Every finding on record at Sun West Choice Healthcare & Rehab

Based on clinical record reviews, facility documentation, staff interviews and policy review, the facility failed to protect the rights of three residents (#38, #24, #23, #11) to be free from abuse from other residents (#39, #22, #10). The deficient practice could result in residents being physically or emotionally harmed.Findings include: -Regarding Resident #38 and #39 Resident #38 was re-admitted to the facility March 30, 2022, with diagnoses that included Alzheimer’s Disease, Dementia in other diseases classified elsewhere, Unspecified Severity, with other Behavioral Disturbance, Hypertension, Depression, Schizoaffective Disorder, and Unspecified Mood [Affective] Disorder. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. A care plan dated January 26, 2023, revealed Resident #38 was an elopement risk/wanderer related to impaired safety awareness, potential for behavior problem of physical aggression towards staff and peers, and placing self on floor. A progress note dated August 10, 2022, revealed that Resident #38 sustained a bite injury from another resident to the back of the left hand. Further review of the progress notes reveal that the resident had behaviors consisting of intrusive wandering and aggression. Resident #39 was re-admitted to the facility June 20, 2022, with diagnoses that included Unspecified Dementia with Behavioral Disturbance, Vascular Dementia with Behavioral Disturbance, Anxiety Disorder Unspecified, Unspecified Severe Protein-Calorie Malnutrition, Unspecified Osteoarthritis Unspecified Site, Hypokalemia, and Irritable Bowel Syndrome Unspecified. A discharge MDS assessment dated [DATE], revealed Resident #39 had a staff assessment for mental status which revealed that the resident had a short-term memory problem and was severely impaired in regard to cognitive skills for Daily Decision Making. The BIMS score was not indicated. Further review of the MDS indicated that the resident had behavioral symptoms that included physical behavior directed toward others containing coding that indicated that the type of behavior occurred 1 to 3 days. A care plan dated August 11, 2022, revealed Resident #39 had the potential to demonstrate physical behaviors related to behavioral and psychological symptoms of dementia, was prescribed psychotropic medications use related to agitation as evidenced by striking out. A progress note dated August 10, 2022, revealed Resident #39 had an altercation with a male resident (Resident #38) that resulted in Resident #39 biting Resident #38’s left hand and causing an injury. Resident #39 could not tell the progress note writer what provoked her to bite Resident #37. The progress note further indicated that Resident #39 is known to be very territorial and does get agitated when others come into her personal space. It was further revealed in the progress note that Resident #39 was not injured during the altercation. A documented report dated August 11, 2022 described the incident as “(Resident #38) was restless and wandering the hallway, approached (Resident #39)’s room. (Resident #39) became agitated as she can be protective of her space. Residents began arguing and when staff tried to intervene, (Resident #39) bit (Resident #38) on his left hand causing broken skin. A five-day investigation conducted by the facility revealed that, on August 10, 2022, in the Behavioral Unit, (Resident #38) was observed in the hallway, restless and pacing back and forth. (Resident #38) raised his hand in front his face and (Resident #39) leaned forward and bit (Resident #38) on the left hand between the thumb and the pointer finger. As soon as staff were able to intervene, they removed (Resident #39)’s teeth from (Resident #38)’s hand. The resultant removal of (Resident #39)’s teeth resulted in a tear to (Resident #38)’s left hand. The five-day report further indicated that a C.N.A. had witnessed Resident #39’s mouth on Resident #38’s hand and assisted Resident #38 with the removal of his hand from Resident #39’s mouth and then separated the two. -Regarding Resident #24 and Resident #22 Resident #24 was admitted initially on April 5, 2022, and was re-admitted to the facility on [DATE] with diagnoses that included Alzheimer’s disease, bipolar disorder, and major depressive disorder, recurrent, severe with psychotic symptoms. A care plan focus, initiated on June 26, 2022, indicated that Resident #24 was an elopement risk/wanderer. An additional problem focus, initiated on July 11, 2022, revealed that Resident #24 had potential for a behavior problem of physical aggression towards staff and peers, verbal aggression, yelling out, and banging on doors. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. A nursing note on October 23, 2022 indicated that Resident #24 was involved in an altercation with another resident, in which Resident #24 was punched on the right side of the head by the other resident. An additional nursing progress note dated October 23, 2022 revealed that a nurse had observed Resident #24 walking towards the nursing station with a shocked and confused expression. The nurse assessed the resident and found that the resident had a raised, discolored area on the right side of his head, which is stated to be in the area of the reported abuse. Resident #22 was admitted to the facility on [DATE] with diagnoses that included schizophrenia and depression. Review of the MDS dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment. This MDS indicated that during the assessment period, the resident had exhibited verbal behavioral symptoms towards others one to three days and other behavioral symptoms not towards others one to three days. A nursing note dated October 23, 2022 at 3:00PM revealed that Resident #22 was agitated due to confusion and a wet bed. The note indicated that Resident #22 lashed out physically and hit another resident on the head. An additional nursing note dated October 23, 2022 at 3:00PM revealed that a nurse had observed Resident #24 at 2:45PM in his room, and the resident had asked for assistance to change clothes. The nurse observed at this time that Resident #24’s incontinent product was wet and indicated that staff would assist him soon. The nurse indicated that another resident (Resident #24) was observed sitting in a chair asleep in the hallway at this time, as the nurse was returning to the nursing station. The nurse sat at the nursing station to chart until other staff reported the altercation. Interview was conducted on August 29, 2025 at 9:28AM with a Certified Nursing Assistant (CNA/Staff #172) who confirmed that she had witnessed the altercation between Resident #22 and Resident #24. The CNA stated she had worked with the two residents frequently, and recalled that the two residents did not like each other and often had tension between the two. The CNA explained that Resident #24 frequently wandered into other residents’ rooms, and Resident #22 did not like this, as Resident #22 was very protective of his belongings. The CNA stated that on October 23, 2022, she witnessed Resident #24 sleeping in a chair outside of Resident #22’s room. Resident #22 then approached Resident #24 and appeared to hit him. The CNA stated that Resident #22 had suspected that Resident #24 had gone into his room and may have stolen something. The CNA explained that following the event, the two residents were separated. Interview was attempted with other witnesses, but the other staff witnesses were unable to be reached for interview. -Regarding Resident #23 and Resident #22 Resident #23 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, depressive disorder, and Parkinson’s disease. The MDS dated [DATE] revealed a BIMS score of 8, indicating moderate cognitive impairment. A nursing note dated February 26, 2023 indicated that Resident #23 was involved in a resident-to-resident altercation. The note detailed that while attempting to leave the dining room, Resident #23’s wheelchair got tangled with another resident’s wheelchair, and staff attempted to separate the two. The note indicated that the other resident struck Resident #23 in the face, causing a lower lip laceration. The residents were then separated. Resident #22 was admitted to the facility on [DATE] with diagnoses that included schizophrenia and depression. Review of the MDS dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment. This MDS indicated that during the assessment period, the resident had exhibited verbal behavioral symptoms towards others one to three days and other behavioral symptoms not towards others one to three days. A nursing note dated February 26, 2023 indicated that Resident #22 was involved in a resident-to-resident altercation when leaving the dining room. The note indicated that the two residents’ wheelchairs were tangled up, and Resident #22 struck another resident in the face, causing injury to the lower lip. Staff separated the two residents. A review of the facility investigation dated February 26, 2023 revealed that a staff member and multiple residents reported witnessing Resident #22 hit Resident #23. -Regarding Resident #11 and Resident #10: Resident #11 was admitted to the facility on [DATE] with diagnoses that included intracranial injury and psychotic disorder with hallucinations. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS also revealed that the resident did not have any hallucinations, delusions, or physical or verbal behaviors towards others during the assessment period. A review of the MDS dated [DATE] revealed no short-term memory impairments and that the resident was independent with decision making regarding tasks of daily life. This MDS indicated that during the assessment period, the resident had exhibited physical and verbal behavioral symptoms towards others one to three days and other behavioral symptoms not towards others four to six days. The nursing progress note dated August 12, 2023 revealed that two Certified Nursing Assistants (CNAs) had called the nurse to the dining room, stating that an altercation had occurred between Resident #11 and Resident #10. The note indicated that the two residents were talking at the dining table and got into an argument. Resident #10 attempted to elbow Resident #11, and Resident #11 then hit Resident #10. Staff then attempted to escort Resident #11 away when Resident #10 stood and hit Resident #11 in the back before falling to the ground. The note indicated that the two residents were assessed and no injuries were found. Resident #11 continued to be aggressive with staff and was sent out to the hospital for evaluation. Resident #10 was admitted to the facility on [DATE] with diagnoses that included hemiplegia/hemiparesis following cerebral infarction affecting non-dominant left side and hypertension. Review of the MDS dated [DATE] revealed a BIMS score of 14, indicating intact cognition. The care plan focus, initiated June 26, 2023, indicated that Resident #10 had a behavior problem, related to resisting care, declining or throwing medications, and being aggressive with staff at times. The nursing progress note dated August 12, 2023 revealed that the nurse was called to the dining room, stating that an altercation had occurred between Resident #11 and Resident #10. The note indicated that the two residents were talking at the dining table and both became verbally aggressive. Resident #10 attempted to elbow Resident #11, and Resident #11 then hit Resident #10. Staff then attempted to escort Resident #11 away when Resident #10 stood and hit Resident #11 in the back before falling to the ground. Interview was attempted with the staff members working the day of the incident who may have witnessed the altercation, but none of the staff could be reached for interview. Interview was conducted on August 28, 2025 at 8:41AM with a Certified Nursing Assistant (CNA/Staff #95), who stated that she would consider a resident hitting another resident to be abuse, and she would report this immediately to the administrator after separating the residents. The CNA reported that she often worked on the behavioral unit, so she had received training on how to de-escalate conflict. She reported that if a resident were to begin to scream at another resident or staff, she would try to give the resident space. She stated that this often helps. Interview was conducted on August 28, 2025 at 8:46AM with a Registered Nurse (RN/Staff #92), who stated that she often works with residents with behaviors, and they can get agitated easily. She stated that the difference between behaviors and abuse can sometimes be difficult to determine, but she stated that physical contact would be considered abuse. The RN explained that if a physical altercation occurred, the two residents should be separated and assessed for injury. Then, the manager, doctor, family, and administrator should be notified. Interview was conducted on August 29, 2025 at 10:35AM with the Director of Nursing (DON/Staff #151), who stated that abuse is anything willful, intentional, and deliberate. The DON stated that any physical altercations between residents are reported as abuse allegations. She also stated that the residents in the facility are mostly confused and do not know what they are doing. During this interview, the DON explained that she was not working at the facility when the altercation with Resident #22 and Resident #4 occurred, nor when the altercation with Resident #22 and Resident #23 occurred. She did explain that she remembered that Resident #22 was cognitively impaired and had behaviors, which she felt could be managed at the facility. Additionally, the DON stated that while she was present in her role when the altercation between Resident #10 and Resident #11 occurred, she could not recall details about the incident. Review of the facility policy titled, “Abuse: Prevention of and Prohibition Against”, revealed that residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Based on record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure basic life support including CPR (cardio-pulmonary resuscitation) according to the physician order and the advance directives was provided for one resident (#56) prior to the arrival of the emergency medical personnel. The deficient practice resulted in the resident's advance directives not followed and delay in initiation of basic life support including CPR and risk for serious injury and harm. As a result, a condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The census was 134. Findings include: On [DATE] at 12:41 p.m., a condition of IJ was identified. The administrator (staff #510) and director of nursing (DON/staff #504) were informed of the facility's failure to initiate basic life support including CPR prior to arrival of the emergency medical service (EMS). The DON stated staff would not start CPR if a resident still had vital signs. The administrator and DON presented the removal plan on [DATE] at 2:11 p.m. The administrator, DON and clinical resource (staff #508) were informed that the removal plan was not acceptable; and, must not be a copy of the regulation or guidance. It also failed to include steps or actions that taken to ensure no residents are or will likely be affected by the deficient practice; details on how they will keep the residents safe and free from harm, impairment or death caused by the non-compliance; date when in-service training was started and expected to be completed for all staff; identify the staff that would complete the in-service training; identify the topic of the in-service training they would provide to staff; and, actions the facility will take if a staff did not complete the required in-service training. In an interview conducted on [DATE] at 3:15 p.m., the DON stated that the facility did not have contract or registry staff; and, the facility did not require therapist to have CPR certification. A revised removal plan was received on [DATE] at 4:45 p.m. and was not accepted; and, failed to include how the facility identified the residents that may be affected; date all in-house review was started and expected to be completed; how in-house reviews will be conducted and where will these reviews be documented; how the facility would address residents with advance directives to include full code and DNR (do-not-resuscitate) in an in emergency situations; what is the therapists expected to do in the event of a code during a therapy session with a resident with full code status; and, date when in-service training was started and expected to be completed for all staff. Another revised removal plan was presented by the DON on [DATE] at 9:44a.m. The administrator was informed that the removal plan was not accepted because it failed to: address residents with DNR (Do Not Resuscitate) in emergency situations; change the plan of correction to removal plan; include therapy staff in the in-service training provided; and, include the start dates of random reviews to verify implementation of appropriate measures for acute changes of condition. On [DATE] at 10:31 a.m., the administrator presented a revised removal plan and was accepted. The accepted removal plan included: -Full house review and random reviews of current residents for advance directives and code status; -Resident monitoring and evaluation for acute change of condition at leat every shift through routine delivery of care; -In-service training for all nursing staff on advance directives, full code status, basic life support and administering CPR when cardiac and/or respiratory arrest occur; -In-services training for all staff (therapy, dietary, housekeeping and laundry, maintenance, social service, etc.) on acute change in condition and notification of nursing staff immediately; and, -Completion of competency skills on CPR using the American Healthcare Association and AED manufacturer guidelines. On [DATE] at 12:21 p.m., the condition of IJ was removed after multiple observations were conducted of the facility implementing their removal plan which included resident and staff interviews, record review and in-service training of staff. -Resident #56 was admitted on [DATE] with diagnoses of hypertension, benign prostatic hyperplasia (BPH), non-Alzheimer's dementia, depression, and obstructive sleep apnea (OSA). The admission note dated [DATE] revealed that the resident was alert and oriented x ,d+[DATE] and was able to make needs known. Per the documentation, the resident was admitted for skilled PT (physical therapy)/OT (occupational therapy) following a ground level fall that resulted in right femur fracture. The advance directive form signed by resident representative (RR) and dated [DATE] revealed that should the resident wanted the following: -Cardiac resuscitation measures (CPR); -Artificial nutrition (tube feeding) if unable to accept nourishment by mouth; -Artificial hydration (IV hydration) if unable to accept hydration by mouth, unless IV hydration was used as comfort measure and will not prolong my death; -hospitalization (related to terminal condition); -Antibiotics therapy to be given to reduce or eliminate the infection, as long as the antibiotic will not prolong inevitable death; and, -Pain medication to be given to eliminate apparent pain, even if this poses a risk of depressing respiration and hastening my death. Review of a physician order dated [DATE] revealed the resident had a CPR/Full code status. The late entry history and physical note dated [DATE] included the resident was laying in bed resting with CPAP (continuous positive airway pressure) on. Assessments included sleep apnea with CPAP, hypertension and dementia. Plan included to monitor BP (blood pressure) and CPAP at bedtime and when napping during the day as needed. The physician orders dated [DATE] revealed the following orders: -CPAP at maximum IPAP (inspiratory positive airway pressure) 18 cm (centimeter)/H20 (water) and minimum EPAP (expiratory positive airway pressure) 8 cm/H20 with face mask at night and PRN while napping during the day and at bedtime for Sleep Apnea; and, -Oxygen titrate between ,d+[DATE] liters per minute (LPM) via nasal cannula (NC) as needed to maintain oxygen saturation over 90% every shift for hypoxia and SOB (shortness of breath). The care plan initiated on [DATE] revealed the resident used a CPAP related to OSA. The goal was to have no signs and symptoms of poor oxygen absorption. Interventions included to give medications as ordered; monitor for signs and symptoms of respiratory distress and report to the physician as needed: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusions, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color; and placing of CPAP with face mask at night and PRN (as needed) while napping during the day. The physician progress note dated [DATE] included the resident was alert and oriented x2. Assessments included dementia, psychosis, sleep apnea and hypertension. Plan was to monitor blood pressure closely. The skilled weekly review dated [DATE] revealed the resident required moderate assistance with bed mobility and transfers, stand-by assistance with upper body dressing; maximum assistance with lower body dressing, and, dependent on showers/bathing. Per the documentation, resident had OSA with CPAP at night and oxygen. A Minimum Data set (MDS) assessment dated [DATE] included the resident had a BIMS (Brief Interview for Mental Status) score of 6 indicating the resident had severe cognitive impairment. Active diagnoses included stroke, hypertension, benign prostatic hypertrophy (BPH), hyperlipidemia, non-Alzheimer's dementia, malnutrition, depression, obstructive sleep apnea, muscle weakness, cognitive communication deficit. The assessment also included that the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. A psychiatric note dated [DATE] included the resident was alert and oriented x 2 with appropriate responses and had diagnoses of obstructive sleep apnea and dementia. The daily skilled notes dated [DATE] through 14, 2024 revealed that the resident was alert and oriented x 3; had diagnoses of obstructive sleep apnea and dementia; and, was on CPAP at bedtime and as needed. The skilled weekly review dated [DATE] included the resident had OSA with CPAP at night and was on oxygen. The physician progress note dated [DATE] revealed the resident had sleep apnea with CPAP and hypertension. Plan was to monitor BP and heart rate (HR) and to continue with CPAP at bedtime and when napping during the day as needed. Review of physician's orders dated [DATE] at 08:52 revealed a discontinue order for the as needed Oxygen. A nursing note dated [DATE] revealed the resident sustained an unwitnessed fall with no injuries. Per the documentation, the resident was in the wheelchair and attempted to turn, pushed too far and fell . It also included that the resident reported that he did not realized that he pushed too far. The documentation that neuro checks were initiated; and, the provider and family were notified. Review of the physician progress note dated [DATE] included the resident was awake, alert, had intermittent confusion and reported falling and had some back pain. Plan was to monitor mental status for acute changes, monitor BP and HR and to continue with CPAP at bedtime and when napping during the day as needed. Per the documentation, code status was full code. The change in condition note dated [DATE] at 1:15 a.m. revealed that the resident had a fall. Vital signs were as follows: BP of ,d+[DATE], pulse of 76, respiration of 19 and oxygen saturation of 95% in room air. The vitals signs dated [DATE] at 2:41 a.m. included resident had BP of ,d+[DATE], regular pulse of 75 bpm (beats per minute), respiration of 18 breaths/minute and oxygen saturation of 98% room air. The nursing progress note dated [DATE] at 5:36 a.m. included that the resident was found sleeping on the floor in his room next to his wheelchair, was snoring and was laying on his left side with hands under his head. Per the documentation, staff attempted to assist the resident into the wheelchair and the resident became upset and indicated that he was asleep and did not want to get up. It also included that the nurse explained to the resident that he was asleep on the floor and staff was going to assist him back to bed; but, the resident insisted that he was not on the floor. Further, the documentation included that the resident had dementia and sun downs and denied falling from his bed. The documentation also included that neuro checks was initiated and the physician and RR were notified. The medication administration record (MAR) for [DATE] revealed documentation that at 6:00 a.m. the resident was administered with pain medication. The nursing progress note dated [DATE] at 6:55 a.m. revealed the resident was unresponsive to verbal and tactile stimuli at 6:30 a.m. Per the documentation, the head of bed was elevated, CPAP on, and vital signs of BP of ,d+[DATE], blood glucose of 249, pulse rate of 44 bpm, respiration of 24 breaths/minute and oxygen saturation of 98%. The documentation also included that there was emesis observed and the resident's fingertips to bilateral hands were cyanotic which was contradictory to the documented oxygen saturation of 98%. Further, it included that 911 was called and the physician, DON and ADON (assistant DON) were notified. The nursing home to hospital transfer form signed and dated [DATE] revealed the resident was alert, disoriented but can follow simple instructions; and, had CPR/full code for code status. Devices and treatments included CPAP. Per the documentation, the reason for transfer was that the resident was unresponsive. Vital signs at 6:40 a.m. included a BP of ,d+[DATE], HR (heart rate) of 44, respiratory rate of 24; and, at 6:41 a.m., oxygen saturation of 98%. Despite documentation that the resident had a low BP and was cyanotic from the fingertips to bilateral hands, there was no documentation of what the facility have done to address these issues while waiting for EMS (emergency medical services). The prehospital care report from EMS included impressions of difficulty of breathing, altered mental status, shortness of breath and respiratory distress. The documentation included that EMS arrived on scene at [DATE] at 6:36 a.m. and found the resident unresponsive with a GCS (Glasgow Coma Score) of 7 which indicated the resident was in coma. Per the documentation, the facility reported to EMS that the resident slept on the floor and staff had been checking the resident all night and the resident was fine; and that, staff did not know when the resident went unresponsive or if the resident actually fell . The documentation also included that the resident was pale, cyanotic and remained unresponsive, had palpable rapid irregular pulse, had agonal respirations, had room air oxygen saturation of less than 50%, had non-reactive pupil on the left eye and sluggish pupil on the right eye. It also included that the resident was unresponsive to IO (intraosseous) insertion, was cardioverted at 125 joules and ventilation with BVM (bag valve mask) and supplemental oxygen at 25 lpm (liters per minute) was performed and did not react to the [NAME] airway (non-inflatable cuff used in resuscitation) placement. The hospital admit-transfer-discharge information note dated [DATE] at 6:54 revealed the resident arrived via EMS and was unresponsive in atrial fibrillation with RVR (rapid ventricular response). The documentation included that upon arrival at the ED (emergency department) the Glasgow coma score was 3 indicating the resident was in coma and the oxygen saturation was 87% bag valve mask. Per the documentation, the resident was unresponsive, had tachycardic heart rate, no gag reflex, no corneal reflex, non-responsive, had nonreactive pupils 1 mm (millimeter) on the left and 4 mm on the right and skin was cold and dry. Coded diagnoses included accidental fall from bed, acute traumatic subdural hematoma with loss of consciousness status unknown. An interview was conducted on [DATE] at 1:10 p.m. with a certified nursing assistant (CNA)/staff #161) who stated that at the start of her shift, she checks the schedule book, gets a report from the outgoing staff and then checks her residents. The CNA stated that when resident was hard to wake up it was a change in condition. The CNA said she will then the nurse stat, check the resident's vital signs. She stated that if a resident was found on the floor, she would ask the resident if they were okay and will call the nurse. She said that she will not touch the resident and would wait for the nurse to do their assessment and give her instructions. In an interview with the licensed practical nurse (LPN/staff #31) conducted on [DATE] at 1:37 p.m., the LPN stated when she comes in for her shift, she and the outgoing nurse will do a nurse to nurse report and both nurses would discuss what happened with each resident during the previous shift. The LPN said that examples of change of condition would be a fall or abnormal vital signs such as an extremely low and high blood pressure that deviates from baseline. She stated that a high blood pressure was 190 systolic blood pressure and lower blood pressure was 60 systolic blood pressure; and that, if this occurs, she will double check the vital signs, inform the physician and wait for new orders. The LPN said that for a low blood pressure, she would also check for lethargy, feeling tired and/or resident not being hungry. She stated that if a resident for a fall, she will go in the patient's room and assess the patient. The LPN said that for an unwitnessed fall, she would do neuro checks and would inform the physician and family about the fall. Further, the LPN stated that residents on blood thinners with significant bleeding and non-responsive and had a fall, she would call 911. The LPN said for a non-responsive resident, she would try to intervene by having the crash cart; and, if the resident was not breathing, the facility has an AED (Automated External Defibrillator) to use. The LPN also stated that if a resident was cyanotic, she would call a code, check the vital signs, check the resident's pulse; and that, during the code, there would be staff running the resident's vital signs or assisting with anything; there would be one leading the code and another performing CPR. Further, the LPN stated that if a resident was cyanotic, extremely tired, slow to response but still breathing, she would call the physician, get the resident's vital signs, reposition the resident; and, if the oxygen saturation was low she would give the resident oxygen after clarifying with the physician. An interview was conducted on [DATE] at 9:49 a.m., with the LPN (staff #50) who worked on Monday, [DATE] when the incident with resident #56. Staff #50 said that she was getting a report from the outgoing nurse when the day shift CNA came to her and reported that the CNA was getting the vital signs of resident #56 who was not responding. Staff #50 stated she went to the resident's room immediately and found the resident looked like he was sleeping with the head of bed elevated and the CPAP on and functioning. Staff #50 said that the resident was taking deeper breaths than normal and she tried shaking him by the shoulder 2 to 3 times but had no answer from the resident. She also said that she squeezed the resident's fingertip and did a sternal rub but received no response from the resident. She stated that she then went out to get a Vitals kit to take vitals and recalled patient was prediabetic so she checked the blood sugar, and the CNA was doing vital signs. She stated she noticed the resident's fingertips were cyanotic so she took the CPAP off and check the resident's mouth, took the dentures out, and the mouth was clean; but, there was emesis in the resident's mouth that looked like a film in the upper palate so she put the CPAP back on to the resident. Staff #50 said that the CNA stayed with the resident while she and the night shift nurse notified the provider who gave an order to send the resident to the hospital. She stated they called 911 and the EMS came within 2 minutes. Staff #50 stated that the resident was breathing and had a pulse the whole time, the CPAP was on and the oxygen saturation was at 98 percent; but, the very tip of the resident's fingertips were bluish gray. Staff #50 stated that neuro checks was in process for resident #56 because the resident had a fall the previous day or night shift. She said that neuro checks are done every 15 minutes times 4, every 30 minutes times 2, and every hour times 6 and then every 4 hours times 4. Staff #50 said that resident #56 was alert and oriented with confusion at times, able to propel his wheelchair by propelling, and required assistance with transfers. During an interview with director of nursing (DON/staff #504) and the clinical resource (staff #505) conducted on [DATE] at 10:25 a.m., the DON stated that for a change of condition, staff would first assess the resident then notify the provider. The DON also said that stated that they transfer resident to the hospital when the level of care cannot be provided in their facility. Review of facility policy titled Advance Directives revised on [DATE] revealed that a resident's choice about advance directives will be recognized and respected. The facility policy on Cardiopulmonary Resuscitation (CPR) and First Aid last revised February 2024 included that it is their policy to administer CPR according to current national guidelines. Once CPR is initiated, it will be discontinued only by a physician's order and/or the arrival of rescue personnel who take over CPR efforts and/or transport the resident. The facility policy on Change of Condition Reporting with review date of February 2024 revealed for Life Threatening Change the licensed nurse will initiate appropriate first aid measures until emergency response personnel arrive on the scene and all nursing actions, physician contacts, resident representative and resident assessment information will be documented in the medical record.

