Every finding on record at Thermopolis Rehabilitation and Wellness

Based on medical record review, staff interview, and standard of practice review, the facility failed to ensure residents received treatment and care in accordance with professional standards for 1 of 4 sample residents (#1) reviewed for a change of condition. This failure resulted in actual harm to resident #1.The findings were:1. Review of the quarterly MDS dated [DATE] showed resident #1 had a mental status that was not assessed, and diagnoses which included ulcerative colitis, renal insufficiency, and anemia. The following concerns were identified: a. Review of a progress note dated 6/29/26 and timed 7:18 PM showed Resident noted with coffee ground emesis and began reporting tightness in [his/her] chest. Lungs clear to auscultation. Heart rate and rhythm irregular. BS [bowel sounds] active x4 [times four] quadrants and tender upon palpation. VS [vital signs] obtained 139/79 BP [blood pressure], 130 HR [heart rate], 90% @ 2 LPM [liters per minute], 25 R [respirations], 99.5 T [temperature]. EMS [emergency medical services] called for transport to ED [emergency department] for eval and treat. Report called into [name] RN at [name of facility] ED. [Name] RN DON notified. [Name of family] notified. EMS into facility, report given, and care relinquished. Resident left facility on EMS stretcher at approx [sic] 1850. b. Review of a progress note dated 7/2/26 and timed 11:15 PM showed Resident returned from hospital at approx [sic] 1805 [6:05 PM] with dx [diagnosis] of pleural effusion, hiatal hernia, and AKI [acute kidney injury]. Resident is AAOX4 [awake, alert, and oriented to person, place, time, and event]. Pleasant with good affect. Able to make needs known and follows commands appropriately. Speech clear, smile symmetrical. Eyes PERRLA [pupils equal, round, reactive to light, and accommodation], brisk. Hand grasps strong and equal. Lungs clear to auscultation. Denies chest pain, SOB [shortness of breath], and heart palpitations. On room air. Heart regular rate and rhythm. BS active x4 quadrants. Abdomen round, soft, tender to touch in lower quadrants. Denies N/V/D [nausea, vomiting, diarrhea]. Resident is continent of bowel, incontinent of bladder. Reports BM [bowel movement] today. Resident has order for full liquid diet and advance as tolerated. Medications taken whole with thin liquids. No chewing or swallowing deficits noted. Utilizing [NAME] for mobility. Edema noted to BLE [bilateral lower extremities]. Resident has scattered bruising to bilat [sic] arms from IV [intravenous] attempts/placement. Resident reports increased anxiety this shift. PRN [as needed] Xanax administered with effectiveness noted. Received PRN Tramadol for reports of generalized pain, effective. Resident is currently resting in bed with eyes closed. Respirations even and non labored. HOB up, bed locked in low position, call light within reach. Plan of care ongoing. c. Review of a progress note dated 7/3/26 and timed 10:53 PM showed At approximately 2045 [8:45 PM] res had coffee ground emesis into trash can. I had tech sit by her bed until it resided. There was no evidence the primary physician was notified of the continued emesis after the resident returned from the hospital. d. Review of a progress note dated 7/4/26 and timed 1:50 AM showed Res [resident] is in bed vomiting black fluids, HOB [head of bed] elevated to high fowlers, res is not c/o [complaining of] of pain at this time VS BP 152/94 HR n90 [sic] O2 90 R18 7/10 pain will continue to monitor. There was no evidence the primary physician was notified of the continued emesis after the resident returned from the hospital. e. Review of a progress note dated 7/4/26 and timed 9:30 AM showed Resident continues to have nausea and vomiting. Had recent hospital stay and they did not find the source of the problem. EGD pland sre [sic] being spoke of. F/U [follow up] Monday. There was no evidence the primary physician was notified of the continued emesis after the resident returned from the hospital. f. Review of a progress note dated 7/6/26 and timed 2:26 PM showed Resident informed what [sic] the nurse is going to contact the doctor for possible EGD [upper endoscopy]. g. Review of a progress note dated 7/8/26 and timed 10:45 AM showed .[name of facility] clinic returned call this morning and discussed general surgery consult had been set up for tomorrow 7/9/26 at 3pm. Notified patient. Spoke with sister regarding appointment as well . h. Review of a progress note dated 7/12/26 and timed 5:38 AM showed when the nurse went in to administer the resident's morning medication, the resident was unresponsive to verbal and tactile stimuli and had agonal breathing. The nurse called EMS and the resident was sent to the ER. i. Review of the hospital record dated 7/12/26 showed the resident had been brought in by ambulance, was hypotensive and unresponsive, and had been admitted to the hospital where s/he peacefully passed surrounded by family. j. Interview with the DON on 8/18/26 at 2:15 PM revealed if a resident had a serious change in condition, they would send the resident to the ER. She stated the nurses called her if they had a concern because they were unable to fax the doctor anymore. She stated they would call and leave a message, but the nurse at the clinic got mad if they called too much. Further interview revealed she followed up with the surgeon for an EGD consult. She stated she expected the nursing staff to document in a progress note if the primary care physician had been called. k. Interview with the regional clinical director on 8/18/26 at 2:30 PM revealed the facility protocol was to assess and monitor the resident, see what was on board, and if that did not work, to notify the provider. Further interview revealed they were only allowed to call the clinic on Tuesdays and Thursdays with concerns if the doctor's nurse was working, and if there was no one there, they left a voicemail on the nurse line, hoped for a call back, and if they did not get one, they sent the resident to the ER. l. Interview with CNA #1 on 8/18/26 at 3:35 PM revealed the resident had been unable to keep anything down, had constantly vomited, and required frequent changing of bedding and clothing. Further interview revealed the vomit looked like coffee grounds. m. Interview with LPN #1 on 8/18/26 at 4:15 PM revealed she recalled the resident had a bout of emesis. Further interview confirmed she did not notify the physician. n. Interview with LPN #2 on 8/19/26 at 10:50 AM revealed the clinic wanted the staff to communicate on Tuesdays and Thursdays. Further interview revealed she received a phone call from the clinic that a general surgery consult had been scheduled for 7/9/26, and she wrote a Communication with Provider note to document the phone call. She reported communication with the clinic was hard and sometimes there was no response for a week or two. o. Interview with the NHA and regional clinical director on 8/19/26 at 11:01 AM revealed the resident had been back and forth to the hospital since April, and the resident's physician had treated the resident's nausea and vomiting with zofran. Further interview confirmed the resident's physician had not been contacted after the resident returned from the hospital on 7/2/26 and had coffee-ground and black emesis. p. Interview with the medical director on 8/20/26 at 3:08 PM revealed attending physicians were obligated to be on-call. Further interview revealed as the medical director, he was available as a back-up for staff to call. 2. According to Wolters Kluwer's Lippincott Nursing Procedures, ninth edition, copyright 2023, e-reader edition page 238 through 249: .Assessment Technique . Document your assessment findings and the technique used to elicit each finding . Indicate the practitioner notified of any abnormal findings and the time of the notification. Document interventions required to treat those finding's as well as the patient's response to those interventions . 3. According to Wolters Kluwer's Lippincott Nursing Procedures, ninth edition, copyright 2023, e-reader edition page 3027: . Monitor the appearance of gastric drainage; report bloody or coffee-ground-color drainage, which may indicate bleeding .

Based on medical record review, staff interview, state survey agency incident database review, and policy and procedure review, the facility failed to accurately and timely report allegations of abuse for 1 of 13 sample residents (#1) reviewed for reportable allegations. The findings were:1. Review of a progress note for resident #1 dated 1/3/26 and timed 3:26 PM showed This nurse was sitting in the dining room with residents. [resident #1] was walking around calmly as normal. [S/He] got close to another resident, and without any queue, wound back with a clenched fist and punched a sitting resident in the face. Resident was immediately redirected and didn't seem to recall any of the situation seconds prior. Resident was immediately removed from situation, and placed on one on one. Resident has no recollection of event so only intervention is one on one at this time . 2. Review of an Allegation of Resident to Resident Abuse for resident #2 dated 1/3/26 and timed 3 PM showed Resident was sitting in dining room when another resident punched [him/her] in the face. Resident did nothing to incur the event and does not recall the situation moments later. Further review showed Resident that caused the incident was removed and put on one to one. This resident was assessed for injury. There is a red mark on [his/her] cheek, but appears to have already been there. No swelling or pain noted. 3. Review of a facility reported incident dated 1/3/26 and timed 5 PM showed Resident [#1] walked near resident [#2] and pushed [his/her] face. Resident [sic] separated and redirected. No injury or distress noted for both residents. Further review showed the allegation was reported on 1/4/26 at 5:45 PM, 24 hours and 45 minutes after the alleged incident. 4. Interview with RN #1 on 2/26/26 at 1:59 PM revealed he did not recall the incident; however, whatever he had documented is what he would have reported to the facility administration. 5. Interview with the administrator on 2/26/26 at 1:09 PM confirmed the allegation resident #1 punched resident #2 was not accurately reported by the facility. The administrator revealed the investigation, which was initiated following the allegation resident #1 punched resident #2, determined resident #1 pushed resident #2. The administrator confirmed the facility reported the results of the investigation as the allegation and not the actual allegation. 6. Review of the policy titled Abuse Reporting and Response published September 2017 showed .4. The Executive Director of designee reports alleged violations to the state survey agency and others officials in accordance with state law (such as Adult Protective Services and local law enforcement as follows: a. Immediately but not later than 2 hours-All allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on observation, staff interview, medical record review, and manufacturer's instruction review, the facility failed to ensure appropriate use of mechanical lifts during 1 random observation of mechanical lift transfers for a sample resident #3. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #3 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, morbid obesity, anxiety disorder and post-traumatic stress disorder. Further review showed the resident was dependent on staff for chair/bed-to-chair transfer. Review of the care plan last revised on 8/15/2025 showed the resident had an ADL function decline related to reduced mobility due to his/her morbid obesity, weakness, and chronic health conditions, and used a mechanical lift for transfers. The following concerns were identified:a. Observation on 11/19/25 at 3:20 PM showed two unidentified CNA's, and RN #1 entered the resident's room to assist him/her out of the wheelchair and into bed using a mechanical lift. Before the resident was transferred, a full body lift sling was placed under him/her, the Invacare Reliant 450 full body mechanical lift was placed over the resident, and the sling was attached to the mechanical lift. An unidentified CNA locked the caster brakes on the mechanical lift, lifted the resident out of the wheelchair, and unlocked the caster brakes as the resident was positioned over the bed. An unidentified CNA locked the caster brakes and then lowed the resident into the bed. b. Interview with RN #1 on 11/20/25 at 1:51 PM confirmed the rear casters were locked when the resident was raised and lowered with the mechanical lift.c. Interview with RN #2 on 11/20/25 at 10:23 AM revealed she would lock the rear casters of the mechanical lift while a resident was being raised, or lowered. d. Interview with the DON on 11/20/25 at 11:29 AM revealed she thought it was ok to lock the casters during the transfer. e. Review of the manufacturer's recommendations for the Invacare Reliant 450 battery powered patient lift provided by the facility on 11/20/25 showed .Lifting the Patient .Warning .Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed, or any stationary object .

