Every finding on record at Spanish Fork Rehabilitation and Nursing

Based on observation, interview, and record review, it was determined for 1 of 16 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the resident sustained four falls with no new interventions implemented and one of those falls resulted in a head laceration that required ten staples. This was identified at a Harm level. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease, aphasia, anxiety disorder, post-traumatic stress disorder, and nondisplaced intertrochanteric fracture of left femur.On 11/18/25 at 10:26 AM, resident 4's door was observed to be closed, and no noises could be heard from the outside of the room. The surveyor entered the room and resident 4 was laying sideways at the foot of the bed with her head and torso on the bed and her bare feet were hanging off the side of the bed touching the floor; she was awake, moving her arms around, and making noises. The room was observed to be dim, no staff were in the room, the bed was in the lowest position, and a fall mat or call light were not observed in resident 4's room. There were no personal items within her reach.On 11/19/25 at 8:07 AM, resident 4's door was observed to be closed, and no noises could be heard from the outside of the room. The surveyor entered the room and resident 4 was awake and calm laying sideways at the foot of the bed with her head and torso on the bed and her bare feet were hanging off the side of the bed touching the floor. The room was observed to be dim with soft music playing, no staff were in the room, the bed was in the lowest position, and no fall mat or call light was observed in resident 4's room. There were no personal items within her reach.On 11/24/25 at 10:01 AM, resident 4's door was observed to be closed and no noises could be heard from outside of the room. The surveyor entered the room and resident 4 was laying in her bed with the blanket on top of her, the bed was in the lowest position, the privacy curtain was drawn closed, the room was dim, and no call light was observed.Resident 4's medical record was reviewed from 11/17/25 through 11/24/25.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident 4 had short and long-term memory problems and severely impaired decision making skills regarding tasks of daily life. It further indicated resident 4 needed substantial/maximal assistance to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and to transfer to and from a bed to a chair or wheelchair.A Care Plan Report initiated on 6/19/25 indicated a Focus of [Resident 4] continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting to injury prevention and quality of life. Risk for falls remains high but current plan priorities safety with the least restrictive measures. It indicated a Goal of, [Resident 4] will be free of falls with injury through the review date. It further indicated the following Interventions:Anticipate and meet the resident's needs. Keep frequently used items within reach. Date Initiated: 6/19/25Follow facility fall protocol if a fall occurs. Date Initiated: 6/19/25Provide resident with high low bed to improve safety. Date Initiated: 10/14/25Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: even floors free from spills and/or clutter; adequate, glare-free light; handrails on walls in the hallway. Date Initiated: 6/19/25Staff to assist resident with a gait belt while transferring or ambulating. Date Initiated: 6/19/25Toilet riser to be placed on toilet to assist resident with toilet transfers for safety. Date Initiated: 6/19/25A Morse Fall Scale dated 6/20/25 at 8:03 AM indicated resident 4 was at a High Risk for Falling, had impaired gait, and overestimated or forgot her limits with her own ability to ambulate.A Health Status Note dated 7/6/25 at 11:59 AM indicated, The CNA (Certified Nursing Assistant) came and got me saying resident was sitting on the floor in her room. By the time I got in there she had gotten herself into bed. I asked her if she had any pain or if she hit her head she said no.An Event Note Template dated 7/11/25 at 8:46 AM indicated an Interdisciplinary Team (IDT) review of the resident being found sitting on the floor in her room on 7/6/25 at 8:50 AM. It further indicated, .Risk Factors and Root Cause Identification: Huntington's disease with impulsiveness. Preventative Measures in Place Prior to Incident: Checking on resident, New Interventions: Resident continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting to injury prevention and quality of life. Risk for falls remains high but current plan priorities safety with the least restrictive measures.An Event Note Template dated 8/18/25 at 6:16 AM indicated, .Event Description: DON [Director of Nursing] heard a loud thud in residents room, nurse went in to assess the noise and noted resident sitting on the floor by her bed crossed leg (sic). Nurse asked resident if she fell and resident replied fall and thumbs up. Risk Factors and Root Cause Identification: Huntington's Disease. Preventative Measures in Place Prior to Incident: resident has refused any interventions. New Interventions: Resident continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting to injury prevention and quality of life. Risk for falls remains high but current plan priorities (sic) safety with the least restrictive measures.It should be noted that there were no new interventions implemented on the care plan after the fall on 8/18/25.A Skilled Progress Note dated 8/29/25 at 7:29 PM indicated, Resident fell on floor around 2300 [11:00 PM]. When examining resident there is a new bump on the back right side of the head. It is not currently open or bleeding.An Event Note Template dated 9/5/25 at 12:40 PM indicated, .Event Date/Time: 8/29/25 @ 2300 [11:00 PM]. Event Description: Resident was found on the floor in her room, it appears that she had fallen. Risk Factors and Root Cause Identification: Resident has Huntington's diseasePreventative Measures in Place Prior to Incident: Resident has had several preventive measures put in place but due to residents huntington's disease she has chorea movement which is uncontrollable and can cause resident to fall due to the movements. At this time the goal is injury prevention and qualityof [sic] life. New Interventions: No new interventions.It should be noted that there were no new interventions implemented on the care plan after the fall on 8/29/25.An Alert Note dated 9/2/25 at 3:45 AM indicated, Pt [patient] had an unwitnessed fall @ around 0205 [2:05 AM] is when she was found. Nurse heard a lot [sic] bang, checked on Pt to find her standing next to her bed, covered in blood. Nurse grabbed gauze to hold in place to the back of her head where the blood appeared to be coming from. Pt was conscious @ time of nurse finding Pt. Nurse went out to find a CNA to come help. CNA was told to hold pressure by nurse, w/[with] more gauze while she called paramedics. Paramedics arrived @ around 0218 [2:18 AM] .Paramedics stated Pt would most likely need stiches [sic], stated laceration was about 1inch in length. Pt gave a thumbs up when asked if she wanted to be sent out to hospital.A Health Status Note dated 9/2/25 at 5:52 AM indicated resident 4 returned from the emergency department and required 10 staples to the back of her head.A Care Plan Report initiated on 9/3/25 indicated a Focus of [Resident 4] is at high risk for falls and injury; with a Goal of Resident will have less episodes of falling and injury; and Interventions that included, Assess for weakness and/or fatigue. Educate resident and/or caregiver(s) on ways to reduce fall risk. Identify safety issues and educate on safety precautions to prevent fall and/or injury.An Event Note Template dated 9/8/25 at 8:15 AM indicated, .Event Date/Time: 9/2/25 @ 0205 [2:05 AM]. Event Description: Nurse heard a loud bang and found the resident standing next to her bed, she was covered in blood and had a laceration to the back of her head. Risk Factors and Root Cause Identification: Huntington's disease. Preventative Measures in Place Prior to Incident: Keep resident comfortable. New Interventions: [Resident 4] continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting toinjury [sic] prevention and quality of life. Risk for falls remains high but current plan priorities safety with the least restrictive measures. Resident was sent to ER [Emergency Room] for staples to the laceration on her head.A hospice Plan of Care Order dated 10/2/25 indicated, Falls. Description: Pt is a high risk for falls and injury. Goal: pt will have less episodes of falling and injury. It further indicated, Activities: 9/9/25- SN [Skilled Nurse] identified safety issues and pt has a soft helmet sn ensure pt is wearing soft helmet for protection. 9/12/25- SN provided education to facility staff on putting the soft helmet on the patient to keep patient from injuring her head when falling. 9/16/25 pt has been wearing a soft helmet to reduce the injuries to her head, staff try to place helmet on pt will wear it for about 20 minutes, Sn educated staff on safety measures to keep pt safe. 9/25/25- SN educated staff and a facility with safety concerns such as ambulating, transfers, safety with showers and dressing patient and to notify us and for any injuries or falls. It further indicated, Huntingtons Disease. Description: Pt has a terminal dx [diagnosis] of Huntingtons Disease.Intervention Type-Assess for cause of altered mental status (e.g. infection, pain, urinary retention, constipation). Activities: 9/5/25- Pt has huntingtons disease which is a neurological disease, she is alert and oriented x2.9/25/25- SN assessed patient for increase in confusion, signs and symptoms of decline with Huntington's disease Sn educated staff and family members on disease progression.An Alert Note dated 10/12/25 at 3:46 AM indicated, Resident had an unwitnessed fall. Resident is on neuro checks. No s/s [signs or symptoms] associated with the fall observed.An Event Note Template dated 10/22/25 at 3:37 PM indicated, .Event Date/Time: 10/11/25 @ 0655 [6:55 AM]. Event Description: Resident was on the floor all the way underneath her bed,Risk Factors and Root Cause Identification: Huntington's disease. Preventative Measures in Place Prior to Incident: resident has had several interventions in place but does not keep them in place. New Interventions: [Resident 4] continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting toinjury [sic] prevention and quality of life. Risk for falls remains high but current plan priorities safety with the least restrictive measures.It should be noted that there were no new interventions implemented on the care plan after the fall, or falls, on 10/11/25 or 10/12/25.An Alert Note dated 10/30/25 at 7:45 AM indicated, I entered the residents room, and found her lying on the side of her bed on the flor [sic]. This was an unwitnessed fall. Neuro checks were started.No new neurological findings were present.An Event Note Template dated 11/4/25 at 9:35 AM indicated, .Event Date/Time: 10/30/25 @ 0745 [7:45 AM]. Event Description: Resident was found lying on her side by the bed, she was unable to describe what she was doing. Risk Factors and Root Cause Identification: Huntington's disease with Chorea. Preventative Measures in Place Prior to Incident: Checking on resident. New Interventions: [Resident 4] continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting toinjury [sic] prevention and quality of life. Risk for falls remains high but current plan priorities safety with the least restrictive measures.It should be noted that there were no new interventions implemented on the care plan after the fall on 10/30/25.On 11/25/25, additional documentation was provided by the Administrator (ADM) through email which included one-hour checks completed on several occasions for resident 4. It included documentation of hourly checks for 24 hours on:5/18/25 through 5/21/25,5/24/25,5/26/25 through 5/27/25, and5/29/25 through 6/1/25.It should be noted that there were no falls documented in resident 4's progress notes within these timeframes.On 11/19/25 at 11:00 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 4 had Huntington's disease and could not hold still. RN 1 stated resident 4 had been found on the floor several times and that she would not really know if she hit her head when the resident fell. RN 1 stated resident 4 grabbed areas that hurt her, like when she had a migraine she would grab her head. RN 1 stated resident 4 would sit on the side of the bed but that she needed assistance to get to her wheelchair. RN 1 stated resident 1 did not have a call light so they had to listen out for her. RN 1 stated fall interventions included her room being close to the nurse's station and a low-to-ground bed.On 11/19/25 at 11:19 AM, an interview was conducted with the CNA 2. CNA 2 stated resident 4 was always on supervision and that they checked on her every 2 hours to see if she was wet or needed a brief change. CNA 2 stated she did rounds and checked on all of her residents every 2 hours. CNA 2 stated she does not have a call light because she could put the cord around her neck. CNA 2 stated she was assigned to resident 4 today and that she was always listening for her and that she checked on her every 15 to 20 minutes because she falls [it should be noted that an observation was completed on 11/19/25 from 1:09 PM to 1:56 PM, and no CNA's or nursing staff were observed to go into resident 4's room for 36 minutes]. CNA 2 stated she would try to get up on her own but she was unable to walk. CNA 2 stated the resident did not have an alarm on the bed and had no fall mat. CNA 2 stated when items were placed in resident 4's bed, she would throw them off.An observation was made of resident 4's room on 11/19/25 from 1:09 PM to 1:56 PM. A CNA was observed to bring resident 4 into her room via wheelchair and shut the door. At 1:20 PM, the CNA left resident 4's room and shut the door. At 1:36 PM, Housekeeping was observed to knock and go into resident 4's room and then leave and shut the door at 1:37 PM. At 1:43 PM, resident 4's roommate came out of the room, shut the door, and then returned to the room at 1:44 PM, went in, and shut the door. At 1:56 PM the Assistant Director of Nursing (ADON) knocked on resident 4's door and entered the room and then left the room and shut the door at 1:56 PM. An interview was conducted with the ADON at 1:56 PM, she stated that staff checked on resident 4 to see if she needed to go to the bathroom or if she was having any pain. The ADON stated resident 4 was on the verge of sleep. The ADON stated she checked on resident 4 every so often because her office was right next to her room and that the assigned CNA was supposed to check on her too.On 11/24/25 at 10:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she did not know if resident 4 was a fall risk but that she had had some falls. LPN 1 stated resident 4 stood up on her own but definitely needed assistance. LPN 1 stated resident 4's bed was low to the ground, her room was right next to the nurse's station, had no extra cords in the room so she did not get tangled in the cords, and she was consistently checked on but was not sure how often. LPN 1 stated it was everyone's responsibility to check on resident 4. LPN 1 stated resident 4 did not have a call light because of the cord and that she would not know how to push it if she did have one. LPN 1 stated she did not know why resident 4's door was kept shut but that her roommate would usually shut the door. LPN 1 stated they could hear when resident 4 would get up because she was very verbal and flailed before she got up and staff could hear that through the shut door. LPN 1 stated resident 4 did not have a fall mat because she might trip on it and that she did not remember resident 4 ever having a fall mat. LPN 1 stated resident 4 did not have a bed alarm or motion sensor and was not aware of her having those interventions before. LPN 1 stated she thought that resident 4 was checked on every hour and that was good timing to monitor the resident.On 11/24/25 at 11:00 AM, an interview was conducted with CNA 1. CNA 1 stated they check on resident 4 every hour but that the timing changed if she was more agitated. CNA 1 stated today she was checked on every hour but it could be every 30 minutes because she had been more agitated lately.On 11/24/25 at 1:54 PM, an interview was conducted with the DON and Corporate Nurse. The DON stated that resident 4 was a hard one because she has Huntington's disease and constant movement. The DON stated she was very unpredictable and would just stand up and walk toward you. The DON stated, she will just jump out of bed. The DON stated when resident 4 got up she could not walk safely and she would fall. The DON stated they tried to put down a fall mat about 4 months ago but they felt it was more of a fall risk. The DON stated she did not think the fall mat trial was documented anywhere in the medical record and that it might have been a conversation. The DON stated resident 4 would remove all items in her bed and that she removed all of her bedding and clothes and would hide stuff. The DON stated that they were trying to keep her safe and that that was a hard thing to do. The DON stated that resident 4 liked to be around people so they would try to keep her out in the common area but if there was too much noise it would make her agitated. The DON stated they kept her door shut to help calm her down because she would get migraines or agitated when there was too much noise. The DON stated resident 4 was not able to communicate but she could give you a thumbs up or down if you asked her if she was having pain. The DON stated she did not know how often staff were doing bathroom checks but the CNAs would check on her every 30 minutes to an hour. The DON stated they all worked together to make sure they took a look at her. The DON stated if the nurses noticed resident 4 was more agitated they would have the CNAs check on her more frequently. The DON stated that resident 4 was very loud and yelling when she got up so staff would hear her when her door was shut. The DON stated the IDT team did identify that her falls happened from midnight to 6:00 AM. The DON stated they were seeing more frequent falls at that time so they provided fall education and ensured staff were doing their rounding on residents.The DON stated that after each fall they meet as a team and discussed what might work for interventions to prevent falls and that they met for resident 4's falls and that there was nothing they could do but try to keep her out of her room and do frequent checks. The DON stated they had not discussed trying a silent alarm or motion detector. The Corporate Nurse stated the nurses would not hear the alarm going off or resident 4 getting out of bed if they were not at the nursing station.On 11/24/25 at 3:04 PM, an interview was conducted with the ADM. The ADM stated that residents with Huntington's were tough to manage at times. The ADM stated that they had resident 4's room close to the nurse's station and checked on her frequently. The ADM stated they had talked about putting some type of sensor but they were concerned that it would cause sensor fatigue for the staff because she moved so much. The ADM stated a pressure alarm was not effective. The ADM stated they tried a helmet but the resident would take it off, tug at it all of the time, and ripped the buckle part off so they ruled it as ineffective and discontinued its use.

Based on observation, interview, and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the food was not served in a sanitary manner and open spices were not dated. Findings included:On 11/24/25 during the tray line of lunch service the following was observed:a. At 11:55 AM, the [NAME] was observed to don gloves and was then observed to push a metal cart out of the way and then pull it back into position with a gloved left hand. The [NAME] was then observed to plate the lunch meal and use the dirty gloved left hand to touch the food as it was placed onto the plate.b. At 11:57 AM, the [NAME] was observed to use a washcloth to wipe off the cutting board near the tray line. The [NAME] was then observed to use the same wash cloth and wipe the edges of the plate to remove excess food. The wash cloth was observed to touch the food that had already been plated. c. At 11:59 AM, the same wash cloth was observed to be used to wipe the gloved hands of the [NAME] and then used to wipe the edge of another plate. The wash cloth was observed to touch the food that had already been plated. d. At 12:01 PM, the [NAME] was observed to reposition all of the food on a plate with the dirty gloved left hand. The [NAME] was then observed to wipe her hands with the wash cloth and and then wipe down the cutting board near the tray line.e. At 12:07 PM, the [NAME] was observed to clean her hands with the wash cloth then reposition some egg rolls on a plate using the dirty gloved left hand. f. At 12:08 PM, the [NAME] was observed to wipe around the edge of a plate with the soiled wash cloth while touching the food that had already been plated.g. At 12:13 PM, the [NAME] was observed to reposition the food on the plate with the dirty gloved left hand.h. At 12:21 PM, the [NAME] was observed to push the metal cart out of the way, pick up the meal tickets, and pull the cart back into place with the gloved left hand. The [NAME] was then observed to wipe her hands and wipe the edge of a plate with the soiled wash cloth. The [NAME] was then observed to place her entire left hand on the face of the plate, plate the food, then rearrange the food with the dirty gloved left hand. i. At 12:23 PM, the [NAME] was observed to remove a meal ticket that had fallen into the rice container and placed a spoonful of rice onto a plate. The [NAME] was observed to use her entire right hand to touch the face of a plate, plate the food, and then wiped the edge of the plate and touched the plated food with the soiled wash cloth. During the final kitchen inspection the following spices were observed to not have an open date:An 11 oz (ounce) container of parsley flakes.An 11 oz container of whole bay leaves.An 11 oz container of Italian seasoning.A 6 oz container of onion powder.A 6 oz container of garlic powder.A 6 oz container of Spanish paprika.A 6 oz container of light chili powder.A 6 oz container of whole rosemary leaves.A 6 oz container of ground black pepper.A 6 oz container of Cajun seasoning.A 6 oz container of dill weed.A 6 oz container of crushed red pepper.A 6 oz container of ground cumin. A 6 oz container of celery salt.A 6 oz container of rubbed sage.On 11/24/25 at 12:31 PM, an interview was conducted with the [NAME] who stated that they never dated the spices when they got them, they just opened them and used them. The [NAME] stated the wash cloth should not touch the food but it could be used to clean the plates. On 11/24/25 at 12:35 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the staff should not touch the food with their hands or gloves that may be dirty. The DM stated they had already talked about this specific issue with the cook and that she should not touch the food and that she should change her gloves after she touches the carts. The DM stated that the staff should not wipe the plates with the dirty wash cloth that they used for cleaning. The DM stated they did not label the spices because they used them so quickly but the spices should be labeled.