Based on clinical record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure care and services that adhere to accepted standards related to medications administration was provided to one resident (#125). The deficient practice could result in resident not receiving the necessary treatment needed. Findings include: Resident #125 was admitted on [DATE] with diagnoses of dementia, hypertension, atrial fibrillation, and depression. The care plan initiated on April 7, 2024 revealed the resident had altered cardiovascular status hypertension, atrial fibrillation, trans ischemic attack history. The goal was that the resident will remain free from signs and symptoms of hypertension. Interventions included give antihypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate, and effectiveness, notify physician of any signs and symptoms of cardiovascular complications: nausea, vomiting, shortness of breath, decreased capillary refill, chest pain/discomfort, monitor for and document any edema, monitor/document abnormalities for urinary output and report significant changes to the physician. The physician order dated April 6, 2024 revealed the following orders: -Lisinopril (antihypertensive) 20 mg (milligram) give one tablet by mouth one time a day for hypertension; -Carvedilol (antihypertensive) 6.25 mg give 1 tablet by mouth 2 times a day for hypertension; and, -Midodrine (alpha adrenergic agonist) 5 mg give 1 tablet by mouth every 24 hours as needed for hypotension. Review of the admission MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 5 indicating the resident had severe cognitive impairment. The MDS also revealed that the resident had no health conditions or chronic diseases that result in a life expectancy of less than 6 months. The NP (nurse practitioner) progress note dated June 5, 2024 revealed that staff reported that the resident had not been eating. Assessments included dementia and hypertension. Plan was to monitor BP (blood pressure), HR (heart rate) and rhythm and laboratories in the morning were ordered. Per the documentation, the resident's BP was controlled. The late entry NP progress note dated June 7, 2024 included that the resident was not eating and drinking well; appeared tired; was not answering questions; and that, an order to was given to the nurse for one liter of IV (intravenous) fluids. It also included that staff were continue to encourage oral intake. The condition follow-up note dated June 8, 2024 revealed that the resident was s/p (status post) IV hydration, was more alert but remained somewhat lethargic; and, oral fluids were encouraged and accepted at 50%. The BP record for June 8, 2024 was 128/74 mmHg (millimeters mercury) at 6:51 a.m. and 133/77 mmHg at 8:27 p.m. The condition follow-up note dated June 10, 2024 included BP was 113/62 mmHg; and that, the IV hydration was completed. The BP record for June 10, 2024 were as follows: -128/72 mmHg at 4:31 p.m. -116/62 mmHg at 5:27 p.m.; and, -120/60 mmHg at 11:52 p.m. The BP record on June 11, 2024 included the following: -115/61 mmHg at 1:41 a.m.; -95/67 mmHg at 2:52 p.m.; and, -95/65 mmHg at 5:30 p.m. The medication administration record (MAR) for June 2024 revealed that June 11, 2024 at 2:52 p.m., Midodrine was administered to the resident. However, there was no documentation found in the clinical record that Midodrine was administered at 5:30 p.m. for a BP reading of 95/65 mmHg; and that, the physician was notified. The BP record on June 13, 2024 was 80/62 mmHg at 7:53 a.m. and was 65/33 mmHg at 10:08 a.m. and 10:23 a.m. Despite documentation of low BP at 7:53 a.m., 10:08 a.m. and 10:23 a.m. on June 13, 2024, there was no evidence found that Midodrine was administered to the resident. Review of the MAR for June 2024 revealed that Lisinopril and Carvedilol were documented as administered to the resident at 8:00 a.m. on June 13, 2024 (approximately 7 minutes from the time BP reading of 80/62 mmHg). The clinical record revealed no documentation of any interventions put in place to address the resident's low BP readings at 7:53 a.m., 10:00 a.m. and 10:23 a.m.; and that, the physician was notified. The nursing note dated June 13, 2024 at 12:08 p.m. included that the resident was sent to the hospital due to low BP and per physician and family request. An interview was conducted on August 30, 2024 at 8:11 a.mm with a certified nursing assistant (CNA/staff #150) who stated that when she comes in for her shift, she would check the assignment book to see which residents she has and would do walk-in rounds during report. The CNA said that while waiting for the resident's breakfast, she would starts taking vital signs for her residents at around 6:30 a.m.; and this usually take around 30 minutes to an hour to finish taking vital signs for all residents assigned to her. She said that she would then document the resident's vital signs in the electronic record at around 7:30 a.m. The CNA said that abnormal BP reading would be a BP above 140/80 mmHg and under 100/60 mmHg; and that, she would notify the nurse immediately about the abnormal BP reading. An interview was conducted with another CNA (staff #135) on August 30, 2024 at 8:25 a.m. Staff #135 stated that when he arrives for his shift, he gets a report from the night shift, checks his assignment, and then start to get vital signs for residents assigned to him. He said that he starts taking resident vital signs from 6:00 a.m. through 7:00 a.m., documents the vital signs in the electronic record within same time frame up to 7:30 a.m. so the nurse has the vital signs results on hand and could do medication pass. Staff #135 stated after finishing taking resident vital signs, he will check the resident rooms, pass out breakfast which was served at 7:00 a.m. Staff #135 stated that an abnormal and high blood pressure would be150/80-90 mmHg and low blood pressure would be 100/60 mmHg; and that, he would report these abnormal vital signs to the nurse so the nurse can possibly administer medication if needed and to make sure that the resident was okay. In an interview with a registered nurse (RN)/staff #58) conducted on August 30, 2024 at 8:44 a.m., the RN stated that the 8:00 a.m. scheduled medications can be given at 7:00 a.m.; and that, documentation in the MAR revealed the use of the following codes: (a) check mark to indicate medication was administered; (b) Number 2 to indicate Hold/See Nurses Notes; (c) Number 10 to indicate hospitalization ; and, (d) Number 12 to indicate blood pressure parameters. The RN said that when giving blood pressure medications, she will look for the resident's current blood pressure, pulse and their physical state such as being alert. She stated that she will not administer an antihypertensive medication such as lisinopril if the systolic blood pressure was less than 90 mmHg, if pulse was anything less than 60 for pulse, and she will notify the provider of the resident vital signs. During an interview with director of nursing (DON/staff #504) and the clinical resource (staff #505) conducted on September 3, 2024 at 10:25 a.m., the DON stated that for a change of condition, staff would first assess the resident then notify the provider. The DON said that they transfer resident to the hospital when the level of care cannot be provided in their facility; and that, when a resident is transferred, they would notify their family and complete the notice of transfer/discharge. Regarding resident #25, the DON stated the resident had lisinopril 20 mg by mouth every day for hypertension scheduled to be administered at 8:00 a.m. and carvedilol 6.25 mg twice a day scheduled to be administered at 8:00 a.m. and 5:00 p.m. The DON stated that on June 13, 2024 at 7:53 a.m. the resident's BP was 80/62; and, the actual time lisinopril and carvedilol were given to resident #25 on June 13, 2024 was at 8:26 a.m. She stated that staff were expected to call/notify the provider when the BP was low and to follow physician orders. Further, the DON stated that resident #125 was transferred out due to low blood pressure per family request. She stated that the resident's BP was 60/33 at 10:23 a.m.; and the resident was transferred out at 10:49 am on June 13, 2024 for low blood pressure. The facility policy on Administration of Drugs with revision date of February 2024 included that medications shall be administered as prescribed by the physician. Medications must be administered in accordance with the written orders of the attending physician.