Based on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors for 1 of 11 sampled residents (#40). The findings were: 1. Review of the 11/14/25 admission MDS assessment showed resident #40 had a BIMS of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, atrial fibrillation. hypertension, presence of cardiac pacemaker, hypo-osmolality and hyponatremia. Further review showed the resident received a vasopressor medication, midodrine, which was administered based on blood pressure parameters. Review of the physician orders dated 11/14/25 showed the resident received midodrine 5 milligrams (mg) by mouth three times daily with meals for hypotension. The following concerns were identified.a. Review of the physician orders dated 11/14/25 showed May stop midodrine if blood pressure above 110.b. Review of the medication administration record showed the resident's blood pressure prior to his/her scheduled noon dose of midodrine administration on 11/16/25 at 1:06 PM was 122/41. Further review showed the medication was administered by MA-C #1.c. Interview with MA-C # 1 on 11/19/25 at 12:30 PM revealed if a resident's BP was higher than the ordered parameters to administer midodrine, she would hold the medication, document a progress note, and notify her supervisor or charge nurse.d. Interview with MA-C # 1 on 11/19/25 at 12:35 PM revealed that she contacted the physician on 11/16/25 to obtain parameter orders because there weren't any at the time of administration. e. Review of medical records during the survey dates showed no evidence of the physician being contacted on 11/16/25 regarding the resident's blood pressure reading of 122/41. f. Review of the resident's weights and vitals for 11/16/25 showed the resident had a blood pressure of 107/56 at 8:07 AM, 122/41 at 1:06 PM, and 101/41 at 4:42 PM. No other blood pressures were documented.g. Review of a progress note provided by the regional clinical director at the survey, exit dated 11/19/25 and timed 1:30 PM showed the effective date was 11/16/25 at 1:28 PM. Further review showed midodrine HCL Oral Tablet 5 mg Give 1 tablet by mouth with meals for hypotension [sic] BP [blood pressure] was taken prior to giving med and was low. Vital machine was used before getting vitals recorded. So after meal, BP showed that it was above the perimeter [sic] to give.2. Interview with the DON on 11/20/25 at 10:30 AM revealed staff were expected not to administer midodrine if the blood pressure was outside of the ordering parameters.

Based on observation, staff interview, and review of policy and procedures, the facility failed to ensure effective infection prevention practices were implemented during one random observation of linen transportation. The findings were: 1. Observation on 11/17/2025 at 2:25 PM showed RN #3 walked down the East hall with unbagged soiled linen in her hands and transported them to the soiled laundry bin. 2. Interview with the infection prevention coordinator and NHA on 11/20/25 at 11:35 AM revealed soiled linen should be bagged before being removed from rooms and transported to the soiled laundry bin. 3. Review of the Centers for Disease Control and Prevention standards of practice titled Laundry and Bedding, last revised 1/08/24, showed soiled laundry should be bagged prior to transporting to the soiled linen room. 4. Review of the facility policy titled Infection Control Policies and Practices, last revised 5/30/23, showed .6. The Executive Director or Governing Board, through the QAPI and infection control committees, have adopted our infection control policies and practices, as outlined herein, to reflect the Center's needs and operational requirements for preventing transmission of infections and communicable diseases as set forth in current OBRA, OSHA and CDC guidelines and recommendations .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure physician notification of a resident change in condition for 1 of 4 sample residents (#1) reviewed for a change of condition. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a mental status that was not assessed and diagnoses which included diabetes mellitus and non-Alzheimer's dementia. The following concerns were identified:a. Review of the medication administration record for September 2025 showed the resident received insulin degludec, blood sugar check twice per day, Januvia 100 mg daily, and metformin 100 mg twice per day for diabetes mellitus which were all discontinued on 9/9/25. b. Review of a progress dated 9/7/25 and timed 11:53 PM showed Pt. [patient] observed slumped in recliner. Diaphoretic with AMS [altered mental status]. Unable to follow simple commands. VS [vital signs] 100F [Fahrenheit], 88 FSBS [fingerstick blood sugar], 99/47BP [blood pressure] 72BPM [beats per minute] NSR [normal sinus rhythm] 12 RR [respiratory rate] 90% RA [room air]. O2 [oxygen] NC [nasal cannula] applied. EMS [emergency medical services] notified for transport. Attempts were made to contact NPOA [power of attorney] and Charge Nurse to no result. Awaiting transport at 2358. Face sheet and MAR [medication administration record] given with verbal report to paramedic.c. Review of a progress note dated 9/9/25 and timed 11:10 AM showed New medication name, dose, frequency and diagnosis. Signs/symptoms of side effects.: Resident came back from hospital with new orders which include: discontinuing all sugar lowering agents both oral and subcutaneously. Nursing to d/c [discontinue] glucose checks. Nursing continues delirium precautions. There was no evidence the primary physician was notified of the discontinued medications and glucose monitoring.d. Review of a progress note dated 9/17/25 and timed 2:14 AM showed the CNA reported the resident was exhibiting signs and symptoms of hyperglycemia which included polyuria, polydipsia, and polyphagia. The nurse obtained a blood glucose measurement via fingerstick which returned a result of 501. The note showed the facility would obtain a urine specimen to check for ketones and notify the oncoming nurse. Further review showed no evidence interventions were implemented or the physician was contacted.e. Review of a progress note dated 9/17/25 and timed 9:12 AM showed the nurse obtained a blood glucose prior to breakfast which measured 494. The nurse contacted the physician's office to see if the physician would like to resume sliding scale insulin and received no new orders.f. Review of a progress note dated 9/17/25 and timed 1:22 PM showed the physician called and wanted to get another blood sugar completed and start the resident on a low sliding scale. The blood glucose at that time was 567.g. Interview with RN #1 on 10/22/25 at 4:36 PM revealed on 9/17/25 when the resident had symptoms of hyperglycemia, he contacted the nurse coming on shift after him and she contacted the physician. The RN revealed the facility procedure was to send a fax to the physician; however, he felt the response needed to be sooner than they received from a fax. The RN revealed he did not call the physician because the facility did not have insulin he would have been able to administer to the resident. h. Review of the emergency kit content list showed the available medications included insulin lispro, insulin NHP [intermediate acing insulin], insulin regular, insulin glargine, insulin detemir, and insulin aspart.i. Interview with the administrator, DON, regional clinical director #1 and regional clinical director #2 on 10/23/25 at 9:37 AM revealed if a resident was displaying signs or symptoms or a change in condition, they would expect the nurse to assess the resident and monitor. If the condition worsened, they would expect the nurse to notify the physician. They revealed if a resident was experiencing elevated or low blood sugars, they would expect the physician to be notified per the physician's parameters and they would expect the nurse to call the physician and not send a fax. j. Interview with the administrator and regional clinical director #1 on 10/23/25 at 11:32 AM confirmed the resident's medications and monitoring was discontinued following the hospital visit. Further they revealed notification of the physician would be based on nursing judgement if the resident did not have notification parameters.k. Interview with the resident's physician on 10/24/25 at 9:42 AM revealed the resident had a history or high blood glucose levels and she would expect the facility to notify her if the blood glucose was greater than 400. She revealed she was not notified of the discontinuation of insulin and blood glucose monitoring when the resident returned from the hospital on 9/9/25 and she was not notified of the elevated blood glucose on 9/17/25. Further she revealed she would expect the facility to call and not fax and there was always an on-call physician during off hours.2. Review of the facility policy titled Hypoglycemia/Hyperglycemia Recommended Guidelines last updated August 2025 showed .3. Recommended provider notification parameters are blood sugar < [less than] 70 or > [greater than] 350 per American Diabetic Association however, providers may have varied parameters for notification .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents receive quality of care and treatment to meet the resident's mental, physical, and psychosocial needs for 1 of 4 sample residents (#1) reviewed for diabetic treatment. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a mental status that was not assessed and diagnoses which included diabetes mellitus and non-Alzheimer's dementia. The following concerns were identified:a. Review of an admission physician note dated 6/17/25 showed the resident had type 2 diabetes mellitus and the assessment/plan included a glucose monitor to his/her left arm to preventfinger stick blood sugar monitoring 3 times per day.b. Review of the medication administration record for September 2025 showed the resident received insulin degludec, blood sugar check twice per day, Januvia 100 mg daily, and metformin 100 mg twice per day for diabetes mellitus which were all discontinued on 9/9/25. Further review showed no evidence of a continuous glucose monitor.c. Review of a progress dated 9/7/25 and timed 11:53 PM showed Pt. [patient] observed slumped in recliner. Diaphoretic with AMS [altered mental status]. Unable to follow simple commands. VS [vital signs] 100F [Fahrenheit], 88 FSBS [fingerstick blood sugar], 99/47BP [blood pressure] 72BPM [beats per minute] NSR [normal sinus rhythm] 12 RR [respiratory rate] 90% RA [room air]. O2 [oxygen] NC [nasal cannula] applied. EMS [emergency medical services] notified for transport. Attempts were made to contact NPOA [power of attorney] and Charge Nurse to no result. Awaiting transport at 2358. Face sheet and MAR [medication administration record] given with verbal report to paramedic.d. Review of a progress note dated 9/9/25 and timed 11:10 AM showed New medication name, dose, frequency and diagnosis. Signs/symptoms of side effects.: Resident came back from hospital with new orders which include: discontinuing all sugar lowering agents both oral and subcutaneously. Nursing to d/c [discontinue] glucose checks. Nursing continues delirium precautions. There was no evidence the primary physician was notified of the discontinued medications and glucose monitoring.e. Review of a progress note dated 9/17/25 and timed 2:14 AM showed the CNA reported the resident was exhibiting signs and symptoms of hyperglycemia which included polyuria, polydipsia, and polyphagia. The nurse obtained a blood glucose measurement via fingerstick which returned a result of 501. The note showed the facility would obtain a urine specimen to check for ketones and notify the oncoming nurse. Further review showed no evidence interventions were implemented or the physician was contacted.f. Review of a progress note dated 9/17/25 and timed 9:12 AM showed the nurse obtained a blood glucose prior to breakfast which measured 494. The nurse contacted the physician's office to see if the physician would like to resume sliding scale insulin and received no new orders.g. Review of a progress note dated 9/17/25 and timed 1:22 PM showed the physician called and wanted to get another blood sugar completed and start the resident on a low sliding scale. The blood glucose at that time was 567.h. Interview with RN #1 on 10/22/25 at 4:36 PM revealed on 9/17/25 when the resident had symptoms of hyperglycemia, he contacted the nurse coming on shift after him and she contacted the physician. The RN revealed the facility procedure was to send a fax to the physician; however, he felt the response needed to be sooner than they received from a fax. The RN revealed he did not call the physician because the facility did not have insulin he would have been able to administer to the resident. i. Review of the emergency kit content list showed the available medications included insulin lispro, insulin NHP [intermediate acing insulin], insulin regular, insulin glargine, insulin detemir, and insulin aspart.2. Interview with the administrator, DON, regional clinical director #1 and regional clinical director #2 on 10/23/25 at 9:37 AM revealed if a resident was displaying signs or symptoms or a change in condition, they would expect the nurse to assess the resident and monitor. If the condition worsened, they would expect the nurse to notify the physician. They revealed if a resident was experiencing elevated or low blood sugars, they would expect the physician to be notified per the physician's parameters and they would expect the nurse to call the physician and not send a fax. 3. Interview with the administrator and regional clinical director #1 on 10/23/25 at 11:32 AM confirmed the resident's medications and monitoring was discontinued following the hospital visit. Further they revealed notification of the physician would be based on nursing judgement if the resident did not have notification parameters.4. Interview with the administrator and regional clinical director #1 on 10/23/25 at 12:10 PM revealed a continuous glucose monitor had not been implemented since admission.5. Interview with the resident's physician on 10/24/25 at 9:42 AM revealed the resident had a history or high blood glucose levels and she would expect the facility to notify her if the blood glucose was greater than 400. She revealed she was not notified of the discontinuation of insulin and blood glucose monitoring when the resident returned from the hospital on 9/9/25 and she was not notified of the elevated blood glucose on 9/17/25.She revealed she would expect the facility to call and not fax and there was always an on-call physician during off hours. Further interview revealed she thought the resident was receiving blood glucose monitoring through a continuous glucose monitor.6. Review of the facility policy titled Hypoglycemia/Hyperglycemia Recommended Guidelines last updated August 2025 showed .3. Recommended provider notification parameters are blood sugar < [less than] 70 or > [greater than] 350 per American Diabetic Association however, providers may have varied parameters for notification .