Based on observation, interview, and record review it was determined, for 1 of 16 sampled residents, that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment; and the comprehensive care plan failed to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, one resident sustained four falls and no new interventions were implemented on the care plan. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease, aphasia, anxiety disorder, post-traumatic stress disorder, and nondisplaced intertrochanteric fracture of left femur.Resident 4's medical record was reviewed from 11/17/25 through 11/24/25.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident 4 had short and long-term memory problems and severely impaired decision making skills regarding tasks of daily life. It further indicated resident 4 needed substantial/maximal assistance to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and to transfer to and from a bed to a chair or wheelchair.A Care Plan Report initiated on 6/19/25 indicated a Focus of [Resident 4] continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting to injury prevention and quality of life. Risk for falls remains high but current plan priorities safety with the least restrictive measures. It indicated a Goal of, [Resident 4] will be free of falls with injury through the review date. It further indicated the following Interventions:Anticipate and meet the resident's needs. Keep frequently used items within reach. Date Initiated: 6/19/25Follow facility fall protocol if a fall occurs. Date Initiated: 6/19/25Provide resident with high low bed to improve safety. Date Initiated: 10/14/25Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: even floors free from spills and/or clutter; adequate, glare-free light; handrails on walls in the hallway. Date Initiated: 6/19/25Staff to assist resident with a gait belt while transferring or ambulating. Date Initiated: 6/19/25Toilet riser to be placed on toilet to assist resident with toilet transfers for safety. Date Initiated: 6/19/25A Morse Fall Scale dated 6/20/25 at 8:03 AM indicated resident 4 was at a High Risk for Falling, had impaired gait, and overestimated or forgot her limits with her own ability to ambulate.An Event Note Template dated 8/18/25 at 6:16 AM indicated, resident 4 had a fall.Preventative Measures in Place Prior to Incident: resident has refused any interventions. New Interventions: Resident continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting to injury prevention and quality of life. Risk for falls remains high but current plan priorities (sic) safety with the least restrictive measures.It should be noted that there were no new interventions implemented on the care plan after the fall on 8/18/25.A Skilled Progress Note dated 8/29/25 at 7:29 PM indicated, Resident fell on floor around 2300 [11:00 PM]. When examining resident there is a new bump on the back right side of the head. It is not currently open or bleeding.It should be noted that there were no new interventions implemented on the care plan after the fall on 8/29/25.An Alert Note dated 10/12/25 at 3:46 AM indicated resident 4 had an unwitnessed fall.An Event Note Template dated 10/22/25 at 3:37 PM indicated, .Event Date/Time: 10/11/25 @ 0655 [6:55 AM] .Preventative Measures in Place Prior to Incident: resident has had several interventions in place but does not keep them in place. New Interventions: [Resident 4] continues to experience frequent falls despite environmental modification, therapy, assistive devices and medication optimization. Due to progression of Huntington's disease with severe Chorea and cognitive decline, the focus of care is shifting toinjury [sic] prevention and quality of life. Risk for falls remains high but current plan priorities (sic) safety with the least restrictive measures.It should be noted that there were no new interventions implemented on the care plan after the fall, or falls, on 10/11/25 or 10/12/25.An Alert Note dated 10/30/25 at 7:45 AM indicated, I entered the residents room, and found her lying on the side of her bed on the flor [sic]. This was an unwitnessed fall.It should be noted that there were no new interventions implemented on the care plan after the fall on 10/30/25.On 11/24/25 at 1:54 PM, an interview was conducted with the DON and Corporate Nurse. The DON stated that resident 4 was a hard one because she has Huntington's disease and constant movement. The DON stated she was very unpredictable and would just stand up and walk toward you. The DON stated, she will just jump out of bed. The DON stated when resident 4 got up she could not walk safely and she would fall. The DON stated they tried to put down a fall mat about 4 months ago but they felt it was more of a fall risk. The DON stated she did not think the fall mat trial was documented anywhere in the medical record and that it might have been a conversation. The DON stated resident 4 would remove all items in her bed and that she removed all of her bedding and clothes and would hide stuff. The DON stated that they were trying to keep her safe and that that was a hard thing to do. The DON stated that resident 4 liked to be around people so they would try to keep her out in the common area but if there was too much noise it would make her agitated. The DON stated they kept her door shut to help calm her down because she would get migraines or agitated when there was too much noise. The DON stated resident 4 was not able to communicate but she could give you a thumbs up or down if you asked her if she was having pain. The DON stated she did not know how often staff were doing bathroom checks but the CNAs would check on her every 30 minutes to an hour. The DON stated they all worked together to make sure they took a look at her. The DON stated if the nurses noticed resident 4 was more agitated they would have the CNAs check on her more frequently. The DON stated that resident 4 was very loud and yelling when she got up so staff would hear her when her door was shut. The DON stated the IDT team did identify that her falls happened from midnight to 6:00 AM. The DON stated they were seeing more frequent falls at that time so they provided fall education and ensured staff were doing their rounding on residents.The DON stated that after each fall they meet as a team and discussed what might work for interventions to prevent falls and that they met for resident 4's falls and that there was nothing they could do but try to keep her out of her room and do frequent checks. The DON stated they had not discussed trying a silent alarm or motion detector. The Corporate Nurse stated the nurses would not hear the alarm going off or resident 4 getting out of bed if they were not at the nursing station.

Based on interview and record review, it was determined, for 1 of 21 sampled residents, that the facility did not ensure each residenthas the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a resident fell and experienced a head laceration and broken ribs after not being checked on for an extended period of time. This resulted in a finding of HARM. Resident identifier: 35. Findings included: HARM Resident 35 was admitted to the facility on [DATE] with diagnoses which included hemipareses and hemiplegia of left non-dominant side, lack of coordination, dysphagia, type II diabetes, muscle weakness, lack of coordination, unsteadiness on feet, gastroesophageal reflux disease, hypertension and Crohn's disease. Resident 35's medical record was reviewed on 10/2/23. On 10/2/23 at 10:02 AM, an interview was conducted with resident 35. Resident 35 was observed to have his family member in his room shaving him. Resident 35 was anxious and stated that he did not want to get anyone into trouble but he did fall out of bed and had gotten hurt. An admission Fall Risk assessment dated [DATE] documented, resident 35 was a high fall risk with a score of 55. A score 45 or higher indicated a high fall risk. An admission Functional Abilities assessment dated [DATE] documented, resident 35 was totally dependent for bed mobility, transfers, and toileting hygiene. An admission Minimum Data Set (MDS) assessment dated [DATE] documented, resident 35 required extensive assistance and was a two person physical assist with bed mobility, transfers, and toilet use. A care plan focus dated 7/21/23 documented, The resident is a fall risk r/t [related to]: Hemiplegia and hemiparesis d/t [due to]: hemorrhagic stroke just prior to admission with significant overall weakness and impaired cognition as well as the use of opiate pain medication. Interventions in place were, Anticipate and meet the resident's needs. Keep frequently used items within reach. Follow facility fall protocol if a fall occurs. Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: even floors free from spills and/or clutter; adequate, glare-free light; handrails on walls in the hallway. Interventions documented after the fall on 7/28/23 included, Bed to remain in lowest position at all times. Mandatory staff education provided concerning routine checks on all resident's. Care for residents. A care plan focus dated 7/21/23 documented, The resident has been 100% [percent] incontinent of bowel and bladder during the LBP [left body paralysis] r/t: Hemiplegia and Hemiparesis L [left] side after hemorrhagic CVA [cardiovascular accident] prior to admission and overall muscle weakness and impaired mobility. Interventions in place were, INCONTINENT: Check q [every] 2-3 hrs [hours] and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN [as needed] after incontinence episodes. The Certified Nursing Assistant (CNA) bed mobility, toilet use and transfer task history for July 27, 2023 revealed resident 35 was provided total assistance with these cares at 9:59 PM and was not assisted again until 3:33 AM the following day. Resident 35's nursing progress notes were reviewed and revealed the following: a. A Skilled Nursing note dated 7/27/23 at 8:31 PM revealed, .Resident [35] is pleasant and compliant with all cares, he requires 2-person assistance with all cares and is incontinent and immobile. b. An Incident Note dated 7/28/23 at 3:09 AM revealed, Found resident on the floor at 0220 [2:20 AM] after hearing him yelling someone help me and his tube feed beeping. Resident was prone with a pool of blood under his head. Nurse had CNA call 911 and had help supporting residents head and neck to turn him face up again. Resident complained of his shoulder and back hurting and said he hit his head and that the IV [intravenous] stand then hit him in the back. Paramedics arrived at close to 0230 [2:30 AM] and did a thorough assessment of resident. It is believed he will need stitches to close the laceration above his right eye. c. A Health Status Note dated 7/28/23 at 5:37 AM revealed, Resident discharged from [local hospital] after falling off the bed at 0230. Resident has broken ribs 7-10 and stitches above his right eye. Physician notified. d. An Event Note dated 8/3/23 at 11:13 AM revealed, Event Description: On 7/28/23 at 0225 [2:25 AM] staff nurse found the resident on the floor after hearing him yelling 'someone help me' and his tube feed beeping. Resident was prone with a pool of blood under his head. Nurse had CNA call 911 and had help supporting residents head and neck to turn him face up again. Room was dark, resident dressed in night time attire. Paramedics arrived at close to 0230 [2:30 AM] and did a thorough assessment of resident. It is believed he will need stitches to close the laceration above his right eye. New interventions: .Resident returned from the hospital with a laceration above his eye and 4 broken ribs. Routine neuro checks and alert charting initiated. After further investigation by DON [Director of Nursing] and watching video footage the resident had not been checked on for 4 1/2 hours by the CNA staff. Education provided to all staff on 7/28/23 for proper care of residents. Administration looking into disciplinary action. Routine neuro checks and alert charting completed. No additional injuries or abnormalities noted. The exhibit 358 had alleged that on 7/28/23 at 2:20 AM, resident 35 fell out of bed. On 7/29/23, the resident's [family member] informed the DON that the resident fell out of bed and experienced a laceration to the head, the residents [family member] felt the fall was result of neglect. Resident was sent to the [local hospital] and rib fractures were detected. Adult Protective Services (APS) and the Ombudsman were notified. The resident experienced increased pain from the head laceration and rib fractures. An investigation was completed by the Administrator (ADM). The allegation was not verified, There is no evidence of abuse or neglect. The corrective actions taken were, NA [Not Applicable]. Summary information from the investigation included, Resident had a recent stroke causing dementia and left side paralysis, BIMS [Brief Interview for Mental Status] score of 13, patient had an unwitnessed fall out of bed on his right side resulting in a laceration to the face which required stitches and three broken ribs. On 10/4/23 at 9:08 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she heard beeping from resident 35's room so she went to his room and found him on the ground with his pole on top of him. RN 1 stated she told the other staff to call 911 and went to assess the resident. RN 1 stated resident 35 had reached for something and fell out of bed. RN 1 stated there was a lot of blood from the gash on resident 35's head. RN 1 stated resident 35 was not fully coherent at that time during his stay and was unpredictable and was always trying to reach and move with his right arm that had not been affected by the stroke. RN 1 stated resident 35 was a 2 person assist and had his call light pinned to his shirt. RN 1 stated resident 35's bed was at normal height but after that day it was put on the lowest setting and a fall mat was placed on the floor. RN 1 stated resident 35 was not able to tell the staff when he was soiled so the aides were supposed to check on him every 2 hours, and after the fall they were supposed to check on him more often. On 10/4/23 at 9:24 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 35 was assigned to his section on the night of the fall. CNA 1 stated he had gotten behind on his rounds and did not help resident 35 as soon as he should have. CNA 1 stated the nurse found resident 35 on the ground and called for help. CNA 1 stated on the night shift the facility was divided into two sections, one half of the building was for one CNA and the other was for the other CNA. CNA 1 stated they do rounds on the residents every 2 hours for those who need it. CNA 1 stated that resident 35 was a resident who needed checked on at least every 2 hours. CNA 1 stated resident 35 was a 2 person assist, and when they assisted him they would raise the bed up to waist level and then put it back down when finished with cares. CNA 1 stated resident 35's bed was not as low as they kept it now, it was a little below waist level. CNA 1 stated there was not fall mat on the floor. CNA 1 stated resident 35 had not fallen before this incident. CNA 1 stated there was some training the staff went over after the incident occurred. CNA 1 stated resident 35 had just gotten moved to his section and he had honestly forgotten resident 35 was there and that was completely on him. On 10/4/23 at 1:24 PM, an interview was conducted with the DON. The DON stated falls may happen but they were preventable and the staff were expected to make sure the residents were checked on routinely, briefs were changed as needed, and that the resident's needs were met. The DON stated resident 35 fell out of bed and the nurse on duty got emergency services to the facility right away and they took the resident to the hospital. The DON stated the CNA in charge of resident 35's care was new and did not receive support from the other CNA like he should have. The DON stated he had watched the camera recordings from that night and resident 35 had not been checked on for more than 4 hours. The DON stated that the fall resident 35 experienced could have been prevented and was unnecessary. On 10/4/23 at 2:35 PM, an interview was conducted with the ADM. The ADM stated he had investigated resident 35's fall and had talked with the nurse and CNA's but could not locate the notes on the incident. The ADM stated he did not verify it as neglect due to the fact the resident was quite confused at the time and received his injuries from falling out of bed. The ADM stated the services that the facility should have provided were to check on the resident and provide cares as needed. The ADM stated the staff are expected to check on the residents at least every 2 hours if not more. The ADM stated he had no documentation that the resident was not taken care of as he looked at the notes from that date. The ADM stated resident 35 was not a fall risk when the incident occurred and after the incident interventions were put into place. On 10/2/23 the facility Abuse Policy dated 6/14/23 was provided and documented abuse under the section titled, Policy statement as corporal punishment and involuntary seclusion. This facility does not condone resident abuse and shall take every precaution to prevent resident abuse. All occurrences of resident abuse, suspected abuse, neglect and injuries of unknown source shall be promptly reported to the facility abuse coordinator for investigation. Number 7 under the section titled, Definitions defined neglect as, the failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interview and record review it was determined, for 4 of 21 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, allegations of physical, sexual, and verbal abuse were not thoroughly investigated to determine if abuse occurred. Resident identifiers: 24, 31, 35 and 94. Findings include: 1. Resident 24 was admitted to the facility on [DATE], readmitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unsteadiness on feet, difficulty in walking not elsewhere classified, dysphagia unspecified, multiple sclerosis, type 2 diabetes mellitus without complications, bladder-neck obstruction, chronic kidney disease stage 3 unspecified, chronic idiopathic constipation, pressure ulcer of sacral region stage 3, pressure ulcer of sacral region unstageable, repeated falls, pressure ulcer of sacral region stage 2, urinary tract infection, site not specified, other obstructive and reflux uropathy, acute kidney failure with tubular necrosis, metabolic encephalopathy, encounter for fitting and adjustment of urinary device, acute respiratory failure with hypoxia, pneumonia unspecified organism, other lack of coordination, unspecified abnormalities of gait and mobility, vascular dementia unspecified severity with anxiety, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness, unspecified symptoms and signs involving cognitive functions and awareness, severe sepsis without septic shock, dysphagia pharyngoesophageal phase, gastro-esophageal reflux disease without esophagitis, muscle weakness (generalized), other abnormalities of gait and mobility, chronic fatigue unspecified, vitamin D deficiency unspecified, long term (current) use of insulin, dysarthria following cerebral infarction, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, paralytic gait, major depressive disorder single episode unspecified, folate deficiency anemia unspecified, essential (primary) hypertension, hypothyroidism unspecified, and hyperlipidemia unspecified. Resident 24's medical record was reviewed 10/2/23 through 10/4/23. Resident 24 was noted to have a Brief Interview for Mental Status (BIMS) score of 3, suggesting a severe cognitive impairment. On 10/03/23 at 9:53 AM, an attempt was made to conduct an interview with Resident 24 in his room regarding this incident. Resident 24 was non-interviewable. On 10/4/23 at 9:20 AM an interview was conducted with Registered Nurse 1 (RN 1). RN 1 stated that Resident 24 will sometimes brush his hand against her rear end. RN 1 stated that she was told that Resident 24 had sexual behaviors. He will constantly try to grab employees and other residents. If he is redirected, he will stop immediately. RN 1 stated that his behaviors generally happened in the dining room. RN 1 stated Resident 24 was seated near another male resident and was not seated by women during mealtimes. On 10/4/23 at 1:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 24 has sexual tendencies that the facility monitors. The DON stated that interventions for these tendencies included removing Resident 24 from the situation and redirecting him. The DON stated that Resident 24 was aware that his behaviors are inappropriate. The DON stated that Resident 24 had exposed himself to staff several times in his room. The DON stated that no female residents should be in male rooms. The DON also stated that Resident 24 only comes out of his room during mealtimes. The facility abuse binder was reviewed. The only documentation for this investigation were Forms 358 and 359. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included dementia, peripheral vascular disease, hypertension, lack of coordination, other amnesia, osteoporosis, and muscle weakness. Resident 31's medical record was reviewed on 10/2/23. The exhibit 358 revealed that staff became aware of the incident on 4/6/23 at 11:15 AM. The exhibit revealed that resident 31 alleged, [Resident 24] tried to kiss resident [31] and flashed his genitals. The exhibit 359 revealed that Per interview [resident 31] stated that she went into resident 24's room to check on him after lunch and give him some water, he asked her to come close so he could hear her, when she came close he tried to pull her in for a kiss, she said they're not like (sic) and she's not interested in that and she pulled away. Then he began undoing his pants and exposed his genitalia. She said I don't want any part of that, that's not how we are and left the room. Stated she hasn't talked with him since. A summary of interviews of the staff revealed, RN was made aware of the allegation on 4/6 and immediately informed the administrator. Only information made aware to her was that of the incident, she was not a witness to the incident. Staff were not made aware of any incidents between [resident 31] and [resident 24] on the day of the alleged incident. [Resident 24] is a LTC (Long Term Care) resident that admitted [DATE]. He is currently being treated with a primary diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side. He has a most recent BIMS (Brief Interview of Mental Status) score of 3. [Resident 24] has difficulties with communication, although he can express himself he has muffled/slurred speech, he also has other symptoms and sight involving cognitive functions and awareness. [Resident 31] admitted [DATE]. She is currently being treated with a primary diagnosis of Dementia. She has a most recent BIMS score of 9. She fairly independent with mobility and has enjoyed being of service to some of her fell ow residents that are not as mobile, and enjoys new friendships. Resident 31 has been assisting to make sure her friends have water and get to and from activities. She went to check in on [resident 24] the day of the allegation after lunch and bring him some water, it is then that she stated he tried to kiss her and exposed himself to her. She left his room and has not had interaction with him since. She has stated she does not feel threatened by him in any way, that sharing the dining room with him still in comfortable and as they are both in separate hallways and she will not be going into his room that she is comfortable and safe. There were no additional interviews provided. On 10/2/23 at 1:11 PM, an interview was conducted with resident 31. Resident 31 stated there was a man who lived at the facility who would pull her in and kiss her. Resident 31 stated the man was resident 24. One day she made the mistake of going to his room and he pulled her down to give her a kiss, he was lying in bed. Resident 31 stated that before she knew it he had unzipped his pants and was playing with his genitals and then wanted her to play with his genitals. Resident 31 stated she left his room right away but did not tell anyone at the facility about it. Resident 31 stated that a police officer came to talk with her and that nothing has happened since with the man. Resident 31 stated she liked to help all of the residents with their bibs at lunch time or if they needed water but they told her that she can not do that anymore. Resident 31 stated she feels safe in the facility and has not had any other interactions with resident 24. Resident 31 stated she has good friends at the facility and the staff are kind and take good care of her. On 10/4/23 at 1:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 24 had sexual tendencies. The DON stated they try to keep the residents safe by monitoring those tendencies, removing the person from those situations, and being aware. The DON stated he was unaware of this incident but would look into it. The DON stated the staff will usually inform him and he can go talk with resident 24. The DON stated he will talk with resident 31 to ensure she is ok and will make sure all safety guards are in place. The DON stated the residents are on two different hallways so it is odd that resident 31 would have been in resident 24's room. 3. Resident 35 was admitted to the facility on [DATE] with diagnoses which included hemipareses and hemiplegia of left non-dominant side, lack of coordination, dysphagia, type II diabetes, muscle weakness, lack of coordination, unsteadiness on feet, gastroesophageal reflux disease, hypertension and Crohn's disease. Resident 35's medical record was reviewed on 10/2/23. Exhibit 358 revealed the staff became aware of the incident on 7/28/23 at 2:20 AM. The exhibit revealed, Resident's [family member] reported that the Resident had fallen out of bed on 07/29/2023 and feels like it was due to neglect. Resident was assessed and a laceration to the head was found as well as a rib fracture. The Resident complained of increased pain due to injuries and was sent to the hospital for an evaluation. APS (Adult Protective Services) and Ombudsman were notified. Exhibit 359 revealed, Per interview, resident [35] is confused and does not remember. A summary on interviews of the staff revealed, Patients wife told DON that she felt the fall was a result of neglect. The nurse in charge that night was walking down the hall when she heard a cry for help. She responded immediately providing proper care until EMS (Emergency Medical Services) arrived. Resident [35] had a recent stroke causing dementia and left side paralysis, BIMS score of 13, patient had an unwitnessed fall out of bed on his right side resulting in a laceration to the face which required stitches and three broken ribs. There were no additional interviews provided. On 10/2/23 at 10:02 AM, an interview was conducted with resident 35. Resident 35 was observed to have his family member shaving him. Resident 35 was anxious and stated that he did not want to get anyone in trouble but he had fallen out of bed and gotten hurt. An admission Fall Risk assessment dated [DATE] documented, resident 35 was a high fall risk with a score of 55. A score 45 or higher indicated a high fall risk. An admission Functional Abilities assessment dated [DATE] documented, resident 35 was dependent for bed mobility, transfers and toileting hygiene. An admission Minimum Data Set (MDS) dated [DATE] documented, resident 35 required extensive assistance and was a two person physical assist with bed mobility, transfers and toilet use. Resident 35's nursing progress notes were reviewed and revealed the following: a. A Skilled Nursing note dated 7/27/23 at 20:31 (8:31 PM) revealed, .Resident [35] is pleasant and compliant with all cares, he requires 2-person assistance with all cares and is incontinent and immobile. b. An Incident Note dated 7/28/23 at 3:09 AM revealed, Found resident on the floor at 0220 (2:20 AM) after hearing him yelling someone help me and his tube feed beeping. Resident was prone with a pool of blood under his head. Nurse had CNA call 911 and had help supporting residents head and neck to turn him face up again. Resident complained of his shoulder and back hurting and said he hit his head and that the IV (intravenous) stand then hit him in the back. Paramedics arrived at close to 0230 (2:30 AM) and did a thorough assessment of resident. It is believed he will need stitches to close the laceration above his right eye. c. A Health Status Note dated 7/28/23 at 5:37 AM revealed, Resident discharged from [local hospital] after falling off the bed at 0230 (2:30 AM). Resident has broken ribs 7-10 and stitches above his right eye. Physician notified. d. An Event Note dated 8/3/23 at 11:13 AM revealed, Event Description: On 7/28/23 at 0225 (2:25 AM) staff nurse found the resident on the floor after hearing him yelling someone help me and his tube feed beeping. Resident was prone with a pool of blood under his head. Nurse had CNA (Certified Nursing Assistant) call 911 and had help supporting residents head and neck to turn him face up again. Room was dark, resident dressed in night time attire. Paramedics arrived at close to 0230 (2:30 AM) and did a thorough assessment of resident. It is believed he will need stitches to close the laceration above his right eye. New interventions: .Resident returned from the hospital with a laceration above his eye and 4 broken ribs. Routine neuro checks and alert charting initiated. After further investigation by DON and watching video footage the resident had not been checked on for 4 1/2 hours by the CNA staff. Education provided to all staff on 7/28/23 for proper care of residents. Administration looking into disciplinary action. Routine neuro checks and alert charting completed. No additional injuries or abnormalities noted. The exhibit 358 had alleged that on 7/28/23 at 2:20 AM, resident 35 fell out of bed. On 7/29/23 the resident's [family member] informed the DON that the resident fell out of bed and experienced a laceration to the head, the residents [family member] felt the fall was result of neglect. Resident was sent to the [local hospital] and rib fractures were detected. APS and the Ombudsman were notified. The resident experienced increased pain from the head laceration and rib fractures. An investigation was completed by the Administrator (ADM). The allegation was not verified, There is no evidence of abuse or neglect. The corrective actions taken were, NA (Not Applicable). Summary information from the investigation included, Resident had a recent stroke causing dementia and left side paralysis, BIMS score of 13, patient had an unwitnessed fall out of bed on his right side resulting in a laceration to the face which required stitches and three broken ribs. On 10/4/23 at 9:24 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 35 was assigned to his section on the night of the fall. CNA 1 stated he had gotten behind on his rounds and did not help resident 35 as soon as he should have. CNA 1 stated the nurse found resident 35 on the ground and called for help. CNA 1 stated on the night shift the facility was divided into two sections, one half of the building was for one CNA and the other was for the other CNA. CNA 1 stated they do rounds on the residents every 2 hours for those who need it. CNA 1 stated that resident 35 was a resident who needed checked on at least every 2 hours. CNA 1 stated resident 35 was a 2 person assist, and when they assisted him they would raise the bed up to waist level and then put it back down when finished with cares. CNA 1 stated resident 35's bed was not as low as they kept it now, it was a little below waist level. CNA 1 stated there was not fall mat on the floor. CNA 1 stated resident 35 had not fallen before this incident. CNA 1 stated there was some training the staff went over after the incident occurred. CNA 1 stated resident 35 had just gotten moved to his section and he had honestly forgotten resident 35 was there and that was completely on him. On 10/4/23 at 1:24 PM, an interview was conducted with the DON. The DON stated falls may happen but they were preventable and the staff were expected to make sure the residents were checked on routinely, briefs were changed as needed, and that the resident's needs were met. The DON stated resident 35 fell out of bed and the nurse on duty got emergency services to the facility right away and they took the resident to the hospital. The DON stated the CNA in charge of resident 35's care was new and did not receive support from the other CNA like he should have. The DON stated he had watched the camera recordings from that night and resident 35 had not been checked on for more than 4 hours. The DON stated that the fall resident 35 experienced could have been prevented and was unnecessary. On 10/4/23 at 2:35 PM, an interview was conducted with the ADM. The ADM stated he had investigated resident 35's fall and had talked with the nurse and CNA's but could not locate the notes on the incident. The ADM stated he did not verify it as neglect due to the fact the resident was quite confused at the time and received his injuries from falling out of bed. The ADM stated the services that the facility should have provided were to check on the resident and provide cares as needed. The ADM stated the staff are expected to check on the residents at least every 2 hours if not more. The ADM stated he had no documentation that the resident was not taken care of as he looked at the notes from that date. The ADM stated resident 35 was not a fall risk when the incident occurred and after the incident interventions were put into place. 4. Resident 94 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, unsteadiness on feet, diabetes type II, chronic kidney disease, delusional disorder, seizures, dementia and hypertension. Resident discharged from the facility on 3/22/23. Resident 94's medical record was reviewed on 10/2/23. Exhibit 358 revealed that staff became aware of the incident on 3/16/23 at 8:15 AM. The exhibit revealed, Resident 94 had eloped from the facility, resident [94] reported a fall but workup and imaging completed with no major injuries, minor laceration to elbow. Exhibit 359 revealed that, Per interview, resident [94] unable to express comprehensive story line, but continually stated he wanted to get out for a walk, thought he lived in [NAME], and he needed to get a job so he went to look for a job. A summary on interview of the staff revealed, Resident has has continued wandering and exit seeking behaviors. Has had hallucinations of someone else in his room or that he no longer lives in the facility and cannot go to his room to sleep. States he needs to leave to go to his job. Has required frequent checks and constant redirection. [Resident 94] is a Long Term Care resident who has been with us since November 2022. [Resident 94] has a primary diagnosis of Paranoid Schizophrenia, he also has Dementia and suffers from hallucinations and delusions. He has a history of Homelessness and on his most recent BIMS he scored a 4/15. [Resident 94] has had one other elopement in the past and has had a wander guard on his right wrist since. As previously mentioned he did experience a fall while out of the facility and was treated in the ER, (emergency room ) imaging was completed with no complications or major injury, his skin tear was treated with standard bandages. [Resident 94] normally is very pleasant and cooperative with care, he does wander the facility and is typically easily redirected but as of late with his hallucinations he has had an increase in exit seeking behavior and has required frequent supervision. A care plan focus dated 1/13/23 documented, At risk for injury due to wandering resident has wandered away from this facility without signing out on LOA (Leave of Absence) as well as Dx (diagnosis) of paranoid schizophrenia with use of scheduled psychotropic medication. Interventions put in place were, Encourage resident to stay in common areas of building for observation if needed. Resident to wear wandergaurd. Skin to be checked beneath wander guard QD (every day) for s/sx (signs/symptoms) breakdown. Wander guard to be checked weekly for proper functioning. When wandering, redirect resident to another activity. Wander assessment to be completed quarterly and prn to monitor for ongoing need of wandergaurd. Anticipate and meet the resident's needs. Keep frequently used items within reach. An admission Wander/Elopement Risk evaluation dated 11/29/23 documented, Resident [94] has been assessed and deemed to not be a wander/elopement risk. An other Wander/Elopement Risk evaluation dated 1/13/23 documented, Resident [94] has been re-assessed and deemed to be a wander/elopement risk. On 10/04/23 at 1:18 PM, an interview was conducted with the DON. The DON stated that when resident 94 first came to the facility he was not a wander risk, he liked to walk around but he didn't try to leave. The DON stated that each door had a shut down on it if the resident who wore a wander guard got within 5 feet the door would lock automatically. The DON stated the maintenance man routinely checks the doors to make sure the alarms worked. The DON stated resident 94 liked to wander. The DON stated resident 94 liked to hang around in the dining room and when the nurses were doing their walking rounds he was able to slip out the door in the dining area. The DON stated while they looked for resident 94 the local hospital called and told them he was a patient in the emergency room . The DON stated a bystander had seen him and taken him to the local fire department and they had transported him to the hospital. The DON stated he reviewed the camera footage from the facility and the staff had seen resident 94 a few minutes prior to him leaving. The DON stated there was a malfunction with the dining room door and after that they had to manually lock the whole door. The DON stated the door company came and fixed it the next day. The DON stated based on those things and to keep the resident safe it was recommended he be transferred to a more secure location. On 10/04/23 at 2:30 PM, an interview was conducted with the ADM. The ADM stated the maintenance man kept logs of checking the doors. An observation was made of the log that was done for August of the routine door checks. The ADM stated he was unsure where the other logs were since the maintenance employee had since stopped working there. The ADM stated the transportation director would be doing the door audits now and he will do them twice weekly. 47432