Based on record review, staff interviews, and policy review, the facility failed to ensure an abnormal lab results for one resident (#91) were promptly communicated to the provider. The deficient practice could result in complications and/or worsening of resident's health. Findings include: Resident #91 was admitted on [DATE] with diagnoses of dementia, dysphagia, type 2 diabetes mellitus, and psychotic disorder. The ADL (activities of daily living) care plan dated July 26, 2024 revealed the resident had ADL self-care performance deficit related to dementia, impaired mobility and UTI (urinary tract infection). Interventions included for staff to provide up to extensive assistance with bed mobility, dressing, toilet use, transfers, personal hygiene and locomotion on and off unit. Another care plan dated July 26, 2024 included that the resident had bowel/bladder incontinence related to dementia and impaired mobility. Intervention included to monitor/document for signs/symptoms of UTI. The late entry NP (nurse practitioner) progress note dated August 7, 2024 revealed the resident had been having nausea and vomiting, had IV (intravenous) fluid running and had a pending urine culture. Assessment included leukocytosis. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The nutritional care plan revised on August 10, 2024 included the resident had potential nutritional problem and required diuretic treatment with fluid related weight changes and abnormal labs expected. Interventions included to obtain and monitor lab/diagnostic work as ordered, to report results to the physician and to follow-up as indicated. Review of physician order dated August 16, 2024 revealed an order for a urine culture and sensitivity for leukocytosis for 2 days. This order was transcribed onto the MAR for August 2024 and revealed documentation was coded as 1 indicating refusal on August 18, 2024 Review of the nursing progress note dated August 19, 2024 revealed that the urinalysis (UA) result was back; and that, the NP was notified. Per the documentation, there were no new orders and will wait for culture and sensitivity result. The UA result with collection date of August 19, 2024 revealed abnormal results: moderate leukocyte, trace protein and trace-intact blood. It also included a final urine culture result of >100,000 CFU/ml (colony-forming units per milliliter) of Klebsiella pneumoniae (bacteria) ESBL (Extended-spectrum beta-lactamases). Per the documentation, the lab result had a report date of August 22, 2024. Despite documentation of the laboratory result, the clinical record revealed no evidence that treatment was provided and started from August 22, 2024 to August 28, 2024. There was also no evidence found that the physician was notified of the urine culture result from August 22 through August 27, 2024. The physician progress notes on August 28, 2024 at 8:21 a.m. included that the physician was asked to see the resident due to concerns for change in mental status. Per the documentation, the resident's family had been requesting blood work because the family thought that the resident had UTI as the resident's mental status changed. Per the documentation, urinalysis was reviewed and showed positive for UTI; and that, the resident was not at her baseline during the visit. Assessments included leukocytosis and UTI - Klebsiella. Plans were to start on oral antibiotics for underlying UTI; and if the clinical picture changes will start IV antibiotics; and, consider starting IV fluids for volume contraction. The nursing note dated August 28, 2024 revealed that the resident's family was notified of the UA results and the starting of the oral antibiotics. The physician order dated August 28, 2024 revealed an order for Amoxicillin-Pot Clavulanate (antibiotic) 875-125 mg (milligram) give 1 tablet by mouth every 12 hours for bacterial infection for 10 days. This order was transcribed onto the MAR but was also marked as pending confirmation. There is no evidence found in the clinical record that the antibiotic was administered to the resident. A nursing progress note dated August 29, 2024 at 4:25 a.m. revealed that Resident #91 had UTI and was ordered amoxicillin; and that, the resident became unresponsive, was spasming, had fluctuating vitals and could not swallow her antibiotics. Per the documentation, physician requested for the resident to be sent out to the hospital. An interview was conducted on August 29, 2024 at 1:38 p.m. with a licensed practical nurse (LPN/staff #31) who stated that it was the responsibility of the nurse to tell oncoming staff about pending labs during nurse to nurse report; and that, the nurses should check the lab book to be aware of pending labs for residents under their care. The LPN said that in order to check the status of lab results, a nurse can call and ask the lab or check in the electronic health record (EHR) under the results tab. She also stated that urine cultures typically take 2-3 days before a result is received; and, once results were received, staff should immediately notify the physician and put a nursing note into the clinical record. In an interview with the DON conducted on August 30, 2024 at 10:27 a.m., the DON stated that lab results should be reported to the physician once the result is received. She said that the expectation was for nursing staff to look at any lab results throughout their shift and notify the physician of any changes or new results. Regarding resident #91, the DON stated that the most recent urine culture result was received on August 22, 2024; but stated that the result did not seem right and would call in the Infection Preventionist to address this lab result. An interview with the DON and the Infection Preventionist (IP/staff #97) was conducted on August 30, 2024 at 10:44 a.m. The IP stated that sometimes the lab results do not reflect correctly in the EHR; and that, the urine culture result for resident #91 was received on August 28, 2024 and not on August 22, 2024 as noted in the EHR. Further, the DON stated that it was important to address things when made aware; however, she does not believe that the resident's lab result was reported to the facility until August 28, 2024. A telephone interview was conducted on August 30, 2024 at 10:50 a.m. with a representative from the laboratory where the urinalysis and urine culture of resident #91 was processed. The lab representative stated that the laboratory order for a urine culture for resident #91 was received by the lab on August 19, 2024; and, the results were reported to the facility on [DATE] at 11:44 a.m. The lab representative further stated that any results sent to the facility would be available in their EHR within a few minutes. On August 30, 2024 at 12:46 p.m., the DON presented an email correspondence from the laboratory's Director of Sales and Marketing who wrote that laboratory was investigating the laboratory results for requisition for resident #91. The email also included that the laboratory had received the lab request on August 19, 2024 with the final report being reported on August 22, 2024 at 11:44 a.m. In a telephone interview with the laboratory customer service representative conducted on September 3, 2024 at 10:16 a.m., he stated that urine cultures normally take 3-4 days but that results are instantly reported to the facility. Further, the lab customer service representative stated that the urine culture result for resident #91 was reported to the facility on [DATE]. Review of the facility policy titled Change of Condition Reporting revealed that all changes in resident condition should be communicated to the physician and documented. This policy further specifies that changes such as changes in behavior and abnormal laboratory results should be communicated to the provider promptly, and the notification should be documented.

Based on clinical record review, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent a fall with injury. The deficient practice resulted in a fall with injury. Findings include: Resident #1 was readmitted on [DATE] with diagnoses that included epilepsy, personal history of traumatic brain injury (TBI), hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side. A care plan initiated on March 29, 2023 included the resident had ADL (activities of daily living) self-care performance deficit related to TBI and was at risk for falls related to right sided weakness. Interventions included two-staff participation with transfers and wearing of safety helmet, frequent reminder to allow staff to supervise while ambulating, call light be within reach, encourage to call for assistance as needed, wearing appropriate footwear when ambulating or wheeling in wheelchair and keeping needed items such as water in reach. The care plan dated April 7, 2023 included the resident had bowel/bladder incontinence related to impaired mobility. Interventions included to ensure there was an unobstructed path to the bathroom. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The MDS assessment also indicated that the resident required limited one person assist for transfers, walking, and locomotion and used a walker and/or wheelchair as mobility devices. The discharge note dated July 21, 2023 included the resident left facility and was transported by a family member for a brain surgery. Per the documentation, the resident's vitals were stable with no acute distress and the provider was aware of surgery. A physician order dated July 24, 2023 included for the bed may be placed against the wall to increase living space in room. A fall risk evaluation dated July 24, 2023 revealed a score of 14 indicating the resident was high risk for fall. The assessment included the resident has had a history of 1-2 falls in the past three months, had balance problem while standing/walking, decreased muscular coordination/jerking movements, change in gait pattern when walking, and required use of assistive devise. A physician note dated July 24, 2023 revealed the resident had left-sided cranioplasty on July 21, 2023; and that, during hospitalization , the resident had a seizure-like episode in the recovery room after surgery and was transferred to ICU (Intensive Care Unit) for close monitoring and neurocritical care. Per the documentation, during the physician's examination at the day of discharge, the resident did not require oxygen, denied shortness of breath, chest pain, nausea, vomiting, diarrhea, fevers, or loss of consciousness. Assessment included CCM (Cerebral cavernous malformations) medical management treatment and plan. The plan was to continue seizure precautions per facility, follow up with neuro surgery/neuro as outpatient, and fall precaution. A nursing note dated July 25, 2023 included skin examination for re-admission revealed an incision to left side of head from temple to mid-forehead in a C-shape, approximately 25 centimeters long, with approximately 42 staples in place, was open to air, with no redness, drainage or separation noted along incision. It also included that there were no signs/symptoms of infection, non-tender to touch and the resident denied pain. Further, the documentation included that the resident had non-skid socks in place and bed in low position. The skin care plan dated July 26, 2023 included that the resident had actual impairment to skin integrity related to surgical wound to scalp with staples. Interventions included to follow facility protocols for treatment of injury. The condition follow-up note dated July 26, 2023 revealed resident was monitored for readmission s/p (status post) skull bone flap replacement and postoperative seizure activity. A condition follow-up note dated July 27, 2023 indicated that the resident was monitored for readmission s/p skull bone flap replacement and postoperative seizure activity. Per the documentation, no distress, seizure activity was noted or reported and the staples to scalp were intact with no signs/symptoms of infection. It also included that resident tolerated all medications and the vitals were within normal limits. The physician progress note dated July 31, 2023 included the resident was alert and oriented x2, had surgical scar to the left side of the head and had right hemiparesis. Assessments included history of SDH/SAH (Subdural hemorrhage/subarachnoid hemorrhage) s/s decompressive craniectomy; s/p cranioplasty on July 21; and, generalized weakness. Plan was CCM medical management treatment and plan and fall precautions. Review of the comprehensive care plan did not include any focus of care, goals, desired outcomes, and specific interventions related to the resident's recent cranioplasty from July 25 through August 2, 2023. A physician order dated August 3, 2023 included for an order that the bed may be placed in appropriate position for safety. The comprehensive care plan was revised on August 3, 2023 to include the following interventions initiated: -Anticipate and meet needs; -Bed in appropriate position for safety; -Educate resident/family about safety reminders and what to do if a fall occurs; -Follow facility fall protocol; -Maintain a clear pathway, free of obstacles; -May place bed against wall to increase living space in room; -Encourage to use bell to call for assistance; -Converse with resident while providing care; and, -Explain all procedures/task before starting. A Nurse Practitioner (NP) progress note dated August 8, 2023 included that the resident was up in chair, ambulated independently and denied pain/headache. Physical exam of the skin noted surgical scar to left side of head. Another NP progress note dated August 15, 2023 revealed the resident was up and ambulating on unit and was talking more clearly; and that, the nurse reported that he resident's pulse was sometimes low due to propranolol. Physical exam of skin noted surgical scar to left side of head. Assessment was CCM medical management treatment and plan. Plan included to continue seizure precautions-per facility and fall precaution. Review of the fall risk evaluation dated August 18, 2023 revealed a fall risk score of 9 indicating medium risk for falls. The assessment also included the resident had a history of 1-2 falls in the past three months, had balance problem while standing/walking, decreased muscular coordination/jerking movements, and change in gait pattern when walking. A nursing note dated August 18, 2023 included that the nurse heard a loud noise in resident's room and upon entering found the resident on the bathroom floor with head against the wall with significant amount of bleeding. Per the documentation, the resident reported that he tripped on commode that was in the bathroom; and that, 911 was called because resident had recent surgery to the head. A physician order dated August 18, 2023 revealed an order to send the resident to the ED (Emergency Department) for evaluation and treatment regarding fall. The nursing home to hospital transfer form dated August 18, 2023 included the resident was transferred to the hospital for a fall with injury. Under relevant information, there was no mention that the resident had a recent cranioplasty. Review of the fire department incident report revealed that on August 18, 2023 revealed the resident was found on the floor in the bathroom with head dressed and bandaged. Per the documentation, resident had moderate amount of blood on his head and face, would occasionally moan but was unresponsive to verbal stimulus. Detailed findings included bleeding, deformity, laceration and swelling to the head. The documentation also included that the laceration was approximately 6 inches long was full thickness with brain matter protruding from the wound. The report also included that the resident's initial acuity was Critical /Immediate; and that, after assessment and treatment, the resident's final acuity was unchanged. It also included that the resident was transported to the hospital emergency department. An undated graphic photo provided by the complainant revealed that the resident was lying down with leads on his chest, nasal cannula on his nose and blood-stained gauze was lying beside the resident's head. The photo revealed the resident had dried blood stain on his forehead and deep laceration extending from the top of his forehead just by the hairline to almost the length of the top of his head with the wound opened and something white was protruding from the open wound on the top of the head. The facility's incident report with a locked date of August 21, 2023 included that on August 18, 2023 a loud noise was heard in the resident's room and the resident was found in the bathroom floor with his head against the wall and had significant amount of bleeding. The report included that the resident described that he tripped over a commode that was in the bathroom. Further review of the fall risk care plan revealed that the intervention of frequent safety checks and frequent reminder to allow staff to supervise while ambulating was not initiated until August 18, 2023. An IDT (interdisciplinary team) fall committee note dated August 21, 2023 revealed the resident had a fall incident on August 18, 2023, was found on the floor in his bathroom and had a laceration to his head. Per the documentation, 911 was called due to recent craniotomy and resident was admitted to the hospital. The documentation also included that resident reported that he tripped on his commode while getting off the toilet and fell forward. Per the documentation, the commode was in place to raise the toilet seat to an appropriate height for the resident. Further, the note revealed that the resident was ambulatory with supervision with no assistance, had a recent left craniotomy and had history of TBI with decompressive craniotomy, seizure disorder; and, worked with therapy for strengthening. It also included that resident will often get up alone and walk around his room and staff provided frequent safety reminders and redirection. However, review of the clinical record revealed no documentation that resident #1 was provided safety reminders, redirection, or education regarding ambulating without supervision/assistance. During an interview with a licensed practical nurse (LPN/staff #5) conducted on August 25, 2023 at 1:35 pm, the LPN stated that interventions for residents at risk for fall included frequent checks and lots of education if the resident were alert and oriented. The LPN said that an incident report is completed following a fall; and, if the fall was unwitnessed then neuro checks were also completed. The LPN said that even when the fall was witnessed but if the resident hits their head, neuro checks and assessments were completed. Regarding resident #1, the LPN said that he was familiar with resident #1 who was new at the facility for rehabilitation and was moved to North station. The LPN said that resident #1 was a very pleasant man who was making great strides with rehab, was improving his vocabulary and making daily improvements with regards to being able to do things for himself; and that, the resident was highly motivated. The LPN said that resident #1 had a surgery in which part of the resident's skull removed and replaced; and that, the suture line was healing. He stated that the resident's room was close to the nurse's station; and that, there were no orders for mat on the floor. He said sometimes, the resident would call for help and sometimes would not call for help and those were the times that he had to be reminded. The LPN said that resident #1 was a standby assist; and that, resident #1 normally listens when told not to get up and wait. However, the LPN said that the resident does try to get up. He also said that maybe if he had gotten to the room to give the resident his medications 10 seconds prior or if somebody saw him getting up, then resident #1 would have been reminded and he would not have gotten up and fell . The LPN said that certified nursing assistants (CNAs) and the nurses conduct rounds on the resident but staff was him frequently and so were the nurses. He stated that resident #1 was not on a specific rounding timeframe. However, since resident #1's roommate was actively passing, there were always people there. Regarding the fall incident, the LPN said that the interventions in place at the time of the resident's fall included frequent reminders and education since the resident needed constant reminder, call for help (resident would acknowledge that it was important) and bed was in low position. At the time of the fall, the LPN said that he was in the process of preparing the resident's medication when he heard a loud noise and he went to the resident's room and found that the resident was not in bed. The LPN said that he tapped on the door and when he opened the door, the resident was on the floor leading to the restroom; and that, the resident was putting 2-3 words together. The LPN stated that he then applied pressure to the wound and asked the resident what happened; and that, the resident kept mixing his words and kept pointing to the commode, was not sensible, and spoke in a lower tone compared to his normal voice. Further, the LPN stated that prior to the resident's fall, the suture line to the resident's wound was healed and nothing was open, the staples had been removed. However, after the fall, it looked like there was a significant wound and there was a lot of bleeding so he yelled for 911 to be called. The LPN said that the resident's wound was right in the frontal area about a centimeter from the healed suture line and that skin on the head being pulled back a little. The LPN stated he could not tell how deep the wound was but that it had some thickness to it and was a pretty good laceration. Further, the LPN said that he applied pressure and waited for 911 since the wound looked beyond his scope of care. The LPN said that he was not aware that the resident was not back yet; and that, he thought the resident was coming back the same day. He said that he last spoke to the resident's family who told him that they were waiting for the test results then the resident would come back to the facility. However, the LPN said that when another nurse called the hospital on Tuesday, August 22, 2023, the nurse was told that the resident was on life support and there were brain matter coming out of his skull. The LPN said that this information was not confirmed. An interview with a CNA (staff #10) was conducted on August 25, 2023 at 2:09 p.m. Staff #10 stated that interventions for fall risk resident usually consisted of: redirecting and assisting them, letting them know how to use the call light and ask for assistance, help them get into bed, and ensure call light was within reach. The CNA noted that some residents are care planned to have mat on the floor and/or bed lowered to the floor. Staff #10 stated that she was familiar with resident #1 and that he was a pleasant man who had to be redirected several times. She said resident #1 is supposed to use his wheelchair to ambulate. However, resident #1 walks around without his wheelchair. Since resident #1 is unstable, he has to be told not to get up without using a wheelchair so he does not fall. Staff #10 stated that when resident #1 is left alone, he then gets up without the wheelchair and walks instead. She said that resident had a fall; and, when the fall occurred, she was across the hall and heard a bump and a nurse yelling for help and she took the resident's vitals. The CNA said that the nurse asked resident #1 what happened and resident said he got up, tripped on the commode and hit his head. The CNA said there was blood everywhere and they put pressure on the resident's head and called 911. She stated that one person was taking vitals, and another nurse and another CNA were helping. The CNA said that she heard the resident say that he tripped and hit himself on the wall which was contradicting what the LPN (staff #5) had said regarding resident's ability to say what happened. The CNA stated that the interventions in place for resident #1 at the time of the incident included call light in place, mat on the floor, lowered bed, ensure that things resident needs were within reach to prevent him from doing things he was not supposed to, and redirect if resident does things that are not safe. The CNA further stated that she does not think there was anything that could have been done to prevent the resident from falling. A phone interview with another LPN (staff #15) was conducted on August 28, 2023 at 8:59 a.m. She stated that upon admission residents are assessed for fall risk and based on this, they determine if there are orders for safety. She said that safety education is provided if resident is coherent enough to agree; and that, they also do a toilet schedule and fall risk management. Staff #15 stated that she only took care of resident #1 twice; and that, resident #1 just sat at the side of the bed and listened to music and seemed to respond better in Spanish. She stated that during the night shift, resident #1 asks for help before getting up and would turn on his call light. Staff #15 stated that resident #1 suffered a fall the morning before she returned to shift. Staff #15 said that at the time of the fall, the fall interventions in place for resident #1 included toilet schedule, might have had a mat on the floor but she was not sure, and was care planned for safety. She stated that since she was always in the hall, when she worked with him, she checked on him approximately every 45 minutes. Staff #15 stated that for the night shift, resident #1 was pretty compliant. However, she was not sure if it was the same for the day shift. Staff #15 stated that when she cared for him, resident #1 had a large incision on his head, but it was healing, there was no drainage or anything open. During an interview with the Director of Nursing (DON/staff #50) conducted on August 28, 2023 at 2:03 p.m., the DON stated that her expectation was for staff to identify residents' risk for falls and implement interventions that are ordered and care planned. She stated that the interventions for fall risk residents depends on the resident and the evaluation. The DON said that her expectation was for staff to identify who the high-risk residents are and follow physician's orders for interventions, conduct frequent checks for safety, ensure items are within reach and to toilet resident frequently. Furthermore, the DON said that if an intervention was not working, they meet as IDT (interdisciplinary team) to create new interventions and that if a resident wants to lay on the floor, that would be included in the care plan. The DON said that it also her expectation a risk management is completed in the electronic record following a fall incident; and that, there are IDT notes in the electronic record, the team reviews information during standup, talk about interventions, and discuss during weekly fall meeting on Friday for opportunities and trends. She also said that it is expected that new interventions are put in place after a fall incident and the interventions are based on the assessed needs of the resident. She stated that if a resident fell and goes to the ER (emergency room ) then that was an intervention and they would reevaluate the interventions when the resident returns. Regarding resident #1, the DON stated that she was not too familiar with resident #1 without looking at his clinical record; however, she stated that she knew the resident and that the resident was working with therapy. Further, the DON stated that resident #1 was encouraged to use call light but gets up on his own and had to be redirected. The facility policy titled Fall Management System reviewed June 2023 indicated that it was their policy to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Furthermore, residents with a fall risk eval score of 10 or above are considered high risk and will have an individualized care plan developed which includes measurable objectives and timeframes. The policy also included that the care plan interventions will be developed to manage falls and will consider the particular elements of the assessment that put the resident as risk. Review of the facility policy titled Documentation and Charting revised July 2022 revealed that it is their policy to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care. The facility policy on Comprehensive Person-Centered Care Planning reviewed October 2022 stated that comprehensive care plan will include resident's needs identified in the comprehensive assessment and any specialized services, resident's goals, and desired outcomes.