Based on record review, resident representative and staff interview and policy and procedure review, the facility failed to meet professional standards of quality for 1 of 3 sample residents (#1) reviewed for diagnostic service orders. The findings were: 1. Review of the re-entry MDS assessment dated [DATE] showed resident #1 had severely impaired cognitive skills, did not ambulate, and required substantial/maximal assistance for transfers. Resident #1 had diagnoses which included presence of left artificial hip joint, difficulty in walking, and neurocognitive disorder with Lewy bodies. The following concerns were identified: a. Review of a progress note dated 6/6/25 and timed 2:39 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers . b. Review of a progress note dated 6/7/25 and timed 2:46 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers. Therapy requests that staff continue using the manual glider at this time and provide resident proper verbal and tactile cues . c. Review of a progress note dated 6/8/25 and timed 4:58 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t verytight [sic] tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers. Therapy requests that staff continue using the manual glider at this time and provide resident proper verbal and tactile cues . d. Review of a progress note dated 6/9/25 and timed 2:34 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t verytight [sic] tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers. Therapy requests that staff continue using the manual glider at this time and provide resident proper verbal and tactile cues . e. Review of a progress note dated 6/9/25 and timed 8:30 AM showed Called Dr. [primary physician] office talked to [office nurse], asked if we could get an order for X-Ray to the left hip. f/u with response. f. Review of a progress note dated 6/9/25 and timed 4:56 PM showed Dr, [sic] [primary physician] office called talked to [office nurse], there is an X-ray order over at the hospital. Will set up transportation to get [him/her] over there tomorrow. g. Review of a progress note dated 6/10/25 and dated 2:59 AM showed .PT has requested nursing to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers . h. Review of a progress note dated 6/11/25 and timed 2:17 AM showed .Abductor wedge in use for proper leg placement to avoid hip/joint issues. PT has requested nursing to see about getting an x-ray to the left hip d/t very tight tension and limited ROM . i. Review of a progress note dated 6/12/25 and timed 4 PM showed LATE ENTRY Appointment / Transportation Follow Up: Called radiology to confirm order was received. Called [name of outside entity] for transportation. Appointment scheduled for 6/16 at 9 AM. Notified staff. j. Review of a progress note dated 6/13/25 and timed 4:05 PM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and also when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d.t continuation of odd alignment of hips seated and standing . k. Review of a progress note dated 6/14/25 and timed 3:29 AM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d/t continuation of odd alignment of hips seated and standing . l. Review of a progress note dated 6/15/25 and timed 3:12 AM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d/t continuation of odd alignment of hips seated and standing . m. Review of a progress note dated 6/16/25 and timed 12:38 AM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d/t continuation of odd alignment of hips seated and standing . n. Review of a progress note dated 6/16/25 and dated 1:14 PM showed Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Trauma (fall or related) . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: sent out for evaluation B: New Testing Orders: -X-ray . o. Review of a progress note dated 6/16/25 and dated 5:42 PM showed Called hospital talked to [name], asked how [resident #1] was doing and if they decided on what they were going to do with [his/her] left hip, she stated that they have tried to put it back in place a couple of times unsuccessfully. they [sic] are still waiting for the doctor to make a decision for surgery. I will f/u again tomorrow. p. Review of a progress note dated 6/17/25 and dated 4:42 AM showed Resident sent our [sic] to [hospital name] for XR of previously repaired hip. Hip found to be out of socket at that time and Resident has been out of facility all NOC . q. Review of a progress note dated 6/17/25 and dated 4:37 PM showed [Resident] returned from [hospital] with our transportation around 14:45. [S/he] has dislocated internal Left hip prosthesis. Non weight bearing to left side. weights [sic] and vitals taken and placed in charting. [s/he] has a fentanyl 12.5 mg patch to the right side for mild pain. and [sic] Tramadol 50mg every 6 hours PRN for a higher level of pain . r. Review of a progress note dated 6/24/25 and timed 1:56 PM showed Per [orthopedic physician] verbal: Resident is WBAT. Hip will always be this way. Resident may participate in activities as comfortable and able. s. Review of a progress note dated 6/24/25 and dated 5:01 PM showed [name] from Dr. [physician] office called states that [resident #1] is to be non weight bearing. Again [sic] non weight bearing, placed in communication as well. t. Review of a progress note dated 6/25/25 and dated 12:32 PM showed Notified MD of orthopedic MD recommendation to be WBAT. No changes at this time. 2. Interview with resident #1's representative on 7/7/25 at 1:48 PM revealed s/he had not complained of additional pain, but had not been putting weight on his/her left leg during transfers, and stated maybe s/he did the thing s/he wasn't supposed to do after her hip surgery in March, like leaning over; s/he doesn't know what s/he's doing. 3. Interview with LPN #1 on 7/7/25 at 2:07 PM revealed she had called the physician and asked for an order at the request of therapy because they wanted to know the placement of the resident's hip. She reported the resident had reported increased pain a couple of weeks prior and it was under control and managed with Tramadol. Further interview revealed that she was unaware there had been no transportation available. 4. Interview with PTA #1 on 7/7/25 at 2:18 PM revealed the resident had fallen in March 2025, and was sent out of town for a hemiarthoplasty. She reported that surgeon did not want to see the resident for a follow-up appointment, and gave orders for toe touch weight bearing and to use a glider for transfers. She reported therapy had discharged the resident after one month of treatment because s/he had met her goals, and then at the end of May, they received another referral because the resident had more difficulty with transfers. She reported the PT requested a urinalysis and a hip x-ray from the nurse, and it had to be requested a few times in order to get it done. 5. Interview with the hospital social worker on 7/7/25 at 2:40 PM revealed there had been a delay in making the decision to send the resident in for the x-ray. She confirmed the physician's order was a routine order that had been put in on 6/9/25. She stated the physician had signed the verbal order on 6/10/25 at 8:11 AM, and the x-ray was scheduled by the facility for 6/16/25. She reported she spoke with the DNS on 6/16/25 and asked why the x-ray had not been scheduled in a timely manner, and was told the facility van did not work and outside transportation had to be arranged. 6. Interview with LPN #1 on 7/7/25 at 3:16 PM confirmed the order for the x-ray was verbal, and there was no confirmation by fax for the order. 7. Interview with the DNS on 7/7/25 at 3:20 PM confirmed transportation had to be scheduled from an outside source because the facility van was broken, and she did not think it was a huge rush. She reported she called the radiology department on 6/12/25 to confirm the order was in, called the clinic and set up the appointment for 6/16/25, and then scheduled transportation with a community provider. She reported she called the hospital and let them know the resident had been non-ambulatory because there had been confusion and the hospital staff and physicians were unaware the resident was non-ambulatory. Further interview revealed if an order is taken by an LPN it goes through the LPN and was not signed off by an RN. Further, she confirmed the facility administration was aware of the delay to obtain xrays for resident #1 and a PIP had been initiated to address the timeliness of the services. 8. Interview with the DNS on 7/7/25 at 4:40 PM revealed when a verbal order was taken it was then documented in the chart, not with a fax. She confirmed there was no evidence of the priority of the order and no evidence the order was clarified. 9. Review of the Physician Order Recaps policy last updated April 2024 showed .Policy Statement: Physician orders are reviewed and revised daily, via the Electronic Health Record .Procedure 1. The licensed nursing staff is responsible for inputting admission, telephone and verbal physician's orders into the EHR immediately upon receipt from the provider. 2. The Director of Nursing establishes the licensed clinician responsible for recap and reconciliation of New, Discontinued, or Completed orders in the EHR daily and initiates corrections daily. 3. New Telephone and Verbal Physicians orders are signed routinely or a minimum of once per month by the provider either electronically via the EHR, or printed and signed in wet ink and scanned into the Documents tab . 10. Review of the State of Wyoming Board of Nursing, Chapter 3: Scope and Standards of Nursing Practice and CNA Role effective date 9/7/2017 to current showed .Section 4. Scope of Nursing Practice for the RN and the LPN .(v) Seek clarifications of orders or direction when needed; .

