1 was looking at her when he hit her. SM 1 stated that CNA 1 reported that the DON had been contacted, was aware of the situation, but allowed LPN 1 to finish his shift. SM 1 stated that CNA 1 now refused to work with LPN 1, and had asked to exclusively work in the memory care area of the facility. SM 1 stated that CNA 1 reported that LPN 2 had also witnessed the incident. SM 1 stated You ' re not supposed to hit a resident. they sent [resident 1] out (to the hospital), and when he came back, [LPN 1] wouldn ' t let him (resident 1) stay in his room. SM 1 stated that when resident 1 returned from the hospital, he/she saw LPN 1 and LPN 2 take resident 1 down to the memory care area of the facility because LPN 1 took things into his own hands. SM 1 stated that LPN 2 stated that resident 1 has to stay over here because [LPN 1] won ' t have him there in his assigned area. SM 1 stated that LPN 1 was stating he refused to take care of resident 1. SM 1 stated that resident 1 sat in his recliner in the hallway of the locked memory care area for the rest of the night. On 8/22/22, resident 1 ' s medical records were reviewed. On 8/9/22, the physician attending to resident 1 in the emergency room documented that the patient is a [AGE] year-old male with history of dementia . Nursing staff were concerned because of his altercation and the patient was struck in the upper back. At this point time (sic) the patient complains of no significant anger or agitation. He does have some mild upper back pain. He is quite calm and was transported to the hospital and in route he was quite calm as well. at this point time (sic) this patient does not meet any criteria for involuntary hold and he should be able to be discharged home to the facility. He is not a risk of harm to himself or others. The patient has been calm and cooperative in the ER (emergency room ). As discussed, please try to avoid any altercations at the facility. The physician documented that his/her clinical impression was that resident 1 was Agitated and had a Back contusion. On 8/22/22 at 6:07 PM, an interview was conducted with LPN 1. LPN 1 stated that prior to 8/9/22,he had only worked with resident 1 on two occasions. LPN 1 stated that on 8/9/22 he was told during shift change by another nurse that resident 1 was having delusions and was stating that a Mr. White was propositioning women at the facility and not paying them. LPN 1 stated that later that evening he was seated on one end of the nurses station completing some charting, when resident 1 walked up and chucks a glass of water at me. So I went around to the end of the nurses station to see what ' s happening. He (resident 1) had his fists up and is swinging. I attempted to block him . and hold him away. [Note: This particular nursing station desk is large and situated at the intersection of four halls. It is shaped like a letter L. From the center of the desk to exit the nursing station, on either end, is approximately 8-10 feet.] LPN 1 stated that he had bruises on his right upper chest and neck from where resident 1 had hit him. LPN 1 stated that we got pulled away from each other and that LPN 2 and LPN 1 got him (resident 1) down to his room, at which point LPN 1 called the police and told them that he had just been assaulted. When asked to describe the incident in more detail, LPN 1 stated that resident 1 walked to the area of the nurses station where LPN 1 was seated and threw a glass of water on him. LPN 1 stated that he did not say anything to the resident but that he did stand up, walked to the end of the nurses station and confronted resident 1 to determine why the resident had thrown water at him. LPN 1 stated that the resident started walking toward him and both fists were coming at me . I was trying to deflect and get him away, and he ' s deflecting. I ' m trying to get him off to the wall. There ' s three or four staff and I ' m trying to say ' what ' s your deal? ' and ' what ' s your problem? ' and ' what ' s going on? ' to the resident. LPN 1 stated that he was trying to get resident 1 against the wall because I don ' t know what he ' s capable of. LPN 1 stated that at that time all I want to do is control him and keep everyone else safe, and I don ' t know what he ' s capable of. LPN 1 stated that resident 1 was coming at me and LPN 2 was trying to pull him off of me . I attempted to grab his hands . I don ' t fight an [AGE] year old man. LPN 1 state [TRUNCATED]

Based on observation, interview, and record review it was determined, for 1 out of 38 sampled residents, that the facility did not provide a resident diagnosed with dementia appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being. Specifically, a resident with a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifier: 13. Findings included: Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 13's medical record was reviewed on 12/14/21. A quarterly Minimum Data Set (MDS) dated [DATE], revealed that resident 13 had short and long term memory problems. The MDS further revealed resident 13 was severely impaired with cognitive decision making. The MDS revealed resident 13 had [CONDITION(S)], disorganized thinking, altered level of consciousness continuously. A care plan dated 3/23/21, revealed [Resident 13] has impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia. Can be physically aggressive to staff. Bites self at times. The goal was [resident 13] will maintain current level of cognitive function through the review date. The intervention developed was Administer medications as ordered. Monitor/document for side effects and effectiveness. On 12/13/21 at approximately 2:00 PM, an observation was made of resident 13 in her room. Resident 13 was in bed with the window shades closed and the lights off. On 12/15/21 at 10:25 AM, an observation was made of resident 13. Resident 13 was in her room with the lights off and window shades closed. Resident 13 was observed to have her legs hanging off the bed. Resident 13 was observed to sit up and fall backwards. At 10:47 AM, the Assistant Director of Nursing 2 was observed to look into resident 13's room but did not enter. At 10:55 AM, a staff member entered resident 13's room and covered her with a blanket and moved the floor mat closer to the bed. On 12/15/21 at 2:35 PM, resident 13 was observed to crawl on the floor toward the nurses station wearing a shirt and brief. Registered Nurse (RN) 2 stated to a Certified Nursing Assistant (CNA) that resident 13 had the behavior of crawling out of the bed and on the floor and it was care planned. RN 2 was observed to ask the CNA to get resident 13 a wheelchair. Resident 13 was observed to be placed in the wheelchair and was observed leaning forward and doing a climbing motion toward the floor. On 12/16/21 at 12:23 PM, an observation was made of resident 13. Resident 13 was observed in the dining room in her wheelchair. Resident 13 was observed to have her shirt hanging off of her right shoulder. Resident 13's right shoulder was observed to have a scrap and a large bruise. Resident 13 was observed to be wheeled through the hall by CNA 11. CNA 11 was observed to pull resident 13 back in her wheelchair by her shoulder multiple times. Resident 13 was observed to lean forward and almost fall out of the wheelchair multiple times. Resident 13's progress notes revealed the following: [Note: There were no progress notes from 9/10/21 until 10/3/21.] a. On 10/3/21 at 5:34 AM, This nurse was alerted by floor aides that resident was on the floor. Resident found laying face down with her feet at the head of her bed and her head at the foot of her bed. This nurse noted 2 skin tears, 1 each to bilat (bilateral) elbows. b. On 10/15/21 at 12:22 PM, Resident was found sitting on the floor next to her bed at 1155 (11:55 AM). She has 2 skin tears on her right elbow, they were cleaned and covered. c. On 10/30/21 at 2:59 PM, Resident cleaned up. Aide tried to get her in the shower, but she fought her. Scratched Aide on Left arm. Resident would not get dressed. d. On 11/1/21 at 6:53 PM, Resident was trying to ambulate to her room from the hallway, she had been sitting in her w/c (wheelchair) getting ready for lunch, I didn't see her fall but I heard it. She fell face forward and has bruising around her right eye, and some skin tears on her right arm that she will not let me put a bandage on. e. On 11/4/21 at 6:30 PM, Resident was resting in her bed throughout the day. Around 1300 (1:00 PM) she was noted to be very restless, she had taken her brief and pants off and the room seemed very warm and