Based on closed clinical record review, staff interview, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure the MDS (Minimum Data Set) assessment was accurate for one resident (#121). The sample size was 25. The deficient practice could result in an inaccurate assessment and resident not receiving the appropriate care and services needed. Findings include: Resident # 121 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, down syndrome, restlessness and agitation, adult failure to thrive, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, syndrome of inappropriate secretion of antidiuretic hormone, hyperkeratosis of [NAME], and personal history of urinary (tract) infections. An Admission Minimum Data Set (MDS) dated [DATE] for Resident # 121 included that the Brief Interview for Mental Status (BIMS) was not conducted because the resident was rarely/never understood. The assessment included that the resident had an ok short- and long-term memory with memory/recall ability for staff names and faces only. The assessment included that the resident's cognitive skills for daily decision making was severely impaired. The assessment included that the resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The assessment included that the resident did not have oxygen while not a resident or while a resident. Review of the clinical record revealed the following provider orders: -CHECK O2 SATS (oxygen saturations) every shift and apply oxygen when SATs are <90% -Continuous Oxygen- Titrate between 1 and 5 LPM (liters per minute) VIA NC (nasal cannula) to maintain O2(oxygen) SATS (oxygen blood saturation) OVER 90% every night shift for sleep apnea (ordered 12/3/2022) -Transfer to hospital one time only for SOB (shortness of breath), Low O2 (oxygen) Review of the clinical record revealed the following vital signs: -Oxygen Saturations: --11/30/2022 5:05 pm 94.0 % on room air --12/2/2022 1:31 am 92.0 % while on oxygen via nasal cannula --All values within normal limits from 12/2-12/14 --12/14/2022 11:06 am 96.0 % Room Air --12/14/2022 12:09 am 85.0 % Room Air A Nursing note dated December 1, 2022 at 6:42 pm included that the resident's oxygen saturation was 85%. The note included that the nurse that wrote the note provided oxygen via simple mask at 5 liters per minute. Review of the Medication Administration Record (MAR) for December 2022 revealed resident #121 was administered oxygen at 2 LPM (liters per minute) on December 3 and 4, 2022. During an interview conducted on February 2, 2023 10:17 am with a MDS nurse (staff #146), staff #146 stated that on the day of admission she looks at hospital records, notes, assessments, and the resident to complete the 7 day look back period. Staff #146 stated the MDS is responsible for triggering care areas on the care plan. Staff #146 stated that oxygen should have been coded on the MDS. An interview was conducted on February 2, 2023 at 10:52 am with the Director of Nursing (DON/staff #11). The DON stated that care plans are generated from the MDS assessment and as resident needs change. The DON stated that the expectation is the MDS be accurate at the time of the assessment. The DON stated that the oxygen should have been captured on the MDS for resident #121. A facility policy titled Resident Assessments (revised 5/2022) included that it is the policy of this facility that resident assessments shall be developed and reviewed on a timely basis based on resident condition and RAI guidelines. The RAI manual revealed steps for assessment of special treatments that stated to code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula.

Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure that comprehensive care plans were developed for one resident (#121) using oxygen therapy. The deficient practice could result in residents needs based on the comprehensive assessment not being met. Resident # 121 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, down syndrome, restlessness and agitation, adult failure to thrive, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, syndrome of inappropriate secretion of antidiuretic hormone, hyperkeratosis of [NAME], and personal history of urinary (tract) infections. An Admission Minimum Data Set (MDS) dated [DATE] for Resident # 121 included that the Brief Interview for Mental Status (BIMS) was not conducted because the resident was rarely/never understood. The assessment included that the resident had an ok short- and long-term memory with memory/recall ability for staff names and faces only. The assessment included that the resident's cognitive skills for daily decision making was severely impaired. The assessment included that the resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The assessment included that the resident did not have oxygen while not a resident or while a resident. Review of the clinical record revealed no documentation of a care plan for oxygen use or respiratory. Review of the clinical record revealed the following provider orders: -CHECK O2 SATS (oxygen saturations) every shift and apply oxygen when SATs are <90% -Continuous Oxygen- Titrate between 1 and 5 LPM (liters per minute) VIA NC (nasal cannula) to maintain O2(oxygen) SATS (oxygen blood saturation) OVER 90% every night shift for sleep apnea (ordered 12/3/2022) -Transfer to hospital one time only for SOB (shortness of breath), Low O2 (oxygen) Review of the clinical record revealed the following vital signs: -Oxygen Saturations: --11/30/2022 5:05 pm 94.0 % on room air --12/2/2022 1:31 am 92.0 % while on oxygen via nasal cannula --All values within normal limits from 12/2-12/14 --12/14/2022 11:06 am 96.0 % Room Air --12/14/2022 12:09 am 85.0 % Room Air A Nursing note dated December 1, 2022 at 6:42 pm included that the resident's oxygen saturation was 85%. The note included that the nurse that wrote the note provided oxygen via simple mask at 5 liters per minute. Review of the Medication Administration Record (MAR) for December 2022 revealed resident #121 was administered oxygen at 2 LPM (liters per minute) on December 3 and 4, 2022. During an interview conducted on February 2, 2023 10:17 am with a MDS nurse (staff #146), staff #146 stated that on the day of admission she looks at hospital records, notes, assessments, and the resident to complete the 7 day look back period. Staff #146 stated the MDS is responsible for triggering care areas on the care plan. Staff #146 stated that oxygen should have been coded on the MDS. An interview was conducted on February 2, 2023 at 10:38 am with a Licensed Practical Nurse (LPN/staff #118). Staff #118 stated that when there is an admission order or a change of condition that results in an order for a new treatment, that treatment is added to the care plan. Staff #118 stated that he would have updated the care plan to include oxygen for resident #121. An interview was conducted on February 2, 2023 at 10:52 am with the Director of Nursing (DON/staff #11). The DON stated that care plans are generated from the MDS assessment and as resident needs change. The DON stated that the expectation is the MDS be accurate at the time of the assessment. The DON stated that the oxygen should have been captured on the MDS for resident #121. A facility policy titled Care Planning (revised 11/22) included that it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be revised as needed and interventions will be implemented. The care plan will be revised as needed for order changes or resident changes in condition and interventions will be implemented as appropriate.

Based on review of clinical records, staff interviews, and facility policies and procedures, the facility provided a psychotropic medication for Bipolar disorder for one resident (#72) without a diagnosis of Bipolar disorder: Findings include: Resident # 72 was admitted on [DATE] with diagnoses that included unspecified fracture of right calcaneus, subsequent encounter for fracture with routine healing, other viral pneumonia, other coronavirus as the cause of diseases classified elsewhere, acute respiratory failure with hypoxia, urinary tract infection, site not specified, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic neuropathy, asthma, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, chronic kidney disease, stage 4 (severe), long term (current) use of insulin, obesity, depression, long term (current) use of anticoagulants, fibromyalgia, and dysphagia. Review of the clinical record revealed no diagnosis of bipolar disorder. Review of the clinical record revealed the following provider order: -ARIPiprazole (used to treat certain mental/mood disorders such as bipolar disorder) Oral Tablet 2 MG (ordered 1/15/2023), give 1 tablet by mouth one time a day for bipolar disorder aeb (as evidenced by) mood lability Review of the Medication Administration Record (MAR) for January 2023 revealed that resident #72 was administered ARIPiprazole from January 16 through 31, 2023. A care plan initiated on January 15, 2023 for psychotropic medication use related to bipolar disorder included goals that the resident would be free from drug related complications and would have decreased episodes of mood lability. The interventions for these goals included administering medications as ordered, monitor for target behavior symptoms, and discuss with medical doctor for ongoing need of medication. A BHS (behavioral health service) provider note dated January 31, 2023 at 11:59 am included that the resident had a diagnosis of major depressive disorder, single episode. Review of the provider note dated January 31, 2023 did not include any documentation of a diagnosis of bipolar disorder. An interview was conducted on February 2, 2023 at 10:38 am with a Licensed Practical Nurse (LPN/staff #118). Staff #118 stated that when a psychotropic medication is ordered the he would verify the order, obtain a consent from the resident or representative, and verify the diagnosis. Staff #118 stated that there is no diagnosis of bipolar in the clinical record that he found for resident #72. An interview was conducted on February 2, 2023 at 10:52 am with the Director of Nursing (DON/staff #11). The DON stated that the expectation of the staff is to make sure psychotropic medications are administered as ordered. The DON stated that the staff need to obtain consents, verify the orders, and monitor the resident for the behaviors or moods to make sure the medication is treating the diagnosis associated with the order. The DON stated that resident #72 does not have a diagnosis of bipolar. A facility policy titled Psychoactive Medication (revised 11/2022) included that a physician's order is necessary for the use of a psychoactive medication. Psychoactive medications are to be administered only when required to treat the resident's medical symptoms. No psychoactive medications will be utilized without a specific physician's order, or without a diagnosed specific condition, and will include the target behavior.

Based on observations, staff interviews, record review, and policy reviews, the facility failed to ensure infection control practices were followed. The deficient practice could result in the spread of infection, including COVID-19. Findings include: An entrance conference was conducted with the Director of Nursing (DON/ staff #101) on August 15, 2022 at 8:25 AM. The DON stated that the facility was currently in an outbreak due to 4 residents that had tested positive for COVID-19. Further, she explained that the facility protocol was to place newly admitted residents and residents that were not up to date on their COVID-19 vaccinations on contact and droplet precautions for a 10-day observation period. The DON stated the facility had multiple rooms that were ordered contact and droplet precautions. She explained that residents are placed on precautions if they have not completed their COVID-19 vaccination series or the residents are not up to date on their COVID-19 vaccinations which included all of the CDC recommended booster dosages. Further, she stated that residents are placed on the contact and droplet precautions for 10 days then the resident's physicians' orders are discontinued and then the resident can come out of their rooms. The DON provided the surveyor with a facility map that had identified the 6 resident rooms that were on precautions for the 10-day observation period. On August 15, 2022 at 10:45 AM an observation was conducted of a resident #10's room. The room that was observed was designated on the provided map as on contact and droplet precautions; however, there was no signage on the door, and there was not a cart outside the door for personal protective equipment (PPE). The room was observed with two female staff members inside of the room. The staff members appeared to be assisting the resident with rehabilitative services. Additionally, the two staff members were observed wearing N95 masks and gloves. The two staff members were observed without wearing a gown or protective eyewear while conducting rehab services with the resident. An interview was conducted on August 15, 2022 at 11:38 AM with Certified Nursing Assistant (CNA/staff# 120). The CNA stated that if a resident is on precautions for COVID-19 or observations because they (the residents) are newly admitted , then they are required to be on contact and droplet precautions. Further, the CNA explained that the nursing staff is notified at the beginning of the shift what residents require precautions. Additionally, the CNA stated that staff will also see signs hanging near the residents' room that indicate what type of precautions such as Contact or Droplet precautions. The CNA stated that the signs are to notify anyone entering the room that the resident may have increased risk of infection. Further, he stated that if there is not the appropriate signage at the door and the resident needed to be on precautions, then there would be an increased risk to spread COVID-19. The CNA stated that both staff and residents can spread infection even if the resident does not have any symptoms. The CNA also stated that when a resident is on contact and droplet precautions anyone entering the room is required to wear a gown, gloves, an N95 mask, and protective eyewear to decrease the risk of transmission. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of the room for resident #16 was conducted on August 15, 2022 at 11:50 AM. The resident was near the entry to the room without a mask on. A female staff member was walking past and reminded resident #16 to scoot a little further into the room because she did not have a mask. Additionally, the staff member was noted to remind the resident that she was on precautions. The room was noted to have multiple signs near the door. There was a sign for contact and droplet precautions and more signs for instructions on how to don PPE. Additionally, there was a PPE cart near the doorway Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the COVID unit in the facility was conducted on August 15, 2022 at 11:55 AM. The room for resident #3 was observed with signage for the door indicating that the resident was on contact and droplet precautions. Outside of the room there was a PPE cart and the residents' room were located in the COVID unit. Review of the physicians' orders for resident #3 revealed an order that started on August 2, 2022 and was discontinued on August 12, 2022 however, the resident had continued being isolated in the COVID unit after the order had discontinued. An interview with the facility's Infection Preventionist (IP/staff # 89) was conducted on August 15, 2022 at 2:00 PM. The IP stated that the facility's protocol for newly admitted residents is to place them on contact and droplet precautions for an observation period of 10 days to make sure that the resident does not have COVID- 19 and that they classify them as COVID unknown. Further, she stated that when a resident is on contact precautions, then the staff is required to wear gloves, a gown and a surgical mask. She explained that in addition to contact precautions the addition of droplet precautions indicates that the staff should be wearing all the safe PPE as contact, but add an N95 mask and protective eyewear. Additionally, the IP added that she conducts walking rounds to assure that there is appropriate signage on resident rooms and that the PPE carts are stocked with the required equipment. The IP stated that any resident that is not up to date with the COVID-19 vaccination and is newly admitted is required to have physicians' orders for droplet and contact precautions for 10 days. Additionally, she stated that the appropriate signage is required to be on the door. The IP further stated that if there are not physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP explained that if a resident's COVID status is unknown and the staff or visitors were not wearing the required PPE, that the risk to spread infection increases. Another interview with the DON (staff #101) was conducted on August 15, 2022 at 2:20 PM. The DON stated that her expectation is that residents that are new admits should have their vaccinations reviewed and then get orders form the physician to place the resident on a 10-quarantine period for contact and droplet precautions. She explained that the room should be set up with biohazard bins inside the room and doffing instructions inside the room. Further, she stated she would expect the room to have a sign for what type of precautions were ordered outside of the room and further there should be signs for how to don PPE. Further, the DON stated that if a resident is on any type of precautions then they should have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that not following the protocol for precautions would result in an increased risk to staff, residents, and visitors to spread infection. The policy Sun West Choice Health and Rehabilitation Infection Control and Prevention Policy includes residents with confirmed [CONDITION(S)]-CoV-2 infection who have not met criteria for discontinuation of Transmission-Based Precautions should be placed in the designated COVID-19 care unit. In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The Policy: Sun West Choice Health and Rehabilitation Center Section: Administration, Subject: COVID 19 Pandemic includes: To ensure that all new admits/readmits entering the facility that are COVID unknown, not recovered, or are not up to date with COVID 19 vaccines per CDC will be placed on COVID-19 precautions---contact/droplet precautions will be followed for a period of 10 days (or otherwise updated by CDC and local guidelines) at time of admission. New admits/readmits should not leave the room during the l 10 days if possible.