Based on interview and record review, it was determined for 1 of 21 sampled residents, that the facility did not ensure that the resident was free of misappropriation of resident property. Specifically, a nursing assistant stole a resident's credit card and made several unauthorized purchases with the card. Resident identifier: 11. Findings include: Resident 11 was admitted to the facility on [DATE], and readmitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, difficulty in walking not elsewhere classified, chronic obstructive pulmonary disease with (Acute) exacerbation, acute and chronic respiratory failure with hypoxia, epilepsy unspecified intractable with status epilepticus, contracture left wrist, major depressive disorder recurrent moderate, generalized anxiety disorder, age-related physical debility, acute candidiasis of vulva and vagina, other lack of coordination, obesity unspecified, lack of physical exercise, unsteadiness on feet, other abnormalities of gait and mobility, gastrointestinal stromal tumor of stomach, muscle wasting and atrophy not elsewhere classified unspecified lower leg, nausea, constipation unspecified, muscle weakness (Generalized), mixed hyperlipidemia, chronic pain syndrome, hypo-osmolality and hyponatremia, cerebral infarction unspecified, syndrome of inappropriate secretion of antidiuretic hormone, gastro-esophageal reflux disease without esophagitis, personal history of malignant neoplasm unspecified, encephalopathy unspecified, anxiety disorder unspecified, and essential (primary) hypertension. On 3/2/23, an entity report was submitted to the state agency. Form 358 summarized that a nursing assistant at the facility had been caught on tape spending over $1500 on Resident 11's missing credit card. Form 359 summarized that Resident 11 had a safe in her room to store valuables, but at the time of the incident she had been storing her credit card in her nightstand. Staff had assisted in a room search after the card went missing and when the card could not be located, Resident 11's family was notified. The facility verified which charges were unapproved and illegal and disputed the unauthorized charges that had been placed on the card. Resident 11's medical record was reviewed 10/2/23 through 10/4/23. On 10/3/23 at 8:37 AM, an interview was conducted with Resident 11. Resident 11 stated that her credit card went missing and that NA 1 was arrested after police found footage of her using Resident 11 ' s credit card at a retailer. Resident 11 stated that NA 1 had to pay back all of the money that she had spent. Resident 11 was unsure how NA 1 was able to get a hold of her credit card as she keeps it in her purse in her room. On 10/04/23 at 8:32 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when this incident occurred Resident 11's daughter had reached out regarding some charges on Resident 11's credit card that she did not recognize. The DON asked Resident 11 what had happened. Resident 11 stated that she thought someone had gone out and purchased items for her. Resident 11's family provided a bank statement and there were charges from vendors that the facility did not purchase from. The DON stated that there are only two staff members that were in charge of purchasing items for residents, the Resident Advocate (RA) and the Activities Director. (AD) The DON stated that Resident 11's daughter had reached out to the AD to ask if she had purchased the unusual items listed on the credit card statement. The DON stated that the police were then contacted. The Police obtained footage of NA 1 using Resident 11's credit card. NA 1 admitted guilt, was immediately terminated, and escorted off the premises in police custody. The DON stated if the facility purchases items for a resident using their personal credit card, they provide the resident with a receipt from the purchase, but the facility does not keep a copy on file. On 10/4/23 at 12:02 PM, an interview was conducted with the RA and AD. The AD stated that when the theft occurred, she had gone to pick up Resident 11's credit card from her room to purchase some items that Resident 11 had requested. The card could not be found and it had been several weeks since Resident 11's last purchase with the card. Resident 11 was unsure of how long the card had been missing. The RA and AD stated that they informed facility administration of the missing credit card. Resident 11 called her daughter and the police were involved in the investigation. Police obtained footage of NA 1 using Resident 11's credit card at a local store. The RA and AD stated that the only staff members that are authorized to make purchases on behalf of a resident are the administrator, the resident advocate, and the activities director. The RA and AD stated that there are lockboxes in both the administrator's office and the resident advocate/activities director office where all residents are encouraged to store cash, credit cards, and other valuables as a precaution. On 10/423 at 1:41 PM, an additional interview was conducted with the DON. The DON stated that no other residents had complained about having money stolen and that the police interrogated NA 1 heavily to find out whether or not she had stolen any other money or property from any other residents in the facility. The DON stated that the AD went around the facility and ensured that no other residents were missing any property. On 10/4/23 at 8:35 AM, NA 1's personnel file was reviewed. NA 1 signed the facility Abuse Training and Policy Statement of Acknowledgement on 12/7/22. NA 1 passed the registry background check on 12/7/22. NA 1 was not a certified nursing assistant at the time of hire or during the time frame the misappropriation of funds occurred. NA 1 had been enrolled in a certified nursing assistant training program. On 10/4/23 at 9:48 AM, an attempted phone call was made to NA 1 using the phone number listed in the personnel file. The phone line was disconnected and not in service.

Based on interview and record review the facility did not conduct COVID-19 testing based on the criteria for conducting testing of asymptomatic individuals, such as the positivity rate of COVID-19 in a county. Specifically, unvaccinated staff were not tested twice a week when the county positivity rate was High >10%). This occurred for 2 out of 5 sampled staff members. Findings include: Center for Medicare and Medicaid Services (CMS) Memo QSO (Quality Safety & Oversight)-20-38-NH, revised on 4/27/21, reads, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested . Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. [Community COVID-19 activity is High when the county positivity rate in the past week was >10% and minimum testing frequency of unvaccinated staff is twice a week.] The Utah County positivity rates used to determine the frequency for routine unvaccinated staff testing were as follows: · [DATE] Week 1 (10/3/21 to 10/9/21) Prior week's county positivity rate: 11.9% · [DATE] Week 2 (10/10/21 to 10/16/21) Prior week's county positivity rate: 12.2% · [DATE] Week 3 (10/17/21 to 10/23/21) Prior week's county positivity rate: 12.1% · [DATE] Week 4 (10/24/21 to 10/30/21) Prior week's county positivity rate: 11.5% · [DATE] Week 1 (10/31/21 to 11/6/21) Prior week's county positivity rate: 12.5% · (Note: the Utah County positivity rate during these testing weeks was > 10% requiring twice a week testing of unvaccinated employees.) The Director of Nursing (DON) was designated as the facility's Infection Preventionist and COVID-19 Vaccine Supervisor. On 11/9/21, five employees from the list of staff, who had not been vaccinated for COVID-19 were selected as a sample to review. The COVID-19 staff testing logs for October 2021 and November 2021, provided by the DON, were reviewed and revealed the following: 1. Employee 1 met the routine COVID-19 testing requirements 2. Employee (EMP) 2 worked during weeks 1 and 2 of [DATE], however EMP 2 was not tested by the facility for COVID-19 during those two weeks. There were notes in the COVID-19 staff testing log that EMP 2 was reminded to be tested 2 times a week on 10/5/21, 10/7/21, 10/12/21 and 10/14/21. EMP 2 was tested twice a week for COVID-19 during weeks 3 and 4 of October 2021 and week 1 of November 2021. 3. Employee 3 was left off the work schedule and did not need COVID-19 testing. 4. Employee 4 met the routine COVID-19 testing requirements 5. Employee 5 met the routine COVID-19 testing requirements for [DATE] Week 1. EMP 5 did not work [DATE] Week 2. EMP 5 was tested on ly one during [DATE] Weeks 3 and 4 (Received testing on 10/21/21 and 10/26/21). EMP 5 was tested twice on November 2021 Week 1. On 11/9/21 at 1:42 PM, an interview was conducted with the DON. The DON acknowledged that EMP 2 was not tested as required. The DON stated that EMP 5 misunderstood the testing requirements because she was in the process of receiving the COVID-19 vaccine. EMP 5 received her first COVID-19 dose on 10/26/21 and was scheduled to receive her second COVID-19 dose next week.