the heater was turned onto 80 degrees. I turned off the heater and applied the [MEDICATION(S)] cream to her wrists, during this she attempted to swing at this nurse. About an hour after that I administered a prn (as needed) dose of [MEDICATION(S)] at staff request. When I went in her room later, she appeared calm, was resting in her bed, drank her medpass by grabbing my wrist forcefully to bring the cup to her mouth, she took the entire cup of medpass. Black eye noted to right side of her face. f. On 11/5/21 at 3:13 PM, 0715 (7:15 AM). CNA found resident lying on the fall mat next to her bed. She was not able to relate how she got to the floor d/t (due to) baseline confusion. Assessment was done without new injury noted. Noted resolving bruises to right eye and small multiple bruises to both arms from previous fall. g. On 11/9/21 at 6:56 PM, Behaviors Assessment /Observation: no behaviors today Interventions: reposition q (every) 2 hours and prescribed scheduled medications. Resident Reaction to Interventions: responds well. Pain Management: none. Improvement/Decline: stable. h. On 11/27/21 at 10:34 PM, Resident was found crawling on the ground in room .no pain or injury noted.Resident helped back to bed. i. On 12/2/21 at 1:22 PM, CNA reported to nurse that resident was in the dining room eating lunch. CNA had back to resident and heard a 'thump' noise. CNA turned around to find resident on the floor in front of her wheelchair on her knees with her head on the ground. Resident was assisted to her wheelchair by CNA and brought to the nursing station. Nurse assessed resident for injury. Neuro check within resident normal. Resident is alert. When asked if she has any pain, she states 'no'. Resident was assisted to room and laid in bed. j. On 12/5/21 at 1:59 PM, When I entered the room to apply [resident 13's] medication on her wrists, I noticed some bleeding on her left index finger. After applying the ointment, I went to grab wound leaner and 4x4 gauze to clean and assess the wound. While cleaning the wound, I noticed the cut wasn't deep and I left it open to air. k. On 12/15/21 at 9:37 AM, Resident has skin tear on her left forearm about .5 of an inch. It was found while getting her out of the shower. She also has a small skin tear to her right elbow and her rigth (sic) wrist both have dressings intact. Resident 13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] 12.5/2/1 milligram/gram cream three times a day to inner wrist related to agitation. The medication was started on 12/2/21. b. [MEDICATION(S)], Benadryl, [MEDICATION(S)] (ABH) Gel 0.5 mg apply 1 milliliter on skin three times a day related to depressive episode. The medication was started 7/20/21 and discontinued 12/2/21. c. [MEDICATION(S)] tablet 50 MG by mouth related to [CONDITION(S)]. The medication was started on 5/7/21. d. [MEDICATION(S)] Hcl tablet 50 MG by mouth related to [CONDITION(S)]. The medication was started on 5/6/21. Resident 13's Treatment Administration Record (TAR) for December 2021 was reviewed. Resident 13's aggressiveness was monitored twice daily. From 12/1/21 through 12/9/21 resident 13 had 2 episodes of aggressiveness on 12/2/21 and 1 episode on 12/5/21. From 12/10/21 through 12/16/21 resident 13 had 3 to 6 episodes of aggressiveness per day. Resident 13's TAR for November 2021 was reviewed. Resident 13 had episodes of aggressiveness on 11/4/21, 11/6/21, 11/7/21, 11/8/21, 11/9/21, 11/10/21, 11/11/21, 11/12/21, 11/13/21 and 11/20/21. The other days nursing staff documented no aggressiveness. On 12/16/21 at 12:46 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 13 had behaviors of picking and scratching her arms. LPN 2 stated that hospice applied bandages to her wounds on her arms and resident 13 pulled them all off. LPN 2 stated she was not aware of bruising on resident 13. An observation was made of resident 13 with LPN 2. LPN 2 stated resident 13 had bruising on her shoulder, arms, legs, and right ankle. LPN 2 stated resident 13 had a pressure ulcer to her right ankle. On 12/16/21 at 1:34 PM, a phone interview was conducted with resident 13's Hospice RN 1. Hospice RN 1 stated that resident 13 used to climb out of bed and recently she had been climbing out of bed more. Hospice RN 1 stated that she noticed resident 13 had extensive bruising on her body when she performed a bed bath on 12/14/21. Hospice RN 1 stated that resident 13 was administered ABH cream on her wrists three times a day. Hospice RN 1 stated she did not know if the medication was being administered. Hospice RN 1 stated that the ABH cream had not been working for the last few weeks and resident 13 was more restless and clawing at herself. Hospice RN 1 stated resident 13 had open wounds on her arms because she scratched herself. On 12/16/21 at 2:27 PM, an interview was conducted with CNA 2. CNA 2 stated resident 13 pulled off her clothing and picked at her sores. CNA 2 stated staff have asked for tube grips for her arms. CNA 2 stated resident 13 thrashed around in bed and injured herself. CNA 2 stated that resident 13 had taken off her brief and rubbed it everywhere. CNA 2 was observed to look at resident 13's right ankle and stated Oh, my. CNA 2 stated that wound on her foot looked terrible. CNA 2 stated there was a bruise on her foot probably from kicking someone or from her wheelchair. CNA 2 stated resident 13 hurts herself and has very thin skin. CNA 2 stated that she had worked with dementia residents. CNA 2 stated that she sang, made sure resident 13 was warm, and talked to her calmly to calm resident 13. CNA 2 stated that resident 13 was able to pick between 2 different food items but she was non-verbal. On 12/16/21 at 2:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she talked with the hospice nurse about getting mitten's for resident 13 to protect her arms from being scratched. The DON stated she had a [MEDICATION(S)] in her, so she had a hard time with that keeping a resident in a dark room. The DON stated we need to do better for [resident 13]. The DON stated to a CNA that she wanted resident 13 at the nurses station to be monitored. The DON stated that CNAs did not know about caring for resident's and needed more training on dementia care. The DON stated staff needed basic education on care and how to help with residents.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure 2 of 2 residents admitted in the previous 14 days (Resident (R)1 and R2) were isolated to their room(s) and staff used standard, contact and droplet precautions with eye protection during the care of these residents. This failure had the potential to expose all residents, staff and visiting essential personnel, to COVID-19, a [MEDICAL CONDITION] infection that could lead to serious harm or death. On 6/17/20 at 12:00 PM, an Immediate Jeopardy was identified when the facility failed to implement CMS and Centers for Disease Control (CDC) recommended practices to prepare for COVID-19. Specifically, the facility failed ensure two residents who were admitted /readmitted in the previous 14 days were isolated to their room(s) and staff used standard, contact and droplet precautions with eye protection during the care of these residents. A removal plan was accepted and the Immediate Jeopardy was removed on 6/17/20 at 6:10 PM after the implementation of the plan was verified by the surveyors. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. The facility provided the following acceptable removal plan on 6/17/20: - R1 and R2 were immediately isolated to their rooms on droplet, contact and standard precautions with eye protection for 14 days from the time of their admission/re-admission. Surveyors verified the implementation of isolation and transmission based precautions (TBP). Specifically, R1 and R2 were isolated to their rooms. Outside of their rooms(s) there were TBP signage (droplet and contact precautions with eye protection) on the door(s), plastic bin(s) filled with supplies (facemasks, eye protection, gowns, and gloves) and garbage can(s). - On 6/17/20 at 6:10 PM, the Immediate Jeopardy was removed after the facility also verified staff from nursing, housekeeping, kitchen, maintenance, therapy and administration were contacted on 6/17/20 and in-serviced in person, phone or via electronic communications regarding the new procedure to immediately isolate and use TBP for 14 days with all admission/re-admissions. Any staff yet to be in-serviced would receive education prior to the beginning of their next shift. - In addition, the administrator/designee would conduct daily audits on all new admissions/re-admissions to ensure isolation and TBP precautions have been implemented and the Director of Nursing (DON) would perform weekly audits to ensure staff from all departments were appropriately putting on and taking off personal protective equipment (PPE) for the isolation rooms. Any identified concerns would be brought to the attention of the administrator immediately. Findings include: 1. Review of the Admission/Discharge report, dated 6/17/20, revealed R1 and R2 were the only two residents that had been admitted /readmitted in the last 14 days. During an initial facility tour on 6/17/20, starting at 9:50 AM, the rooms occupied by R1 and R2 revealed no evidence of isolation or TBP use. Review of R1's medical record on 6/17/20, revealed R1 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Hospital Discharge report revealed R1 had tested negative for COVID-19 on 6/2/20. Review of the temperature, vitals and respiratory assessments revealed R1 had not shown any signs or symptoms of COVID-19 since her date of admission. Review of R2's medical record on 6/17/20, revealed R2 was re-admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the COVID-19 Lab Report revealed R2 had tested negative for COVID-19 on 6/2/20. Review of the temperature, vitals and respiratory assessments revealed R2 had not shown any signs or symptoms of COVID-19 since her date of re-admission. Further record review revealed no evidence R1 and R2 had been isolated to their rooms with TBP prior to 6/17/20. During an interview on 6/17/20 at 11:10 AM, the Director of Therapy confirmed that both R1 and R2 had left their rooms to receive therapy in the therapy room since they had been admitted /readmitted . 2. During an interview on 6/17/20 at 9:50 AM, the DON stated the facility would accept new admissions/re-admissions after ensuring the resident had had one negative COVID-19 test while residing at the transferring facility. The DON stated, upon admission, the resident would be placed into a private room with limited resident and staff contact for 14 days. The DON stated the admitted residents were not placed on TBPs and they could leave their room with a mask but they were not to interact with other residents. The DON stated the admitted residents were monitored for fever and respiratory symptoms every shift and would be placed in TBP if symptoms of COVID-19 developed. Review of facility policy titled, Table 1: Accepting Hospital admitted d 3/30/20 revealed for: COVID-19 cases present in the surrounding area or community of your hospital catchment area and the patient (resident) is tested and negative for COVID-19, the facility can: - Admit the patient and - monitor for fever and respiratory symptoms per shift. - limit contact with other residents as much as possible. - limit the number of different staff interacting with a resident as much as possible and limit the number of times each shift enters a resident's room. - cohort in rooms (and wings if possible) with similar residents. Review of facility policy titled, Noval Coronavirus Control Plan updated 5/7/20 revealed: 6. Resident Care: a. Observe new admissions (residents) for development of respiratory symptoms and implement appropriate infection prevention practices for symptomatic residents However, review of the Utah Department of Health, Guidelines for Transferring Patients from Hospitals to Long-Term Care Facilities During the COVID-19 Epidemic dated 5/5/20 revealed: Category 2 - Patients investigated for possible COVID-19 If a patient has a negative COVID-19 test and meets usual clinical criteria for discharge, the patient is acceptable for discharge to LTC (Long-Term Care) or AL (Assisted Living) facilities, while recognizing the potential for a false negative test. The receiving LTC or AL facility should place the patient in an individual room and use Standard Contact and Droplet Precautions for 14 days. Patients requiring Aerosol-Generating Procedures will require additional precautions. For patients with active respiratory symptoms (fever, cough, shortness of breath), retest for COVID-19 if symptoms persist. Continue with Transmission-Based Precautions until: - At least 3 days (72 hours) have passed since recovery, defined as resolution of fever (<100.0 F(Fahrenheit)) without the use of fever-reducing medications AND improvement in respiratory symptoms (e.g., cough, shortness of breath); AND, - At least 10 days have passed since symptoms first appeared. In addition review of the CDC's Considerations for new admissions or readmissions to the facility, dated 4/30/20 and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, revealed: Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. - All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. - Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic (no symptoms) [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile (no fever) and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. During a concurrent interview and policy review on 6/17/20 at approximately 10:10 AM, the DON reviewed the Utah guidelines and the CDC's considerations for new admissions or readmissions and stated the facility had not been following the most recent guidance issued on 4/30/20 (CDC) and 5/5/20 (Utah Department of Health). The DON stated she would immediately isolate and implement all recommended COVID-19 PPE for R1 and R2. During an interview on 6/17/20 at 12:00 PM, the Administrator and DON stated they had not been following the most recent admission/re-admission guidelines and they would make the changes immediately.

Based on interview and record review it was determined, for 2 of 7 sampled residents, that the facility did not ensure a resident received treatment and services for a catheter. Specifically, the facility did not follow physician's orders for changing catheter's and one resident became septic from a Urinary Tract Infection [MEDICAL CONDITION]. Resident identifiers: 1 and 2. Findings include: 1. Resident 1 was admitted to the facility on [DATE]. Resident 1 was discharged to the hospital for septic UTI and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 12/30/19, resident 1's medical record was reviewed. A Quarterly Minimum Data Set assessment completed on 12/9/19, documented that resident 1 had an indwelling catheter; resident 1 had a Brief Interview for Mental Status score of 15 which indicated resident 1 was cognitively intact. Resident 1's care plan initiated on 4/23/19, documented a focus area of (Resident 1) had Indwelling Suprapubic Catheter: [MEDICAL CONDITION] bladder, one of the interventions documented was CATHETER: Change catheter Monthly and as needed. A physician's order initiated on 7/20/19, documented Change Suprapubic Catheter to DD (down drain) every 2 weeks and as needed. A review of resident 1's Medication Administration Records (MAR)s and Treatment Administration Records (TARs) from (MONTH) 2019 to (MONTH) 3, 2019, revealed no documentation that resident 1's catheter had been changed from (MONTH) to December. A review of the nurses progress notes from (MONTH) 2019 to (MONTH) 3, 2019 revealed only two notes that documented resident 1's suprapubic catheter was changed during the 8 month period. One note dated 10/5/19, stated Note Text: Replaced suprapubic catheter as per orders. and another note dated 11/18/19, stated . SP (suprapubic) catheter noted with significant amount of sediments. No bladder pain. Interventions: Replaced SP catheter. Cleaned SP site and placed new dressing. A nurses progress note dated 11/20/19, stated Note Text: Resident is post antibiotics for UTI. She is still complaining of burning during urination. Order received to recheck a UA (urine analysis). Resident 1's UA results were reported to the facility on [DATE], and revealed that resident 1 had a UTI caused by the Pseudomonas aeruginosa organism with a colony count of 40,000 colony-forming units per milliliter (CFU/ML), as well as yeast in her urine. The antimicrobial susceptibility showed that the Pseudomonas aeruginosa was susceptible to [MEDICATION NAME], and [MEDICATION NAME]/tazobactam. A physician's order was started on 11/23/19, for [MEDICATION NAME] 200 milligrams (mg) once a day for 7 days to treat the yeast in resident 1's urine. (Note: No treatment was ordered for the Pseudomonas in resident 1's urine.) On 12/3/19, a Nurse Practitioner note documented, I am asked to meet with this patient urgently today as she has had a change in condition. I am told that she started with some changes approximately 4 days ago, a bit more tired than usual. The staff report