Based on review of the State Agency database, State Operations Manuel, clinical record review, staff interviews, and facility policies and procedures, the facility failed ensure that residents' private space was not photographed on a personal electronic device by a Certified Nursing Assistant. The deficient practice could result in further violations of privacy for residents. Findings include: Review of the State Agency database revealed that on April 29, 2022 at 5:16 pm a Certified Nursing Assistant (CNA/staff #69) submitted a complaint that contained 10 photographs. Four of the photos included residents' body parts including two imagines of residents' naked bottoms with open areas and redness. Another photograph included a resident's room with personal photographs. During an interview conducted on May 2, 2022 at 5:15 pm with a Certified Nursing Assistant (CNA/staff #69), staff #69 stated that they still had the photographs they had submitted to the State Agency. Staff #69 stated that they had more photographs that they wanted to share but were unable to because the system would only allow 10 photographs to be uploaded. Staff #69 stated that the photographs were taken at the facility in resident rooms. Staff #69 stated that the photographs included imagines of resident #1, resident #2, resident #3 and resident #4. Staff #69 stated that they knew it was wrong to take the photographs but that they needed them to prove the neglect in care at the facility. Staff #69 stated that the photographs of the resident's bottoms were taken with the help of another CNA (staff #9). Staff #69 stated the photographs were taken in April of 2022. Review on an email dated May 2, 2022 at 7:54 pm from staff #69 to the State Agency included the names of resident #1, #2, #3, and #4 along with the resident's photographs. The email included another resident's first name but did not have a clear identification of the last name. The photographs included in the email showed resident bare bottoms with wounds and stool, a scrotum of a resident, a resident arm with multiple skin tears, a resident bed, stool on the floor, and a dirty adult diaper. Review of the State Operations Manuel revealed that photographs or recordings of a resident and/or his or her private space without the resident's or designated representative's written consent is a violation of the resident's right to privacy and confidentiality. An interview was conducted on May 5, 2022 at 11:52 am with the interim Director of Nursing (DON/staff #21) and a Clinical Resource nurse (staff #33). The DON stated that the expectation is that all staff respect and provide privacy to the residents. The DON stated that consent is obtained on admission to photograph the residents during activities. The DON stated the consent is not for taking pictures of the resident's private areas or any pictures of resident's naked in any state. The DON stated that photographs are not taken as part of the wound care documentation at this facility. The DON stated that a Certified Nursing Assistant (staff #69) was not instructed to take photographs of the residents and stated that no photographs were presented to the facility. The DON stated that the photographs violated the facility's policy on privacy for the residents. A facility policy titled Prohibition of Inappropriate Resident Photos or Videos included facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility. Nursing home residents have a right to personal privacy and confidentiality of their physical body and personal space, including accommodations and personal care. Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of this policy is to ensure that nursing facility staff do not violate these resident rights by taking, keeping, using or distributing photographs or video recordings that would demean or humiliate facility residents, including by sharing such images through social media. If a person has reasonable suspicion that a violation of this policy constitutes a crime committed against a facility resident, the person must report to the state survey agency and at least one law enforcement agency in accordance with the facility's policy on reporting suspicions of crimes against facility residents (the Elder Justice Act policy). Upon receiving a report or allegation of a potential violation of this policy, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPAA). Any such actual or potential violation will be managed as per the facility's HIPAA policies and procedures.

Based on review of the State Agency database, State Operations Manuel, clinical record review, staff interviews, and facility policies and procedures, the facility failed ensure that one staff member (#69) did not keep demeaning photographs of four vulnerable resident (#1, #2, #3, #4) on a personal electronic device. The deficient practice could result in further abuse of vulnerable residents. Finding include: Review of the State Agency database revealed that on April 29, 2022 at 5:16 pm a Certified Nursing Assistant (CNA/staff #69) submitted a complaint that contained 10 photographs. Four of the photos included residents' body parts including two imagines of residents' naked bottoms with open areas and redness. Another photograph included a resident's room with personal photographs. Review of the State Operations Manuel revealed that mental abuse includes abuse that is facilitated or enabled through the use of technology, such as smart phones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it is used, demeans or humiliates a resident(s), regardless of whether the resident provided consent and regardless of the resident's cognitive status, the surveyor must consider non-compliance related to abuse at this tag. This would include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the resident's face, labeling resident's pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position. Depending on what was photographed or recorded, physical and/or sexual abuse may also be identified. -Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on May 2, 2022 at 5:15 pm with a Certified Nursing Assistant (CNA/staff #69), staff #69 stated that they still had the photographs they had submitted to the State Agency. Staff #69 stated that they had more photographs that they wanted to share but were unable to because the system would only allow 10 photographs to be uploaded. Staff #69 stated that the photographs were taken at the facility in resident rooms. Staff #69 stated that the photographs included images of resident #1, resident #2, resident #3 and resident #4. Staff #69 stated that they knew it was wrong to take the photographs but that they needed them to prove the neglect in care at the facility. Staff #69 stated that the photographs of the residents' bottoms were taken with the help of another CNA (staff #9). Staff #69 stated the photographs were taken in April of 2022. During that interview, the surveyor asked staff #69 to submit all of the photographs in her possession to the State Agency. Review on an email dated May 2, 2022 at 7:54 pm from staff #69 to the State Agency included the names of resident #1, #2, #3, and #4 along with the residents' photographs. The email included another resident's first name but did not have a clear identification of the last name. The photographs included in the email showed resident bare bottoms with wounds and stool, a scrotum of a resident, a resident arm with multiple skin tears, a resident bed, stool on the floor, and a dirty adult diaper. Review of the email revealed that staff #69 was still in possession of the photographs taken at the facility. An interview was conducted on May 3, 2022 at 8:39 am with another Certified Nursing Assistant (CNA/staff #9). Staff #9 stated that staff #69 told him that a unit manager (staff #15) had asked her to take the photographs of the residents so staff #9 assisted with getting them. Staff #9 stated that he saw staff #69 showing someone from the leadership team the photographs but stated he did not know the name of the person. Staff #9 stated he did assist in holding the residents while staff #69 took the photographs. During an interview conducted on May 3, 2022 at 1:02 pm with a Unit Manager/Licensed Practical Nurse (LPN/staff #15), staff #15 stated that they had never instructed any staff member to take photographs of the residents for any reasons. During the interview, staff #15 was shown several of the photographs of residents and rooms that were taken by staff #69. Staff #15 was able to identify resident #1, resident #2, and resident #4 in the photographs, even without any face or other identifiers. An interview was conducted on May 5, 2022 at 11:52 am with the interim Director of Nursing (DON/staff #21) and a Clinical Resource nurse (staff #33). The DON stated that the expectation is that all staff respect and provide privacy to the residents. The DON stated that consent is obtained on admission to photograph the residents during activities. The DON stated the consent is not for taking pictures of the resident's private areas or any pictures of residents naked in any state. The DON stated that photographs are not taken as part of the wound care documentation at this facility. The DON stated that a Certified Nursing Assistant (staff #69) was not instructed to take photographs of the residents and stated that no photographs were presented to the facility. The DON stated that the photographs taken by the CNA violated the facility's policy on privacy for the residents. A facility policy titled Prohibition of Inappropriate Resident Photos or Videos included facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility. Nursing home residents have a right to personal privacy and confidentiality of their physical body and personal space, including accommodations and personal care. Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of this policy is to ensure that nursing facility staff do not violate these resident rights by taking, keeping, using or distributing photographs or video recordings that would demean or humiliate facility residents, including by sharing such images through social media. If a person has reasonable suspicion that a violation of this policy constitutes a crime committed against a facility resident, the person must report to the state survey agency and at least one law enforcement agency in accordance with the facility's policy on reporting suspicions of crimes against facility residents (the Elder Justice Act policy). Upon receiving a report or allegation of a potential violation of this policy, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act (HIPAA). Any such actual or potential violation will be managed as per the facility's HIPAA policies and procedures.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure that maintenance and housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior was provided for 7 residents (#24, #63, #11, #74, #31, #41, and #76). The census was 124. The deficient practice could result in resident rooms not having a homelike environment. Findings include: An observation was conducted on January 3, 2022 at 9:45 AM. The hallway and room of resident #24 and resident #63 were noted to have a foul odor. Under the window to the exterior wall of the residents' room and closest to resident #24's bed, wall paper was observed peeling from the base of the window downward to the floor in 2 areas. Behind the wallpaper that was peeling was an open hole in the wall. The hole was observed to be approximately 8 to 10 inches in width and 4 to 6 inches in height. The closet space provided for resident #24 had closet fixture pieces that were wire-like that were on the floor inside that closet, and broken plastic brackets inside of the closet. On the floor near the closet for resident #24 was a thick black substance on and around the baseboard. The corner of the closet was observed to have peeling plaster and wallpaper. At the base of the floor on the base trim was a small hole approximately 1 inch by 1 inch. Wall paper was observed peeling to the right and just under the sink in the room. The wallpaper to the right of the sink was observed to have red dry droplets noted in multiple areas in circular droplet shapes. Also observed were 2 holes in the ceiling and drywall pieces hanging down. The holes were approximately 1 inch and circular shaped over resident #63's bed. Observation of the closet space for resident #62 revealed metal trim exposed to the wall edge near the closet, and the baseboard trim was missing. Wallpaper peeling from the wall and plaster debris was observed on the floor. Resident #63 was observed with no pictures on the wall or in the resident's area and had one bedside table and a bed. The floor space of resident #63 was noted to have 3 dry brown smudges on the floor near the bed. On January 3, 2022 at 12:50 PM, the room for resident #11 was observed. An area approximately 3-4 feet wide from the ceiling to the top of the resident's bed was observed to have wallpaper that had been peeled off. To the left of the bed was a white fiberglass reinforced plastic panel covering the wall that had a hole next to bed at the base of the paneling. The wall was to the left of the resident's bed. An observation was conducted of resident #74's room on January 3, 2022 at 12:52 PM. The electrical outlet next to resident #74's bed was missing the electrical outlet cover plate. The metal outlet cover was sitting on the air conditioning unit to the left of the bed. The outlet was left exposed. Continued observation revealed resident #31's room was also observed with an outlet with no cover plate, the outlet was left exposed. The cover plate was near the air conditioning unit. The Regional Maintenance Director (staff #135) was notified immediately of the safety concern. He stated that this occurrence should be documented in the facilities TELS system for reporting and tracking maintenance repairs. Further, staff #135 stated that he would review the TELS system for work orders for the identified building repair concerns. During an observation conducted on January 4, 2022 at 9:22 AM, the hallway of rooms 137-148 was noted to have a noticeable smell of urine in the hallway. During an observation conducted on January 5, 2022 at 12:33 PM, the interior wall near the exit to the corridor in residents' #41 and #76 room had a brown crusted area to the wall near the light switch. The brown smudged area was observed to be circular and in multiple areas spreading approximately 8 to 10 inches. On January 6, 2022 at 8:46 AM, a door labeled electrical room was observed on the hallway. The outside of the door (in the hallway) was observed to have rust colored brown substance that ran down the door in three areas. The substance was dry and crusted and appeared to have ran approximately 6 inches from top to bottom. A second observation of resident #41 and #76 room was conducted on January 6, 2022 at 8:49 AM. The brown dry smudged substance near the light switch on the wall closest to the corridor was observed to still be there. An interview and observation were conducted on January 6, 2022 at 9:11 AM with the Administrator (staff #136) and the Maintenance Assistant (staff #117). The Maintenance Assistant stated that the facility was alerted to the hole in the wall in resident #24 and resident #63 room. Staff #177 stated that the facility staff replaced the drywall and there was no longer a hole in the exterior wall. Additionally, he stated that the maintenance team went around all of the rooms yesterday (January 5, 2021) and checked all of the light switch plates that were missing or broken and replaced them. Further, he stated that the ply wood under the sink in resident #24 and #63 room was placed there because a resident was pulling the plumbing from under the sink and that there were holes in the ceiling because another resident was pulling the curtains from the ceiling. Staff #117 stated that if the building needs repair he expects the staff on the floor to report it so it can be put into the TELS system for documentation. Additionally, he explained that he knows that is not the current practice. Further, he explained that the staff needs education so they can learn to report the building issues, so that repairs can be addressed. An additional interview was conducted on January 6, 2022 at 9:25 AM with the Maintenance Assistant (staff #117). The Maintenance Assistant stated that he and the Director of Maintenance are new to the facility and that they do not have records or further evidence to provide from the TELS system. Staff #117 stated that instead of utilizing the TELS system of a building repair that need to be completed, the maintenance staff would just go and fix it. Further, staff #117 stated that staff need more education regarding notifying the maintenance team of building repairs that are needed. He stated there are more floor staff to identify concerns than there are of the maintenance team. Staff #117 stated maintenance cannot go room to room every day to identify concerns. An interview was conducted with the Administrator (staff #136) on January 6, 2022 at 10:13 AM. Staff #136 stated that he was unaware of any family or visitor that has filed formal grievances related to the building repair needs. He stated that he expects staff to report any building repair concerns to the maintenance team. Further he stated that the facility utilizes TELS to track building repairs. He stated timeliness of getting repairs fixed is monitored by the leadership team. Further, he stated the TELS system is important to utilize because it helps the facility to be organized and helps staff keep track of things that need to be repaired. The Administrator stated that he was unaware if the TELS system had evidence that work orders were put in the system for the identified items brought to his attention on January 6, 2022 at 9:11 AM. In regards to the residents' room and environment, the Administrator stated that due to the COVID-19 pandemic the facility staff has had difficulty with resident behaviors and room items have had to be removed. Further, staff #136 stated that if there are any areas of concern regarding cleanliness such as brown smeared substance or liquids dried to the walls, he expects the staff to clean it off of the walls using the appropriate disinfectants. On January 6, 2022 at 12:54 PM, an interview was conducted with the Regional Maintenance Director (staff #135). He stated that the facility TELS system does not have any work tickets for any wallpaper or structural holes building concerns. He stated that he has reviewed the TELS system work orders and that the facility has only been entering work tickets for broken beds, televisions that were not working, and call lights. Further, he stated that he recognized that there was a need for housekeepers that are in the rooms every day to be provided education to report building concerns because there are increased risks for missing needed building repairs. Review of the facility policy regarding maintenance requests and work orders revised November 2016 stated it is the policy of this facility to maintain a clean, well repaired building, and provide staff to report any issues needing attention. All work request must be in form of work orders, not verbal (unless emergency situations). The facility uses electronic work orders through TELS. TELS can be accessed through manager's computers, Kiosk, PCC (point click care), and at the nurses' station. Give complete information on all work orders, include what, where, and who is reporting. The facility's infection control policy titled Housekeeping Services revised May 2021 stated it is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI). The housekeeping supervisor will implement effective systems of environmental sanitation, including a regular cleaning schedule for all areas. The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices and high standards of cleanliness. In-service training programs will be held for new personnel as well as older employees for the purpose of introducing them to new techniques and skills. Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. Doorknobs, handrails, bath rails, sink handles, etc. will all be cleaned at least once daily and more often as needed. Cleaning of walls, curtains, blinds, etc. will be completed when dust/soil is visible. The facility policy titled Physical Environment Equipment Maintenance reviewed May 2021 stated it is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety. Electrical and hydraulic equipment will be inspected by the Maintenance Supervisor prior to initial use and on a routine basis to ensure that equipment is working properly. The Maintenance Supervisor will carry out routine maintenance on specified program equipment, as per manufacturer's recommendations and/or program policy. In the event that equipment maintenance or servicing is required between scheduled checks, maintenance requests will be made through TELS. All staff filling out the TELS request will include date, nature of problem. TELS maintenance requests will be checked by Maintenance Supervisor or Designee at least daily. If equipment requires repair other than routine maintenance or servicing, the vendor through which the equipment was purchased will be contacted and arrangements made for repair/replacement.

Based on clinical record reviews, facility documentation, staff interviews, and facility policy and procedures, the facility failed to ensure a copy of the written notice of transfer/discharge for two of two residents (#76 and #37) was sent to the Office of the State Long Term Ombudsman. The deficient practice could result in the ombudsman not being notified of resident transfers/discharges. Findings include: -Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) dated August 31, 2021 indicated the resident was cognitively intact with a score of 11. Review of the progress notes revealed the following: -On October 16, 2021 at 10:17 p.m. change of condition: symptoms or signs of condition change: altered mental state. -On October 16, 2021 at 10:37 p.m. resident refused medications and was noted to have altered mental state. Slurring words or not answering. Leaning over in wheelchair. Nurse Practitioner called and orders received to send to emergency room for evaluation and treatment. 911 called at approximately 9:30 p.m., arrived at 9:40 p.m. and left with resident at approximately 10:00 p.m. All parties notified. -Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed a Change in Condition note dated November 16, 2021 at 10:42 PM that resident #37 had symptoms or signs noted of abdominal pain. A note dated November 17, 2021 at 5:07 PM revealed the resident was sent to the emergency room (ER) for a non-emergency abdominal Computed tomography scan (CT), to rule out an acute abdominal perforate of the bowel. The family was notified via telephone. The Medical Doctor (MD) was present. A verbal physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's clinical record revealed a notice of transfer form dated November 17, 2021 that the transfer/discharge was necessary for the resident's welfare and that the resident's needs cannot be met in the facility due to abdominal pain. The form was signed by the resident representative and dated November 18, 2021. Review of the admission/discharge logs revealed that the Ombudsman was not notified of discharges/transfers in September 2021, October 2021, and November 2021. Facility documentation included a letter from the Social Services Manager (staff #29) stating that she did not know that it was her responsibility to send the discharge list to the Ombudsman each month. An interview was conducted on January 6, 2022 at 2:48 p.m. with the Social Services Manager (staff #29), who stated the Ombudsman wants to be notified at the end of each month regarding discharges, but she just found about it and needs to find out who was sending the notices before her. During the interview, she contacted the Medical Records Supervisor (staff #44) and was told that she was responsible for notifying the Ombudsman regarding transfers and discharges. Staff #29 stated that she has never notified the Ombudsman and would imagine that it has not been done since she started working at the facility in September 2021. During an interview conducted on January 7, 2022 at 10:00 a.m. with the Administrator (staff #136) and the Director of Nursing (DON/staff #133), staff #133 stated the Ombudsman is notified of transfers/discharges via fax/email/calls and it is the responsibility of the Social Services Manager to notify the Ombudsman regarding transfers. Staff #136 stated the Ombudsman was not notified about resident #76 and #37 being transferred to the hospital and he had no evidence that the Ombudsman was notified regarding transfers/discharges for the months of September, October, and November 2021. Further the Administrator stated that there should be at least monthly notification to the Ombudsman. Staff #136 stated however, the management team have identified there is likely a deficient practice for a duration of time related to the notification to Ombudsman, and at this point there is missing Ombudsman notification for these two residents. The facility's policy, Admission, Transfer, and discharged , revised November 2019 stated the facility will notify the Ombudsman per CMS regulations and guidelines.