Based on observation, interview, and record review it was determined that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident with an active diagnosis, medical orders for medication and monitoring of anxiety did not have anxiety addressed in the resident's care plan. This occurred for 1 of 19 sampled residents. Resident identifier: 18. Findings include: Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/8/21, resident 18's medical record was reviewed. On 10/1/21, resident 18's Admission Minimum Data Set (MDS) Comprehensive Assessment revealed that resident 18 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/20/21, when resident 18 was admitted to the facility, resident 18's physician ordered the following two medications to treat resident 18's anxiety disorder: 1. [MEDICATION(S)] (HCl) 25 milligrams (mg) by mouth every 4 hours as needed for Anxiety. Start Date: 9/20/21. End Date: 10/20/21. 2. [MEDICATION(S)] 0.5 mg by mouth three times a day as needed. Start Date 9/20/21. On 9/26/21, resident 18's physician ordered the following monitoring: 1. [MEDICATION(S)] ANTI-ANXIETY MEDICATION SIDE EFFECT (S/E) MONITORING: 0. NONE, 1. DROWSINESS, 2. DIZZINESS, 3. NAUSEA/VOMITING, 4. DRY MOUTH, 5. CONSTIPATION, 6. HEADACHE, 7. FATIGUE, 8. CONFUSION, 9. DEPRESSION, 10. HALLUCINATIONS, 11. ATAXIA OR DRUNK WALK, 12. PALPITATIONS, 13. AGGRESSIVE/IMPULSIVE BEHAVIOR. Monitor every shift for Use of Anti-Anxiety Medications IF NO S/E, MARK 0. IF EXPERIENCING S/E, ENTER number (#) OF ASSOCIATED S/E OR S/E'S patient (PT) IS EXPERIENCING. Start Date: 9/27/21. 2. [MEDICATION(S)] BEHAVIOR MONITORING: # OF VERBALIZATIONS OF ANXIETY Q SHIFT. Monitor every shift. Start Date: 9/27/21. Resident 18's current care plan, initiated on 9/27/21, was reviewed. There were no problems, goals or interventions associated with resident 18's anxiety included in her care plan. On 11/10/21 at 9:50 AM, an interview was conducted with the facility's Director of Nursing (DON). Resident 18's active diagnoses, medical orders and care plan were reviewed with the DON. The DON acknowledged that resident 18's care plan should have included resident 18's problem of anxiety with goals and interventions.

Based on interview, observation and record review it was determined the facility did not ensure that the resident received proper treatment and assistive devices to maintain vision abilities. Specifically, for 1 out of 19 sampled residents, a resident received a new prescription for eye glasses and the new glasses were not ordered as the resident believed they had been. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/8/21 at 9:30 AM, resident 1 was observed in her room. Resident 1 was interviewed and stated her eyeglasses were missing. Resident 1 stated she had difficulty seeing and writing without her eyeglasses unless she put her face very close to the object. No eyeglasses were observed on her bedside table. Resident 1 stated she had gone to the doctor and was supposed to be getting new ones. On 11/9/21, a record review was completed of resident 1's electronic medical record. On 9/13/21, a Physician Visit Note revealed orders for prescription glasses to replace lost ones and [MEDICATION(S)] .005% Opthalmic GTTS (drops). On 9/13/21, a Health Status Note revealed that resident had visited with the eye doctor and the new order for eye drops was sent to the pharmacy and that the house medical doctor (MD) was made aware. There was no mention of the new eye glasses prescription in the note. The September Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/27/21, a care plan focus for resident 1 was revised that stated the resident exhibits impaired activity patterns manifested by poor health limiting activity involvement. An intervention directed toward vision impairment was in place to encourage the resident to sit close to the speaker. No care plan focus, goal or interventions were in place for eye glasses. On 11/09/21 at 11:30 AM, an interview was conducted with the Resident Advocate (RA). The RA stated the process for new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RA stated she was unaware of any prescription needed by the resident. The RA stated that the RA or the Administrator (ADM) are the ones who will take the residents to get new eye glass frames if they are needed. On 11/09/21 at 11:51 AM, an interview was conducted with CNA 1 & CNA 2. CNA 1 & CNA 2 stated the resident did have glasses a couple of months ago but sometimes she will hide things and they are hard to find. We could not find them so we reported them missing to nursing. If something is missing we will try to find it, then we tell the RA, then everyone tries to find it, if it is clothes we will replace it, if it is money they do an investigation. The resident has not gotten any new glasses. On 11/10/21 at 11:31 AM, an interview was conducted with RN 2. RN 2 stated if she needed to find out if a resident wore glasses she would look in the skilled nurse charting for information about whether a resident used eye glasses, contacts or hearing aids. The admission assessment would also help with this information. On 11/09/21 at 12:00 PM, an interview was conducted with the DON. The DON stated if the resident needed appointments then the medical doctor (MD) would approve the appointment to be scheduled and the DON would put the orders in the electronic medical record, then the RA would get the appointments scheduled. The DON stated on the return of the appointment the DON or the nurse on duty will put the orders in the electronic medical record and fill out a notification sheet to send to the MD making them aware of any requested changes. If a MD comes to the facility the process is that the MD will send us the notes and recommendations and the DON get them put in the medical record and ordered if needed. The DON stated he was not sure the resident even had glasses. After viewing the prescription order the DON stated that with this resident the glasses order was missed and the resident was not taken to get her new glasses.

Based on observation, interview and medical record review it was determined that the facility did not ensure that PRN (as needed) orders for [CONDITION(S)] drugs were limited to 14 days, except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days and he or she documented their rationale in the resident's medical record and indicated the duration for the PRN order. Specifically, a resident, who had [CONDITION(S)] drug PRN orders that remained active for more than 14 days without a duration specified by the prescribing practitioner. This occurred for 1 of 19 residents. Resident identifier: 18. Findings include: Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute [CONDITION(S)] with [CONDITION(S)], pneumonia, [CONDITION(S)], chronic pain syndrome, [CONDITION(S)], major depressive disorder, and major anxiety disorder. On 11/8/21, resident 18's medical record was reviewed. On 10/1/21, resident 18's Admission Minimum Data Set (MDS) Comprehensive Assessment revealed that resident 18 had an active diagnosis for an anxiety disorder. On 9/20/21, when resident 18 was admitted to the facility, resident 18's physician ordered the following two [CONDITION(S)] medications to treat resident 18's anxiety disorder: 1. [MEDICATION(S)] (HCl) 25 milligrams (mg) by mouth every 4 hours as needed [PRN] for Anxiety. Start Date: 9/20/21. End Date: 10/20/21. (Note: This [CONDITION(S)] drug PRN order remained active for 30 days.) 2. [MEDICATION(S)] [[MEDICATION(S)]] 0.5 mg by mouth three times a day as needed [PRN]. Start Date 9/20/21. (Note: This [CONDITION(S)] drug PRN order was still active at the time of survey.) Review of resident 18's September 2021, October 2021 and November 2021 Medication Administration Records (MAR) revealed resident 18 had received both [MEDICATION(S)] HCl and [MEDICATION(S)] as ordered for anxiety. Monthly pharmacy reviews were completed. · September 2021's pharmacy review found no irregularities. · October 2021's pharmacy review had no recommendations related to the two active [CONDITION(S)] drug PRN orders, which had both exceeded 14 days. On 10/20/21, a [CONDITION(S)] Meeting was held and resident 18's two [CONDITION(S)] drug PRN orders were reviewed. The [CONDITION(S)] Meeting Review form included the following: Committee recommendations: The [CONDITION(S)] committee reviewed residents [resident 18's] medications and behavior tracking since admission. Committee recommends to discontinue residents [resident 18's] [MEDICATION(S)] and review again next month in November. Additional notes: MD (Medical Doctor) to write a note on the resident's [resident 18's] use of [MEDICATION(S)]. On 10/20/21 at 1:03 PM, an MD Progress Note read, [Resident 18] was reviewed in [CONDITION(S)] meeting today. She takes prn [MEDICATION(S)] and prn [MEDICATION(S)]. Will dc (discontinue) prn [MEDICATION(S)]. Continuing prn [MEDICATION(S)] is warranted given the level of anxiety she has. She will be referred to PASRR (Preadmission Screening and Resident Review) for level 2. Will continue to track behaviors and review at [CONDITION(S)] meetings. (Note: no duration was provided for the PRN [MEDICATION(S)] medication order.) On 11/10/21 at 9:50 AM, an interview was conducted with the facility's Director of Nursing (DON). Resident 18's [CONDITION(S)] drug PRN orders were discussed with the DON. The DON stated that resident 18's [CONDITION(S)] drugs were reviewed in the October [CONDITION(S)] Meeting and that resident 18's physician was going to write a note in resident 18's medical record related to resident 18's continued use of [MEDICATION(S)] PRN. Resident 18's physician note was reviewed and the DON acknowledged that there was no duration added to resident 18's [MEDICATION(S)] PRN order. The DON stated that there was no other documentation from resident 18's physician that documented the duration of this [CONDITION(S)] PRN medication. The DON stated that resident 18's physician would be in the facility that day and that he would ask resident 18's physician to add a specific duration to resident 18's [MEDICATION(S)] PRN order.

Based on observation, interview, and record review the facility did not 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 for 7 of 8 sampled residents. Specifically, residents had direct physical contact with coffee dispenser spouts and inside the coffee container, there was no sanitizer available at the coffee station and no use of ABHR (alcohol based hand rub) by residents prior to use of the coffee dispenser, an open communal box of unwrapped coffee stirrers, lack of 6 foot distancing between residents, and staff were not wearing the appropriate PPE (personal protective equipment) when entering a newly admitted residents' room. Resident identifiers: 1, 3, 4 5, 6, 7 and 8. Findings include: Resident 1, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 3, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 4, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 5, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 6, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 7, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 8, admitted on [DATE], with [DIAGNOSES REDACTED]. 1. On 3/22/21, the coffee station was observed from 11:15 AM to 12:35 PM. The following observations were made: a. On 3/22/21 at 11:42 AM, resident 5 took a coffee stirrer from communal box of unwrapped coffee stirrers with a bare hand. Resident 5 dropped the coffee stirrer onto the floor. Resident 5 picked up the coffee stirrer with his left hand, threw the coffee stirrer away in a garbage can located on the East side of the coffee station, and retrieved a new coffee stirrer with his left hand from the box of unwrapped coffee stirrers. No ABHR was used, and none was available at the coffee station. Resident 5's mask covered his mouth only, not his nose. b. On 3/22/21 at 11:44 AM, resident 6 opened coffee dispenser, lifted the coffee insert out of dispenser, then replaced the insert with bare hands. No ABHR was used, and none was available at the coffee station. c. On 3/22/21 at 11:48 AM, resident 7 was observed to obtain coffee from the dispenser in a personal mug. Resident 7 brought the mug from their room and refilled it at the coffee station. d. On 3/22/21 at 12:20 PM, resident 6 touched the coffee dispenser lid and spout with a bare hand. Resident 6 was not observed to use ABHR, and none was available at the coffee station. Resident 6's mask was hanging off an ear, not covering the mouth or nose. e. On 3/22/21 at 12:28 PM, an observation was made of a dietary staff member who carried a coffee dispenser to the coffee station. The staff member was observed to not be wearing gloves, was not observed to use ABHR, and no ABHR was available at the coffee station. The staff member removed one coffee dispenser and replaced it with a second. The coffee station was not wiped or sanitized. On 3/24/21 at 11:22 AM, a phone interview was conducted with Nurse 1. Nurse 1 stated that the nursing staff were not responsible for the coffee station. Nurse 1 stated that nurses were only involved when residents stated they needed more coffee. On 3/24/21 at 11:43 AM, a phone interview was conducted with the Assistant Dietary Manager (DM 2). DM 2 stated that dietary staff took care of the coffee cart in the hallway. DM 2 stated that the coffee station was wiped down every shift with sanitizing solution in the pink bottle made by Equilab. DM 2 stated that she wiped the top of the cart, the coffee dispensers, and the shelf underneath with the fresh cups, if needed. DM 2 stated that the residents could bring their own cups from their rooms if they wanted. On 3/24/21 at 12:36 PM, a phone interview was conducted with the Dietary Manager (DM 1). DM 1 stated that dietary staff were in charge of bringing out the coffee and restocking the station but it is a group effort. DM 1 stated that the CNA's (Certified Nursing Assistants), dietary, and even HR (human resources) keeps the area clean, not just dietary staff. DM 1 stated that the coffee dispensers came out of the kitchen sanitized; there is a bucket and spray of sanitizer in the kitchen. DM 1 stated that she always wiped the coffee container before it was brought out, but DM 1 stated she did not know if the other staff sanitized the coffee station. On 3/22/21 at 12:40 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the dietary staff cleaned the coffee pots and coffee station regularly. The ADM stated that ABHR should have been available at the coffee station. On 3/24/21 at 4:18 PM, an interview was conducted with the cook. The cook stated that the kitchen staff took care of the coffee, sanitized the coffee dispensers and coffee station cart, and restocked the sugars, stirrers and creamers. The cook stated that she sanitized the coffee station at the beginning of her shift at 5:00 AM, at the middle, and again at end of her shift. The cook stated that only dietary staff were responsible for the coffee station and that clean cups were provided for the residents. 2. On 3/22/21, observations were made of staff's use of PPE and inconsistent isolation precautions from 11:15 to 11:45 AM. The following was observed: a. On 3/22/21 at 11:16 AM, an observation was made of nurse 2 exiting Resident 4's isolation room. Nurse 2 removed her gloves before removing the gown, and did not use ABHR outside of room. Nurse 2 did not immediately use ABHR and walked down the hallway to get ABHR off nurses' cart. On 3/24/21, a record review revealed that Resident 4 left facility every Tuesday, Thursday and Saturday for [MEDICAL TREATMENT] treatments. On 3/20/2021 at 2:16 PM, resident 4's progress note stated: Resident's temperature upon return from LOA (leave of absence) was T (temperature) 96.9 - 3/20/2021 07:17 (7:17 AM) Route: Forehead (non-contact). Resident's risk score based on LOA is 5.0. Based on resident's risk score, the following interventions have been implemented: Resident is at high risk for potential COVID-19 exposure r/t (related to) access of the community and requires quarantine for 14 days. Resident's risk for potentially exposing other residents to COVID-19 will be mitigated to the maximum extent possible through the review date. Notify MD (medical doctor) if resident develops any new/worsened symptoms suspicious for COVID-19 and implement follow up action as directed by the MD. Resident has been educated on new interventions related to COVID LOA risk assessment. b. On 3/22/21 at 11:29 AM, an observation was made of resident 1's door, which was open. Nurse 2 entered resident 1's room wearing no gown and performed resident care. Resident 1's room had no isolation precaution signage observed on the resident's door or outside of the room, and there was no PPE supply cart outside of resident 1's room. (Note: Resident 1 was admitted 3 days prior to the observation.) c. On 3/22/21 at 11:40 AM, an observation was made of resident 1's door, which was open. Nurse 2 again entered resident 1's room with no gown on and performed resident care. There was no isolation precaution signage on the door or outside of resident 1's room, and there was no PPE supply cart outside of the room. On 3/23/21 at 4:12 PM, a phone interview with CNA 1. CNA 1 stated he assumes new admits were COVID tested at the hospital before they came to the facility. CNA 1 stated that new residents were in quarantine for 10-14 days I think and in a single room with a bathroom. CNA 1 stated that the new residents had a COVID test 2 days after admission. CNA 1 stated he didn't know if quarantined residents could have visitors. On 3/24/21 at 12:15 PM, a phone interview was conducted with CNA 2. CNA 2 stated that new residents were on isolation until they had two negative COVID-19 tests. On 3/23/21 at 4:21 PM, a phone interview was conducted with Nurse 2. Nurse 2 stated that she did not know anything about new admission or readmission rules for this facility. Nurse 2 could not state why resident 1 was not on contact precautions. On 3/24/21 at 11:22 AM, a phone interview was conducted with Nurse 1. Nurse 1 stated that all newly admitted residents had been on a 14 day isolation, which changed approximately two weeks earlier. Nurse 1 stated that the change was made to a 7 day isolation with 2 negative COVID tests. Nurse 1 stated that resident 1 refused a second COVID test, but it was OK since he didn't want to leave his room. Nurse 1 could not state why resident 1 was not on contact precautions. 3. On 3/22/21, a continuous observation was made of residents who were not social distancing from 11:15 AM until 12:35 PM. The following observations were made: a. On 3/22/21 at 11:45 AM, resident 3 blocked the East end of the East/West hallway with his wheelchair. Resident 8 touched resident 3 on the shoulder, leaned her face toward resident 3 (within 3 feet), and told resident 3 that he was in the way. Resident 3 was not wearing a mask. (Note: Resident 3 was readmitted to the facility with pneumonia 6 days earlier.) On 3/23/21, resident 3's electronic medical record review was completed. A plan of care note, dated 3/17/2021 at 11:10 AM, revealed: Resident on alert charting for re-admission to facility following hospital stay with [DIAGNOSES REDACTED]. He was assisted to his room to have O2 (oxygen) put on which increased his Sats to 94% on 4L (liters) O2. He has been resting in his room for much of this shift. He started the [MEDICATION NAME] and has no s/s (signs/symptoms) of ASE (adverse side effects) from ABX (antibiotic) use. No other c/o (complaints of) at this time. WCTM (will continue to monitor). On 3/18/2021 12:53 AM, resident 3's Plan of Care Note revealed: Resident on alert charting for re-admission to facility following hospital stay with [DIAGNOSES REDACTED]. He was given meds and sent to bed to put on O2/4L. He is also on alert charting for Abx therapy of [MEDICATION NAME] for pneumonia. No s/s of adverse from Abx. No other c/o at this time. On 3/21/2021 at 1:22 PM, a Plan of Care Note revealed: Resident on alert charting for re-admission on 3/16/21. Also on alert charting for PO (by mouth) Abx therapy for pneumonia. No s/s of adverse effects of ABX. Resident has been able to maintain O2 sats at and above 90% while on 3L via NC (nasal cannula). Resident currently is afebrile (without fever) and denies pain. Will continue to monitor. On 3/23/21, resident 3's Medication Administration Record [REDACTED]. Resident 3 exhibited a cough on every screening. b. On 3/22/21 at 12:30 PM, resident 3 and resident 6 were observed next to each other within 6 feet of the coffee station. Resident 6's mask covered his mouth only. Resident 3's mask hung off his right ear, and was not covering his mouth or nose. Resident 3 exhibited an uncovered cough. c. During the observation, one nurse and two CNAs were observed to pass residents 3 and 6 multiple times. No staff were observed reminding resident 3 or resident 6 to put their masks over their mouth and nose. On 3/23/21 at 4:12 PM, a phone interview was conducted with CNA 1. CNA 1 stated that it was hard to keep residents separated, because they got upset. CNA 1 stated that residents go wherever they wanted. CNA 1 stated that staff reminded residents to keep their masks on when they saw a resident who was not wearing a mask or it was not covering the mouth and nose. On 3/24/21 at 12:15 PM, a phone interview was conducted with CNA 2. CNA 2 stated that all residents should wear a mask when outside of their rooms.