today that she had been confused and lethargic. She has not been eating nor drinking. They are only reporting approximately 50 cc (cubic centimeter) out of her catheter with the last 24 hr (hours). When I meet with the patient she lying in bed. She drifts off to sleep in between our questions. Vital signs: 77/45 (blood pressure), 97.7 (temperature), 70 (pulse), 16 (respirations), 94% (oxygen saturation) on room air. With the patient's current condition I did not feel that stat (immediate) labs would give us enough information quick enough therefore we agreed to send her to the emergency room to evaluate the source of her mental status change. A hospital History and Physical dated 12/3/19, documented History of Present Illness: Patient currently lives at a facility she states that for the last 3 or 4 days she has had progressively worsening fatigue. ER (emergency room ) Course: Patient is unclear the last time her suprapubic Foley catheter was changed. Assessment/Plan: (Resident 1) is a [AGE] year-old female with worsening weakness. Patient presumptively [MEDICAL CONDITION] criteria present on admit secondary to the catheter associated urinary tract infection. Patient has a chronic suprapubic catheter that she presented to the ER with and I am unclear when the last change was. Patient also has an acute kidney injury likely secondary to [MEDICAL CONDITION] physiology. A copy of the UA from resident 1's hospital admission on 12/3/19, revealed that resident 1 had a septic UTI caused by the Pseudomonas aeruginosa and Proteus mirabilis organisms, both with colony counts of >100,000 CFU/ML. (Note: Pseudomonas aeruginosa was the same organism identified in resident 1's UA on 11/20/19, that was not treated.) On 12/30/19 at 1:30 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that floor nurses usually changed resident's suprapubic catheters. RN 3 stated that the nurses relied on the TAR to tell them when a resident had a scheduled catheter change. RN 3 stated that resident 1 did get sediment buildup and blockages which required that the catheter be changed. RN 3 stated that she did not know how often resident 1's catheter needed changed. RN 3 stated that resident 1 never refused cares or treatments. On 12/30/19 at 1:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 1 had a suprapubic catheter, stated that documentation for catheter changes should have been in the TAR. The DON verified that resident 1 did not have any orders in the TAR to change her catheter prior to (MONTH) 2019. On 12/30/19 at 3:16 PM, an interview was conducted with resident 1. Resident 1 stated that her catheter got a lot of sediment buildup. Resident 1 stated that she did not remember the last time her catheter was changed prior to her discharge to the hospital. Resident 1 stated that she had been telling staff for days prior that she had a UTI, stated none of the staff listened to her or addressed it until she went septic and ended up in the hospital. Resident 1 stated that she felt like she had to beg staff to test her and treat her for a UTI. Resident 1 stated that she had a history or UTI's and knew when she had one, stated that her symptoms were burning in her bladder. On 12/30/19 at 3:30 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that they identified the problem for why the catheter change orders were not showing up on the TAR for the nurses. The CRN stated that the batch orders for catheter changes were entered as other, which caused them to not be on the TAR. The CRN stated that because of the error there was no way to communicate to the floor nurses when catheters needed changed. The CRN stated that there was no documentation of resident 1's catheter being changed. On 12/30/19 at 3:57 PM, an interview was conducted with Medical Director (MD) 1. MD 1 stated that he did not treat resident 1's UTI on 11/20/19, because resident 1's colony count was not very high. MD 1 stated that if he remembered correctly resident 1's only symptom was burning in the peri area, so he treated resident 1's yeast infection. MD 1 stated that he would be concerned about resident 1's increased lethargy reported within a few days of the positive UTI results. On 12/30/19 at 4:34 PM, a follow up interview was conducted with the DON. The DON stated that the risk of not treating a UTI was that the resident could go septic. The DON stated that her expectation was that if a UTI was not being treated for [REDACTED]. 2. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] stage 3. Resident 2's medical record was reviewed on 12/30/19. A care plan Focus initiated on 12/14/18, documented that (Resident 2) has an indwelling suprapubic catheter related to a [DIAGNOSES REDACTED]. The Goal initiated was, (Resident 2) will be/remain free from catheter related complications and trauma through review date. The Interventions developed were: a. The resident has a suprapubic catheter. Position the catheter bag and tubing below the level of the bladder. Date initiated was 12/14/18 and revised on 10/3/19. b. Monitor and document intake and output as per facility policy. Date initiated was 12/14/18 and revised on 4/19/19. c. Monitor and document for pain and discomfort due to catheter. Notify MD (Medical Doctor) of pain not relieved with interventions. Date initiated was 12/14/18 and revised on 10/3/19. d. Monitor, record, and report to MD for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Date initiated was 12/14/18 and revised on 10/3/19. e. Provide catheter cares each shift. Change catheter as ordered. Refer to urology as needed. Date initiated was 12/14/18 and revised on 10/3/19. A Nurses Progress Note dated 5/10/19 at 12:31 PM, documented that resident 2 went to a urology appointment. No new updates SP tube changed without any problems. A Nurses Progress Note dated 5/31/19 at 3:23 PM, documented that resident 2 was seen by the urologist today. 18 Fr (French). SP tube changed without difficulty. Patient will return in 3 weeks for next SP tube change. Please send urine for culture tomorrow (6/1/2019). A Nurses Progress Note dated 6/27/19 at 1:36 PM, documented that resident 2 went to his Urologist appointment today. SP tube changed without any problems, he will follow up as scheduled. Next appointment (MONTH) 26, 2019 at 10:15 AM. (Note: No documentation was located in resident 2's medical record regarding the urology appointment on 7/26/19. No additional documentation was located in resident 2's medical record regarding any further urology appointments to have the SP catheter tubing changed.) The (MONTH) and (MONTH) 2019 MAR and TAR were reviewed. No additional documentation was located that resident 2 had his SP catheter tubing changed. (Note: There were no physician's orders located in resident 2's medical record for staff to change the SP catheter tubing for (MONTH) and (MONTH) 2019.) A laboratory report dated 8/8/19, documented a routine urinalysis with a collection date of 8/7/19. The following were documented as Abnormal: a. Appearance Cloudy, reference interval was Clear. b. [NAME] Blood Cell (WBC) Esterase 500 /microliter (ul), reference interval was Negative. c. Protein 30 milligrams per deciliter (mg/dl), reference interval was Negative. d. WBC >100 /high power field (hpf), reference interval was 0-5 /hpf. e. Red Blood Cell 6-10 /hpf, reference interval was 0-5 /hpf. f. Mucus Threads 1+ /low power field (lpf), reference interval was None. g. Bacteria Rare /hpf, reference interval was Negative. h. Granular Casts UA 2-5 /lpf, reference range was None, 0-1, 0, Negative. i. Clumping WBCS Clumps Seen, reference range was No Clumping Seen. j. Urine Budding Yeast 3+ /hpf, reference interval was None. (Note: A staff member noted on the laboratory report wait for C&S (culture and sensitivity) dated 8/8/19.) A Nurses Progress Note dated 8/14/19 at 5:26 PM, documented MD stated no C $ (sic) S needed since resident has a cath (catheter). A Nurses Progress Note dated 8/21/19 at 6:25 PM, documented (Resident 2) has been increasingly lethargic today, though his vitals have been normal. His BP (blood pressure) was 130/83, his O2 (oxygen) was 93%, and his temperature was 98 degrees, and his blood sugar was 265. Even with normal vitals, he continued to be difficult to arouse and even fell asleep in his wheelchair. He said his brain was having a hard time connecting to his body. Given all this information, (MD 1) did a quick assessment and thought it could be a UTI. He ordered a UA with culture and sensitivity, CBC (complete blood count), CMP (complete metabolic panel), Sed (sedimentation) rate, and [MEDICATION NAME] 500mg for 5 days. A lab report dated 8/24/19, documented a routine urinalysis with a collection date of 8/21/19. The following were documented as Abnormal: a. Appearance Cloudy, reference interval was Clear. b. WBC Esterase 500 /ul, reference interval was Negative. c. Protein 100 mg/dl, reference interval was Negative. d. Occult Blood Small, reference interval was Negative. e. WBC >100 /hpf, reference interval was 0-5 /hpf. f. Red Blood Cell >100 /hpf, reference interval was 0-5 /hpf. g. [MEDICATION NAME] Cells (non renal) 6-10 /lpf, reference interval was 0-5 /lpf. h. Mucus Threads 1+ /lpf, reference interval was None. i. Bacteria 2+ /hpf, reference interval was Negative. j. Hyaline Casts 6-10 /lpf reference interval was 0-1 /lpf. k. Clumping WBCS Clumps Seen, reference range was No Clumping Seen. l. Urine Budding Yeast 1+ /hpf, reference interval was None. j. Result 1, pseudomonas aeruginosa >100,000 CFU/ML. k. Result 2, [MEDICAL CONDITION] - resistant Staphylococcus aureus (MRSA) >100,000 CFU/ML. An Event/Alert Charting Progress Note dated 8/24/19 at 10:55 PM, documented . Rt. (resident) was recently diagnosed with [REDACTED]. A Nurses Progress Note dated 9/2/19 at 1:40 PM, documented Orders per MD: no contact precautions necessary, no follow up urinalysis necessary. Keep PICC line in for another day or two & monitor s/s (signs and symptoms) of UTI/bacteremia. orders noted. A Nurses Progress Note dated 9/9/19 at 1:59 PM, documented Resident not responding according to baseline today. Baseline A&O (alert and oriented) x4 (self, place, time, and situation) today resident was only A&O x1-2 to self and place. Not oriented to time and situation. Residents grip unequal able to squeeze with L (left) hand, no squeeze with R (right) hand. Eyes pinpoint not dilating or reactive to light. BP 167/76, P 87, O2 92% on NC (nasal cannula) 5L (liters), RR (respiratory rate) 10. MD contacted orders given to send resident out to hospital to be further evaluated. A Nurses Progress Note dated 9/9/19 at 4:49 PM, documented Resident returned from (local hospital) where he was tested positive for UTI. Order to start resident on an oral ABX (antibiotic). Resident is A&O x4. Residents family member is aware of his return. MD notified. A Nurses Progress Note dated 9/15/19 at 3:55 PM, documented A nurse from (local hospital) called and stated that patient needs to have IV (intravenous) ABX for his UTI. If he gets worse, she suggests sending him to the ED (emergency department). (Infectious Disease MD) would like to have resident in his office first thing Monday morning to begin treatment. A Nurses Progress Note dated 9/16/19 at 1:48 PM, documented Resident was taken to (Infectious Disease MD) clinic at 1200 (12:00 PM) today. Nurse from the clinic called to tell this nurse that resident is being admitted to (local hospital) due to Acute [MEDICAL CONDITION]. House MD was notified. Family was notified. (Note: Resident 2 was readmitted to the facility on [DATE].) A physician's order dated 9/27/19, documented SP catheter site care: Cleanse with normal saline or wound cleanser, pat dry and cover with a split gauze secure with tape. One time a day for Supra pubic Catheter Use. (Note: There were no physician's orders prior to 9/27/19, for staff to perform SP catheter site care.) A physician's order dated 9/29/19, documented Foley catheter care Q (every) shift every shift for Foley Catheter Use. (Note: There were no physician's orders prior to 9/29/19, for staff to perform catheter cares.) A physician's order dated 9/29/19, documented Change Foley catheter on the 28th of each month OR (May change schedule based on resident's last catheter change or admitted ) every night shift every Sun (Sunday) for Foley Catheter Use. The (MONTH) 2019 MAR and TAR were reviewed. The following entries were documented: a. On 9/28/19, a code 9 was documented. (Note: Code 9 according to the TAR Chart Codes was Other/See Progress Notes.) Resident 2 had discharged to the hospital on [DATE] at 9:18 AM, and readmitted to the facility on [DATE] at 6:13 PM. (Note: Resident 2's SP catheter tubing was not changed on 9/28/19.) b. On 9/29/19, a code 2 was documented. (Note: Code 2 according to the TAR Chart Codes was Drug Refused.) A Nurses Progress Note dated 9/30/19 at 5:37 PM, documented . Catheter was changed by Hospice Nurse today, very little urine out put approx (approximately) 100 ml (milliliters) today . On 12/30/19 at 11:50 AM, an interview was conducted with RN 1. RN 1 stated if she was to change a resident's catheter she would chart in a nurses note. RN 1 stated that if a resident was seen by a urologist the resident would return with a note indicating that the catheter was changed and what size of tubing was used. RN 1 stated that if a resident had physician ordered flushes for the catheter the flushes would sometimes be charted on the resident TAR. RN 1 stated that she would not change a resident's catheter without a physician's order. RN 1 stated that she had never had to change a resident's catheter. RN 1 stated that resident 2 never had problems with his catheter but resident 2 did have frequent UTIs. RN 1 stated that resident 2 was followed by a urologist. On 12/30/19 at 2:46 PM, a follow up interview was conducted with RN 1. RN 1 stated that the UA collected on resident 2 dated 8/7/19, was probably due to confusion. RN 1 stated that resident 2 would get agitated when he had a UTI. RN 1 stated that resident 1 was started on an antibiotic 8/1/19, for an ear infection. RN 1 stated that the culture and sensitivity for the UA on 8/7/19, was probably canceled due to contamination of the urine or because there was already an antibiotic in use. On 12/30/19 at 3:38 PM, an interview was conducted with the CRN. The CRN stated that he called the laboratory regarding the UA collected 8/7/19, for resident 2. The CRN stated that UA was a final report and the culture and sensitivity was not completed due to budding yeast. The CRN stated that the MD would have treated with [MEDICATION NAME] or whatever was requested. (Note: There were no orders for resident 2 to be started on an antifungal medication.) On 12/30/19 at 4:03 PM, an interview was conducted with MD 1. MD 1 stated that according to the results of resident 2's UA dated 8/7/19, he would not have treated. MD 1 stated that resident 2 had a lot of yeast in his urine and that would be appropriate with resident 2's frequent antibiotic use. MD 1 stated that he would look at the WBC count and the mucus threads prior to treatment. On 12/30/19 at 4:33 PM, an interview was conducted with the DON. The DON stated that she had worked for the facility since the end of November. The DON stated that she was unsure as to what the facility processes were for changing resident catheters and following up with UA C&S reports. The DON provided no additional information.

Based on observation, interview and record review, it was determined for 3 of 36 sampled residents the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, two residents experienced multiple falls, one with serious injuries, one resident had a manual razor without supervision, and powders and creams were left in resident's rooms. Resident identifiers: 34, 50, and 57. Findings include: 1. Resident 50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 7:30 AM, resident 50 was observed in a common area by the nurses' station. Resident 50 had purplish black coloring on the left side of his face and around his eye. On 2/20/19 at 8:27 AM, resident 50 was observed sitting in his recliner in his room wearing regular socks and no shoes. One of resident 50's shoes was observed in the basket of his front wheeled walker, located across the room from resident 50. The resident's other shoe was not visible. On 2/21/19 resident 50's medical record was reviewed. On 1/23/19, resident 50 was on alert charting due to being admitted to the facility. On 1/24/19 at 4:46 PM, resident 50's event/alert charting revealed interventions of redirecting the resident, and reminding the resident to use the walker to wheelchair when self transferring. On 1/30/19, resident 50 had an initial activity assessment. a. On 2/7/19 at 8:40 PM, an alert progress note was created for a recent fall that resulted in a scrap (sic) to his back. On 2/8/19, resident 50's fall care plan was created. The focus of resident 50's fall care plan was: The resident had an actual fall with minor injury r/t (related to) poor balance. The intervention initiated was to: Monitor/document/report PRN (as needed) x (times) 72h (72 hours) to MD (medical