Based on record review, resident representative and staff interview, and policy and procedure review, the facility failed to meet the needs of residents with regard to the quality and/or timeliness of providing radiology or other diagnostic services for 1 of 3 sample residents (#1) reviewed for diagnostic service orders. The findings were: 1. Review of the re-entry MDS assessment dated [DATE] showed resident #1 had severely impaired cognitive skills, did not ambulate, and required substantial/maximal assistance for transfers. Resident #1 had diagnoses which included presence of left artificial hip joint, difficulty in walking, and neurocognitive disorder with Lewy bodies. The following concerns were identified: a. Review of a progress note dated 6/6/25 and timed 2:39 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers . b. Review of a progress note dated 6/7/25 and timed 2:46 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers. Therapy requests that staff continue using the manual glider at this time and provide resident proper verbal and tactile cues . c. Review of a progress note dated 6/8/25 and timed 4:58 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t verytight [sic] tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers. Therapy requests that staff continue using the manual glider at this time and provide resident proper verbal and tactile cues . d. Review of a progress note dated 6/9/25 and timed 2:34 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t verytight [sic] tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers. Therapy requests that staff continue using the manual glider at this time and provide resident proper verbal and tactile cues . e. Review of a progress note dated 6/9/25 and timed 8:30 AM showed Called Dr. [primary physician] office talked to [office nurse], asked if we could get an order for X-Ray to the left hip. f/u with response. f. Review of a progress note dated 6/9/25 and timed 4:56 PM showed Dr, [sic] [primary physician] office called talked to [office nurse], there is an X-ray order over at the hospital. Will set up transportation to get [him/her] over there tomorrow. g. Review of a progress note dated 6/10/25 and dated 2:59 AM showed .PT has requested nursing to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers . h. Review of a progress note dated 6/11/25 and timed 2:17 AM showed .Abductor wedge in use for proper leg placement to avoid hip/joint issues. PT has requested nursing to see about getting an x-ray to the left hip d/t very tight tension and limited ROM . i. Review of a progress note dated 6/12/25 and timed 4 PM showed LATE ENTRY Appointment / Transportation Follow Up: Called radiology to confirm order was received. Called [name of outside entity] for transportation. Appointment scheduled for 6/16 at 9 AM. Notified staff. j. Review of a progress note dated 6/13/25 and timed 4:05 PM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and also when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d.t continuation of odd alignment of hips seated and standing . k. Review of a progress note dated 6/14/25 and timed 3:29 AM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d/t continuation of odd alignment of hips seated and standing . l. Review of a progress note dated 6/15/25 and timed 3:12 AM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d/t continuation of odd alignment of hips seated and standing . m. Review of a progress note dated 6/16/25 and timed 12:38 AM showed .Hip abduction support with straps is on resident when [s/he] is up in [his/her] wheelchair and when [s/he] is in bed to help with pain management to hip/knee, along with ensuring proper alignment and positioning. Resident has x-ray of left hip scheduled for Monday 6.16.25 d/t continuation of odd alignment of hips seated and standing . n. Review of a progress note dated 6/16/25 and dated 1:14 PM showed Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Trauma (fall or related) . Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: sent out for evaluation B: New Testing Orders: -X-ray . o. Review of a progress note dated 6/16/25 and dated 5:42 PM showed Called hospital talked to [name], asked how [resident #1] was doing and if they decided on what they were going to do with [his/her] left hip, she stated that they have tried to put it back in place a couple of times unsuccessfully. they [sic] are still waiting for the doctor to make a decision for surgery. I will f/u again tomorrow. p. Review of a progress note dated 6/17/25 and dated 4:42 AM showed Resident sent our [sic] to [hospital name] for XR of previously repaired hip. Hip found to be out of socket at that time and Resident has been out of facility all NOC . q. Review of a progress note dated 6/17/25 and dated 4:37 PM showed [Resident] returned from [hospital] with our transportation around 14:45. [S/he] has dislocated internal Left hip prosthesis. Non weight bearing to left side. weights [sic] and vitals taken and placed in charting. [s/he] has a fentanyl 12.5 mg patch to the right side for mild pain. and [sic] Tramadol 50mg every 6 hours PRN for a higher level of pain . r. Review of a progress note dated 6/24/25 and timed 1:56 PM showed Per [orthopedic physician] verbal: Resident is WBAT. Hip will always be this way. Resident may participate in activities as comfortable and able. s. Review of a progress note dated 6/24/25 and dated 5:01 PM showed [name] from Dr. [physician] office called states that [resident #1] is to be non weight bearing. Again [sic] non weight bearing, placed in communication as well. t. Review of a progress note dated 6/25/25 and dated 12:32 PM showed Notified MD of orthopedic MD recommendation to be WBAT. No changes at this time. 2. Interview with resident #1's representative on 7/7/25 at 1:48 PM revealed s/he had not complained of additional pain, but had not been putting weight on his/her left leg during transfers, and stated maybe s/he did the thing s/he wasn't supposed to do after her hip surgery in March, like leaning over; s/he doesn't know what s/he's doing. 3. Interview with LPN #1 on 7/7/25 at 2:07 PM revealed she had called the physician and asked for an order at the request of therapy because they wanted to know the placement of the resident's hip. She reported the resident had reported increased pain a couple of weeks prior and it was under control and managed with Tramadol. Further interview revealed that she was unaware there had been no transportation available. 4. Interview with PTA #1 on 7/7/25 at 2:18 PM revealed the resident had fallen in March 2025, and was sent out of town for a hemiarthoplasty. She reported that surgeon did not want to see the resident for a follow-up appointment, and gave orders for toe touch weight bearing and to use a glider for transfers. She reported therapy had discharged the resident after one month of treatment because s/he had met her goals, and then at the end of May they received another referral because the resident had more difficulty with transfers. She reported the PT requested a urinalysis and a hip x-ray from the nurse, and it had to be requested a few times in order to get it done. 5. Interview with the hospital social worker on 7/7/25 at 2:40 PM revealed there had been a delay in making the decision to send the resident in for the x-ray. She confirmed the physician's order was a routine order that had been put in on 6/9/25. She stated the physician had signed the verbal order on 6/10/25 at 8:11 AM, and the x-ray was scheduled by the facility for 6/16/25. She reported she spoke with the DNS on 6/16/25 and asked why the x-ray had not been scheduled in a timely manner, and was told the facility van did not work and outside transportation had to be arranged. 6. Interview with LPN #1 on 7/7/25 at 3:16 PM confirmed the order for the x-ray was verbal, and there was no confirmation by fax for the order. 7. Interview with the DNS on 7/7/25 at 3:20 PM confirmed transportation had to be scheduled from an outside source because the facility van was broken, and she did not think it was a huge rush. She reported she called the radiology department on 6/12/25 to confirm the order was in, called the clinic and set up the appointment for 6/16/25, and then scheduled transportation with a community provider. She reported she called the hospital and let them know the resident had been non-ambulatory because there had been confusion and the hospital staff and physicians were unaware the resident was non-ambulatory. Further interview revealed if an order is taken by an LPN it goes through the LPN and was not signed off by an RN. Further, she confirmed the facility administration was aware of the delay to obtain xrays for resident #1 and a PIP had been initiated to address the timeliness of the services. 8. Interview with the DNS on 7/7/25 at 4:40 PM revealed when a verbal order was taken it was then documented in the chart, not with a fax. She confirmed there was no evidence of the priority of the order and no evidence the order was clarified. 9. Review of the Physician Order Recaps policy last updated April 2024 showed .Policy Statement: Physician orders are reviewed and revised daily, via the Electronic Health Record .Procedure 1. The licensed nursing staff is responsible for inputting admission, telephone and verbal physician's orders into the EHR immediately upon receipt from the provider. 2. The Director of Nursing establishes the licensed clinician responsible for recap and reconciliation of New, Discontinued, or Completed orders in the EHR daily and initiates corrections daily. 3. New Telephone and Verbal Physicians orders are signed routinely or a minimum of once per month by the provider either electronically via the EHR, or printed and signed in wet ink and scanned into the Documents tab .

Based on medical record review, staff interview, and review of facility policies and CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 1 of 5 sample residents (#11) reviewed for immunizations. The findings were: 1. Review of the medical record showed resident #11 was admitted on [DATE] and was [AGE] years old. Review of the 9/21/23 initial and 3/17/24 quarterly MDS assessments showed the resident was not up to date on pneumococcal immunizations. The reason was not offered. Further review of the medical record showed the resident received the following pneumococcal vaccines: PPSV23 on 6/10/2003 and PPSV23 on 7/18/2008. There lacked evidence the resident was offered a pneumococcal immunization since admission. 2. During an interview on 6/27/23 at 1:39 PM the DON and DDCO stated the resident had received two doses of PPSV23 and confirmed there lacked evidence to show the resident was offered a pneumococcal vaccine since admission. 3. Review of the facility's policy Pneumococcal Vaccination of Residents, (updated March 2022) showed .PCV-20 is recommended for all adults [AGE] years or older .Residents [AGE] years or older should get a dose of PCV-20 even if they have already gotten one or more doses of the vaccine before they turned 65. 4. Review of Adult Immunization Schedule by Age by CDC located at https://www.cdc.gov/vaccines/schedules/hcp/adult.html (accessed 7/2/24) showed individuals [AGE] years or older who previously received only PPSV23 should receive 1 dose of PCV15 or 1 dose of PCV20 at last 1 year after the last PPSV23 dose.