Based on interview and record review it was determined that the facility did not ensure that 1 of 8 sampled residents were free from any significant medication errors. Specifically, a resident was administered [MEDICATION NAME] ([MEDICATION NAME]) which was not prescribed for them, which resulted in dizziness, slurring, and sleepiness for greater than 48 hours. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/25/21, a record review of resident 2's electronic medical record was completed. An assessment of resident 2's mood, recorded in the MDS (Minimum Data Set) section D, dated 1/25/21, revealed that resident 2 had no episodes of feeling tired or having little energy. In section G, functional status, resident 2 was steady at all times when moving form seated to standing position and when walking, turning and transferring. Resident 2's physician's orders included an order for [REDACTED]. On 3/9/21 at 8:30 PM, a nurse administered an [MEDICATION NAME] ([MEDICATION NAME]), 7.5 mg tablet to resident 2 instead of the prescribed [MEDICATION NAME]. Resident 2's physician orders did not include an order for [REDACTED].>Resident 2's Medication Administration Record [REDACTED]. On 3/10/21 at 1:54 AM, the Medication Error report revealed that the floor nurse observed resident 2 to be unsteady on feet and slurring words. The report revealed that the physician was notified. On 3/24/21 at 12:15 PM, a phone interview was conducted with CNA (Certified Nursing Assistant) 2. CNA 2 stated that they participated in the 15 minute checks for resident 2 and one-on-one observations. CNA 2 stated that resident 2 was not acting normal because he was usually very independent. On 3/24/21 at 11:22 AM, a phone interview was conducted with Nurse 1. Nurse 1 stated that resident 2 was really drowsy and sleepy following the medication error. Nurse 1 stated that resident 2 kept trying to get up but because he was so dizzy and sleepy, he became a 1:1 (one-to-one) observation for the CNAs. Nurse 1 reported that resident 2 was still drowsy when he was discharged to the next facility on 3/10/21. Nurse 1 reported that resident 2 was always awake and wandering before the medication error. On 3/34/21 at 10:45 AM, a phone interview was conducted with Nurse 3. Nurse 3 stated that resident 2 was not like himself and required one-on-one observation on 3/9/21 and 3/10/21. On 3/24/21 at 3:30 PM, a phone interview was conducted with one of resident 2's family members (FM 2). FM 2 reported that when they saw resident 2 on 3/10/21, he could not walk straight, and resident 2 complained of a sore throat and vomiting. FM 2 stated that resident 2 was slurring his words. FM 2 reported that the Director of Nursing told FM 2 that resident 2 had received the wrong medication. On 3/24/21 at 3:45 PM, a phone interview was conducted with resident 2's family member (FM 1). FM 1 reported that on 3/10/21 at approximately 2:30 PM, resident 2 required assistance to walk, which was not normal for resident 2. FM 1 stated that resident 2 was stumbling and his face was swollen. FM 1 reported that resident 2 could barely keep himself upright, he was slurring his words, and resident 2 stated to FM 1 that he couldn't stop barfing. FM 1 stated that they observed wet food on the front of resident 2's shirt, which appeared to be throw up. The manufacturer's warning included: Studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) who take antipsychotics (medications for mental illness) such as Oanzapine have an increased chance of death during treatment. Older adults with dementia may also have a greater chance of having a stroke or mini-stroke during treatment. Common side effects included dizziness, feeling unsteady, or having trouble keeping your balance, restlessness, unusual behavior, depression, difficulty falling asleep or staying asleep, weakness, difficulty walking, constipation, weight gain, dry mouth, pain in arms, legs, back, or joints, and breast enlargement or discharge. Serious side effects included [MEDICAL CONDITION], falling, sore throat, fever, chills, and other signs of infection, very stiff muscles, excess sweating, fast or irregular heartbeat, rash that may occur with fever, swollen glands, or swelling of the face, skin redness or peeling, hives, and difficulty breathing or swallowing. https://medlineplus.gov/druginfo/meds/a 3.html

Based on observation, interview and record review it was determined, for 1 of 8 sampled residents, that the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, a resident who was assessed as requiring supervision, eloped from the facility while being unsupervised in the smoking area. This resident had previously eloped from the same location. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavior disturbance, major depressive disorder, diverticulitis, tremor, and [CONDITION(S)]. On 3/22/21, observations were made of the facility's smoking area. Residents were observed to be outside without supervision. Between 10:15 AM and 11:45 AM, five residents were observed to use the outside smoking area on the East side of the building without any staff observation or interaction. On 3/25/21, resident 2's electronic medical record review was completed. A discharge summary dated 3/10/21 for resident 2 revealed two elopements from the facility. Physician orders included a wander guard (an electronic device typically worn on a wrist or ankle that sounds an alarm when a resident is near an exit) that was initiated on 8/31/2020, due to resident 2 being an elopement risk. A quarterly Minimum Data Set (MDS) assessment was completed on 1/25/21 and revealed that resident 2 had progressive neurological conditions, non-Alzheimer's dementia, and tremors. Resident 2 had a Brief Interview for Mental Status (BIMS) score that revealed a score of 4. A score of 0-7 was severe cognitive impact. Resident 2 had wandering with a frequency of behavior of this type occurred daily. A monthly summary form was created on 2/7/21 at 9:44 PM, and revealed that resident 2 ambulated independently without supportive devices, was confused, had changed mental status often, and had poor memory. Resident 2 was anxious, and had poor sleep patters. Another monthly summary was completed on 3/7/21, that also included poor hearing and a mental status of unaware. A Wander/Elopement Risk Evaluation was completed on 1/21/21 at 12:08 AM, and revealed a wander score of 18 out of a possible 28. The risk was high. A wanderguard assessment was completed for resident 2 on 1/21/21 at 10:30 AM. The assessment revealed that resident 2 required a wanderguard with an indication for use as exit seeking/elopement risk. The rationale for the wander guard is that the wanderguard will continue to be utilized as resident likes to wander throughout the day. Resident 2's care plan included: a. The resident uses [CONDITION(S)] medications [MEDICATION(S)] r/t (related to) Behavioral management that was initiated on 7/27/2020. One of the interventions was: Monitor/record occurrence of for (sic) target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. b. A focus of At risk for injury due to wandering was initiated on 7/27/2020 and stated a goal Resident will be able to be redirected when wandering resident will be safe at facility daily during stay. On 8/17/2020, an intervention was included that Staff educated on not allowing a wander risk resident in an unsupervised area without supervision. c. A focus was initiated on 7/27/2020 At risk for injury due to wandering and included interventions including: resident to wear wanderguard .Wander assessment to be completed .when wandering, redirect resident to another activity. d. On 9/3/2020, resident 2's care plan was initiated that stated [Resident 2] exhibits impaired activity patterns manifested by: sensory problems, poor health/pain limits activity involvement, need for reminders and assistance to/from activities, fatigue from treatments, cognitive impairment, mood problems. An MD progress note for resident 2 was completed on 7/15/2020. Resident 2 .has a history of wandering so he has a wander guard .has a wander guard due to elopement risk. A NP (Nurse Practitioner) note created 8/16/2020 at 5:03 PM, revealed .At facility due to dementia .spouse is no longer able to care for him at home. Repeatedly expresses desire to go home, recent elopement has wander guard Dementia . with behavior disturbance .Non smoker . A NP note on 3/1/21 at 6:18 PM, revealed MD was notified of increasing behaviors with [Resident 2]. He is more easily agitated especially when the aides go to shower him. He is very confused when I visit Nursing Notes for resident 2 revealed the following: a. On 7/14/2020 at 2:26 PM, resident 2 was admitted to the facility. Resident [2] is a wander/elopement risk and MD (medical doctor) ordered a wanderguard . b. On 7/15/2020 at 2:18 AM, .He is very confused and cannot remember from one minute to the next. Wandered around the facility and attempted to go out the front door. Has a wanderguard and it is functioning. He had staff call his [family member]. He asked her to come get him . c. On 7/16/2020 at 12:54 PM, .He has been wandering throughout the facility . d. On 7/17/2020 at 2:06 PM, .He wanders throughout the hallway and has a wanderguard on his left wrist . e. On 8/15/2020 at 3:34 PM, a Plan of Care note revealed Resident is on alert charting d/t (due to) elopement. Resident got out of construction fence and left premises. Wanderguard is in place and functioning correctly. f. On 8/17/2020 at 3:12 PM, Resident on alert charting r/t recent elopement. Resident has wandered up the halls a few times today. He has a wander guard in place. No elopement attempts today. g. On 8/18/2020 at 7:02 PM, .Resident .went outside for a brief period and was brought back in with staff . h. On 8/18/2020 at 11:30 PM, .Resident has wandered the halls this evening . i. On 8/20/2020 at 2:05 PM, an Event Note was created stating Staff RN (registered nurse) was altered to come out to the smoking area on East side of building. A resident in the smoking area alerted the staff RN that the resident had left. Resident reported that the other resident had opened the construction fence and left the premises. Staff nurse and two CNA's searched the surrounding area and found resident one block away. Resident was then assisted back to the building without difficulties, and wanderguard alarmed when he entered. Resident was dressed appropriately and no injuries were noted. Risk Factors and Root Cause Identification: Resident is a wander risk, was outside in the smoking fenced area, was able to remove the fence clip holding the chain link fences together and slid through the fences Resident was placed on 15 minute checks. Staff educated on not allowing a wander risk outside in a non-supervised area without supervision. Construction gates secured with breakaway lock and each staff member given a key to the lock with a lanyard they wear during their shift. j. On 11/14/2020 at 6:26 AM, a Plan of Care Note revealed, Resident frequently wanders during the night. The only sleeps from 2300 (11:00 PM) to approx 0300 (3:00 AM) and then he is wake (sic), dressed for the day. He states he is just waiting for breakfast. MD notified of sleeplessness. No new orders at this time. k. On 1/25/21 at 11:33 PM, a Plan of Care Note revealed, .Resident has increased confusion and has been wandering tonight, but he is easily redirected. l. On 2/1/21 at 11:22 PM, a Behavior Note revealed, Resident has been anxious and pacing many times this shift. He has called his [family member] many times. Redirection attempts were usually effective, but only for a short while. Resident was given IBP (ibuprofen) for his sore mouth. Resident attempted to leave the facility several times with grocery bags packed with some of his things, but nurse and aides were able to redirect. Resident didn't become angry, but was determined to leave and go home. He has calmed down and is resting in his room. Closely monitored. m. On 3/7/21 at 10:27 AM, Resident 2 went out the side door into the fenced area. Alarm on door went off. Resident was allowed to go outside. A few minutes later another resident came into the building to alert me that [Resident 2] had climbed over the railing and was leaving the property. The other resident reported that [Resident 2] had fallen in the dirt. This nurse ran out the front door and found [Resident 2] in the parking lot next to an employee car with the door opened. He kept stating he was looking for the car he arrived in and was looking for his keys. Resident understands that he can push the button to silence the alarm on the doors to leave the building. He stated, 'Boy is my brain funny.' Resident was escorted back into the building. He was assessed for injures. He has a cut on his left ring finger .Neuro (neurological) checks started . n. On 3/7/21 at 11:51 PM, Resident on alert charting for elopement risk. Resident tried to go outside twice this evening and was easily redirected and brought back into facility. Increased confusion, resident feeling that he needs to leave building immediately . o. On 3/10/21 at 5:00 PM, .Going to a memory care locked down unit for resident safety p. On 3/15/21 at 12:03 PM, an event note was created by the IDT (interdisciplinary team) including the Administrator and Director of Nursing (DON), revealed preventative measures for the elopement as Wanderguard in place that did alarm. He was allowed outside without supervision . Due to resident's continued exit seeking behaviors, resident was placed on 1:1 (one to one) care and a new facility with a lock down unit was contacted and resident was admitted to that facility on 3/10/21. On 3/7/21, an investigation was completed by the facility. Resident 2 was allowed outside into a fenced area unsupervised. Resident 2 had been more anxious than normal and continues to exit seek. Resident 2 continued to exit seek on 3/8/21 and was placed on fifteen minute checks and then moved to 1:1 observation until resident 2 could be moved to a secure unit at another facility. On 3/24/21 at 12:15 PM, a telephone interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she was in the building assisting another resident when resident 2 jumped the fence. CNA 2 stated that she assisted with completing the 15 minute checks. CNA 2 stated that she was only aware that resident 2 had hopped the fence one time. On 3/23/21 at 4:10 PM, a telephone interview was conducted with CNA 1. CNA 1 stated that there were no smokers who required supervision, so staff did not need to be outside with the smoking residents. CNA 1 stated that residents could be outside with a wander guard, but they needed to have staff with them at all times. On 3/34/21 at 10:45 AM, a telephone interview was conducted with Nurse 3. Nurse 3 stated that resident 2 was not hurt when he eloped from the building on 3/7/21, with the exception of a small cut on his finger. On 3/24/21 at 11:22 AM, a telephone interview was conducted with Nurse 1. Nurse 1 stated that resident 2 had been allowed to go outside to get fresh air multiple times during his stay. Nurse 1 stated that resident 2 was allowed outside without supervision because resident 2 would usually come back in after a few minutes. On 3/23/21 at 4:21 PM, a telephone interview was conducted with Nurse 2. Nurse 2 stated that there is no schedule to check on the residents who were outside in the smoking area. On 3/25/21 at 9:00 AM, a video conferencing call was conducted with the Administrator and Corporate Resource Nurse (CRN). The CRN stated that there was no additional information available to refute that resident 2 had eloped several times from the facility.

Based on interviews and record review, the facility failed to demonstrate that the facility conducted appropriate testing of staff based on the identification of an individual diagnosed with [REDACTED]. As outlined in the CMS Memo QSO-20-38-NH, a facility is considered to have an outbreak when there is a new COVID-19 infection in any healthcare personnel or any nursing home-onset COVID-19 infection in a resident. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or resident for a period of at least 14 days since the most recent positive result. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/25/2020 , Resident 1 was tested for COVID-19 and the facility received the test results on 11/27/2020, which revealed Resident 1 was positive for COVID-19. Due to Resident 1 testing positive for COVID-19, the facility started their outbreak status 11/27/2020 and ended 12/12/2020. All residents were tested 3 times during the outbreak period and all residents' test results were negative. On 12/15/2020 an Infection Control Focused Survey was conducted onsite at the facility. Resident 1's COVID-19 history was discussed through interview and access to the facility's electronic medical record was obtained. Infections Control Policies and Procedures and staff testing logs were requested and received via email. 1. Registered Nurse 1 (RN 1) worked at the facility on the following days during the outbreak period: a. 11/27/ Day Shift b. 11/28/2020 Day Shift c. 11/30/2020 Day Shift d. 12/4/2020 Day Shift e. 12/7/2020 Day Shift f. 12/9/2020 Day Shift g. 12/12/2020 Day Shift 2. Registered Nurse 2 (RN 2) worked at the facility on the following days during the outbreak period: a. 11/28/2020 Evening Shift b. 11/29/2020 Evening Shift c. 12/10/2020 Evening Shift d. 12/12/2020 Evening Shift 3. Registered Nurse 3 (RN 3) worked at the facility on the following days during the outbreak period: a. 11/27/2020 Evening Shift b. 12/1/2020 Evening Shift c. 12/2/2020 Evening Shift d. 12/3/2020 Evening Shift e. 12/5/2020 Evening Shift f. 12/6/2020 Evening Shift g. 12/8/2020 Evening Shift h. 12/11/2020 Evening Shift The facility has an arrangement with an independent laboratory to perform COVID-19 polimerase chain reaction (PCR) tests for its employees. The facility also has a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver and a supply of Point of Care (POC) COVID-19 test kits onsite that they can used to test employees and residents for COVID-19. RN 1 was tested for COVID-19 on the following dates by the independent laboratory during the outbreak period: a. 11/30/2020 - Results were negative b. 12/3/2020 - Results were negative RN 1 was not tested by the independent laboratory, but was listed on the facility's COVID-19 Testing Documentation of Refusals/Issues with Testing log on the following dates. a. 12/8/2020 b. 12/10/2020 RN 2 was tested for COVID-19 on the following dates by the independent laboratory during the outbreak period: a. 11/30/2020 - Results were negative b. 12/8/2020 - Results were negative (Note: the second test was 8 days following the first negative test.) RN 2 was not tested by the independent laboratory, but was listed on the facility's COVID-19 Testing Documentation of Refusals/Issues with Testing log on the following dates. a. 12/3/2020 b. 12/10/2020 RN 3 was tested for COVID-19 on the following dates by the independent laboratory during the outbreak period: a. 11/30/2020 - Results were negative b. 12/8/2020 - Results were negative (Note: the second test was 8 days following the first negative test.) c. 12/10/2020 - Results were negative RN 3 was not tested by the independent laboratory, but was listed on the facility's COVID-19 Testing Documentation of Refusals/Issues with Testing log on the following dates. a. 12/3/2020 On 12/15/2020 at approximately 3:50 PM, a telephone interview was conducted with the facility's administrator. The administrator stated that RN 1 was not scheduled to work on 12/8/2020 and 12/10/2020 and did not have transportation to come into the facility when the independent laboratory was testing employees that week. The administrator further stated that because RN 1 was asymptomatic, that she could refuse testing, but could continue to work during the outbreak period. On 12/15/2020 at approximately 4:50 PM, a telephone interview was conducted with the facility's administrator. The RN working schedule and the staff testing refusal log were requested and received via email. On 12/16/2020 at approximately 11:05 AM, a teleconference call was conducted with the facility's administrator, Director of Nursing and their Corporate Resource Nurse. The CMS Memo was reviewed. It was acknowledged by all that during an outbreak period, all staff and residents should be tested , and all staff and resident that test negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.