doctor) for s/sx (signs and symptoms): Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. On 2/8/19 at 7:31 AM, an interdisciplinary team (IDT) meeting report was created. The IDT meeting minutes proposed an intervention for staff to assist resident 50 with changing his clothing. This intervention was not implemented on resident 50's fall care plan. On 2/8/19, a fall assessment revealed that resident 50 required staff assistance when moving from seated or standing position. Resident 50 was not steady when walking with an assistive device, when turning around while walking, was only steady with staff assistance when toileting, and required assistance when transferring from surfaces. Resident 50 was assessed as having a high risk for falling. On 2/11/19 at 11:26 AM, a nurses' note stated that resident 50 has a healing abrasion and discoloration. Foam dressing applied. Encouraged him to use his walker and to call or ask for help when needed. He is at his baseline of confusion/forgetful. b. On 2/12/19 at 2:21 PM, a nurses' progress note revealed that resident 50 was found down in bedroom with his bottom on the floor and back against his bed frame on the right side of the bed. The (resident) reports reaching for the items he was packing and his legs became weak causing him to lower himself to the floor. Resident 50's care plan was updated on 2/13/19 to include the following: Provide activities that promote exercise and strength building where possible. Provide 1:1 (one to one) activities if bed-bound. (Note: Resident 50 was not bed bound while in the facility. Review of assessments for resident 50 did not include therapy, activities, and restorative nursing.) On 2/13/19, a fall risk assessment was completed for resident 50. Resident 50 was assessed as having a high risk for falling. c. On 2/16/19, resident 50's care plan was updated to indicate that he sustained a fall with injury. On 2/16/19 at 5:45 AM, a skin assessment was performed on resident 50. Resident 50 had left eye bruising, a right elbow skin tear and upper and lower back bruising. On 2/16/19, resident 50's care plan was updated with the note: The resident had an actual fall with minor injury r/t (related to) poor balance. The goal was that resident 50 will resume usual activities without further incident through the review date. On 2/16/19 at 5:43 AM, an event/alert charting progress note was created that stated resident 50 had a witnessed fall. Resident 50 continues with bruise to face and back, continues to transfer and ambulate without asking for assistance. Resident 50's interventions were call light within reach, frequent visual checks, room door kept open, nonskid sock on. These interventions were not included in resident 50's care plan. On 2/16/19 at 4:27 PM, resident 50 was noted to have discoloration with swelling to the L (left) eye socket. On 2/16/19 at 5:40 PM, resident 50 had event/alert charting for an unwitnessed fall. Interventions for the fall were: Resident was educated about using call light. Progress notes for resident 50 from 2/16/19 to 2/24/19, did not include any activity participation notes or therapy notes. On 2/18/19 at 8:06 PM, an IDT event review note revealed that on 2/16/19 resident 50 stated that he sat down because 'my socks are slippery.' On 2/18/19 resident 50 was assessed as having a high risk for falling. On 2/18/19, the following interventions were initiated: i. PT/OT (physical therapy and/or occupational therapy) to Eval/assess (evaluate) give orders as indicated. No orders were included in resident's record. The care plan was not updated with therapy orders or recommendations. ii. Staff to ensure resident has proper footwear on. On 2/18/19 an order was established to Answer calls for assist promptly Increase Supervision PRN (as needed), Assist as Needed for all Transfers, every 2 hour toileting. On 2/19/19 at 9:22 PM, an event/alert charting note stated that resident 50 had an unwitnessed fall. Resident 50 has been ambulating the halls with his walker. Appears to have a steady gait. Resident 50 required 2 hour checks to assist him to the bathroom. On 2/21/19 at approximately 2:00 AM, resident 50 was observed by staff to wander into another resident's room. On 2/22/19 resident 50 was moved to another room in the facility. On 2/24/19 at 11:20 AM, a nurses' note revealed that resident 50 has had increased agitation, with combative behaviors towards staff. Staff is not able to re-direct resident, nor talk to the resident without the resident becoming agitated and throwing his elbow and fist at staff. On 2/24/19 at 2:40 PM, resident 50 was agitated all day and confused.not (sic) easy to redirect. d. On 2/24/19, an incident report revealed that resident 50 sustained a fall with injury. At approximately 5:00 PM, resident 50 was assessed with [REDACTED]. Resident walker was upright on the left side of the resident. The resident presented with sanguineous bleeding from an open laceration laterally posterior upper orbital area. Minimal bruising present, but swelling was present in the area. Three skin tears on L posterior elbow and upper posterior forearm. Resident stated to this nurse 'I was leading a chase dog home to see my aunt' and fell when I tripped over the dog. Resident stated that 'My head hurts, and I feel like wind is blowing through ears.' . Resident taken to his room. Cleaned wound with wound cleaner, applied boarder (sic) gauze to skin tears on elbow/upper forearm. Applied cold pack to laceration on laterally posterior upper orbital area (as the resident allowed). PA (physician's assistant) notified, PA ordered and instructed to send the resident to hospital for CT (computerized tomography) scan (resident takes [MEDICATION NAME] daily) On 2/24/19 at 9:45 PM, a nurses' note was created that revealed resident 50 was being admitted to the medical floor for treatment. On 2/24/19, a hospital history and physical was completed for resident 50. Resident 50 was admitted to the hospital with [REDACTED]. A CT scan of the brain demonstrates small left frontal subdural hematoma with wisps of acute hemorrhagic involvement. There is some effacement of the cortical surface; however, there is no mass effect or midline shift due to his profound cerebral atrophy. The medical decision and plan stated: This patient is an [AGE] year-old male, chronically ill appearing with multiple medical problems, on [MEDICATION NAME] with frequent falls, who presents with frequent fall. He has been diagnosed with [REDACTED]. On 2/20/19 at 3:35 PM, an interview was conducted with CNA 7. CNA 7 stated that she was an agency CNA, and learned what she needed to do for each resident when the previous shift CNA gave rounds. On 2/25/19 at 7:24 AM, an interview was conducted with CNA 3. CNA 3 stated that for residents with fall risks, they put mats by the bed and keep the bed low. CNA 3 stated that she was unaware of any falls out of bed for resident 50. CNA 3 stated that staff keep an eye on residents if they are out of their rooms. CNA 3 stated that residents who were not 100% coherent were at higher risk for falls. On 2/25/19 at 7:27 AM, an interview was conducted with CNA 2. CNA 2 stated that she would look at residents who were at high risk for falls whenever she passed their room. CNA 2 stated that she did not chart every time she observed a resident. On 2/25/19 at 7:52 AM, an interview was conducted with RNA (Restorative Nurse Aide) 2. RNA 2 stated that several residents had a high number of falls. RNA 2 stated that staff told the nurse if one of the residents fell . RNA 2 could not state interventions to keep residents safe from falls. On 2/25/19 at 7:29 AM, an interview was conducted with RN 4. RN 4 stated that she was aware resident 50 fell on [DATE]. RN 4 stated that all residents had call lights answered quickly, and no special care was given to any resident. RN 4 stated that resident 50 should have worn non-slip footwear. RN 4 stated that all residents received two hour rounds, but for residents who had fallen, we check on them more often. RN 4 could not state how much more frequently resident 50 was checked. On 2/25/19 at 7:36 AM, an interview was conducted with RN 1. RN 1 stated that she was the nurse working on 2/24/19 when resident 50 fell . RN 1 stated that she heard a thump and someone yelled for help. RN 1 stated that resident 50 was laying on the floor across from the dining room. RN 1 stated that it was close to dinner time. RN 1 stated that resident 50 had been wandering, so staff members had been doing redirection. RN 1 stated that staff were offering food and hydration, and watching him as much as we could. RN 1 stated that resident 50 was very agitated all day. On 2/25/19 at 4:10 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that staff took him to activities but he wandered away. The ADON stated that resident 50 was wandering frequently, but staff watched him when he was in the hallways. (Note: Resident 50 was not assessed as a wander risk.) On 2/25/19 at 4:11 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that after the fall on 2/7/19, the only intervention initiated was to observe and monitor resident 50 for a change of condition, and that this was not an intervention that would prevent a fall. CRN 1 stated that no interventions were implemented as a result of any PT or OT assessments. CRN 1 stated that resident 50 also fell in his room on 2/13/19, after the fall on 2/12/19, but no additional information was available about that fall. CRN 1 stated that resident 50 had been having delusions and agitation on 2/24/19, before he fell . 