Based on observation, staff interview, and review of staffing schedules, review of the facility grievance log, and review of policy and procedure, the facility failed to respond to an allegation of abuse and protect the resident's right to be free from verbal abuse by a staff member for 1 of 1 sample resident (#1) reviewed. This failure resulted in a delay in an investigation which left the residents unprotected, and a determination of immediate jeopardy. The census was 28. The findings were: 1. Review of a grievance form, provided by staff #1 and written by CNA #1, showed I witnessed [CNA #2] tell [the resident] [s/he] smelled wrong and [s/he] needed to come with him. [The resident] told him [his/her] pants were dry and was refusing. He leaned toward (sic) and yelled loudly at [the resident] to 'Stop I don't have to listen to this Get up!' [The resident] said no and he grabbed [the resident's] left hand and tried to pull [the resident] out of the chair. At that time, CNA #1 stepped in and told CNA #2 he would take over the situation. The grievance form showed the incident occurred on 2/24/24 at 3 PM and was submitted to the business office manager (BOM) on 2/25/24. 2. Review of a witness statement, provided by staff #1 which was written by LPN #1, dated 2/24/24 and timed 3 PM, showed I heard a man yelling at the end of the hall, down from nurse's station. The man was heard yelling and so was patient [the resident]. I realized it was [CNA #2] yelling and immediately started down the hall. By the time I arrived where [CNA #2] and patient were, the other [CNA #1] stepped in and was assisting patient with [his/her] care. [CNA #2] was yelling directly in the patient's face while [CNA #1] was positioning himself between patient and [CNA #2]. Upon my arrival I quickly went to assist [CNA #1] with patient. Patient was noticeably upset, so [CNA #1] and myself assisted patient to [his/her] room. The following concerns were identified: 1. Observation on 3/5/24 from 2:15 PM until 6 PM showed CNA #2 was in the facility and providing care to the residents. 2. Review of the 2024 February and March nursing schedule showed CNA #2 worked a 12-hour shift on 2/25, 3/1, 3/2, 3/3, 3/4, and 3/5. 3. Review of the February 2024 grievance log showed no evidence of the grievance filed by CNA #1. 4. Staff interviews were conducted on 3/5/24 from 3:45 PM through 6:08 PM. a. Interview with the BOM at 4:44 PM revealed CNA #1 had verbally informed her of an incident involving CNA #2 and the resident. The BOM asked CNA #1 to put it in writing and after he did so she gave the grievance form to the ED. The BOM was unaware of the outcome of the grievance. b. Telephone interview with LPN #1 at 5:16 PM revealed she was at the nurse's station when she heard a man yelling and a resident yelling back. The LPN described the yelling to be a different sound than what was normally heard. When she got to the dayroom, she witnessed CNA #2 directly in front of the resident and CNA #1 placing himself between CNA #2 and the resident. c. Telephone interview with CNA #1 at 5:29 PM revealed he was in the dayroom on 2/24/24 when CNA #2 walked in front of resident #1 and told the resident You don't smell right and grabbed the resident's hand and tried to pull him/her out of the chair. The resident protested and said no stating his/her pants were dry. At this time CNA #2 got in the resident's face and started yelling Stop I don't have to listen to this you are coming with me. CNA #1 stated he reported the incident to the BOM who then asked him to fill out a grievance form which he gave to her on 2/25/24. d. Interview with CNA #2 at 5:58 PM revealed he did not recall having any negative interactions with resident #1. He stated the resident did not want male caregivers so he respected [his/her] stance. 5. On 3/5/24 at 7:20 PM the ED was informed of an immediate jeopardy situation in the area of abuse related to the failure to investigate an allegation of abuse and provide protection to residents. 6. The facility submitted an action plan which included the following immediate changes: a. CNA #2 was suspended on 3/5/24 pending an investigation. b. An abuse allegation investigation was started which included resident interviews and reporting of the allegation to the appropriate entities. c. Education was provided to all staff on abuse reporting notification and investigation which included education of oncoming staff before contact with residents. 6. The action plan was accepted on 3/6/24 at 11:36 AM. 7. The implementation of the action plan was verified and immediacy was removed on 3/6/24 at 12:08 PM; however, deficient practice remained at a scope and severity of E. 8. Review of the 2017 Abuse Reporting and Response policy and procedure showed 1. Staff immediately reports all alleged or suspected violations immediately to the supervisor and Executive Director.

Based on medical record review, staff interview, facility grievance log review, policy and procedure review, and State Survey Agency incident database review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 3 sample residents (#1) reviewed for abuse. This failure resulted in actual harm to resident #1 who experienced verbal abuse a reasonable person would have found humiliating, intimidating, demeaning, and degrading. The findings were: 1. Review of the 12/13/23 quarterly MDS assessment showed resident #1 had a mood score of 00 and did not exhibit any behaviors, wandering, or rejection of care during the 7-day look-back period. Further review showed the resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of the resident's care plan showed special instructions to document every shift if the resident had an increase in confusion episodes, escalations in voice, perseverations, or changes in mood or behavior. The following concerns were identified: a. Review of a grievance form, provided by staff #1 and written by CNA #1, showed I witnessed [CNA #2] tell [the resident] [s/he] smelled wrong and [s/he] needed to come with him. [The resident] told him [his/her] pants were dry and was refusing. He leaned toward (sic) and yelled loudly at [the resident] to 'Stop I don't have to listen to this Get up!' [The resident] said no and he grabbed [the resident's] left hand and tried to pull [the resident] out of the chair. At that time, CNA #1 stepped in and told CNA #2 he would take over the situation. The grievance form showed the incident occurred on 2/24/24 at 3 PM and was submitted to the business office manager (BOM) on 2/25/24. b. Review of a witness statement, provided by staff #1 and written by LPN #1, dated 2/24/24 and timed 3 PM, showed I heard a man yelling at the end of the hall, down from nurse's station. The man was heard yelling and so was patient [the resident]. I realized it was [CNA #2] yelling and immediately started down the hall. By the time I arrived where [CNA #2] and patient were, the other [CNA #1] stepped in and was assisting patient with [his/her] care. [CNA #2] was yelling directly in the patient's face while [CNA #1] was positioning himself between patient and [CNA #2]. Upon my arrival I quickly went to assist [CNA #1] with patient. Patient was noticeably upset, so [CNA #1] and myself assisted patient to [his/her] room. c. Review of the February 2024 grievance log showed no evidence of the grievance filed by CNA #1. d. Telephone interview with LPN #1 on 3/5/24 at 5:16 PM revealed she was at the nurse's station when she heard a man yelling and a resident yelling back. The LPN described the yelling to be a different sound than what was normally heard. When she got to the dayroom, she witnessed CNA #2 directly in front of the resident and CNA #1 placing himself between CNA #2 and the resident. Further the LPN stated the resident upsets easily and she observed the resident to have a frowny face and was yelling back at CNA #2. e. Telephone interview with CNA #1 on 3/5/24 at 5:29 PM revealed he was in the dayroom on 2/24/24 when CNA #2 walked in front of resident #1 and told the resident You don't smell right and grabbed the resident's hand and tried to pull him/her out of the chair. The resident protested and said no stating his/her pants were dry. At this time CNA #2 got in the resident's face and started yelling Stop I don't have to listen to this you are coming with me. CNA #1 stated he reported the incident to the BOM who then asked him to fill out a grievance form which he gave to her on 2/25/24. Further the CNA stated the resident's tone of voice was elevated and the pitch was really high. Further interview revealed the resident exhibited a high pitched voice when s/he was upset. f. Interview with CNA #2 on 3/5/24 at 5:58 PM revealed he did not recall having any negative interactions with resident #1. He stated the resident did not want male caregivers so he respected [his/her] stance. g. Review of the resident's care plan showed no documentation of a refusal for male caregivers. Interview with the DON on 3/6/24 at 9:48 AM revealed she was unaware of any request by the resident for only female caregivers. In addition, she stated the resident was cared for on a routine basis by male CNAs on the night shift. h. Review of the State Survey Agency incident database showed an incident was submitted by the facility on 3/5/24 at 8:34 PM. Further review showed allegation of abuse of yelling at resident and rough with cares. Staff member suspended, residents (sic) does not recall the event. Investigation started. i. Interview on 3/6/24 at 12:09 PM with the regional nurse consultant, ED, and DON revealed the facility was not aware of what happened to the grievance form submitted by the BOM. Further interview revealed the DON would feel frustrated if she was in the resident's position, the incident was not okay, and she would be upset. 2. Review of the policy titled Prevention of Abuse, Neglect, Involuntary Seclusion, Exploitation, and Misappropriation of Resident Property, last updated September 2017, showed 1. The Center utilizes the grievance process for concerns expressed by residents, family members, visitors, or others within the Center .4. The Center utilizes a separate Grievances Process for concerns expressed by staff members .7. Center supervisors and staff (as appropriate) correct and intervene in reported or identified situations in which abuse, neglect, exploitation, or misappropriation of property is more likely to occur by analyzing the following .d. The supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care, etc .11. Retaliation against staff or others for reporting concerns is strictly prohibited and will lead to disciplinary action.

Based on observation, medical record review, staff interview, review of facility incident reports and investigations, and facility policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 5 residents (#1) reviewed for abuse. This failure resulted in harm to resident #1, who sustained facial bruising after being struck by another resident. The findings were: Review of the 7/10/23 annual MDS assessment for resident #1 showed the resident was rarely/never understood, wandered daily during the lookback period, and walked with a walker with staff supervision. The resident had diagnoses of arthritis, and Alzheimer's disease. The resident did not take anticoagulants but did take antipsychotic medication during the last 7 days of the MDS look back period. The resident was not coded as having behaviors directed towards others. Review of the 8/1/23 quarterly MDS assessment for resident #2 showed diagnoses which included non-Alzheimer's dementia and diabetes mellitus. The resident had severely impaired cognitive skills, had physical and verbal behaviors towards others, and wandered 1 to 3 days during the lookback period. The resident walked using a walker with staff supervision. The following concerns were identified: 1. Review of the facility's 8/4/23 incident report showed on 8/4/23 at approximately 8:15 PM, CNA #1 was walking resident #1 to his/her room from the unit dining room. As they came to the split in the hall, resident #2 was walking on the other side of the hallway. Unprovoked, resident #2 reached out and hit resident #1 in the face with a semi-closed right hand. CNA #1 immediately intervened and redirected resident #2 to his/her room, then called for a nurse over the walkie-talkie system. LPN #3 came to assess resident #1, and found a bruise forming under his/her left eye where s/he had been struck by resident #2. Local law enforcement, physicians for both residents, and families for both residents were notified. Review of the facility's investigation of the incident showed staff were unable to determine what provoked the incident. a. Interview on 8/21/23 at 7 PM with CNA #1 revealed on 8/4/23 while walking with resident #1, resident #2 walked beside resident #1 and used the back of his/her hand with a semi-closed fist and hit resident #1 in the left side facial area, leaving a mark. Furthermore, the staff member stated resident #2 made a statement that resident #1 took her blanket. The staff member also stated the action was intentional by resident #1. b. Interview on 8/22/23 at 2 PM with the executive director and regional nurse consultant confirmed resident #1 was hit in the face by resident #2. c. Observation on 8/21/23 at 4:30 PM showed resident #1 walking in the hall with a green bruise covering an area from the left eyelid to the left cheekbone. d. Review of the policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation updated October 2022 showed: That each resident had the right to be from physical abuse; defined Willful as when the individual acted deliberately, not that the individual must have intended to inflict injury or harm, physical abuse included hitting and slapping, and further review showed resident to resident abuse altercations are reviewed as potential abuse.

Based on observation, and staff interview, the facility failed to ensure medications for resident use were not expired in 1 of 3 medication storage units ( secure unit medication cart). The findings were: 1. Observation on [DATE] at 2:44 PM of the secure unit medication cart with LPN #1 showed 54 tablets of hydrocodone-acetaminophen ,d+[DATE] mg tablets had expired ,d+[DATE]. Interview with the LPN at that time confirmed the medication was for resident use and expired. 2. Interview with the DON on [DATE] at 2:54 PM revealed it was the expectation for the nurses to check the expiration date and dispose of the medication if expired. 3. Interview with the assistant executive director on [DATE] at 4:51 PM revealed the facility did not have a policy related to prescription medication expirations.