Based on observation, interview, and record review, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service and safety. Specifically, concerns were identified related to the cleanliness of food preparation equipment, the cleanliness of the food storage equipment, the frost build up in all freezers and the dish machine drain without a 2 inch air gap. Findings include: On 7/29/19 at 8:40 AM, an observation was made of the facility kitchen. Observations were made of the following: a. The oven had dried food splatters on the outside. The top of the oven door had dried food splatters and had a greasy film. b. The hood vent over the stove had a greasy film with dust debris. c. The shelf above the stove had a greasy film and dust debris. d. The kitchen cabinets had dried food splatters. e. The top cabinet to the left of the stove had food debris inside with a pan of thawing rolls directly underneath the cabinet. f. A waffle maker inside the top cabinet to the left side of the stove was covered in dried waffle batter. g. A crock pot in the bottom cabinet to the left of the oven had dried food splatters while the lid had white food substance fingerprints. h. The refrigerator had dried food splatters on the side near the serving area with white food substance fingerprints on the front of the refrigerator. i. The inside of the refrigerator had food debris and dried sticky spills. j. Inside the refrigerator was a container of a purple liquid and a container of a sugar free purple liquid without a label and a date. k. The dry storage area near the kitchen had a package of hamburger buns with one bun left and open to air. l. Four of the six plastic bins were covered with onion skins. The six plastic bins had dried food debris on the handles as well as a black substance. m. The dish machine pipe did not have a two inch air gap. n. The top of the dish machine had dust debris and a white dried film. o. The freezer in the break area had two loaves of honey whole wheat bread without a date. The freezer had a thick buildup of frost and needed to be defrosted. p. The freezer in the dry storage area had food debris in the bottom. On 7/29/19 at 9:02 AM, an interview was conducted with the facility Dietary Manager (DM). The facility DM stated that she did the heavy duty deep cleaning weekly, but that she had workers that had been off for the holiday and was unaware if the cleaning had taken place. The facility DM stated that she did not have a log documenting the cleanings. The facility DM stated that she usually defrosted the freezer monthly and was not aware of the buildup. The facility DM stated that she was unaware of the two inch air gap requirement for the pipe coming from the dish machine. The facility DM stated that the purple liquid was punch and had been made the night before. On 7/30/19 at 9:47 AM, an observation was made of the dish machine. The Dietary Worker (DW) 1 was asked load the dish machine. The DW 1 was observed to move a crate of silverware and a bowl that needed to be washed from near the sink and placed it near the dish machine. The DW 1 was observed to take out a crate of clean dishes from the dish machine and place it in the spot next to the sink where the dirty silverware and bowl had been. Under the crate of clean dishes the area had a large amount of water from the dirty silverware as well as multiple food particles. On 7/30/19 at 10:30 AM, an interview was conducted with the facility DM. The facility DM stated that the clean dishes were normally placed around the corner on the clean counter top and put away. The facility DM stated that the clean dishes should not have been placed in the dirty area.

Based on observation and interview it was determined for 4 of 21 residents that the facility did not provide appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. Resident identifiers: 14, 16, 19, and 29. Findings include: 1. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19 at 1:30 PM resident 14 was interviewed. Resident 14 stated, the food is sometimes good, sometimes bad. About once a week my breakfast is burned so badly I can't eat it. When asked if she was able to make substitutions or request an alternate meal resident 14 stated, you can't substitute meals during meal time. You have to let them know in advance that you'll want something else to eat. They don't let you return food. If you try they get mad. Resident 14 stated she had voiced her concerns with meal substitutions during resident council but had never had her complaints resolved. 2. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19 at 1:30 PM resident 19 was interviewed. Resident 19 stated that at breakfast last week, her french toast was burned so badly she was unable to eat it. When asked if she was able to make substitutions or request an alternate meal resident 19 stated, I went to the serving window and asked one of the kitchen staff for a bowl of cottage cheese but she told me there are no substitutions. 3. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19 at 8:43 AM resident 29 was interviewed. Resident 29 stated, they don't have very good different food options so I have to eat what they offer. They will offer a peanut butter and jelly sandwich but you have to wait until everyone's done eating. Resident 29 stated she had voiced her concerns with meal substitutions but had not had any type of satisfactory resolution. 4. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 12:14 PM, an interview was conducted with resident 16. Resident 16 stated that she did not want the sweet and sour chicken as she was allergic to chicken. Resident 16 stated that the food was not very good. Resident 16 stated that they have a lot of chicken and the food could be better. Resident 16 was unaware if she could have an alternate meal. On 7/31/19 at 10:44 AM, an interview was conducted with The Dietary Worker (DW) 2. The DW 2 stated that the alternate menu consisted of a grilled cheese sandwich, peanut butter and jam sandwich, tuna sandwich and chef salad. When asked if a resident could request an alternate meal during the meal if they decided they did not like it or want it, the DW 2 stated we don't really do that. The DW 2 stated that's just how the company set it up, they have to request an alternate meal usually two hours before. The DW 2 stated I'm ok if they request the alternate an hour before. The DW 2 stated that they did not have frozen hamburger patties to make a hamburger for a resident if they requested. The DW 2 stated that she thought making a hamburger for a resident during the meal service would be doable and that maybe we should add that to the menu somewhere.

Based on observation, interview and record review it was determined for 3 of 21 sample residents, that the facility did not provide food and drink that was palatable and attractive. Specifically, residents complained that the food was not palatable. Resident identifiers: 14, 16 and 19. Findings include: 1. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 1:56 PM, an interview was conducted with resident 14. Resident 14 stated that there was a lot of chicken and a lot of ham as well. Resident 14 stated that she would like to have a hamburger. Resident 14 stated that rarely did the staff offer a substitute and if they did, they could not get a warm alternate meal. Resident 14 stated that the food is not great. 2. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 12:14 PM, an interview was conducted with resident 16. Resident 16 stated that she did not want the sweet and sour chicken as she was allergic to chicken. Resident 16 stated that the food was not very good. Resident 16 stated that they have a lot of chicken and the food could be better. 3. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 1:45 PM, an interview was conducted with resident 19. Resident 19 stated that some days it's ok, some days it's not when asked about the food. Resident 19 stated that she was unaware if she could have an alternate meal. On 7/29/19 an observation was made of the lunch meal. The lunch meal consisted of sweet and sour chicken, ham fried rice and a roll. The lunch meal was observed to be monochromatic in color. On 7/31/19 a lunch tray was requested. On 7/31/19 at 12:17 PM, a lunch tray was received and tested . The lunch consisted of pork with a ginger glaze, oven roasted potatoes, yellow squash, a roll and peach cobbler for dessert. The lunch tray was observed to be monochromatic in color. The meal was tasted by two surveyors. The pork was bland. No ginger glaze could be tasted on the pork. The potatoes were tasty but a little over cooked. The yellow squash was over cooked and mushy. The roll was sitting next to the yellow squash and the bottom of the roll was soggy from the water from the squash. The peach cobbler was bland and without any seasoning.

Based on observation, interview, and record review it was determined that the facility did not consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Specifically, 5 of 21 sample residents submitted grievances and recommendations regarding meal variety and substitutions, uncomfortable facility temperatures, and missing clothing that were not acted upon. Resident identifiers: 10, 14, 17, 19, and 29. Findings include: 1. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19 at 1:30 PM resident 14 was interviewed. Resident 14 stated, the food is sometimes good, sometimes bad. About once a week my breakfast is burned so badly I can't eat it. When asked if she was able to make substitutions or request an alternate meal resident 14 stated, you can't substitute meals during meal time. You have to let them know in advance that you'll want something else to eat. They don't let you return food. If you try they get mad. Resident 14 stated she had voiced her concerns with meal substitutions during resident council but had never had her complaints resolved. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19 at 1:30 PM resident 19 was interviewed. Resident 19 stated that at breakfast last week, her french toast was burned so badly she was unable to eat it. When asked if she was able to make substitutions or request an alternate meal resident 19 stated, I went to the serving window and asked one of the kitchen staff for a bowl of cottage cheese but she told me there are no substitutions. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19 at 8:43 AM resident 29 was interviewed. Resident 29 stated, they don't have very good different food options so I have to eat what they offer. They will offer a peanut butter and jelly sandwich but you have to wait until everyone's done eating. Resident 29 stated she had voiced her concerns with meal substitutions but had not had any type of satisfactory resolution. On 7/31/19 resident council notes were reviewed. Complaints regarding variety in meals were documented in (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019. Complaints regarding mealtime substitutions were documented in (MONTH) 2019 and (MONTH) 2019. 2. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 9:13 AM resident 10 was interviewed in her room. Resident 10's room was noticeably hotter than the hallway. It was observed resident 10 had three oscillating fans in her room, all blowing on her. When asked if she was hot, resident 10 stated, we've been down this road before. Anything I ask for or complain about wont get fixed. On 7/31/19 at 10:04 AM resident 10 was again interviewed in her room. Resident 10's room was noticeably hotter than the hallway. When asked if she was hot, resident 10 stated, you asked me the same thing on Monday. I'll tell you again, there's no point complaining when nothing will ever change Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 10:10 AM resident 17 was interviewed. Resident 17 stated, The dining room is so hot I have to eat lunch in my room. Resident 17 stated he had voiced his concerns with high facility temperatures but had not had any type of satisfactory resolution. On 7/30/19 at 8:43 AM resident 29 was interviewed. Resident 29 stated, The dining room gets so hot it sets off my migraines and I have to eat in my room. Resident 29 stated she had voiced her concerns with high facility temperatures but had not had any type of satisfactory resolution. On 7/31/19 resident council notes were reviewed. Complaints regarding high, uncomfortable facility temperatures were documented (MONTH) 2019 and (MONTH) 2019. 3. On 7/30/19 at 9:00 AM resident 29 was interviewed. Resident 29 stated that clothing had gone missing from her room. Resident 29 stated, I filled out the grievance form and gave it to staff but nothing ever happened. On 7/30/19 at 1:14 PM the facility Resident Advocate (RA) was interviewed. The RA stated, There's a missing item binder at the nurse's station. Residents fill out the form, then we take care of it from there whether it's going through laundry or attempting to track down the missing item in the facility. Regarding resident 29's complaint of missing clothing, the RA stated, Her grievance was addressed at the (MONTH) 11th 2019 resident council. A few residents complained about missing clothing. She signed the resolution form. The RA stated that the resident's signature meant that she was happy with the resolution. When asked what the resolution was , the RA stated That we brought up all the unclaimed items from laundry for her to look through. When asked if resident 29 had claimed any of the unclaimed items that were brought up from laundry, the RA stated she didn't know. On 7/31/19 at 10:50 AM resident 29 was interviewed again. When asked if she was satisfied with the resolution she stated, No, I never got my missing clothes back. When asked about her signature on the resolution form resident 29 stated, (RA) just makes us sign it.

Based on observation, interview, and record review it was determined, for 1 of 21 sample residents, that the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, one resident did not have consistent recommendations by the facility Registered Dietitian while the resident had a weight loss of 19.55%. Resident identifier: 16 Findings include: Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 12:14 PM, an observation was made of resident 16 as she was in her room for lunch. Resident 16 was observed to have her lunch in front of her. Resident 16 was observed not to eat. On 7/29/19 at 12:14 PM, an interview was conducted with resident 16. Resident 16 stated that she did not want the sweet and sour chicken as she was allergic to chicken. Resident 16 stated that the food was not very good. On 7/29/19 at 12:36 PM, an interview was conducted with resident 16. Resident 16 stated that she ate her cookie. An observation of resident 16's lunch revealed that she drank her Med Pass 60 milliliters (ml). Resident 16 stated that she was not offered an alternative for lunch. On 7/30/19 at 12:10 PM, an observation was made of resident 16 as she was in her room for lunch. Resident 16 was observed to have her lunch in front of her. Resident 16 was observed not to eat. On 7/31/19 resident 16's medical record was reviewed. The weight's for resident 16 revealed the following: a. 5/1/2019 12:54 169.8 Lbs (pounds). b. 5/6/2019 23:56 168.2 Lbs. c. 5/14/2019 15:14 162.4 Lbs. d. 5/21/2019 10:06 159.2 Lbs. e. 5/27/2019 12:38 153.2 Lbs. f. 6/5/2019 08:48 149.8 Lbs. g. 6/11/2019 10:52 147.5 Lbs. h. 6/18/2019 09:49 146.3 Lbs. i. 6/25/2019 10:46 142.6 Lbs. j. 7/1/2019 13:21 143.6 Lbs. k. 7/8/2019 15:33 143.2 Lbs. l. 7/16/2019 13:13 141.6 Lbs. m. 7/23/2019 10:36 139.6 Lbs. n. 7/30/2019 15:33 136.6 Lbs. Resident 16's weights revealed that she had significant weight loss of 9.78% in the first month after admission to the facility and significant weight loss of 19.55% in three months after admission to the facility. The Registered Dietitian Notes revealed the following entries: a. 5/21/2019 11:13 (AM) Nutrition/Dietary Note Note Text: Discussed in nutrition risk committee meeting due to significant overall weight loss since admission. Weight has declined 6.2% x ~ 3 weeks despite reports and observations of good oral intake. Resident is known to eat 75-100% of most regular portioned meals. She enjoys meals in the dining room. Her blood sugars vary widely despite consistent oral intake. IDT (Interdisciplinary Team) decided to continue weight monitoring and make no changes att (at this time). If further weight loss noted, will re-evaluate and change plan of care. b. 6/5/2019 20:03 (8:03 PM) Nutrition/Dietary Note Note Text: Discussed in nutrition risk committee meeting with RD, DON (Director of Nursing), DM (Dietary Manager) attending. CBW (Current Body Weight)=149.8# which indicates a loss of 2.2% x 1 week, and 10.9% x 1 month. Staff reports that resident has been weak with increased pain and decreased mobility. Blood sugars have alsobeen (sic) variable with highs and lows noted. Intake appears to have declined and staff indicates her appetite has declined as well. NSA (no sugar added) med pass will be added for supplementation. Will ctm (continue to monitor). A weight change note revealed, 6/18/2019 11:45 Weight Change Note Note Text: WEIGHT WARNING: Value: 146.3 Vital Date: 2019-06-18 09:49:00.0 -5.0% change ( 8.1% , 12.9 ) -7.5% change ( 13.8% , 23.5 ) -10.0% change ( 13.8% , 23.5 ) Discussed in nutrition risk committee meeting with RD, DON, and DM attending. CBW is down a small amount from last week. Weight down significantly overall as indicated above. Weight more stable x 2 weeks. Resident accepts 100% of med pass on most occasions. Staff has indicated that resident will not/can not cut up her own meat, and if not done forher (sic) she will not eat it. Chopped meat has been added to orders and care plan. Staff will assist her and provide her meals in a way that she can and will easily eat. Will ctm. A physician's note revealed, 6/26/2019 11:44 MD Progress Note Late Entry: Note Text: Recertification visit s: (Resident name redacted) has not had any new illnesses or injuries. She has chronic pain. FLACC scores show pain appears to be under control with current meds. She has had weight loss but weight has been stabilizing the past couple weeks. She istaking (sic) supplements. She wants to go home and does not understand why she still needs to be here. We had a meeting with Donna and her spouse today wt 142 o: alert,older female, confused HEENT: no scleral icterus oropharynx moist Lungs: clear Cv: RRR nl s1s2 Abd: soft, nontender, BS+ Ext: no [MEDICAL CONDITION] A/P 1. Major [MEDICAL CONDITION], recurrent, severe - she is receiving [MEDICATION NAME] and [MEDICATION NAME]. Will continue to track behaviors. We are attempting to wean off [MEDICATION NAME]. Will review at [MEDICAL CONDITION] (sic) 2. Dementia with behavioral disturbance -will continue to track behaviors. Patient's husband does not feel he can manage her behaviors at home 3. Type II DM - sugars are quite variable. Insulin was decreased and she is not currently having low sugars. She eats erratically which makes it difficult to manage sugars 4. HLD - on statin 5.[MEDICAL CONDITION]- continue losartan and [MEDICATION NAME] 6. Weight loss - supplements are ordered. Will continue to monitor. physician's orders [REDACTED]. a. Sugar Free Med Pass 2.0 three times a day for weight loss, 60 ml (milliliters) Supplement 6/6/2019 07:00 b. Reduced Concentrated Sweet diet, Regular texture, Regular consistency chopped meat 6/18/2019 12:00. c. Reduced Concentrated Sweet diet, CHOPPED texture, Regular consistency Diet 7/26/2019 18:25. (NOTE: No new interventions could be located in resident 16's medical record to show that facility staff attempted to increase resident 16's nutritional intake and to decrease further weight loss after 6/18/19.) A facility Dietary Profile dated 5/3/19 revealed that resident 16 likes Froot Loops and that (Resident 16's name redacted), comes to us with a poor appetite. She has chosen to eat her meal in the dining room. She has a poor appetite. She is able to have her wants and needs known. The task of What percentage of the meal was eaten in resident 16's medical record revealed that resident 16 had eaten 0-25% of her meal 21 times, 26-50% of her meal 38 times, 51-75% of her meal 18 times and 76-100% of her meal 10 times from 7/2/19 through 7/31/19. On 7/31/19 at 10:38 AM, an interview was conducted with the facility Registered Dietitian (RD). The facility RD stated that she was aware that resident 16 had a 29.55% weight loss in the last three months. The facility RD stated that she was unsure of the interventions that had been put into place for resident 16. The facility RD stated that resident 16 would get upset when people would cue her too much to eat. The facility RD stated that resident 16 did not have much of an appetite. On 7/31/19 at 10:43 AM, an interview was conducted with the Dietary Worker (DW) 2. The DW 2 stated that residents usually did not ask for alternatives but that they had grilled cheese, tuna fish or chef salads as alternates. When asked if the residents could request a different hot meal during a meal if they did not like what was served, the DW 2 stated we don't really do that. That's just how the company set it up. They have to request usually two hours before, but I'm ok with one hour. The DW 2 stated that she did not know why the request had to be made two hours in advance and stated I guess that's just how it is. The DW 2 stated that she was not aware that resident 16 had ever had Froot Loops that she liked. On 7/31/19 at 12:10 PM, an observation was made of Certified Nursing Assistant (CNA) 2 as she sat in resident 16's room to assist with feeding resident 16. On 7/31/19 at 12:39 PM, an interview was conducted with the facility Corporate Resource Nurse (CRN). The facility CRN stated that the latest intervention was just yesterday and the intervention was to sit with the resident and cue her and encourage her to eat. The facility CRN stated that the facility RD wanted to try that intervention first to see if they could get resident 16 to eat more before they increased her supplement or fortified her diet. The facility CRN stated that eating would increase her nutrition. The facility CRN stated that in the last week specifically, resident 16 had started to tell the facility that she was allergic to everything. The facility CRN stated that they had talked with resident 16's husband and he informed them that resident 16 was not allergic to any foods. The facility CRN stated that they could not feed resident 16 froot loops three times a day just because she liked them. On 7/31/19 at 12:58 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 16 usually came to the dining room for her meals but had started to refuse to come to the dining room. CNA 1 stated that the intervention of sitting with resident 16 to cue and encourage her to eat was not new, that they had always placed resident 16 at the assisted table and tried to cue and encourage her to eat. On 7/31/19 at 1:02 PM, an interview was conducted with CNA 2. CNA 2 stated that usually resident 16 would come to the dining room for her meals but lately has refused. CNA 2 stated that the CNA staff often sat with resident 16 in the dining room to cue and encourage her to eat. CNA 2 stated that she had never see resident 16 request an alternate meal and did not know if staff was consistently offering an alternate when she did not want to eat. CNA 2 stated that resident 16 had never had Froot Loops cereal.