2. Resident 57 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 57's medical record was reviewed on 2/20/19. A quarterly MDS dated [DATE] revealed that resident 57 sustained 1 fall with no injury since the last MDS was completed on 12/15/18. A fall risk assessment completed on 1/31/19 revealed resident 57 was at high risk for falls. a. A nursing progress note dated 11/10/18 at 5:51 AM revealed, CNA came and informed me of resident being on the floor. Resident found sitting on the floor by his bed. Stated he hit his head. Top of head with some redness. Stated he was trying to get to the bathroom and fell out of bed. Resident was wet. Had skid socks on. Resident takes [MEDICATION NAME] and potassium at HS (hours of sleep). Resident also has a new order for prn (as needed) [MEDICATION NAME] for anxiety attacks which was given to him earlier in the day. An incident report dated 11/10/18 and revised on 1/23/19 revealed, At 2315 (11:15 PM) CNA came and informed me that resident was on the floor. Resident found sitting on the floor by his bed. Stated he was trying to get to the bathroom and fell out of bed. Immediate Action Taken was Full body assessment done. Assisted up into chair and toileted and cleaned up. There were no interventions listed. An IDT Review dated 11/12/18 revealed, .New interventions: Neuro check initiated. RR (resident representative) and MD (medical doctor) notified. [MEDICATION NAME] administration time changed from HS to daytime, Staff educated to assist resident with cares as he is not able to perform them as well as before, Provider asked to assess pain and [MEDICAL CONDITION] medication. A progress note dated 11/14/18 at 4:08 PM revealed, Resident has remained safe this shift. No risk of fall. Shoes in place, toileted every 2 hrs (hours). A care plan dated 11/12/18 reveled, The resident is at risk for fall r/t Confusion, Gait/balance problems, incontinence. The goal was, The resident will have no injury from halls through the review date. Interventions developed on 11/12/18 were, Anticipate and meet the resident's needs, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, The resident needs prompt response to all requests for assistance, Ensure that the resident is wearing nonskid socks and shoes at all times as he allows. b. A progress note dated 1/15/19 at 2:49 PM revealed, Found resident this am (morning) in bathroom on his right side. Resident said that he was trying to get back into his wheelchair and could not. Resident had bowel movement on clothing, shoes and floor. Neuros started. Provider notified and family notified. No discoloration to right cage noted. An incident report dated 1/15/19 with a revision date of 2/8/19 revealed, Found resident on R (right) side in bathroom. Resident had bowel movement on shoes, pants and on the floor. Resident had shoes on. The Immediate Action Taken was Area cleaned up. Resident changed and cleaned up. There were no interventions documented. An IDT review dated 1/16/19 revealed, .New interventions implemented: Acute care visit to see if labs need to be done. 2-hour toileting continues. A progress note dated 1/16/19 at 5:27 PM, Resident was seen by PA. A care plan dated 11/12/18 reveled, The resident is at risk for fall r/t Confusion, Gait/balance problems, incontinence. The goal was, The resident will have no injury from halls through the review date. An intervention dated 1/18/19 revealed, Offer assist resident to toilet Q (every) 2-3 hours and PRN. c. A progress note dated 1/19/19 at 12:54 AM revealed, At 0000 (12:00 AM) CNA found resident lying on floor between bed and w/c (wheelchair). This nurse assessed patient and found several thin pink abrasions on back, probably from impact with w/c during the fall. No bleeding noted. Resident was groaning in pain from the fall and given PRN [MEDICATION NAME]. No signs of redness or swelling on head from fall. Resident brought to the nurses station for better supervision. An incident report dated 1/19/19 with a revision date of 1/29/19 revealed, .When asked what happened, the resident stated 'My car went out on me'. Res is baseline confused. There were no interventions documented. A progress note dated 1/23/19 at 1:17 PM revealed, Follow up on fall, abrasion on back. Intermediate pain present. There was no IDT note documented. A care plan dated 11/10/18 and revised on 1/25/19 revealed, The resident has had an actual fall: The goal developed was The resident will resume usual activities without further incident through the review date. Interventions dated 1/23/19 revealed Continue interventions on the at-risk plan, For no apparent acute injury, determine and address causative factors of the fall, Monitor/document /report PRN (times) 72h to MD for s/sx (signs/symptoms). d. A progress note dated 1/25/19 at 4:45 AM revealed, Resident was found on floor beside bed this morning at 0445 (4:45 AM). Resident was assessed for injuries, none noted. Resident has loose BM (bowel movement) on bed that came out of his brief. Linens change and res assisted back into bed. Brief changed. Res is baseline confused and did not know why he got out of bed. Res denied hitting his head. Neuros started. PRN [MEDICATION NAME] given for soreness. An incident report dated 1/25/19 with a revision date of 1/29/19 revealed the same description as the progress note on 1/25/19. The Immediate Action Taken was .kept bed in low position, call light in hand. There were no interventions documented. An IDT review dated 1/29/19 revealed, .Preventive measures prior to event: 2-hour toileting, CLWR, non-skid socks on, frequently checked on by staff, staff assists in ADLs (activities of daily living), weekly skin checks. The New interventions implemented: Position resident properly in bed and w/c. Monitoring in place. A care plan dated 11/10/18 and revised on 1/25/19 revealed, The resident has had an actual fall: The goal developed was The resident will resume usual activities without further incident through the review date. An intervention dated 1/25/19 revealed, Position pt (patient) properly in be (sic) bed and w/c. e. A progress note dated 1/31/19 at 2:51 PM revealed, .CNA informed this nurse that resident was on the ground by his bed. When entering the room found resident sitting on the ground be (sic) his bed. Resident stated he was trying to get into his wheelchair. Non-skid socks in place, call light in reach, bed was in low position, brakes on wheelchair. Assessment completed. no injuries, resident denies pain or hitting his head. Staff assisted resident in to (sic) wheelchair. The interventions documented were Resident moved to hallway where staff can watch him more closely. An incident report dated 1/31/19 with a revision date of 2/1/19 revealed no interventions documented. An IDT review dated 2/1/19 revealed, .Risk factors: [MEDICAL CONDITION] with behavioral disturbances; [MEDICAL CONDITION]; anxiety disorder; resident has recently had distressing delusion; resident has a history of verbal aggressions that are usually redirectable from staff; Incontinent to B/B (bowel and bladder) r/t dementia and cognitive loss, history of falls. Preventive measures prior to event: wearing non-skid socks, CLWR, bed in lowest position, brakes on wheelchair, 2-hour checks/toilet schedule.New interventions implemented: MD and family notified, monitoring in place, fall mat placed. A care plan dated 11/10/18 and revised on 1/25/19 revealed, The resident has had an actual fall: The goal developed was The resident will resume usual activities without further incident through the review date. An