Based on clinical record reviews, staff interviews, review of facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for 8 residents (#27, #64, #75, #33, #52, #66, #63, and #37), by failing to conduct the Brief Interview for Mental Status (BIMS) and for one resident (#75) regarding hospice. The sample size was 25 residents. The deficient practice could result in not identifying necessary care needs and treatment. Findings include: -Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's significant change MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's annual MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #66 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's significant change MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #37 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. An interview was conducted with the MDS coordinator (staff #7) at 10:45 a.m. on 1/6/2022. She stated that she completes the MDS assessments as per the required MDS schedule including on admission, quarterly, annually, and also when residents have significant changes. She said that social services complete the cognition section of the MDS that includes the BIMS for the residents and she is not involved in this. She said that once this section and the rest of the MDS are complete, she will go into the assessment, ensure it is done and submit it. She said that regarding the BIMS and cognition part of the assessments, she has noticed that they are not always done and unfortunately, by the time she notices this, it is too late to complete it for the resident so she has to mark it as not assessed and move on. She said that she believed the issue was a change in social services with staffing, as about 4 months ago they went without a dedicated social worker for a while. She said that since a new one was hired, there were still a few issues because the new social worker did not quite understand the system, but this has improved. She said that the cognition section including the BIMS assessment should be completed for each resident. She said that even though she noticed the issue with the MDS assessments, she does not believe that it was ever addressed in Quality Assurance (QA). During an interview conducted with the social services manager (staff #29) at 10:58 a.m. on 1/6/2022, she said that she has only been in the facility for a few months and that things were kind of a mess. She said that she is responsible for completing the BIMS and cognition part of the MDS assessment. She further said that for a while she was not completing everything correctly per the facility's system and that she has since learned the right way to do it. An interview was conducted with the Director of Nursing (DON/staff #133) at 11:29 a.m. on 1/6/22. She said that she does not have any role in the completion of the residents' MDS assessments in the building. She said she has an MDS coordinator who takes on that role. She said that it is her expectation that the assessments are done timely and accurately. She said she was not aware that some of the assessments were not being completed accurately. She said that normally, her MDS coordinator will bring any noted issues to her attention. She said she was not aware of any action items regarding this in QA and this was the first she had heard of the issue. Review of the RAI manual revealed that the MDS assessment must accurately reflect the resident's status. The manual included that the section for cognition is intended to determine the resident's attention, orientation, and ability to register and recall new information. These items are crucial factors in many care planning decisions. Further, the manual indicated that most residents are able to attempt the BIMS and the interview assists in identifying needed support. -Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Care Plan initiated on October 18, 2021 revealed the resident had a terminal prognosis and was admitted to hospice. The goal was that the resident's comfort would be maintained. Interventions included coordinating care with hospice to provide activities of daily living care to the resident, and comfort and support to the resident and family. However, review of the quarterly MDS assessment dated [DATE] did not reflect the resident was receiving hospice services while a resident in the facility. An interview was conducted on January 7, 2021 at 12:23 PM with the MDS nurse (staff#7), the Director of Nursing (DON/staff #133) and Clinical Resource (staff #129). The MDS nurse stated that if a resident resides in the facility and has received hospice services in the last 14 days, section O of the MDS assessment should be marked Yes for hospice. The MDS nurse reviewed the resident's record and stated the resident started receiving hospice services on October 14, 2021 and that the quarterly MDS assessment did not included the resident was receiving hospice care which would indicate there was a discrepancy in the assessment. Staff #129 stated that there was an oversight from an MDS resource nurse that reviews and audits MDS assessments for accuracy and completion. Review of the facility's accuracy of MDS assessment policy, dated 5/2021, revealed that the policy of the facility is to ensure the assessment accurately reflect the resident's status. The procedure included that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and are knowledgeable about the resident's status needs, strengths, and areas of decline. The procedure included that a Registered Nurse (RN) must conduct or coordinate each assessment with the appropriate participation of health professionals. The policy included that the mental condition of the resident determines the appropriate level of involvement of physicians, nurses, therapists, activities professionals, social workers, dietitians, and other professionals. The policy included that on an assessment, the MDS coordinator is responsible for certifying the overall completion once all individual assessors have completed and signed their portions of the MDS. Review of the RAI manual revealed that the MDS assessment must accurately reflect the resident's status. The manual included that if the resident received hospice care while a resident in the facility and within the last 14 days, check hospice care while a resident.

Based on clinical record reviews, resident and staff interviews, and facility policies and procedures, the facility failed to ensure adequate monitoring and supervision was provided for six residents (#s 107, 76, 41, 32, 83, and 82). The deficient practice could result in other residents being denied the right to privacy and personal space. Findings include: Resident #107 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, anxiety, and major depressive disorder. Review of the care plan for elopement risk/wanderer dated February 25, 2021 revealed the resident wanders on the unit. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, and re-direct resident when he wanders. Review of progress notes revealed that resident #107 wandered into other residents' rooms continuously, such as: on March 14, 2021 continue intrusive wandering at all times and took off clothing often difficult to redirection, becomes physically aggressive up onto redressing for him. -on March 20, 2021 one episode of noted persistent intrusive wandering and physically aggressive. Resident is wandering into each room and takes things from peer all time difficult to redirection. Resisted with personal care and attempted to hit CNA. Need one to one at times. -on March 21, 2021 one episode noted of persistent intrusive wandering and increased in afternoon. Resident wandering into each room and takes things from peer all times as upset peer, difficult to redirect. -on May 11, 2021 episodes of wandering in and out of residents' rooms, urinating on the hallways, attempts to be physical when redirected. -on October 23, 2021 states resident observed with intrusive wandering and exit seeking. Keeps taking off his clothes, hard with redirection. -on December 13, 2021 states intrusive wandering, won't stay in bed. continually wandering into other residents' rooms. Difficult to redirect. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a staff assessment for mental status indicating the resident was moderately impaired of cognitive skills for daily decision making. It also included that the resident wandered for 1 to 3 days during the look-back period. Continued review of progress notes revealed the following: -on December 19, 2021 states episodes of persisted intrusive wandering into peers' room and caused them agitation and damaged things. -on December 27, 2021 revealed that the resident continuously wondering unit, intrusive to peers, staff continuously redirecting resident throughout the night while resident is awake. -on January 1, 2022 states continue intrusive wandering as bothered peers all times, difficult to redirection. Review of behavioral progress notes revealed continuous wandering and removing clothing and wandering into other residents' rooms: -on May 10, 2021 resident wandering and stripping clothes. -on May 10, 2021 resident wandering all day rummaging through patients' rooms. -on May 25, 2021 wanders around and stripping off clothes. Review of a follow-up psych evaluation dated December, 15, 2021 stated the resident was being seen for psychiatric follow up. Staff notes that patient is frequently impulsive and intrusively wanders continuously. Review of the Nursing Home to Hospital Transfer Form dated January 1, 2022 revealed the resident was being transferred for behavioral symptoms (e.g. agitation, [CONDITION(S)]). Not accepting back due to behavioral issues affecting peers. Regarding residents #107, #76, #41, and #32 -Resident #76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included [CONDITION(S)], major depression, post-traumatic stress disorder ([CONDITION(S)]), and anxiety. A care plan dated August 27, 2021 stated the resident was at risk for Re-traumatization related to history of trauma Post-Traumatic Stress Disorder ([CONDITION(S)]). Resident makes up stories about other residents, will have delusional thinking about other residents in the facility. The goal was that the resident would have no evidence of emotional, physical and psychological problems. Interventions included anticipate and meet needs. Review of the Brief Interview for Mental Status (BIMS) dated January 3, 2022 revealed a score of 9 indicating the resident had moderately impaired cognition During an interview conducted with resident #76 on January 3, 2022 at 9:00 a.m., she reported that she was asleep in her wheelchair and when she woke up, resident #107 was in her room. Resident #76 stated resident #107 had his penis out and was trying to put it in her roommate's mouth. Resident #76 stated that she screamed and her roommate (resident #41) woke up. Resident #76 stated that she did not remember the date of the incident, but stated that she did remember it was dark outside. Resident #76 said she wanted to call the Sheriff's department but was told by a female staff not to report it because it would cause trouble for the facility. Resident #76 also stated that another female resident (#32) has some stories about resident #107. -Resident #41 was admitted to the facility on [DATE] with diagnoses that included alcohol use, unspecified with alcohol-induced persisting amnestic disorder, dementia, and adult failure to thrive. A BIMS dated January 3, 2022 indicated the resident has a moderate cognitive impairment with a score of 8. Resident #41 was interviewed after the interview with resident #76 on January 3, 2022 at 9:00 a.m. Resident #41 said that she did not remember waking up and finding resident #107 trying to put his penis in her mouth, but he does come into her room all the time. -Resident #32 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] disorder, delusional disorders, and cognitive communication deficit. The admission MDS assessment dated [DATE] included a BIMS score of 13 indicating the resident was cognitively intact. The assessment also included that the resident did not hallucinate or have delusions during the look-back period. During an interview conducted with resident #32 on January 3, 2022 at 10:14 a.m., resident #32 stated that there are two guys that come into her room. She said one wears a red shirt, and one has hearing aids. She stated that she thinks they were both in the military. She said that one of the men came into her room the day before yesterday and tried to put his penis by her mouth. Resident #32 said that she reported it and staff told her that they do not mean what they are doing. She stated that she is afraid of them, emotional, challenged to not go crazy. Regarding residents #107, #83, and #82 -Resident #83 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] disorder, dementia, and [CONDITION(S)]. The quarterly MDS assessment dated [DATE] included a BIMS with a score of 15 indicating the resident was cognitively intact. An interview was conducted on January 5, 2022 at 11:27 a.m. with resident #83, who stated that resident #107 and #82 are always coming into her room and going through her things. She said that she has reported this to staff, but they don't care. During the interview, a male resident, identified as resident #82, came to the door of the room in a wheelchair. Resident #82 started to roll in and resident #83 told him to go away. Resident #82 sat at the door and resident #83 repeated in a stronger/louder voice, get out. Resident #82 then backed up and left. Resident #83 stated that she yells up to 20 to 30 minutes before a staff will come to her room and redirect them. -Resident #82 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, anxiety, and major depressive disorder. Review of the BIMS dated February 27, 2021 revealed a score of 5 indicating resident #82 has a severe cognitive impairment. The resident has a care plan for actual behavior problems related to unspecified dementia with behavioral disturbance dated February 20, 2021. Target behaviors included exit seeking/elopement risk, sexually inappropriate, and verbal/physical aggression. Interventions included to intervene as necessary to protect the rights and safety of others and staff should be aware that the resident will attempt sexually inappropriate behaviors towards (peers and staff). Staff should provide care in pairs. Review of progress notes revealed multiple incidents where the resident entered other residents' rooms, such as: -On November 22, 2020 resident noted to be exhibiting intrusive behaviors this shift, wandering into other's rooms. -On September 26, 2021 resident continues to exit seek and continues with intrusive wandering goes through others belongings and hits staff at times. -On December 14, 2021 resident with noted behaviors of intrusive wandering times 3. An interview was conducted on January 5, 2022 at 10:07 a.m. with an activity's assistant (staff #73), who stated that resident #107 does wander in other residents' rooms and does touch their things, but she has not seen him take things. An interview was conducted on January 5, 2022 at 10:21 a.m. with a certified nursing assistant (CNA/staff #116). She stated that some of the male residents may wander into other residents' rooms and when this happens, she will redirect them immediately. She said there was an incident last week where resident #32 was in her room and she heard her screaming. Staff #116 stated that she went to the resident's room and the resident told her that the male resident (#107) was disrobing and exposing himself. Staff #116 stated that resident #107 was in the room, but he had his clothes on. She said resident #107 removes his clothing in the hallway, but she has not seen him do it in a resident's room, and he is not being sexual. The CNA stated that she thinks resident #107 does it because he is wet and uncomfortable, so he pulls his brief off. Staff #116 said that resident #32 screams when someone enters her room and she thinks it is because resident #32 gets confused about what is happening. The CNA stated that she will redirect the resident out of resident #32's room because the resident should not be in there. Staff #116 stated that she feels they are short staffed and it is difficult to monitor all the residents on the hall. During an interview conducted on January 5, 2022 at 10:51 a.m. with a licensed practical nurse (LPN/staff #28), she stated that some of the residents will disrobe because of behavior. The LPN said resident #107 is an intrusive wanderer and does disrobe, but it is usually because he is wet. An interview was conducted on January 5, 2022 at 1:02 p.m. with a CNA (staff #134), who stated that there are not enough staff to monitor the residents that wander into other residents' rooms. Staff #134 stated that they do the best they can and just try to redirect them. She said the female residents will usually press their call-light when another resident enters their room and staff will go to check why the call-light is on. On January 6, 2022 at 10:24 a.m., an interview was conducted with a CNA (staff #4), who stated that there are three CNAs on the South Hall and one is assigned to each hall to provide care and monitor residents. She stated that residents #82 and #107 and another resident wanders into other residents' rooms. She stated that she knows that resident #76 has complained of resident #107 coming into her room. Staff #4 stated that she was told by another staff, but she cannot remember which staff, that resident #32 reported resident #107 was in her room and attempting to show his penis. She stated that the CNAs do their best, but cannot monitor the residents who wander when they are in a resident's room providing care. The CNA stated that when she does see a resident go into another room, she will redirect and shut the resident's door, but knows that it is happening. She stated that resident #107 does remove his clothing. She said there are not enough staff to monitor the residents wandering and to provide care. She said that the CNA is supposed to remain in the hallway to monitor the residents, but cannot do that if in a room providing care for another resident. On January 7, 2022 at 10:16 a.m., an interview was conducted with the Director of Nursing (DON/staff #133). She stated residents that wander into other residents' rooms should be redirected by any staff. The DON stated there should be constant redirecting and staff should be keeping the residents busy. The DON said she did not know resident #107, #82, and another resident were going into the female residents' rooms, prior to this week. The facility's policy, Nursing Services, Sufficient Staff , revised May 2021 stated it is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment. The facility policy, Resident Rights. Reporting Reasonable Suspicion of a Crime, revised November 28, 2018 stated the facility will take action to protect and prevent abuse and neglect from occurring within the Facility by identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as: -Taking, touching, or rummaging through other's property; -Wandering into other's rooms/space.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure advanced directive was accurately documented for one of two sampled residents (#27). The census was 124. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Advance Directive form in resident's #27 clinical record revealed that the resident does not want cardiac resuscitation measures (CPR) and does not want artificial nutrition (tube feeding) if unable to accept nourishment by mouth. The form also revealed that consent was received from the resident's family member on [DATE] and the form was signed by the facility representative on [DATE]. However, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record did not reveal the resident had changed the advance directive from DNR (Do Not resuscitate) to full code. An interview was conducted with a Licensed Practical Nurse (LPN/staff #28) on [DATE] at 11:35 AM, who stated advance directive is filled out on admission by the admission nurse and then an order is entered into PCC (Point Click Care/electronic record). Staff #28 stated the resident or resident's POA (Power of Attorney) can change the advance directive at any time. She stated in that case, a new form is signed and the resident clinical record is updated. The LPN stated she will look at the nursing assignment sheet or the PCC to look for a resident's code status. She then looked at the assignment sheet and stated that resident #27 is a full code. The LPN stated the code status in the resident's chart should match with what the resident or their POA signed on the advance directive form. Staff #28 looked at resident's #27 chart in PCC and stated that the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN then reviewed the advance directive form signed on [DATE], and stated the resident representative signed for DNR. She stated the code status did not match and stated the resident records needed to be updated. The LPN stated if a resident received CPR when the resident had signed for DNR then it becomes a legal issue. An interview was conducted with the Director of Nursing (DON/staff #133) on [DATE] at 11:19 AM. She stated the advance directive form is filled out on admission by the admission nurse and the admission nurse is the one placing the order. The DON stated then she will go through the admissions paperwork to make sure everything is correct and trust the staff that they completed the admission work. She stated that after the nurse informed her about resident #27 code status, she immediately checked, confirmed with the POA and corrected the resident's clinical record. The DON stated the facility was audited and there were no other issue with advance directive beside resident #27. The facility policy titled Advance Directive Documentation revised on [DATE] stated that the admission coordinator, or social service director shall provide the resident or responsible agent information regarding the right to formulate an advance directive, inquire whether he/she has completed an advance directive and document in the resident health record.