Based on medical record review and staff interview, the facility failed to ensure residents received a gradual dose reduction (GDR), unless contraindicated, for psychotropic medication for 1 of 5 sample residents (#5) reviewed for unnecessary medications. The findings were: 1. Review of the 2/25/23 quarterly MDS assessment showed resident #5 had diagnoses that included non-Alzheimer's dementia and anxiety disorder. Further, the resident received an antipsychotic on 7 days during the look-back period and a GDR was not attempted, nor did the physician document a contraindication. Review of physician orders showed the resident received Ziprasidone HCl (antipsychotic, brand name Geodon) 60 mg once per day plus 40 mg once per day since 7/26/22. The following concerns were identified: a. Review of the medical record showed no evidence a GDR of the Ziprasidone HCL was attempted. b. Review of a physician's progress note dated 2/14/23 showed Pharmacy review performed with recommendation GDR Geodon. The patient has been decreased to 40 mg BID [twice per day] in the last several days. However, review of the physician orders and the medication administration record (MAR) for February, March and April 2023 showed the resident remained on Ziprasidone HCL 60 mg once per day and 40 mg once per day. c. On 4/20/23 at 9:05 AM the assistant executive director stated she called the physician's office on 4/19/23. She stated he had a signed response to a pharmacy recommendation from February 2023 regarding the Geodon in his office. However, she stated neither the facility nor the pharmacist had received the response. She stated the physician's office faxed the response to them last night. d. Review of the faxed Consultant Pharmacist Recommendation to Physician showed Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter. This resident has been taking Geodon 60 mg am and 40 mg pm since July 2022 without a GDR . The physician's written response was to reduce the dose of Geodon to 40 mg po bid. The physician signed it 2/13/23.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure ostomy care was provided according to the care plan for 1 of 1 residents with an ostomy (#24). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #24 entered the facility on 10/18/22 and had a BIMS score of 15 out of 15, indicating intact cognition. Bowel elimination showed the resident had an ostomy. The diagnoses included personal history of malignant neoplasm of large intestine, diabetes mellitus, and muscle weakness. Review of the current care plan showed and intervention last revised on 12/2/22: Monitor Colostomy every shift and as needed; dressing change per protocol. Provide Colostomy care and monitor for any skin breakdown, and an intervention last revised on 10/27/22: [Resident name] has an alteration in gastro-intestinal status r/t [related to] Colostomy (history of Colon Cancer) and GERD. [Resident name] will remain free from discomfort, complications or [signs and symptoms] s/sx related to gastro-intestinal alterations through review date. The following concerns were identified: a. Observation on 4/18/23 at 10:41 AM showed the resident had an ostomy. Interview at that time with the resident revealed s/he was admitted to the facility with the ostomy. b. Review of the physician orders showed there were no orders for the ostomy care. c. Review of the progress notes showed the last entry related to the ostomy was dated 3/5/23 at 5:42 PM Wafer and bag changed once this shift, showing 43 days without written documentation of ostomy care. Review of the treatment administration record (TAR) showed no evidence of monitoring the ostomy. Review of the weekly skin assessment reports showed no evidence of an ostomy site skin assessment. d. Interview with the assistant executive director on 4/19/23 at 6:31 PM revealed there was no order for the ostomy care, and the care plan really did not address the ostomy. e. Interview with the assistant executive director on 4/20/23 at 9:15 AM revealed the skin assessments would not show the ostomy because it was pre-existing and not new. Further, she revealed she was unable to find a facility policy and procedure for ostomy care.

Based on medical record review and staff interview, the facility failed to ensure a written notice of transfer was provided to the resident or resident's representative for 2 of 2 sample residents (#36, #41) who were hospitalized . The findings were: 1. Review of progress notes showed resident #36 was transferred to the hospital on 4/11/23. The resident returned to the facility on [DATE]. Review of the medical record showed a copy of a Facility notice of Discharge form that was e-mailed to the Ombudsman on 4/13/23. However, there lacked evidence the resident or resident's representative received written notice of the transfer. 2. Review of progress notes showed on 3/20/23 resident #41 was transferred to the emergency room . A progress note dated 3/21/23 showed the resident was admitted to the hospital, and would be discharged to hospice care in another city. Review of the medical record showed a copy of a Facility notice of Discharge form that was e-mailed to the Ombudsman on 3/23/23. However, there lacked evidence the resident or resident's representative received written notice of the transfer/discharge. 3. During an interview on 4/20/23 at 10:25 AM the assistant executive director stated the facility had a Resident Notice of Transfer or Discharge Form but they only issued that form if the resident was transferring for good. She stated they did not provide the form to residents or the resident's family for transfers to the hospital.

Based on review of facility medical records and hospital medical records, review of facility incident reports, review of the facility grievance logs, resident and staff interview, and review of facility policy and procedure, the facility failed to protect the resident's right to be free from deprivation of goods and services necessary to avoid physical harm and pain for 1 of 8 sample residents (#1) reviewed for abuse and neglect, and further failed to protect the resident's right to be free from verbal or mental abuse by a staff member for 1 of 8 sample residents (#2) reviewed for abuse and neglect. This failure resulted in harm to resident #1, who required evaluation at the emergency department and admission to the hospital for an indwelling urinary catheter that was degraded. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #1 was admitted to the facility on [DATE]. The resident had a BIMS score of 13 of 15 indicating the resident was cognitively intact. Admission diagnoses included hypertension, viral hepatitis, seizure disorder, hepatic failure, cirrhosis of the liver, and indwelling urinary catheter. Review of the resident's care plan, undated, showed the resident required extensive assist of 1 person for ADLs, and had a Foley catheter, and cirrhosis of the liver with ascites. The following concerns were identified: a. Review of the nursing progress notes dated 3/5/23 as a late entry for 12:43 AM showed the resident was sent to the hospital emergency department by ambulance at approximately 11 PM for abdominal pain, and non-functioning Foley catheter. Attempts to flush the catheter were unsuccessful and the catheter was not draining. The resident's penis, scrotum and pubic area had increased pain and swelling. b. Review of the medical record from the local hospital dated 3/5/23 showed the resident was seen in the emergency department for a blocked Foley catheter, and swelling and inflammation in the perineal area including the scrotum and penis. The records noted the resident's Foley catheter was badly deteriorated and the probable cause of the infection. The resident was admitted to the hospital for antibiotic therapy. The penis was so swollen the only access obtained was by inserting an 8 French (a small catheter usually used on small children) Foley. c. Interview with the risk management nurse at the local hospital on 3/10/23 at 1 PM revealed the resident's Foley catheter was in deplorable condition when the resident came to the emergency department, and when they asked the resident when it was last changed the resident indicated the catheter had not been changed since October, 2022. d. Interview with the resident while at the hospital on 3/10/23 at 1:20 PM confirmed the Foley catheter had never been changed at the nursing home, and that s/he had been admitted last October. e. Review of the resident's care plan, undated, showed Foley catheter related to terminal condition of cirrhosis of liver with ascites and interventions included catheter changes as protocol. f. Review of the physician orders failed to show any specific orders for care of the Foley catheter. g. Review of the facility standing orders showed catheter care to be as directed by nursing staff. h. Interview with the interim administrator on 3/10/23 at 9 AM revealed the urinary catheter care in this instance was very poor care and did not meet facility expectations. 2. Review of the admission MDS assessment dated [DATE] showed resident #2 was admitted to the facility with diagnoses which included diabetes mellitus, and anxiety disorder. Further review indicated the resident had a BIMS score of 15 of 15 indicating the resident was cognitively intact. The following concerns were identified: a. Review of the facility grievance log indicated on 2/15/23 the resident complained the former administrator of the facility had approached the resident in his/her room and wanted the resident to take a particular medication for his/her blood sugar. The resident refused and expressed concerns about the medication. The resident reported the former administrator then indicated to the resident if s/he did not want to work with the facility to fix their condition s/he would be kicked out and have to go someplace else. b. Interview with resident #2 on 3/9/23 at 3 PM revealed the grievance was accurate and reiterated the occurrence. Further interview revealed the resident had been a lifelong diabetic and felt the condition was controlled with Humalog (insulin). The resident regarded the former administrator's statement as a threat, but felt safe at the facility since the former administrator was no longer working at the facility. The resident stated the former administrator had also called his/her parents and threatened them in the same manner. c. Review of the facility's 2/23/23 incident report showed the former administrator refused to be interviewed for the facility's investigation of this incident, and her employment was terminated. d. Interview with the interim administrator on 3/10/23 at 9 AM confirmed that verbal or mental abuse would not be tolerated and that was the expectation for all of their facilities. 3. Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation updated October 2022, showed Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse .neglect .The center implements policies and processes so that residents are not subjected to abuse by staff . and .Neglect: Failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), resulting in physical harm, pain, mental anguish, or emotional distress.

Based on medical record review, resident and staff interview, and review of facility investigation documentation, the facility failed to ensure residents received medication according to physician order for 2 of 8 sample residents (#1, #5) reviewed for medication administration. The findings were: Interview with the interim administrator on 3/9/23 at 10:30 AM revealed when they took over interim supervisory operation at the nursing home they received complaints about the special cream being used on residents and its nature, and investigated on 2/19/23. Further interview confirmed the cream had been used on resident #1 and resident #5. Review of the facility's investigation showed the former administrator had applied an ointment called Dragon Balm to residents #1 and #5. Law enforcement were called and tested the ointment, which was determined to contain significant levels of THC. The ointment was taken by law enforcement as evidence. The following concerns were identified: 1. Review of the February, 2023 MARs for residents #1 and #5 showed no evidence of a physician's order for Dragon Balm ointment. 2. Review of the admission MDS assessment dated [DATE] for resident #1 showed the resident was admitted to the facility on [DATE]. The resident had a BIMS score of 13 of 15 indicating the resident was cognitively intact. Interview with the resident on 3/10/23 at 1:20 PM revealed the resident did not know what medications s/he took, or what ointments or creams might have been applied. 3. Review of the quarterly MDS assessment dated [DATE] for resident #5 showed the resident was admitted to the facility on [DATE]. The resident had a BIMS score of 15 of 15 indicating the resident was cognitively intact. Interview with resident #5 on 3/9/23 at 2:30 PM revealed s/he knew exactly what medications the facility was administering to him/her, because s/he insisted on being told. In further interview the resident declined to discuss their medications further. 4. Interview with the interim administrator on 3/9/23 at 10:30 AM confirmed the facility expectation that all medications administered to residents must be ordered by a physician.