Based on observation and interview, it was determined for 4 of 21 sampled residents that the facility did not provide the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for a resident diagnosed with [REDACTED]. Resident identifiers: 6, 19, 26, and 179. Findings include: 1. Resident 179 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/1/18, a review of resident 179's medical record was completed. Resident 179's discharge summary from her prior Assisted Living facility was reviewed and revealed the following relevant information. a. Resident 179's [DIAGNOSES REDACTED]. b. The assisted living facility's physician documented the following: i. On 6/9/16, resident 179 is engaging and sociable in my inquiries . She becomes somewhat emotional as she describes her husband and her concerns about him . her knowledge of his condition and his situation is quite distorted by her capacity to integrate information Her thinking is disorganized, obviously, but she does have an emotional response to what it is that she's thinking about. Receptive and [MEDICAL CONDITION] is noted, the speech she does produces fluent and intelligible Mental status testing is hampered by her receptive and [MEDICAL CONDITION]. She does respond to her name. She is unable to name her spouse or her address the city state day date or year. She is not routinely able to understand in order to follow commands. She is not able to register or perform calculations or repetitious speech Her form of thought is disorganized and tangential and she has delusions based in her confusion . ii. On 6/15/16, .She apparently has become friendly with one of the male residents. When asked about him she says oh I love him . iii. On 6/24/16, Patient is seen due to impulsive behaviors. She has been attracted to another male resident and has been seeking him out in an affectionate fashion and the 2 of them had engaged at least once in an attempt but not completed, consensual sex act. Her family has not provided permission for her to have such engagements with other residents and the staff have undertaken measures to keep them from inappropriate contact . She expresses that she is angry and hurt because her friend is not attending to her as she desires. She does not express unrelieved sexual interest. She does not actually specify a specific feeling or statement or action initiated by the other resident that makes her feel hurt . She is fretful and anxious and obsessing in her thoughts over another resident . She has delusions based in her confusion and lack of insight iv. On 6/24/16, Since admission the patient has begun exhibiting impulsive behaviors including impulsive sexual behaviors. She has developed an obsession with another male resident and seeks him out area her relationship with him has resulted in her experiencing feelings of frustration hurt and anger when he is not compliant with her desires or demands. She also has exhibited restlessness and exit seeking. [MEDICATION NAME] seems like the most appropriate and useful medical intervention I can offer this woman If necessary to manage mood or behavior disturbances it is possible a mood stabilizer such as [MEDICATION NAME] or an SSRI might reduce some of her labile mood, impulsiveness and obsessive thoughts. a. On 3/24/18 at 9:00 PM, facility staff documented, Resident (179) was found standing in cafeteria next to another resident (26) that was seated at a table with his chair turned to the side. The resident was holding the hand of a male resident who had his hand on her breast. Both residents were laughing and smiling. Both residents were fully clothed. Resident redirected into hallway and away from the male resident. Resident was compliant with redirection. Resident 179's Quarterly Minimum Data Set ((MDS) dated [DATE] documented that resident 179 had a Brief Interview for Mental Status (BIMS) score of 03 indicating that resident 179 was severely cognitively impaired. Resident 26's Annual MDS dated [DATE] documented that resident 26 had a BIMS of 04 indicating that resident 26 was severely cognitively impaired. On 3/25/18 at 10:36 PM, facility staff documented, Resident on alert charting for an incident with another resident. Resident on q (every) 15 minute checks for safety. Resident has not had any inappropriate behaviors with the other resident or any other resident's this noc (night) shift. Will continue to monitor. On 3/27/18 at 2:32 PM, the following was documented in an Interdisciplinary Team (IDT) note, Event Description: On 3/24/18 around (9:00 PM) nurse on duty saw resident (179) in the dining room with a male resident (26). The male resident was seated at a table in the cafeteria and the resident was standing in front of him. The male resident's hand was on the resident's chest over her breast and the resident was resting her hand over the male resident's hand. The resident (179) had relaxed body language, and was laughing and smiling. She appeared to be a willing participant in the interaction. Risk Factors: Resident is cognitively impaired with a [DIAGNOSES REDACTED]. Resident lived in the same assisted living facility with the male resident previously and they had personal interactions with each other at the assisted living facility. The resident calls the male resident by her husband's name and may think that the male resident is her husband. Preventative Measures: There have been no previous interactions between these two residents of a sexual nature within this facility. Resident has not had previous interactions of a sexual nature with any other residents either. New Interventions: At the time, the nurse redirected the residents to separate from each other. Although the resident appeared to be a willing participant in the interaction, the nurse was concerned r/t (related to) resident's cognitive status and felt it was best to redirect the residents away from each other until able to get clarification from administrative staff regarding the boundaries of such interactions between two cognitively impaired residents. Administrative staff agreed that while residents were willing participants and do have the right to interact with each other in that way, given the resident's cognitive status, it would be best to seek clarification from the ombudsman regarding the situation. The ombudsman confirmed that residents have the right to interact with each other in a sexual manner as long as both residents are participating willingly. She recommended that the facility reach out to resident's family to determine their guidance to the facility for any boundaries r/t resident's interaction with the male resident. Facility staff have been unable to get in touch with resident's family. Resident has been placed on q 15 minutes checks so resident can be monitored r/t her interactions with other residents until the facility can get in touch with her family and obtain clarification from them. The interdisciplinary team does not feel that this interaction constitutes an alleged violation of abuse as both residents appeared to be willing participants in their interaction. On 3/26/18, a care plan for Resident enjoys having physical/sexual interactions with other male residents. was created with the goal to Resident's right to self determination, privacy, dignity and visitors of her choosing will be respected through the review date. Staff will ensure that resident is protected from abuse through the review date. The interventions for the care plan included: Facility has attempted to contact family and determine any boundaries that family desires for facility to set with resident r/t physical interactions with other residents. No response from family.; Facility IDT clarified with ombudsman that residents with impaired cognition have the right to interaction with other residents in physical/sexual ways as long as both parties are consenting to the interaction; and Staff will ask resident each time she is witnessed to engage in sexual interactions with other residents if she is participating in the interaction of her own volition to establish consent and willing participation. A psychosocial evaluation completed by the consultant social worker was reviewed. The evaluation was dated 3/28/18. The evaluation documented that resident 179 was alert and oriented times 1 and had poor memory and orientation with confusion. The evaluation documented that resident 179 was capable of making her needs known and was mostly understood. The evaluation documented that resident 179 had hypersexuality that is being monitored by staff members and is being redirected. The evaluation documented that resident 179 had an impulse disorder that is secondary to her dementia. The evaluation documented under special needs to continue to redirect and maintain appropriate boundaries with other male residents. Recommendations for resident 179 included redirection, encouragement, validation, and emotional support. It was noted that this was after resident 179's first incident with a male resident at the facility and after the care plan for physical/sexual interactions was created. It was also noted that the CSW recommended to redirect resident 179 and to maintain boundaries with other male residents while the care plan directed staff to ensure resident was participating of her own free will. There was not an assessment of resident 179's capacity to consent which demonstrated her knowledge of relevant information, including risks and benefits; and rational that it was consistent with her values. b. On 4/13/18 at 11:36 PM, facility staff documented, Resident (179) was found in another resident's room (resident 79) with her shirt off. Resident did not appear afraid and did not show any s/s (signs or symptoms) of fear, or worry when found. Resident stated she was there on her own will. Residents separated. Resident assessed for injury or harm to well being. Resident happy and cooperative and no injury noted. On 4/18/18 at 9:33 AM, the following was documented in an Interdisciplinary Team (IDT) note, .Risk Factors: Resident is cognitively impaired with a [DIAGNOSES REDACTED]. Preventative Measures: After the previous encounter with the other male resident, the IDT sought clarification from the ombudsman regarding interactions of a sexual nature involving cognitively impaired residents to ensure that resident's rights were being respected while also ensuring that the facility was acting appropriately to protect her. The ombudsman indicated that residents have the right to interact with each other in a sexual manner as long as both residents are consensually participating. The ombudsman recommended to get in touch with resident's family to determine the family's level of comfort with resident interacting with other male residents sexually and any boundaries they desired for staff to enforce. Facility staff have been unable to get in touch with any family members to discuss this. Her husband has dementia as well and her stepchildren do not feel comfortable being involved in her care. The facility attempted to seek guardianship for the resident given her cognitive deficits, but she doesn't have money to pay for a private guardian and the public guardian office declined to accept resident's case. New Interventions: Upon discovering the situation, the CNA immediately asked the resident if she was ok. The resident stated yes, and laughed. The CNA called for the nurse, and the nurse came to assess the situation. As it was around the time resident usually goes to bed, the CNA helped resident dress then walked with her to her room. The nurse performed an assessment and resident exhibited no s/s of injury or psychological distress. Her body language was relaxed. Nurse reported this incident to the facility abuse coordinator/administrator to ensure it was properly reported and investigated. UDOH (Utah Department of Health), APS (Adult Protective Services), ombudsman and MD (Medical Director) also notified. No staff members or residents witnessed how resident came to be in the male resident's room, but resident did state she was in the room of her own volition. The administrator interviewed resident regarding the incident and she stated she was a consenting adult. Given resident's cognitive status, it is unclear if she remembered the incident the administrator was referencing, but she answered the question as if she did and her actions at the time of the incident support her statement. After investigating the circumstances surrounding this incident, the IDT had concluded that his incident does not constitute sexual abuse as all observations support that consensually participating in the interaction. No additional interventions warranted at this time. There was not an assessment of resident 179's capacity to consent which demonstrated her knowledge of relevant information, including risks and benefits; and rational that it was consistent with her values. c. On 5/1/18 at 8:17 AM, an IDT note documented the following information, On 4/28/18 CNA went into the dining room and found resident (179) sitting next to another resident (6) holding hands, it appeared that the resident was touching the other resident genital area. Resident (179) appeared to have relaxed body language and was smiling. She did not attempt to move away from the male resident or leave the dining room when the staff member entered the dining room. Risk Factors: Resident is cognitively impaired with a [DIAGNOSES REDACTED]. Preventative Measures: After the previous encounter with the other male residents, the IDT sought clarification from the ombudsman regarding interactions of a sexual nature involving cognitively impaired residents to ensure that resident's rights were being respected while also ensuring that the facility was acting appropriately to protect her. The ombudsman indicated that residents have the right to interact with each other in a sexual manner as long as both residents are consensually participating. The ombudsman recommended to get in touch with resident's family to determine the family's level of comfort with resident interacting with other male residents sexually and any boundaries they desired for staff to enforce. Facility staff have been unable to get in touch with any family members to discuss this. Her husband has dementia as well and her stepchildren do not feel comfortable being involved in her care. The facility attempted to seek guardianship for the resident given her cognitive deficits, but she doesn't have money to pay for a private guardian and the public guardian office declined to accept resident's case. New Interventions: Upon discovering the situation, CNA immediately asked the resident if she was ok, the resident said yes. The resident did not pull away from the other resident and had relaxed body language. The nurse performed an assessment and resident exhibited no s/s of injury or psychological distress. Nurse reported to the facility abuse coordinator/administrator to ensure proper report of incident. The administrator interviewed resident regarding the incident and she stated yes i did that. Given the resident's cognitive status it is unclear if she remembered the incident the resident was referencing. After investigating the circumstances surrounding this incident the IDT concluded that this incident does not constitute sexual abuse as all observations support that resident was willing participant in the interaction. On 5/7/18 at 10:08 AM, the Resident Advocate documented the following, . (Resident 179's) current BIMS score is a 03 and has remained an 03 since admission . (Resident 179) is a very social persona and likes to visit with other residents. She has a husband who is at a independent living in Salt lake his name (redacted). (Resident 179) states she has several children but the facility has been unable to verify this. (Resident 179's) husbands children have been some what supportive in participating in her care but state they have minimal information about (Resident 179) . They have given all the information that they are aware of. (Resident 179) is at risk for wondering (sic) and she currently wears a wonder (sic) guard. (Resident 179) likes to go out on walks and likes to be out on the back patio. (Resident 179) is easily redirected if she tries to go in other residents rooms or outside without supervision. (Resident 179's) long term plan is unknown at this time due to not being able to get in contact with her children or other family members. There was not an assessment of resident 179's capacity to consent which demonstrated her knowledge of relevant information, including risks and benefits; and rational that it was consistent with her values. d. On 6/11/18 at 7:00 PM, facility staff documented the following, CNA witnessed resident engaged in sexual intercourse with another resident (Resident 19). Resident acknowledged consent and participation in the sexual activity of their own free will and showed no signs of distress. MD and resident's family notified. On 6/13/18 at 6:15 PM, CNA found that resident was sitting next to a male resident in his room on his bed. Resident's shirt was pulled up and her stomach was exposed. Resident was removed from the male resident's room by staff. On 6/13/18 at 10:00 PM, facility staff documented the following, Resident entered/attempted to enter room of a male resident 4-5 times between 1800 and 2100. (Resident 179) and the male resident reported that they were just talking. It was communicated during report that (Resident 179's) family was displeased with this behavior and had requested that it not occur. Due to this request, I redirected the residents with each occurrence. However, at approximately (9:00 PM) both residents entered the male resident's room unnoticed, while staff were busy with patient care duties. I knocked on his door, heard no response, so opened door a bit to attempt redirect. Both residents were clothed and stated they were talking and would be out shortly. Neither showed any signs of distress. At this time, the male resident had placed a chair in front of his door to block it. I went to give report to the nurse coming on shift and one of the CNAs continued to monitor the situation. After completing report, I was notified that (Resident 179) had come out of his room and gone to her own room. During this time, no sexual activity was witnessed, multiple redirect attempts were implemented per (Resident 179's) family's request and both residents stated that they were fine and just talking. On 6/16/18 at 3:44 PM, facility staff documented Nurse observed resident holding hands with another resident in the dining room. The nurse then witnessed resident kiss this resident. Resident acknowledged consent and participation in kissing at her own free will. She did not show any signs of distress. DON, and administrator notified. Resident was watched after event and no concerns were noted. On 6/19/18 at 10:46 AM, the following was documented in an IDT note, Event Description: On 6/11/18 around (7:00 PM), CNA entered a male resident's (19) room for routine rounds and observed this resident engaged in sexual intercourse with him. Resident was lying on resident's bed with her legs in the air while resident had sex with her. The male resident became agitated and told the CNA to leave. The CNA notified the nurse of what was occurring and the nurse responded to assess the situation. After gaining access to the room, the nurse asked the resident if she was ok. Resident (179) responded, We're just f***ing and we're going to do it again! Resident confirmed she was a willing participant in the sexual interaction. She appeared to be in no acute distress. Risk Factors: Resident has been friendly with other male residents of the facility and had previous instances of sexual interactions with other male residents which have been consensual in nature. No previous interactions of this magnitude have occurred previously. Preventative Measures: After the previous encounters with the other male residents, the IDT sought clarification from the ombudsman regarding interactions of a sexual nature involving cognitively impaired residents to ensure that resident's rights were being respected while also ensuring that the facility was acting appropriately to protect her. The ombudsman indicated that residents have the right to interact with each other in a sexual manner as long as both residents are consensually participating. The ombudsman recommended to get in touch with resident's family to determine the family's level of comfort with resident interacting with other male residents sexually and any boundaries they desired for staff to enforce. Facility staff have previously been unable to get in touch with any family members to discuss this. Her husband has dementia as well and her stepchildren do not feel comfortable being involved in her care. The facility attempted to seek guardianship for the resident given her cognitive deficits, but she doesn't have money to pay for a private guardian and the public guardian office declined to accept resident's case. Facility staff continue to monitor resident when she is seen being friendly with other male residents and staff redirect and intervene as indicated. New Interventions: Nurse assessed the situation at the time it occurred and was able to determine that the resident was participating consensually in sexual intercourse and abuse was definitively ruled out. No injuries were observed by the nurse at the time r/t sexual intercourse. DON (Director of Nursing), administrator, MD and resident's family notified. Resident's husband expressed that he would like resident to be re-directed from having sexual interactions with other male residents if staff are able, but understands that staff can't force her away if resident is not willing to leave the situation. Ombudsman was consulted regarding this situation and confirmed that as long as both residents are participating consensually and of their own volition, they have the right to self-determination and privacy to have physical relationships with other residents. Staff have been educated regarding resident rights and have been educated to ensure that resident feels safe and is willing to be alone in the other resident's room with the male resident each time they are witnessed going in to his room. If staff become knowledgeable that sexual intercourse has occurred, it is to be reported to the MD and an assessment completed to monitor for injuries or pain that may have been sustained during intercourse as the resident allows. Resident has continued to spend time with the male resident and goes into his room alone with him and closes the door. She has responded at times to redirection and sometimes continues to assert her wish to have privacy with him in his room. No further incidents of sexual intercourse have been witnessed by staff. Staff have been intervening to the extent that they witness the residents going into the male resident's room alone together to ensure that resident feels safe and is desiring to be alone with the other resident. No concerns for abuse have arisen. (MD)performed an assessment of resident's peri-area on 6/12/18 as resident was c/o (complaints) soreness and no s/s of injuries were observed. (MD) states that if resident continues to desire to participate in sexual intercourse, she may have a lubricant or [MEDICATION NAME] cream if desired. Nursing staff will offer this to the resident as indicated. There was not an assessment of resident 179's capacity to consent which demonstrated her knowledge of relevant information, including risks and benefits; and rational that it was consistent with her values. On 7/31/18 at 7:55 AM, CNA 1 was interviewed. CNA 1 stated that resident 179 did what you tell her to do. She's like a little kid. CNA 1 stated that resident 179 tended to do sexual things with another resident. CNA 1 stated that resident 179 only did sexual things with resident 19. CNA 1 stated that in the beginning staff would separate the residents, but after the administration reviewed the incidents with family staff were educated that residents could be sexual if they were consenting. CNA 1 stated that if the residents did sexual things in public staff were to redirect them. On 7/31/18 at 8:00 AM, CNA 2 was interviewed. CNA 2 stated that resident 179 was quite confused and was on 15 minute checks related to a recent elopement. CNA 2 stated that resident 179 was typically aware of who she was and where she was. CNA 2 sated that residents 179 and 19 liked to be together and that staff monitor them. CNA 2 stated that staff would frequently check on resident 179 and resident 19 when they are together and if they engaged in sexual acts the nurses would do an incident report. On 7/31/18 at 8:20 AM, the CNA Coordinator (CNAC) was interviewed. CNAC stated that resident 179 required reminders for her Activities of Daily Living and that staff needed to ensure her WanderGuard was in place. CNAC stated that residents 179 and 10 thought that they were partners. CNAC stated that resident 179 and 19 go into each others rooms and staff ask both residents if they were ok. On 7/31/18 at 8:30 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 179 was only alert and oriented to herself and required reminders for Activities of Daily Living. RN 1 stated that resident 179 and resident 19 were sweet for each other. RN 1 stated that resident 179 would refer to resident 19 as her husband. On 7/31/18 at 8:40 AM, the Resident Advocate (RA) was interviewed. The RA stated that resident 179 was not oriented times 3. The RA stated that resident 179's husband lived in an Assisted Living facility and had dementia. The RA stated that resident 179's stepchildren were not comfortable being involved in her care and that the Office of Public Guardianship had refused her case. The Ra stated that resident 19 and 179 held hands and go into resident 19's room and close the door. The RA stated that on one occasion resident 19 and resident 179 engaged in sexual intercourse and both families had been notified. The RA stated that resident 179 will talk about her husband and did recognize him if shown a picture of him. The RA stated that resident 179 will refer to resident 19 as her friend. The RA stated that facility staff are able to determine consent by asking resident 179 if she is okay and if she feels safe and knows what she's doing. The RA stated that when resident 179 and 19 were engaged in sexual intercourse, resident 179 responded that they were f***ing. The RA stated that staff were uncertain if resident 179 remembered the event later but that she was aware of her actions at the time. The RA stated that the MD did an assessment after resident 179 and 19 engaged in intercourse and she was okay. The RA stated that the Consultant Social Worker (CSW) had not been a part of the IDT meetings but had been updated on all incidents with resident 179. The ombudsman was involved in resident 179's sexual activities and has advised staff that impaired residents have the right to engage in sexual activities. On 7/31/18 at 8:45 AM, the Admin was interviewed. The Admin stated that resident 179 knew who she was and that she lived at the facility. The Admin stated that resident 179 in the past had mad advances towards other men however after she became involved with resident 19 she had not. The Admin stated that resident 179 did not remember who her husband was. The Admin stated that after the first incident with resident 179 the facility involved the Ombudsman. The Admin stated that based on the direction from the Ombudsman training was provided to all staff. The Admin stated that staff were trained that they needed to ask the resident every time if she was consenting due to her impaired memory. The training entitled Intimacy and Sexuality in Long Term Care included the following information: RE: Resident Rights and Regulatory Balance for Sexual Intimacy: . There are no established standards or laws about the abilities required for people with cognitive impairment to participate in an intimate or sexual relationship. However, we are required to provide a private place for the act to occur. There are four basic considerations to be considered if a sexual act between two cognitively impaired residents is consensual. 1. Ability of the resident to voluntarily participate. Does the resident have enough cognition to voice or demonstrate through observed behavior his/her willingness or non-willingness to participate at the time surrounding the sexual act? 2. The ability to say no. (verbally or non-verbally). A person must also have the ability to say no or in some other way indicate a refusal or rejection of someone's overtures . 3. The Ability to be safe from harm. Consideration should be given for the person with cognitive impairment to be free from harm. This can refer to physical harm such as [MEDICAL CONDITION] or psychological harm such as undesired separation from each other. follow the event the nurse needs to perform a check and ensure that both residents are free from any harm, accidents, and/or other health issues. 4. The ability to be free from exploitation or abuse. A resident with cognitive impairment should not be taken advantage of or used by another person. For example, if a male resident has a BIMS score of 13-14 . he should not be allowed to engage in any sexual activity with an resident who has a BIMS score of 3-9 . This type of act would violate the requirement for both people to voluntarily participate . See Sexual Activity Capacity for Consent Assessment (SACCA ) for additional help and documentation outlines . Interventions. Staff should always attempt to intervene if any resident appears to be in distress or a recipient of any harm or abuse. However, resident rights should always be considered first with any resident self-directed action. Each resident may have family, friends, and/or other individuals listed as contacts. Often, we involve these contacts in their directed Plan of Care through their Interdisciplinary Team (IDT). POA. families with Power of Attorney (POA do not trump a residents rights, and is only used if the resident cannot make a decision for themselves (i.e. pt, unconscious and needs direction for medical care) . The training outline documented the following Possible Intervention Suggestions Address the real need, distraction, redirection, activities, supervision, offer socialization in public, supervised area, use of facility to separate residents, when necessary, resident has an appointment or meeting. On 7/31/18 at 9:32 AM, the Corporate Resource Nurse (CRN) was interviewed. The corporate resource stated that resident 179 was a sexual person in her earlier life and that was a characteristic that she still possessed even with her [DIAGNOSES REDACTED]. The CRN stated that resident 179 does redirect if her flirtations are not reciprocated. The CRN stated that resident 179 will subtlety flirt and only progress when flirtations are reciprocated, so they have not considered medications to control her desires/behaviors. On 7/31/18 at 9:31 AM, the DON and CRN were interviewed. The DON stated that staffed called her after resident 19 and resident 179 were found in bed togethe (TRUNCATED)