Based on clinical record review, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that an allegation of sexual abuse for one resident (#32) was reported to the State Agency. The deficient practice could result in allegations of abuse not being reported as mandated by federal guidelines. Findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set assessment dated [DATE] included a brief interview mental status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment also included the resident did not hallucinate or have delusions during the look-back period. During an interview conducted with the resident on January 3, 2022 at 10:14 a.m., resident #32 stated that there are two guys that come into her room. She said that one of the men that came into her room the day before yesterday and tried to put his penis by her mouth. She said that she reported it and staff told her that they do not mean what they are doing. She stated that she is afraid of them, emotional, challenged to not go crazy. An interview was conducted on January 5, 2022 at 10:21 a.m. with a certified nursing assistant (CNA/staff #116). She said last week she heard resident #32 screaming in her room. Staff #116 stated she went to the resident's room and the resident told her that a male resident was disrobing and exposing himself. Staff #116 stated the male resident was in the room but had on clothes. She also said that she has received training about abuse and she is supposed to tell the nurse/manager when a resident makes an allegation of abuse. The CNA stated that that she did not report it because it is standard behavior for that resident to wander and to remove clothing, and it is standard behavior for resident #32 to scream and make allegations. Staff #116 stated that since the resident still had his clothing on, she did not think that anything happened. On January 6, 2022 at 10:24 a.m., an interview was conducted with another CNA (staff #4), who stated that she was told by another staff, but could not remember which staff, that resident #32 had reported a resident was in her room attempting to show his penis. She stated that she does not know what was done about the complaint. On January 7, 2022 at 10:16 a.m., an interview was conducted with the Director of Nursing (DON/staff #133). She stated the staff should have reported the allegation made by resident #32 to her, and she would have reported the allegation to the State Agency, Adult Protective Services, the Sheriff, and the Ombudsman. The facility policy, Reporting Reasonable Suspicion of a Crime, revised November 15, 2018 stated it is the policy of this facility to protect its residents from abuse, neglect, exploitation and misappropriation of resident property. The facility likewise seeks to protect its residents from being subjected to incidents of crime, and to ensure that any such incidents (or reasonable suspicion of such incidents) are reported in a timely manner to the State Survey Agency and local law enforcement. When a covered individual (referred to herein as staff') suspects a crime has occurred against a facility resident, he/she must report the incident to the State Survey Agency and local law enforcement. The staff member shall report the suspicion immediately but not later than 2 hours after the crime has been committed. Staff must also report the suspicion of an incident to the Administrator.

Based on clinical record review, staff interviews, review of facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a significant change in status Minimum Data Set (MDS) assessment was completed for one resident (#75) who was admitted on hospice services. The sample size was 25. The deficient practice could affect residents' continuity of care. Findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A hospice informed consent revealed the consent was signed by the resident's legal guardian for a start of benefits on October 14, 2021. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Care Plan initiated on October 18, 2021 revealed the resident had a terminal prognosis and was admitted to hospice. The goal was that the resident's comfort would be maintained. Interventions included coordinating care with hospice to provide activities of daily living care to the resident, and comfort and support to the resident and family. However, continued review of the clinical record did not reveal a significant change in status MDS assessment had been completed. An interview was conducted on January 7, 2021 at 12:23 PM with the MDS Nurse (staff #7), the Director of Nursing (DON/staff #133), and Clinical Resource (staff #129). The MDS nurse stated that when a resident is admitted to hospice services, a significant change in status MDS assessment is required to be completed. The MDS nurse reviewed resident #75's record, and stated that there was not a significant change in status assessment for the start of hospice services on October 14, 2021 for this resident. Staff #129 stated that there was an oversight from an MDS resource nurse that reviews and audits MDS assessments for accuracy and completion. The facility policy titled Frequency of Assessments revised May 2021 stated it is the policy of this facility that resident assessments shall be developed and reviewed on a timely basis, based on resident condition and RAI guidelines. The RAI manual stated a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home.

Based on observation, staff interviews, and facility policy, the facility failed to ensure infection prevention and control standards were maintained when handling one resident's (#70) medication during medication administration. The sample size was 6. The deficient practice could result in transmission of infection. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication administration observation was conducted on January 5, 2022 at 7:57 AM with a Registered Nurse (RN/ Staff #118). Staff #118 was observed preparing medications for resident #70. During the observation, the RN was observed to take out the resident's medication named [MEDICATION(S)] (antihypertensive) tablet 50 mg. The medication was in a blister pack/card and was observed to have two tablets left in the card. The RN was then observed to pop one tablet of [MEDICATION(S)] 50 mg into the medication cup. During the observation, both of the tablets from the medication blister pack were observed to fall out of the card. One tablet was observed to fall in the medication cup and one tablet was observed to fall on top of the medication cart. The nurse was then observed to pick up the tablet that fell on top of the medication cart without gloves and place it back in the blister pack. The nurse was observed to tape the blister pack so that the medication would not fall out and placed it back inside the medication cart. Following the observation, the nurse was asked about resident #70's [MEDICATION(S)] 50 mg tablet. The nurse stated that when she tried to pop one tablet of [MEDICATION(S)] into the medication cup, both of the tablets fell out. She stated one tablet went into the medication cup and one fell on top of the medication cart. She stated she placed the remaining tablet that fell on top of the cart into the blister card, taped it and placed the card back in with the resident's other medication cards. An interview was conducted with the RN (staff #118) on January 5, 2022 at 9:57 AM. She stated when a medication pill falls on the floor, she will discard the medication. She stated if narcotics medications fall on the floor she will call the unit manager and waste the narcotics in sharps containers. She stated that she tries to pour medications directly from the container into the medication cup to minimize touching. The RN stated that she will discard medications that fall on top of the cart and tries not to touch the medication with her hands due to infection risks. She stated that she tries to keep her hands as clean as possible but her hands still will not stay clean as hands have many bacteria. She stated that if she touches the pill with her hands there is risk of infection transmission. When asked about the observation, she stated that she should have discarded the medication once it fell on the cart. The RN stated she saved the medication because the resident had only one medication left so she was worried that the resident might run out of the medication; therefore, she placed the tablet that fell on top of the cart back into the medication blister card. She stated it has not happened that the residents run out of medications but she was worried about it. She stated she has not discarded the medication. She stated she should have discarded the medication. An interview was conducted with the Director of Nursing (DON/staff #133) on January 7, 2022 at 11:19 AM. She stated her expectation from the nurses is for them to perform hand hygiene before giving medications, after popping the medications and after giving the medication. She stated the staff should not be touching the pills with their hand. The DON stated that if the medication pill falls on the top of the medication cart, the pill should be wasted and not given to the resident. The DON stated there is a risk for infection if the nurses are touching the medication pills with their hand. The facility's policy Medication Administration - Oral stated it is the policy of the facility to accurately prepare, administer and document oral medications. Wash hands or use hand sanitizer. Remove unit does medications from cards into med souffle cup for resident. The policy did not include the procedure to follow if the medication did not go into the medication cup.

Based on observation, interview, and record review the facility failed to implement basic infection control practices to prevent transmission of blood borne pathogens during 2 of 2 observations when staff performed blood glucose monitoring for Residents R1 and R2. The facility failed to sanitize/disinfect a glucometer (device to test blood glucose) between use on residents. Additionally blood glucose testing supplies were contaminated when moved from one resident room to another and from one medication cart to another without sanitization or use of a barrier. Twenty four residents who required blood glucose testing were placed at risk for serious and potentially life-threatening blood-borne illness which constituted immediate jeopardy. 2. The facility failed to ensure staff donned, doffed, and used PPE (personal protective equipment) in accordance with accepted standards of practice to prevent contamination of PPE intended for reuse and to prevent transmission of infectious organisms from one person, object, or surface to another. The facility failed to ensure residents were provided or offered hand hygiene prior to eating. These failures placed all residents in the facility at risk for potential facility-transmission of COVID-19 illness. Findings include: Blood Glucose Testing The medical record indicated R1 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on the non-COVID unit on 7/8/20 at 11:13 AM LN2 prepared supplies to perform a blood glucose test on Resident R1. LN2 wore a mask and eye protection and put on gloves at the medication cart in the corridor. LN2 carried a container of glucose test strips, 3 lancets (to puncture the skin) and the glucometer in her hands. LN2 stepped into R1's room and placed the supplies directly on the bedside stand. LN2 did not place a barrier on the bedside stand. A gown hung on a hook near the door, LN2 donned the gown. LN2 opened the bottle of test strips and inserted a strip into the machine. LN2 used one lancet to prick the skin and squeezed the finger to form a droplet of blood. LN2 held the glucometer up to R1's finger to allow blood to run into the test strip. R1 then placed the glucometer with the test strip still in it back on the bedside table while she removed her gown and gloves. LN2 used hand sanitizer then carried the glucometer, the test strip container and the lancets in her hand, LN2 discarded the used lancet in the sharps container and placed the test strips, remaining two lancets, and glucometer directly on the surface of the medication cart with no barrier and no cleaning or disinfection of the glucometer The medical record indicated R2 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 tested positive for COVID-19 5/15/20 and was since recovered. At 11:21 AM LN2 took the contaminated glucometer, test strips, and two lancets from the medication cart to R2's room and placed them on the over bed table with no barrier. LN2 donned a gown and gloves and performed the blood glucose test on R2, inserting the test strip, lancing the finger, and holding the glucometer up to the droplet of blood on the finger. Upon completion of the test, LN2 held the used lancet and the test strip container in her hand and removed the glove by rolling it down so the test strip container and lancet were inside the glove which she then discarded in the trash can. LN2 said the strip bottle was empty. LN2 placed the unused lancet and the glucometer on the medication cart with no barrier and no cleaning or sanitization of the glucometer. LN2 wheeled the medication cart down the corridor to the nursing station where LN1 sat. LN2 asked LN1 if she had bleach wipes and LN1 said she did. LN2 moved the contaminated glucometer to LN1's medication cart near room [ROOM NUMBER]. LN2 did not place a barrier on the medication cart. LN2 was interviewed at 11:22 AM. When asked if the glucometer required sanitization, LN2 replied, I put it on her cart [referring to LN1], that's why I told her, she will wipe it down. When informed surveyor did not observe sanitization of the glucometer between use with R1 and R2, LN2 said Oh, I forgot. When asked the expectation, LN2 said the glucometer should be wiped down with bleach wipes after every use. When asked if the surface of the medication cart should be sanitized since the contaminated glucometer sat directly on it, LN2 said it would be a good idea. LN2 did not sanitize the surface of the medication cart. At 11:25 AM LN1 used bleach wipes to sanitize the glucometer then placed the glucometer on a tissue (barrier) on the medication cart. LN1 said she left it to air dry. LN1 did not sanitize the surface of the medication cart where the contaminated glucometer had been. LN1 carried glucose testing supplies to room [ROOM NUMBER] and asked surveyor to wait until she donned a gown, then denied surveyor access to observe. At 12:07 PM the glucometer was observed on top of LN1's cart on a facial tissue. During an interview on 7/8/20 at 12:50 AM the visiting DNS (representing facility DNS) LN3 provided a list of 24 residents who currently required blood glucose testing. LN3 reported the facility had six medication carts with five glucometers available for shared-use in the facility. The glucose testing observations were shared with LN3 who stated the observed practice was not consistent with facility policy and procedure. LN3 concurred failure to sanitize the glucometer after every use was not consistent with accepted infection control standards and CDC blood glucose testing requirements. The Centers for Disease Control and prevention (CDC) online at cdc.gov/injection safety/blood-glucose-monitoring.html Article titled; Infection Prevention During blood Glucose Monitoring and Insulin. Administration read in part; An underappreciated risk of blood glucose testing is the opportunity for exposure to blood borne viruses (HBV, [CONDITION(S)] virus, and [CONDITION(S)]) through contaminated equipment and supplies if devices used for testing (e.g., blood glucose meters, fingerstick devices) are shared. Outbreaks of [CONDITION(S)] B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes where residents often require assistance with monitoring of blood glucose levels. The CDC has become increasingly concerned about the risks for transmitting [CONDITION(S)] B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring, CDC is alerting all persons who assist others with blood glucose monitoring of the following infection control requirements: *Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. *If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. *If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. *Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters). Do not carry supplies and medications in pockets. Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood. Indirect contact transmission is the transfer of an infectious agent (e.g., HBV) from one resident to another through a contaminated intermediate object (e.g., blood glucose meter) or person. With some blood glucose meters that require pre-loading of the test strip, the device may come into direct or close contact with the resident's fingerstick wound. If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent residents can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the resident never directly contacts the meter. Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient's finger or handling the test strip. Blood can then be transferred to the meter when healthcare personnel handle the meter to obtain the reading. If the meter is not cleaned and disinfected after use, the blood remaining on the meter can be transferred to subsequent patients via healthcare personnel hands when they handle the meter and then assist with fingerstick procedures. The facility administration provided the facility infection control Policy/Procedure titled; Glucometer, Cleaning and Decontamination of. The policy stated: It is the policy of this facility to follow recommendation from the CDC or manufacturer's guidelines. The Procedures section directed: If no visible organic material is present, disinfect after each use the exterior surfaces following the manufacturer's direction or may use a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/[CONDITION(S)] label claim, or a dilute bleach solution of 1:0 (one part bleach to 9 pars water) to 1:100 concentration. On 7/8/20 at 1:45 PM the facility administrator and LN3 were informed verbally that immediate jeopardy (IJ) was identified related to failure to sanitize the glucometer after each use, failure to sanitize two contaminated medication carts, and contamination of stock supplies (test strips and lancets) when carried from one resident room to another without sanitization. Written notice of IJ was provided to the administration at 2:25 PM. The facility responded with immediate action to sanitize all medication carts and glucometers. The facility provided a written plan of removal that included physician notification regarding affected residents, review of glucometer disinfection policy and inservice training related to glucometer use and glucometer cleaning for all licensed nurses on duty. LN3 said glucometer training will be required for all licensed nurses before being allowed to work. The facility provided a written IJ removal plan on 7/8/20 at 2:30 PM. On 7/8/20 implementation of the removal plan was verified through interviews of licensed staff and direct observation of glucose testing. At 4:05 PM LN4 conducted a blood glucose test on R11 implementing infection control measures including use of barriers and disinfection of the glucometer after use. LN5 conducted a blood glucose test on R5 at 4:20 PM and LN2 performed glucose testing on R2 implementing appropriate infection control measures. The administrator was informed the immediacy was removed on 7/8/20 at 5:00 PM. 2. PPE - personal protective equipment During the entrance interview on 7/8/20 at 9:15 AM the Administrator (FA) stated the facility had a 24 bed designated COVID unit with physical separation from the other nursing units and dedicated staff. FA said all 19 residents in the COVID unit were known positive for COVID-19 when admitted from the community with no facility-transmission of COVID-19 since 6/2/20. LN3 said the facility followed CDC guidelines and maintained droplet precautions for all residents house wide. LN3 said all facility staff wore N95 face masks and face shields at all times. The facility implemented extended use (5 days) for face masks, and washable gowns one per patient per shift. LN3 said the facility had policies and procedures to direct staff how to don (put on), doff (take off), and store PPE (personal protective equipment) for re-use. LN3 said all staff were trained how to use, to don, and to doff PPE. The facility provided a CDC handout that described how to don and doff PPE. The handout directed; PPE must be donned correctly before entering the patient area. PPE must remain in place and be worn correctly for duration of the work in the area. PPE should not be adjusted (retying gown, adjusting respirator/facemask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. The order for donning: 1)hand hygiene 2)put on isolation gown and tie all of the ties 3)N95 (already wearing) 4)face shield (already wearing) 5)perform hand hygiene before putting on gloves then enter room. The order for doffing; 1)remove gloves in a manner to not cause additional contamination of hands 2)remove gown in gentle manner, avoiding forceful movement. Reach up to shoulders and carefully pull gown down and away from the body. 3)May now exit room. 4)hand hygiene. Observation on 7/8/20 at 10:40 AM revealed paper bags hung from a rope attached to the wall (like a clothesline) in the corridor near the breakroom. The paper bags each had a staff member's name printed on it. The paper bags were not sealed, they were left open at the top. Some of the paper bags contained N95 face masks and some also held face shields. Printed instructions attached to each bag for Extended Use of Face Masks directed staff to reapply the face mask for extended use: 1. Ensure the container belongs to the correct HCW (health care worker). 2. Remove the mask from the breathable container, grasping it by the loops or ties. 3. Apply the mask as instructed, without touching the outside mouth portion. At 10:42 AM, nursing assistant NAC1 approached the paper bags and removed an N95 mask from one of the bags. NAC1 explained the masks were re-used for 5 days and then changed. NAC1 handled the mask with both hands and touched the inside and outside of the mask while putting it on. NAC1 did not perform hand hygiene before or after donning the mask and proceeded through double corridor doors to the nursing units. NAC1 did not don the face mask in a manner to prevent contamination and did not comply with facility directions posted in plain sight at the mask station. On 7/8/20 at 11:05 AM on the non-COVID unit, housekeeping staff HK1 exited room [ROOM NUMBER] wearing a face mask, goggles, a disposable gown, and gloves. Without changing gloves or hand hygiene, HK1 retrieved supplies from the housekeeping cart and re-entered the room. At 11:10 HK1 exited the room, placed items on the housekeeping cart then proceeded to remove the gown and gloves. HK1 grabbed the gown in the front and forcefully pulled at the gown, the right sleeve tore, HK1 continued to pull at the gown fanning the bottom of the gown. Finally the gown tore at the neck and HK1 pulled the gown away from her body removing the gloves at the same time. When asked about removing the gown and gloves in the corridor, HK1 said that was the way she did it adding that sometimes it was really hard to break the ties loose. HK1 said she was trained how to use PPE. HK1 said she had to wear full PPE in all resident rooms. Corporate nurse CNA1 was present during the observation and said the gown and gloves should be removed at the threshold then discarded in the room and the gown should not be fanned and waved about. On 7/8/20 at 11:15 AM during observation of care, LN2 donned gloves at the medication cart, then after entering the room, donned the re-usable gown that hung in the room (111). LN2 did not tie the gown ties. While LN2 performed a glucose test, the gown repeatedly fell forward and hung down off the shoulders exposing LN2's upper chest and arms On 11:46 AM while observing lunch delivery, HK1 was observed sweeping the floor in room [ROOM NUMBER] while NAC2 served lunch. The administrator passed by and was informed of the observation. The administrator directed HK1 to delay sweeping resident rooms while food was present. HK1 again went into the corridor wearing full PPE and stood at the housekeeping cart about 12 feet away from room [ROOM NUMBER]. HK1 pulled at the disposable gown and fanned it vigorously causing the gown to wave around as she attempted to break the gown's neck ties. On 7/8/20 between 12:09 PM and 12:20 PM, NAC3 and NAC4 delivered lunch to residents in their rooms. NAC3 donned a reusable gown and gloves in room [ROOM NUMBER]. LN5 handed a meal tray to NAC3 who delivered it to R12. NAC3 assisted to prepare the tray. NAC3 did not provide or offer hand hygiene to R12 before eating. NAC3 did not perform hand hygiene or change gloves after serving R12 and proceeded to prepare the meal tray for R13. NAC3 delivered lunch to the residents R4 and R16 in room [ROOM NUMBER]. NAC3 did not provide or offer hand hygiene to the residents before eating. NAC4 donned a gown and gloves but did not tie the gown ties. NAC4 delivered lunch to R14. NAC4 did not tie the gown ties. NAC4 leaned over the bed and her gown fell forward off her shoulders and in front of her hips. NAC4 moved the bed linen around looking for the bed control and when she leaned over to look beside the bed her uniform scrubs were exposed and made contact with the bed linens and bed frame. NAC4 located the control and adjusted the bed. No hand hygiene was provided or offered to R14 prior to eating. NAC4 picked up used facial tissues and reached her entire hand into the trash can to discard them. NAC4 removed the gown, then the gloves. NAC4's gloves were contaminated by the used tissues and by touching the bed linen and bed control. NAC4 touched the gown intended for reuse with the contaminated gloves when removing it. While still at the door, R14 requested a dinner napkin. Without performing hand hygiene, NAC4 donned one glove and stepped into the room to hand R14 the napkin. NAC4 finally performed hand hygiene with ABHR (alcohol based hand rub). In an interview immediately following the observation, NAC4 confirmed the papers she discarded were used Kleenex (facial) tissues and were considered dirty or contaminated. When asked to describe the order in which to remove the gown and gloves; NAC4 said gloves should be taken off first. NAC4 said she did not gown-up to deliver the napkin because she just stepped into the room and she was quick. On 7/8/20 at 3:15 PM, NAC5 was interviewed regarding droplet precautions and use of PPE. While speaking; NAC5 held her mask away from her face. NAC5 did not perform hand hygiene after touching her face mask. After the interview, NAC5 went directly down the corridor to speak to a co-worker and was again observed to hold her mask away from her face when speaking. No hand hygiene was observed after NAC5 touched her mask. During an interview on 7/8/20 at 6:30 PM LN3 said all staff were trained how to use PPE including how to don and doff. LN3 said the facility held several training sessions regarding PPE and she could not explain why staff failed to follow facility policy and procedure. LN3 concurred that hand hygiene and correct use of PPE were key elements to prevent the spread of COVID-19 in the nursing home.