Based on observation, medical record review, review of an incident timeline, family and facility staff interview, interview with hospital staff, policy and procedure review, review of an emailed update, and review of professional standards, the facility failed to protect the resident's right to be free from neglect. Specifically, the facility failed to provide timely interventions consistent with professional standards for 1 of 1 residents with significant burns (#1). This failure resulted in a delay in transfer to a burn center for assessment and intervention by qualified staff, and a determination of immediate jeopardy. The census was 45. The findings were: 1. Review of the 11/24/22 quarterly MDS assessment showed resident #1 had diagnoses which included diabetes mellitus, atrial fibrillation, coronary artery disease, hypertension, and non-Alzheimer's dementia. The assessment showed the resident had no pressure ulcers or other skin conditions at that time. The resident's brief interview for mental status could not be completed due to severe cognitive impairment, and s/he required the extensive assistance of one staff person for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed). Review of the resident's care plan showed an 8/31/21 plan related to diabetes mellitus with an intervention to avoid exposure to extreme heat and cold. 2. Interview with CNA #4 on 1/10/23 at 6:25 PM revealed she was working the morning of 1/7/23, and found the resident between 3:45 AM and 4 AM with the bed pushed from the wall and the resident's feet on the heater unit with the vent cover missing, so both feet were on the fins and pipes (the hot elements) within the heater unit. It was apparent that the resident's feet were both burned in areas with some peeled skin and some blood, so she got the resident's feet away from the hot elements and onto the bed, and called for the nurse, who arrived promptly. The CNA had last checked on the resident during rounds at around 1:45 AM. She had no experience with burns, but could tell the resident's feet had burns. The resident did not appear to be in pain, but did rub the feet together, so the CNA continued to prevent that. When the nurse arrived she took over, and they placed the bed away from the wall and secured the bed wheel brakes, that had not been not locked in place. The CNA said the brakes should have been on, and she was not sure why that was not the case. 3. Interview with LPN #1 on 1/10/23 at 6:05 PM revealed she came to the resident's room at about 4:15 AM on 1/7/23 promptly after staff alerted her there was an issue. CNA #4 was with the resident and the resident was in bed. The LPN noticed the resident's feet were burned bilaterally. She saw blood and areas on both feet that were obviously burned. She said she had no experience with burns. She ensured the resident's feet were on the bed, then notified the ED/RN at around 4:25 AM rather than calling the physician or the emergency department. The ED/RN arrived approximately 30 minutes later, and the ED/RN took over. 4. Review of a 1/7/23 nursing progress note timed 10:01 AM as a late entry showed, [ED/RN] was called at 0430 [4:30] AM to return to the building due to resident burns. Resident was on [his/her] bed when [ED/RN] arrived. [His/her] feet bilaterally had 2nd degree burns .Right foot-lateral aspect of the foot from toe to arch 16x13 cm [centimeters] with the epidermis removed. The 5th, 4th, and 3rd toe are involved. 4-5th from tip to base 3rd 1.5 cm. Was cleaned and then covered with Silvadine, telfa, abd [abdominal pad], kerlix, and then an ace wrap. Left [foot]-from medial aspect of foot 9x4cm including first toe with epidermis removed red in color. Where that end (over the arch) 2x3 blister filled fluid. This area too was covered in Silvadine, telfa, abd, kerlix, and ace wrap. POA, DNS was notified. MD [DO #1] was notified and orders given for wound care treatment, abx [antibiotics] and supplements to aide in healing due to the resident's medical condition. Resident will be monitored for infection, Tylenol will be given for pain. MD did not think the resident needed to go to the ER. Family agreed. 5. Interview with the ED/RN on 1/10/23 at 4:45 PM revealed she received a call from the facility on 1/7/23 at around 4 AM regarding the resident having burned [his/her] feet on the heat vent by the bed. She arrived in approximately 30 minutes and it was apparent the resident had burned both feet, which she felt included some 2nd degree burn areas. She noticed the heat vent cover was off, exposing the hot pipes and fins. She cleansed the resident's feet with normal saline (NS) and wrapped them, then called the local emergency department and found out DO #1 was the physician on call (for both the facility and the emergency department), then made several attempts to contact DO #1. When she did contact DO #1, she sent pictures of the resident's bilateral foot burns to DO #1 on her phone. DO #1 felt the ED/RN was best trained to care for the resident's burns, not the local emergency department. DO #1 gave orders for wound care. 6. Review of the wound care certification information for ED/RN confirmed she was wound care certified with an expiration date of 5/26/2026. However, interview with the ED/RN on 1/13/23, at 1:55 PM revealed that while she was once certified in burn care, she had not been certified in burn care for the last 6 years. 7. Review of the facility policy titled, Change of Condition published May 2017, under Policy Statement: .Changes in condition are documented in the resident's record, and the resident is monitored via alert charting. If it is determined that the resident's condition is unstable and/or beyond the scope of services provided by the community, the resident is transferred to the hospital for evaluation. 8. Review of a timeline of the event provided by the facility showed the ED/RN unsuccessfully attempted to speak with the physician at the local emergency department 5 times between 4:50 AM and 9 AM. At 9:42 AM (over 5 hours after the burns were discovered), the emergency room physician, DO #1, called back, and the ED/RN explained the resident had sustained 2nd degree burns to both feet. The ED/RN sent photos of the injuries to DO #1. Orders were received to dress the resident's feet and add a multivitamin, vitamin C, and Arginaid (a supplement intended to help with wound healing) to the resident's medications. According to the timeline, it was DO #1's opinion that nothing different would be done at the hospital, and the resident should be kept at the facility to decrease the anxiety of transfer. At 11:36 AM, the ED/RN called the facility's medical director regarding the resident's burns. At that time, the medical director provided an order for Keflex (an antibiotic), but did not intervene to send the resident to the emergency department. 9. Review of the American Burn Association's Burn Center Referral Criteria found at http://ameriburn.org/wp-content/uploads/2017/05/burncenterreferralcriteria.pdf and retrieved on 1/13/23 showed Burn injuries that should be referred to a burn unit include: . 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints .3. Third degree burns in any age group . 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality . 10. Review of the nursing progress note dated 1/8/23 and timed at 3:16 PM showed Family had called early AM asking that the resident be sent to the ER (emergency room ) for evaluation. [ED/RN] spoke with [emergency room doctor - DO #1] and she did not feel the need to have [the resident] taken out in the cold and disrupt [his/her] routine because [s/he] was getting the needed care in the facility. [DO #1] called the [POA] and explained all this to [the POA] and the appropriate care that [the resident] needed and that the ER would do nothing different for [the resident] and that it is not an admitting dx [diagnosis]. [The POA] then called ED/RN and explained they did not have confidence in [DO #1] and what other measures could be taken. ED/RN explained the medical director could be called .and asked if he would come in and check the resident. They agreed to that. Messages left for [the medical director]. After 2 hours of no response from [the medical director] ED/RN called the [POA] and asked what the next steps needed to be. It was explained that the dressings needed to be changed. The POA stated [s/he] would like to come in and look at the feet [him/herself]. ED/RN waited for family to arrive and then proceeded with the dressing change. The wounds on the feet looked a lot better today they are pink red in areas . both no change in size other than the skin around the edges needed to be removed. Resident had +1 edema in the left foot and will work on keeping feet elevated. The right outer foot is the largest with no blisters 5-4-3 toe remains unchanged. Left inner aspect of the foot is the affected area with only the 1st toe burned. All area's pink red and moist. Skin on the edges of the toe wound needed removed. Both feet were cleansed with NS (normal saline), Silvadine was placed on the burned area, followed with telfa abd ace wrap. Resident tolerated dressing change without crying out. Will continue daily dressing change. 11. Continued review of the timeline of the event provide by the facility showed on 1/8/23 between 8:30 AM and 12 PM, the resident's POA texted the facility requesting the resident be sent to the emergency room for evaluation. The ED/RN called the POA and explained they would be glad to send the resident, and they would inform DO #1, who was the physician on call at the emergency room . The POA informed the facility they wanted the resident to be evaluated by a different physician, and asked about sending the resident to a hospital in a different town. It was explained to the POA that the facility could call emergency medical services (EMS) to transport the resident, however, EMS would be required to take the resident to the local emergency room . The ED/RN told the POA she had been in contact with the facility's medical director, and could ask the medical director to come and see the resident. The POA agreed to this. At 12 PM, the RN/ED messaged the medical director to ask if he would stop in and see the resident. At 3:40 PM, the medical director called and informed the facility he was out of town, and could come to see the resident after he had returned home, or Monday or with rounds on Tuesday. The timeline further showed the ED/RN called the resident's POA at 3:45 PM and told the POA what the medical director had offered. According to the timeline, the POA told the ED/RN the medical director did not need to come in that night, and agreed the medical director could see the resident on Monday or Tuesday. Tuesday was decided and agreed upon by all. 12. Interview with the ED/RN on 1/11/23 at 12:10 PM confirmed she initially thought the resident's bilateral burns had some 2nd degree areas as the most severe. She stated that on 1/8/23 the resident's foot color changed a bit. Some areas of the skin were starting to peel around the edges, with about 30% of the right foot having those type skin issues. The 5th toe on the right foot was 100% affected by burns at that time, with skin peeling and encrusted. This went to between the 3rd and 4th toe with the webbing affected. The third toe was peeling at the top, and there was an open area between the 3rd and 4th toe. There were no plantar burns to either foot. On the left foot there was an open skin area on the great toe at approximately 75-80% and went from pink to a deep red. Near the arch there was a 2 cm blister that was intact. There was no erythema, swelling, or weeping noted to either foot at that time. It look like some epidermis was sloughing off. By 1/9/23 there was a 1 cm erythema area, and on the right foot there was a thin area in the center that turned whitish. Overall, the left foot was a darker red. Because the family had agreed the medical director would see the resident on Tuesday, 1/10/23, she made no further attempts to send the resident to the emergency department. 13. Review of the American Burn Association's Got Burned? When to Seek Medical Attention found at https://ameriburn.org/wp-content/uploads/2020/03/got-burned-1.pdf and retrieved on 1/13/23 showed medical attention should be sought when the burn is located on the face, ears, eye, hands, feet or genital area. Additional review showed if the burn is red, blistered, swollen and very painful, it may be a second degree burn. If the burn is whitish, charred or translucent, or the skin is peeling off, with minimal sensation in the area, it may be a third degree burn. 14. Interview with DO #1 on 1/11/23 at 3:35 PM revealed she was on-call for the local emergency department and the facility from Friday the 6th through Monday the 9th of January 2023. She did not remember a call on 1/7/23 from the ED/RN, but did remember the call from the ED/RN on 1/8/23 concerning a family request for the resident be transferred to the emergency department related to the burns. She stated that she believed the ED/RN, who was wound care certified, could handle the resident's burns better than the staff at the hospital. DO #1 felt the resident would have been seen at the local emergency department and just sent back to the facility. She did not believe the resident's burns were that bad. She confirmed she called the resident's POA back on 1/8/23 promptly after she received the call from the ED/RN, and she told the POA the resident should not come to the local ED, that s/he was getting adequate care at the facility, and she had given physician orders concerning wound care. She stated that in her conversation with the POA, she mentioned the cold weather being an impediment to transfer related to comfort, and discussed whether the resident should be placed on comfort measures instead of aggressive treatment for the burn injuries. She felt the decision was professionally sound to have the resident remain at that facility instead of facilitating a transfer to the local emergency department. 15. Interview with the POA on 1/11/23 at 4:15 PM revealed [s/he] was not pleased with the 1/8/23 conversation with DO #1. The POA stated [s/he] expressed to DO #1 the desire for the resident to be transferred to the local ED for assessment, and stated DO #1 was resistant to having the resident transferred. The POA lost confidence in DO #1, and afterward, when ED/RN stated the difficulty of transferring the resident to a hospital further away without being transferred to the local ED first, the POA felt the only option left was to wait for the medical director to arrive and assess the resident. 16. Review of the nursing progress note dated 1/9/23 and timed at 8:15 PM showed Resident has tolerated the day with no issues. Dressings were changed to bilateral feet. When cleansed skin did slough off the toes. Tissue on both feet pink/red/left is a little darker around the toe. On the left foot it did bleed through the dressing and was reinforced. Resident was given tylenol throughout the day. 17. Interview with the ED/RN on 1/11/23 at 10:45 AM confirmed she had contacted DO #1 on 1/7/23 regarding request for transfer to the ED, and again on 1/8/23 regarding the family request to send the resident to the local ED. She further confirmed neither she nor other facility staff made any additional requests to send the resident to the local ED, and she felt she could have been more assertive concerning those requests. She relayed information to the medical director, but did not ask him to intervene with DO #1 regarding requests to transfer the resident to the local ED. 18. Review of the nursing progress note dated 1/10/23 and timed at 9:30 AM showed Late entry-Resident dressing bilateral had [strike] through bleeding noted. Dressings removed and a color change to discharge was noted. Burn area to top of I right foot is starting to turn a yellow color appears to look like eschar. There is with slight redness around the normal skin area's. The toes remained pink and red with skin continuing to slough. Right foot was cleansed with Normal saline and a thin cover of silvadine was placed- abd kerlex and then and ace wrap. The left foot also had a change in exudate color no odor to both. Burn is pink red in most places with slight darker area around the large toe. This foot was cleansed again and wrapped in the same manner. Further review of the medical record showed no evidence a physician was contacted about the state of the burns, and there was no attempt to send the resident to the emergency department. 19. Observation on 1/10/23 at 3:50 PM in the treatment room (room [ROOM NUMBER]) showed the medical director, ED/RN, DNS, and POA with the resident for assessment of bilateral feet trauma/burns (first time a physician had assessed the resident's burns in person since the burns were sustained on 1/7/23). The DNS documented the wound measurements as the physician dictated to her at that time. The resident was asked about pain and appeared to be in no distress. The medical director and ED/RN removed the resident's dressings, and cleaned the wounds to both feet with saline and 4 by 4 sponges. The left foot had burns under and around the great toe, which had red, whitish, and yellowish areas. The measurements were 13 cm long by 5.5 cm across. At that time, the medical director told the POA he was going to contact a burn center. He stated that he felt the resident's feet must have been on the exposed heater fins and pipes for a while. The resident's right foot burns were then measured, and the burns extended from the 4th and 5th toes to two-thirds of the way back toward the heel. The measurements were 16.3 cm length by 11.3 cm across, with reddened, whitish, and yellowish areas. The wounds on both feet had areas that appeared dry and areas that appeared moist, with no obvious infection. The medical director stated at that time the wounds were high risk. 20. Interview with the medical director on 1/10/23 at 4:05 PM confirmed the resident should have been sent to the local emergency department on 1/7/23 at the time the resident sustained the burns, that parts of the burns were at least 3rd degree burns, and that he would start immediately contacting burn centers to have the resident transferred as soon as possible. He confirmed the process regarding transferring residents to the local emergency department would need to be reviewed and revised. 21. Review of the American Burn Association's Burn Center Referral Criteria found at http://ameriburn.org/wp-content/uploads/2017/05/burncenterreferralcriteria.pdf and retrieved on 1/13/23 showed second degree burns are partial thickness burns. The skin may be red, blistered, or swollen. The burns are very painful. Third degree burns are full thickness burns. They may appear whitish, charred or translucent, with no pin prick sensation in the burned area. 22. Review of progress notes dated 1/11/23 and timed 10:08 PM showed the resident was supposed to be transferred to a burn center in another state by helicopter, however, weather on 1/11/23 caused a delay. Review of a progress note dated 1/12/23 and timed 8:40 AM (5 days after the burns were sustained) showed Life flight arrived and report given to them. Resident was loaded on to gurney with no issues. 23. Review of an email sent by the POA to the State Survey Agency on 1/22/23 at 6:22 PM showed the resident underwent surgery for the burns on 1/20/23. The surgeon performed bilateral amputation of both feet. This left a few toes on each side. [The resident] is currently still in ICU [the intensive care unit] with both feet bandaged with a wound vac [vacuum] on the right foot and a skin graft on the left foot. On 1/11/23 at 6:03 PM the executive director was informed of an immediate jeopardy situation in the area of neglect related to the failure to provide ongoing assessment and interventions for a resident with significant burns to the feet bilaterally. The facility submitted an action plan which included the following immediate changes: a. Ongoing identification and assessment of acute changes in condition that require the physician to be notified in order to meet the resident's needs in a timely manner. Resident #1 was transferred to a higher level of care. b. The initial audit for residents who had a change in condition was completed on 1/11/23. c. Education on the process was provided to licensed nurses on 1/12/23. d. A change in process that, if an attending physician refuses to provide the required transfer order, nursing staff will contact the medical director for that transfer order. The action plan was accepted on 1/13/23 at 12:10 PM. The implementation of the action plan was verified and immediacy was removed on 1/13/23 at 1:25 PM; however, deficient practice remained at a scope and severity of G.