intervention dated 1/31/19, Provide activities that promote exercises and strength building where possible. Provide 1:1 activities if bedbound. (Note: Resident 57 was not bedbound.) f. A progress note dated 2/2/19 at 8:45 PM revealed, Unwitnessed fall, Pt found on floor in room. Interventions: PT assessed with [REDACTED]. An incident report dated 2/2/19 revealed, CNA (name removed) was making rounds and found resident on his back on the floor, some of the bedside items and things in the nearby closet were out of place. Pt did not appear to have any new injuries and he was assist (sic) back to his bed. Pt still oriented to person (baseline) and initial vitals were stable. PT did appears (sic) more anxious than previously and was unable to explain what happened. The Immediate Action Taken was Pt was assisted back into his bed, brief changed and made comfortable.Pt placed under close observation as staffing available. An IDT review dated 2/4/19 revealed, Root Cause: Appears Resident was trying to get something out of his closet and fell . New interventions implemented: Pharmacy consult to evaluate medications. Continue fall monitoring/frequent checks/2-hour toileting. There were no interventions developed on the care plan until 2/8/19. The intervention developed was Ensure call light is within reach. (Note: The same intervention was documented on the at risk for falls care plan dated 11/12/18 after resident 57 experienced a fall on 11/10/18.) g. A nursing progress note dated 2/10/19 at 5:07 PM revealed, This nurse was at the nurses station when this nurse heard a call for help coming from the Cambridge 2 hallway. This nurse immediately went to the hallway and found the resident sitting on his buttock between the residents wheelchair and empty wheelchair on the floor. Resident was not able to describe how he fell . This nurse and CNA assisted the resident back to this wheelchair. This nurse took the resident to this (sic) room and completed a head to toe assessment. No injury noted, and resident denied any pain at the time. Resident presented with mild crackles in L (left) upper lung and heavy discharge from both nostrils and a mild cough. Resident had appropriate foot wear on, wheelchair was locked and resident breif (sic) was dry and was toileted one (hour) prior to the fall. Neuros initiated per facility protocol.MD ordered to have the following STAT labs drawn. An incident report dated 2/10/19 revealed the same information as the above nursing note. There was no IDT review of the fall. The care plan was not updated after the fall on 2/10/19. h. A progress note dated 2/11/19 at 2:23 PM revealed, CNA informed this nurse that resident was on the ground in his room. This nurse assessed. Found resident sitting on floor mat in front of wheel chair. Nonskid socks in place, bed was low, chair brakes on. No injuries found on assessment. Resident denies pain. Staff assisted resident back into wheelchair. An incident report dated 2/11/19 and revised on 2/12/19 revealed the same documentation as the progress note above. An IDT review note dated 2/11/19 revealed, New interventions implemented: Treatment orders in place from skin tears. A progress note dated 2/11/19 revealed, New Intervention for fall: PT consult for strength and mobility. The care plan dated 11/10/18 revealed an intervention dated 2/12/19, Neuro-checks initiated. (Note: This was a treatment that was provided.) Another intervention developed 2/11/19 was, PT consult for strength and mobility. (Note: There was no documentation that a PT consult was completed.) h. A progress note dated 2/13/19 at 11:01 AM revealed, I was walking down the hall back to the nurses station and saw (resident 57) on the floor in front of his wheelchair. He had been previously watching TV, no one was there to witness the event. I got another CNA and together we took the residents vitals and helped him into his chair. Resident states that he doesn't know how he fell and feels no pain. No injuries are seen at this time, will continue to monitor and will be placed on neuro checks. An incident report dated 2/13/19 revealed, I was walking down the hall back to the nurse's station and saw (resident 57) on the floor in front of his wheelchair next to the nurse's station. I found a CNA and together we took vitals and helped him back into his chair. When asked what happened the resident said 'I don't know'. Resident does not complain of any pain or injury. Resident denies hitting his head. Resident has been very anxious and restless for the past 2 hours and has not responded to the prn [MEDICATION NAME] (0.5mg) that was given earlier. There were no interventions documented. An IDT review dated 2/15/19 at 7:46 AM revealed, .New interventions implemented: Continue to Encourage Resident to attend activities, continue frequent checks/toileting every 2 hours/near nurses' station when awake, check range of motion every shift. The care plan dated 11/10/18 revealed interventions dated 2/18/19 which was 5 days after the resident 57's fall. The interventions were Check range of motion every shift and PT/OT to Eval (evaluate)/assess give orders as indicated. A progress note dated 2/22/19 revealed Resident is being seen by PT for gait, transfers, balance, and strengthening. Resident is being seen by ST for swallow and cognition. Resident is participating well towards his goals and continue with plan of care. On 2/21/19 at 3:32 PM, an interview was conducted with CNA 14. CNA 14 stated that resident 57 crawled out of bed often which were considered falls. CNA 14 stated that resident 57 had his bed in the low position when he was in it. CNA 14 stated that resident 57 did not use a call light and was not cognitive enough to use a call light. On 2/21/19 at 11:35 AM, an interview was conducted with CNA 5. CNA 5 stated that interventions she was aware of to prevent resident 57 from falling were fall mats, she had asked a nurse about getting a non-slip pad for his wheel chair and staff were to check on resident 57 often. CNA 5 stated that checking on resident 57 often' meant to check him every 30 minutes or so. CNA 5 stated that she checked on resident 57 as often as she could but there were not enough staff to check on him every 30 minutes. On 2/25/19 at 8:39 AM, an interview was conducted with DON. The DON stated that after each fall new interventions needed to be developed and not reused. The DON stated that call light for 2/8/19 should not have not been reused. The DON stated that she did not know why ensure call light is within reach was used if staff were reporting that resident was unable to use the call light. On 2/25/19 at 10:36 AM, a follow up interview was conducted with the DON. The DON stated that Unit Manager 1 told her that using the call light would have been appropriate at one time but not appropriate currently. The DON stated that there was not a PT or OT consult completed after the intervention was documented on 2/11/19 and 2/18/19. The DON stated that she was not sure how often frequent checks were to be completed. 3. On 2/19/19 at approximately 12:30 PM, an observation was made of the bathroom of room [ROOM NUMBER]. The door to the resident room and bathroom were open and there was a medicine cup with a white powder and another medicine cup with a blue cream in it. The medicine cups were not labeled. On 2/25/19 at approximately 2:30 PM, an interview was conducted with CNA 13. CNA 13 stated that all creams and powders should be secured because of resident with dementia. On 2/25/19 at 2:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that she provided CNAs powders and creams but they were not to leave them in resident rooms. 4. Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/21/19 at approximately 11:40 AM, an observation was made of resident 34 in her wheelchair at the nurses station. The resident was observed to be gripping a disposable shaving razor. CNA 11 asked the resident if she could please take the razor, and resident 34 denied it. Resident 34 was asked how she obtained the razor but resident 34 stated that she was not telling anyone. CNA 11 offered to assist resident 34 with shaving to obtain the razor from her. CNA 11 was observed to wheel resident 34 to the bathroom to provide assistance. On 2/21/19 at 11:45 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that disposable shaving razors were stored in the shower room and the clean utility room, and that both rooms were locked. RN 4 stated that she was not sure how the resident got a hold of the razor. RN 4 stated that resident 34 had not cut herself.