Based on clinical record reviews, facility documentation, staff, resident and interviews, hospital documentation and policy and procedures, the facility failed to ensure that one resident (#25) was free from neglect and that one resident (#6) was free from abuse by a staff member. Findings include: -Resident #25 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of an incident report dated (MONTH) 12, (YEAR) at 10:30 a.m., revealed the resident was leaning forward in the wheelchair while reaching for something that she had dropped on the floor, and staff lowered the resident to the floor. Review of a fall risk evaluation dated (MONTH) 21, (YEAR) revealed the resident was at high risk for falls. Review of the activities of daily living (ADL) care plan dated (MONTH) 12, (YEAR) revealed the resident was to be kept in common areas as much as possible and to lie her down after meals and activities, as soon as she reaches her room. A nursing progress note dated (MONTH) 17, (YEAR) included the resident was found by a CNA (Certified Nursing Assistant) lying on the floor. The note included the resident had blood on her forehead from a 2 centimeter (cm) cut above her right eye, and had swelling and bruising to the left forehead above the left eye. Review of the Nursing Post fall assessment with a fall committee review date of (MONTH) 23, (YEAR), revealed the resident had a fall on (MONTH) 17 at 6:00 p.m. with injury. The documentation included that the resident was lying on the floor next to her bed. The resident had been seen in her room sitting in a wheelchair 10 minutes prior to the fall. The assessment included the resident said that she slid from the wheelchair. The committee recommendations included to keep the resident in common areas as much as possible, and to lie her down as soon as she returns to her room after meals and activities. Review of the Fall Risk Evaluation dated (MONTH) 19, (YEAR) revealed the resident was at high risk for falls. Review of a significant change Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, the resident required extensive assistance with bed mobility, transfers and total assistance with toileting and locomotion. The MDS further included that the resident had a fall with injury, since the prior assessment. A fall care plan revised on (MONTH) 25, (YEAR) included a problem for the potential for injuries related to falls. A goal was for the resident to be free from injuries from falls. Approaches included to keep the resident in common areas as much as possible, and to lie the resident down as soon as possible after she returns from the dining room or activities. A nursing progress note dated (MONTH) 20, (YEAR) at 12:21 p.m. included the resident slid from her wheelchair and complained of left shoulder pain. A physician's orders [REDACTED]. Review of the x-ray report dated (MONTH) 20, (YEAR) revealed the resident had a subacute [MEDICAL CONDITION] left clavicle. A physician's orders [REDACTED]. Review of the Emergency Department documentation dated (MONTH) 20, (YEAR) revealed the resident had a closed displaced [MEDICAL CONDITION] clavicle. A nursing progress note dated (MONTH) 20, (YEAR) at 11:30 p.m. revealed the resident returned from the hospital. An addendum to the nursing progress note regarding the fall on (MONTH) 20, (YEAR) was added on (MONTH) 28, (YEAR). The note included that the resident was observed on the floor next to her bed, with her feet still in the footrests of the wheelchair. The note also included that the resident was observed in her wheelchair, prior to the fall. A Nurse Practitioner progress note dated (MONTH) 28, (YEAR) revealed the resident had a fall on (MONTH) 20, (YEAR), while trying to reach for the remote which was on the floor. Although the resident's plan of care included that the resident was to lie down after meals and activities, or be placed in common areas and was not to be left alone in the wheelchair in her room, the resident was left in her room alone and fell from the wheelchair and sustained a clavicle fracture on (MONTH) 20. An interview was conducted with the resident's family member on (MONTH) 17, (YEAR) at 3:30 p.m. She stated that the resident falls when she tries to get herself from the wheelchair to the bed. She stated that staff were not supposed to leave the resident alone in the wheelchair and that staff are supposed to take the resident out of the dining room last, and then put her right into bed. An interview was conducted with resident #25 on (MONTH) 18, (YEAR) at 8:45 a.m. She stated that she remembers that she fell about a month ago and broke her shoulder. She stated that she was in her room alone when she fell and that she had wanted to go to bed. She stated that she put her call light on and staff did not come quickly enough, so she tried to get herself to bed without help. A phone interview was conducted with a Licensed Practical Nurse (LPN/staff #177) on (MONTH) 18, (YEAR) at 9:47 a.m. She stated that she was caring for the resident at the time of the fall in February. She stated that she was at the desk and an activity aide came and told her that the resident was on the floor. She stated that she did not know how long the resident had been in the room. An interview was conducted with the Activity Director (staff #31) on (MONTH) 18, (YEAR) at 2:00 p.m. She stated that none of the activity aides who worked on the day when the resident fell had any recollection of finding the resident on the floor and reporting it to the nurse. An interview was conducted with a Certified Nursing Assistant (CNA/staff #80) on (MONTH) 19, (YEAR) at 9:00 a.m. She stated that they have to follow the plan of care for a resident. She stated that if the plan of care includes the resident needs to be put in bed as soon as she returns to her room, and the resident was in her room in the wheelchair alone and the resident had a fall and broke a bone, then that would be neglect. An interview was conducted with a LPN (staff #148) on (MONTH) 19, (YEAR) at 9:10 a.m. He stated that they are required to follow the plan of care for residents. He stated that if the care plan for a resident stated the resident needed to be put in bed as soon as she returned to her room, and the resident was left unsupervised in the room and fell and broke a bone, that should have been identified as neglect. An interview was conducted with the Director of Nursing (DON/staff #143) on (MONTH) 19, (YEAR) at 10:58 a.m. She stated that she expects staff to know the plan of care and follow it for the residents. She stated the definition of neglect is not taking care of a resident properly. She stated that sometimes the resident takes herself to her room and tries to go to bed and at times the family puts her in her room and leaves her alone in the wheelchair when they leave. She stated that the family was there that day and the DON does not know if the family notified staff that she was leaving. Staff #143 stated that when staff noted that the resident was up in the room in the wheelchair prior to the fall, they should have identified the risk. An interview was conducted with a LPN (staff#151) on (MONTH) 19, (YEAR) at 12:03 p.m. She stated that the family was not visiting prior to the resident's fall on (MONTH) 20, (YEAR). She stated that the family came to visit the resident after the fall, because she called the family about the fall. Staff #151 stated that she did not know the resident was in the room alone, until she was notified of the fall. She said the CNA's bring the residents back to their room after meals. Another interview was conducted with staff #151 on (MONTH) 19, (YEAR) at 12:25 p.m. She stated that she interviewed the CNA who was working in the resident's section at the time of the fall for the IDT post fall assessment dated (MONTH) 21. She stated the CNA reported that the resident had last been checked at 10:30 a.m. on (MONTH) 20, however staff #151 stated that she does not remember the name of the CNA she interviewed. Review of the Fall and Risk Assessment policy revealed the facility will do a timely assessment of resident's fall risk, in order to put corresponding interventions in place to minimize injury. The policy further included that staff will determine what equipment and interventions are appropriate to keep the resident safe and the interventions will be included in the plan of care. -Resident #6 was admitted to the facility on (MONTH) 10, 2009, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that resident #6 resided on the secured dementia behavioral unit. Review of a quarterly MDS assessment dated (MONTH) 10, (YEAR) revealed the resident scored a 3 on the BIMS, indicating severe cognitive impairment. Per the MDS, the resident was assessed as having physical behavior symptoms directed toward others during 1 to 3 days of the 7 day look-back period, had verbal behavior symptoms directed toward others daily, had behaviors of refusing care daily, and had delusions. The resident was also assessed to require extensive assistance with bed mobility and total assistance with transfers. Review of the facility's investigation revealed that on (MONTH) 9, (YEAR) at approximately 4:30 p.m., staff reported that the resident had a bruise to the right forearm and an investigation was initiated regarding the injury of unknown origin. Per the report, during the investigation two additional allegations were reported as follows: a CNA (staff #170) spit on the resident and poured water on the resident. The investigative report included the following staff statements: -A CNA (staff #144) reported that she was with staff #170 in the resident's room providing care. She reported that staff #170 was mad at resident #6, as the resident was upset about receiving care. She reported the resident spit at staff #170 and staff #170 spit back at the resident. She also reported that staff #170 held down the resident's arm, but she did not know how hard. Staff #144 said that staff #170 was pulling the resident's arm to get her to hold onto the mobility bar on the bed. She said the bruise was not present before the resident received care. Staff #144 also reported that the resident threw a cup full of liquid at staff #170, and then staff #170 got mad and took a pitcher of juice and poured it on the resident and then threw a cup of water on the resident as well. Further review of the investigative documentation revealed that staff #144 was the only witness regarding holding down the resident's arm and the spitting incident, however, there were other witnesses to the water incident. The documentation included additional statements as follows: -A LPN (staff #78) who was the charge nurse at the time of the water incident reported that he entered the dining room and observed that the resident had a wet, soaked face and torso. He said staff #170 told him that the resident was going to throw a glass of water on her, but she slapped it out of her hand and the resident got wet. -A CNA (staff #178) wrote that her back was turned, so she did not see what happened, but said she saw that the resident was wet and there was juice on the floor. -A CNA (staff #98) wrote that she saw staff #170 come into the area and then the resident started yelling that the CNA had beat her. She stated that the resident threw juice on staff #170 and staff #170 then took a pitcher of water and poured it on the resident's face and head. -A LPN (staff #179) wrote that the resident did not have a bruise on her forearm prior to (MONTH) 9, (YEAR), and that staff notified her of the bruise. Per the statement, the bruise measured 6 centimeters (cm) by 5.75 cm and was raised by 1.5 cm. Staff #179 stated she notified the nurse practitioner and an x-ray was ordered. -The CNA (staff #170) who was providing care to the resident with staff #144 reported that prior to this incident, the resident had said her arm was hurting, but she could not see any injury. She said on that day the resident was upset. She said she turned the resident from side to side and helped the resident put her hands on the bed rails, because the resident could not do this on her own. She said the resident started screaming. She reported that she did not turn the resident roughly. Staff #170 said that during care the resident spit at her, but she did not spit back. Staff #170 also said that the resident threw a cup of water on her and in the process of throwing water, the resident got herself wet and got her (staff #170's) pants wet. She said that she got the pitcher of water, so she could give the resident more water. The report included that the resident was interviewed and stated that she did throw water on the CNA(staff #170), but only after the CNA threw water on her. Per the investigation, additional staff interviews revealed that staff #170 was often difficult to work with, would rush residents and was rough with them at times. Further review of the investigative report revealed the facility substantiated the allegation regarding the water incident. However, the other two allegations regarding the bruise and the spitting could not be substantiated. Review of the x-ray results revealed that they were negative for a fracture. A quarterly MDS dated (MONTH) 5, (YEAR) revealed the resident scored a 3 on the BIMS, which indicated the resident had severe cognitive impairment. An interview was conducted with the unit manager (LPN/staff #78) at 2:00 p.m. on (MONTH) 17, (YEAR). He said that he did remember the incident between the resident and staff #170. He said that he was not involved in the issue with the bruising or the spitting, but did see the resident after the water incident. He said he walked into the dining room and saw that the resident had water dripping from her face. He stated that he asked what had happened and staff #170 said that the resident was going to spill the water, so she grabbed it and it splashed on the resident's face. He said the resident was pretty wet and the water was dripping down her face. Staff #78 stated the resident seemed to be in shock and was just sputtering. In an interview with staff #170 at 2:30 p.m. on (MONTH) 17, (YEAR), she said that she remembers the day in question. Staff #170 stated that she and another CNA (staff #144) were providing care to the resident. She said the resident was spitting at them and calling them names. She said the resident has bruises often and was complaining of pain in her arm, prior to that day. She stated that the charge nurse had asked the resident what happened and the resident said that the big girl hurt her arm. She denied holding the resident's arm to restrain her and denied spitting back at the resident. Staff #170 stated that she was only trying to provide care to the resident and the resident was resisting and swinging at her. She said the only thing that she did do that maybe she should not have done was when in the dining room, the resident tried to throw water at her and she instinctively swatted the cup away, which caused the resident and herself to get wet. She said there was not much water on the resident and none on the ground. She said the resident does not like some of the CNA's, so she makes allegations toward them. During the survey, a telephone interview was attempted with staff #98, however, she was unable to be reached. An interview was conducted with a CNA (staff #144) at 12:00 p.m. on (MONTH) 18, (YEAR). Staff #144 stated that she remembered the incident. She said that she first noticed a bruise on the resident's arm, after providing the resident care with staff #170. She said that they were in the resident's room and the resident was getting combative and when she did, staff #170 held the resident's arm tight against the resident's body. She said she did not know if this caused the bruise, but it seemed like the CNA was holding the resident's arm pretty tight. She also said that at one point, the resident spit at staff #170 and staff #170 spit back, but she was unable to tell if spit had gotten on the resident. Staff #144 said that after this, the resident was wheeled into the dining room. She said she observed staff #144 pour a pitcher of juice on the resident's head. She said after this, the charge nurse came in and asked who did it and the resident indicated that staff #170 had done it. She said that sometimes staff #170 would be rough with residents, but never in an abusive manner. She said that she was just rude at times. She said the resident is difficult to work with and does yell at staff and tries to kick or hit them. She said she felt that the water incident was abuse and that the resident seemed pretty upset by it. During an interview with the Administrator (staff #58) at 8:55 a.m. on (MONTH) 19, (YEAR), he stated that he recalled the incident and there were three separate allegations. He said it was difficult to substantiate the allegations regarding rough handling and the spitting, as there was only one witness, but they did substantiate the water incident because there were a few witnesses. He said after substantiating this, he terminated the CNA and reported her to the board of nursing. Review of the Abuse policy and procedures revealed the facility is to take appropriate steps to prevent the occurrence of abuse and neglect. The policy included that each resident has the right to be free from abuse and neglect. The policy defined abuse as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish. Neglect was defined as the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Mistreatment was defined as inappropriate treatment of [REDACTED].