Based on observation, interview, and record review it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. Specifically, hot water temperatures in 5 resident rooms throughout the facility and in the resident tub room/bathroom and resident shower room were observed to range in temperatures from 130 to 154 degrees Fahrenheit. The deficient practice identified, in regards to the hot water, was found to have occurred at an Immediate Jeopardy level due to the potential risk of scalding and 3rd degree burns to the residents residing within the facility. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 3/27/17 at 1:55 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to hot water temperatures. PLAN: On 3/28/17 at 7:00 AM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 3/28/17 stated the following: Attn (attention): (Name of Long Term Care Manager) Utah Department of Health Mr. (Name of Long Term Care Manager), As identified on our attached Plan of Correction we allege removal of the Immediate Jeopardy for F323. Corrective actions have been taken to remove the Immediate Jeopardy for F323 as of 8:00pm, on March 27th, 2017. As part of our Plan of Correction we completed the following: * Maintenance Director immediately adjusted both water heaters to lowest setting. * Maintenance Director emptied the water tanks. * Maintenance Director installed a lock to water heater closet. * Administrator and/or designee performed water temp (temperature) checks initially every 30 minutes, but checked hourly after initial temp as all temps were recorded lower and ultimately the hot water was turned off. * Staff were educated on regulated water temps in resident areas. *Water temps continued to be checked through additional repairs. * A licensed plumber completed install of water temp valves on all three water heaters to ensure water temp parameters remained within specified ranges. * Water temps will continue to be checked tonight and will continue to ensure compliance. Please consider this Plan of Correction our credible allegation of removal of the Immediate Jeopardy for F323 as of 8:00pm today, March 27th, 2017. Sincerely, (Name of Administrator) Administrator On 3/28/17, the surveyors confirmed removal of the Immediate Jeopardy situation as of 3/27/17. Deficient practice with the potential for more than minimal harm remained for the risk of injury. Findings include: Immediate Jeopardy: A. On 3/27/17 at 10:50 AM to 10:57 AM, hot water temperatures were checked in resident rooms. The following water temperatures (all temperatures are listed in degrees Fahrenheit) were observed: 1. Room 120 - 150 degrees 2. Resident Tub Room/Bathroom - 154 degrees 3. Resident Shower Room - 142 degrees 4. Room 115 - 144 degrees 5. Room 117 - 146 degrees 6. Room 111 - 130 degrees 7. Room 109 - 130 degrees The above listed temperatures were taken with both a digital and analog thermometer in the presence of two surveyors. B. On 3/27/17 at 11:35 AM, hot water temperatures were checked in resident rooms. The following water temperatures (all temperatures are listed in degrees Fahrenheit) were observed: 1. Room 120 - 150 degrees 2. Room 117 - 140 degrees 3. Room 115 - 142 degrees 4. Resident Tub Room/Bathroom - 150 degrees 5. Resident Shower Room - 148 degrees 6. Room 111 - 143 degrees 7. Room 109 - 142 degrees The above listed temperatures were taken with both the analog thermometer and the facility's digital thermometer in the presence of two surveyors and the Maintenance Director. On 3/27/17 at 11:35 AM, an interview was conducted with the facility Maintenance Director. The facility Maintenance Director stated that the water temperatures were too hot and that he did not know why the temperatures were reading so hot. The Maintenance Director stated that the possibility existed that facility staff had turned up the water temperatures over the weekend since they had a washing machine that was not working properly and they needed hot water for dishes and showers. On 3/27/17 at 11:48 AM, an interview was conducted with the Maintenance Director and the Administrator. The Administrator stated that the newer front portion of the building was controlled by a separate water heater and that would explain why the water temperatures were cooler in those resident rooms. The Administrator stated that there were washing machine issues over the weekend that could have contributed to the high water temperatures. The Administrator and Maintenance Director stated that the water heater does not have a mixing valve. The Administrator further stated that earlier in the day the water heater was set to Hot and he turned the water heater down to Medium approximately 20 minutes ago. The facility Maintenance Director stated that he was going to put a lock on the water heater closet and was going to get a mixing valve placed on the water heater to assist with keeping the water temperatures lower. On 3/27/17 at 11:48 AM, an observation was made of the water heater closet located downstairs in the dry food storage area of the facility with two surveyors present, the Administrator, and the Maintenance Director. The water heater closet was observed to be unlocked, thus allowing for anyone in the facility to gain entrance to adjust the water heater temperatures. The water heater was observed to be set at Medium. Manufacturer documentation on the water heater revealed that 3rd degree burns happen in less than 5 seconds with temperatures at 140 degrees. 3rd degree burns happen in 30 seconds with temperatures at 130 degrees. An observation of the valve gauge above the water heater indicated that the water was 130 degrees. On 3/27/17 at 11:52 AM, an interview was conducted with the facility Maintenance Director. The facility Maintenance Director stated that the valve gauge above the water heater was not a mixing valve and that the temperature of the valve could not be adjusted. The facility Maintenance Director stated that the valve gauge was not an anti scald valve. On 3/27/17 at 12:16 PM, an observation was conducted of the water heater with the Maintenance Director. The water coming out from the valve gauge continued to read a temperature of 130 degrees Fahrenheit.

Based on interview, record review, and observation, the facility did not ensure that 1 of 26 sample residents did not develop a pressure sore. Specifically, a resident developed a pressure sore in the facility, and was not observed to be respositioned at the appropriate times. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/20/14 resident 1's medical record was reviewed. Resident 1's History and Physical (HP) dated 4/24/14 was reviewed. Review of the HP revealed that on 4/24/14, resident 1 experienced a fall at the facility, during which she fractured her right hip. Resident 1's "Weekly Skin Evaluation Progress Notes" were reviewed. Facility staff documented that as of 5/27/14, resident 1's right hip incision was "well healed". On 5/29/14, a physician's telephone order was written for staff to discontinue their skin evaluations every other day, as resident 1's incision was "resolved/healed". A physician's progress note dated 7/11/14 was reviewed. The physician documented that resident 1's skin was "intact". On 7/23/14, facility staff documented in a nurses note that resident 1 was noted to have a "black (and) yellow scab . . . on (right) hip. Encouraged client to position off of Left hip." (Note: A care plan dated 8/11/14 revealed that resident 1 had "impaired cognitive function/dementia or impaired though processes r/t (related to) short term memory loss, impaired decision making, long term memory loss, (and) difficulty making decisions.") On 7/24/14, facility staff documented in a nurses note that resident 1's "scab on (right) hip remains dry (and) intact. Black in appearance, red surrounding tissue hematoma-like." On 7/26/14, facility staff documented in a nurses note that resident 1 required the assistance of one staff member with "all ADLs (Activities of Daily Living), transfers . . . repositioning in bed . . ." On 8/25/14, facility staff documented in a nurses note that resident 1 "has unstageable pressure sore to (right) hip measures 1.6 x 2.0 x 0.1 (centimeters). 50 (percent) slough, 30 (percent) [MEDICATION NAME], (and) 20 (percent) eschar noted, distant edges slight redness periwound. . . " Resident 1 was referred to the wound clinic for evaluation and treatment. On 8/25/14, facility staff completed a Braden Scale for resident 1. Resident 1's Braden Scale score was 13, indicating she was at moderate risk for developing a pressure sore. On 5/10/14, the facility completed a significant change Minimum Data Set (MDS) Assessment for resident 1. Pressure ulcers was triggered on the MDS, and facility staff indicated they would develop a care plan. Facility staff did not develop a pressure sore care plan for resident 1 until 8/25/14, which was after the resident had already developed the pressure sore. On 8/27/14, facility staff documented in a nurses note that resident 1's wound dressing was changed "due to heavy drainage". On 8/27/14, facility staff documented in a nurses note that resident 1's wound was assessed by a wound nurse and that the wound had "100 (percent) yellow slough . . . moderate exudate, 1.60 x 2.20 (centimeters)." On 8/27/14 a wound clinic staff member documented that resident 1 had a "Pressure ulcer" that was "unstageable". On 8/27/14, a physician's telephone order was written for staff to apply "Santyl nickle (sic) thick to wound bed, then cover with calcium alginate cover (with) bordered foam" to resident 1's wound each day. Resident 1's "ADL Flow Record" for September 2014 was reviewed. Staff documented on the ADL Flow Record that resident 1 required extensive assistance from one staff member for bed mobility and toilet use. Resident 1's "Nurse Aide's Information Sheet" was reviewed. Facility staff documented on the sheet that resident 1 was to be repositioned every 2 hours. On 10/22/14, a continuous observation was made of resident 1. At 7:25 AM, resident 1 was observed to be in the dining room during the breakfast meal. Resident 1 was not repositioned until 9:55 AM (two and a half hours later), when a CNA told the resident she was going to give her a shower, as the CNA wheeled resident 1 out of the dining room. On 10/23/14 an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 1 was dependent on staff for toileting and bed mobility. On 10/23/14, the facility Director of Nursing (DON) was asked to provide additional information indicating that resident 1's pressure sore was avoidable. The DON did not provide additional information.

Based on interview and record review the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, for 1 of 26 sample residents, internet privileges were revoked for inappropriate behavior. Resident identifier: 28. Findings include: Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/21/14 at 8:30 AM, an interview was conducted with resident 28 regarding her quality of life during her stay at the facility. Resident 28 stated that she had lived at the facility for four months and that she had had her internet privileges taken away on two occasions, the first time for 24 hours and the second time for 48 hours. Resident 28 stated that this decision was made by the Director of Nursing (DON) and Administrator (ADM) who stated "You have to be punished". When asked about the situation, resident 28 stated that she had been loud and yelled at a staff member. Resident 28 stated that she was upset and felt she was being "picked on" because another resident hit and bit a staff member with "no consequences". When asked about her feelings about having her internet privileges removed, resident 28 stated that, "It's not fair" and that she had been so upset by it that her "heart has been racing". Resident 28 then stated, "It's abuse. They can only (expletive) on me so much. . . They took my personal property. Being on Facebook is therapeutic for me. So taking my internet is like taking away my therapy. It's all I have here." Resident 28 stated that she had brought her own computer and modem into the facility and was "pissed" that her internet privileges were taken away. When asked if she had spoken with the facility social worker about her concerns, resident 28 stated "You've gotta be kidding." Resident 28 stated that she had other concerns about her treatment at the facility, but felt the social worker did not listen to her concerns or advocate for her. Resident 28 stated that the social worker advocated for the staff, not the residents. On 10/23 at 10:00 AM, resident 28 stated that the first time her internet privileges were removed was a month ago, and she was told by Registered Nurse (RN) 1 that if she was "good" she could have her internet privileges back. Resident 28's medical record was reviewed on 10/22/14. Resident 28's progress notes were reviewed. Facility staff documented the following regarding resident 28's leisure time: a) On 7/25/14, resident 28 was cognitively intact, had verbal behaviors, and was independent in her leisure activities. b) On 8/28/14, resident 28 ". . . spends much of her time in her room on her computer. . . " c) On 10/6/14 resident 28's favorite things to do were to "take care of her baby (doll), listen to popular music, and play games or follow Facebook on her computer." d) On 10/7/14 resident 28 " . . . prefers to stay in her room and enjoys being on the internet playing games and social media." Resident 28's progress notes also revealed the following two incidents regarding privileges being revoked: a) On 8/6/14 "resident (28) was heard from nurse station yelling at CNA (Certified Nursing Assistant) to tell nurse to bring prn (as needed) pain medication that she did not call for until just now. CNA (and) nurse went in together to (?) client began over again to yell and curse at nurse. Client repeatedly shouted "(expletives deleted). I've been nice to you." Was given her medications as requested nurse then left room, shutting door behind. returned to nurse station, all while client could be heard continuing to yell at nurse. A few minutes later, (resident 28) appeared at nursing station continuing to yell and curse at nurse and demanding the phone and phone book. nurse stated "I am taking you back to your room unless you lower your voice this instant. You are not permitted to awake all of our residents who are sleeping." Nurse came around behind wheelchair and took hold of handles and began to turn the wheelchair. (Resident 28) stated "I'll lower my voice. Just give me the phone and phone book." Stated to client "You will lower your volume to a civil tone and you will maintain it while you are out of your room or you will have neither phone, nor directory." Client stated "I'm lowering my voice." Given the things she wanted, (resident 28) began raising her voice and cursing about how she is not respected, repeatedly calling nurse (expletives deleted) . . . " b) On 9/15/14, "Instructed client that she would not have phone priveleges (sic) if she continues to be rude (and) disrespectful of other residents rights of use and time. Client began to cry. Stated "It's my brain injury. I get blamed for everything." Remained in room (and) requested to be left alone except for meds (medications), snacks, toileting, (and) other ADLs (Activities of Daily Living)." On 9/19/14, the facility social worker documented that she was working to complete a "behavior plan" for resident 28. This document could not be located. On 10/23/14 at 10:30 AM, an interview was conducted with the DON. The DON confirmed that resident 28's internet privileges had been removed. The DON stated that the consultant social worker "said to take it away". On 10/23/14 at 9:30 AM, an interview was conducted with ADM 1. ADM 1 confirmed that he had taken away resident 28's internet access because the resident was swearing and use of the internet"is a privilege because the facility pays for it". When asked if he had developed a behavior plan, or signed a contract with the resident about her behaviors, ADM 1 stated he had, but was unable to locate the document. On 10/23/14 at 10:00 AM, an interview was conducted with ADM 2. ADM 2 confirmed that resident 28's internet privileges had been removed. ADM 2 stated that his social work consultant "told us to do it". ADM 2 provided surveyors with the following written communication from the social work consultant with regard to resident 28: "I am wishing you the best of luck with this one . . . Monitor her carefully for suicide attempts. Set firm boundaries. . . don't let her manipulate staff. . . "