Based on observation, medical record review, family and staff interview, water boiler temperature audits review, and review of an email update, the facility failed to ensure the resident environment remained free of accident hazards for 1 of 1 residents (#1) with burns received from the heat source in their room. This failure resulted in harm to resident #1, who sustained burns that required transport to a burn center, amputations and skin grafts. The facility implemented corrective actions prior to the survey. These actions were verified by the survey team and the facility was determined to be in compliance on 1/8/23. The findings were: Review of the 11/24/22 quarterly MDS assessment showed resident #1 had diagnoses which included diabetes mellitus, atrial fibrillation, coronary artery disease, hypertension, and non-Alzheimer's dementia. The assessment showed the resident had no pressure ulcer or other skin conditions at that time. The resident's brief interview for mental status could not be completed due to severe cognitive impairment, and s/he required the extensive assistance of one staff person for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed). Review of the resident's care plan showed an 8/31/21 plan related to diabetes mellitus with an intervention to avoid exposure to extreme heat and cold. The following concerns were identified: 1. Interview with CNA #4 on 1/10/23 at 6:25 PM revealed she was working the morning of 1/7/23, and found the resident between 3:45 AM to 4 AM with the bed pushed from the wall and the resident's feet on the heater unit with the vent cover missing. The resident's feet were on the fins and pipes (the hot elements) within the heater unit. It was apparent that the feet were both burned in areas with some peeled skin and some blood, so she got the resident's feet away from the hot elements and onto the bed, and called for the nurse, who arrived promptly. The CNA had last checked on the resident during rounds at around 1:45 AM. The CNA said she had no experience with burns, but could tell the resident's feet were burned. 2. Review of the facility-documented water boiler temperatures from 12/5/22 to 1/7/23 showed the temperatures at the boiler were consistently 160 degrees F, and water from the boiler was utilized in the heating system throughout the facility. 3. Observations on 1/10/23 from 2:30 PM to 3:20 PM in all resident rooms and common areas, showed all heat vent covers were attached. 4. Observation on 1/10/23 at 3:50 PM in the treatment room (room [ROOM NUMBER]) showed the medical director, administrator, DNS, and POA with the resident for assessment of bilateral feet trauma/burns The DNS documented the wound measurements as the physician dictated to her at that time. The resident was asked about pain and appeared to be in no distress. The medical director and administrator removed the resident's dressings, and cleaned the wounds to both feet with saline and 4 by 4 sponges. The left foot had burns under and around the great toe, which had red, whitish, and yellowish areas. The measurements were 13 cm long by 5.5 cm across. At that time, the medical director told the POA he was going to contact a burn center. He stated that he felt the resident's feet must have been on the exposed heater fins and pipes for a while. The resident's right foot burns were then measured, and the last 2 toes were involved to two-thirds the way back toward the heel. The measurements were 16.3 cm length by 11.3 cm across, with reddened, whitish, and yellowish areas. The wounds on both feet had areas that appeared dry and moistened, with no obvious infection. 5. Interview with the medical director on 1/10/23 at 4:05 PM confirmed the resident's burns had areas that were at least third degree burns. 6. Review of an email sent by the POA to the State Survey Agency on 1/22/23 at 6:22 PM showed the resident underwent surgery for the burns on 1/20/23. The surgeon performed bilateral amputation of both feet. This left a few toes on each side. He is currently still in ICU [the intensive care unit] with both feet bandaged with a wound vac [vacuum] on the right foot and a skin graft on the left foot. Review of the facility's 1/7/23 Self-initiated Immediate jeopardy .Abatement showed the following: Concern: 84 yr [year] old [gender], admitted [DATE] with dx of dementia, EPS [extra-pyramidal symptoms], a-fib [atrial fibrillation], DM [diabetes mellitus], ASHD [atherosclerotic heart disease], and IBS [irritable bowel syndrome]. Identified resident while sleeping in a low bed inadvertently extended [the resident's] legs out of the bed and displaced the floor board heater cover which left [the resident's] feet exposed to heat without the protection of the heater cover. Resident experienced second degree burns to the left great, second, and third toes and an area on left medial foot and blisters to right foot. 1. Resident assessed by RN for burns to bilateral feet. Physician notified and appropriate treatment order obtained and provided .Identified heater panel cover secured on 1/7/23 to prevent another occurrence. 2. Initial audit completed via Executive Director of floor heater panel covers throughout Center to assess for any others which may have the potential to be dislodged. Those that were identified as a concern were repaired starting on 1/7/23 and completed on 1/8/23. 3. Education provided to IDT [interdisciplinary team] regarding weekly audits of heater panel covers for secure placement as assigned. Ongoing audits by IDT related to assigned rooms to assess for secure placement of heater panel covers will be completed weekly times three months. Education provided to current staff to notify Executive Director immediately if they should observe an unsecured heater panel cover. 4. Initial ad-hoc QAPI held with Medical Director on 1/7/23 to discuss occurrence. Initial and ongoing audits will be reviewed via the QAPI process monthly times three months for further discussion and recommendations. 5. Correction date: 1/8/23.

Based on observation, medical record review, and staff interview, the facility failed to adequately treat pain for 1 of 8 sample residents (#21) assessed as having pain. The lack of timely pain intervention resulted in harm for the resident. The findings were: Review of the 1/25/15 admission MDS assessment for resident #21 showed the resident was severely cognitively impaired with a Brief Interview for Mental Status score of zero, and had [DIAGNOSES REDACTED]. The following concerns were identified: 1. Review of nurse charting dated 3/22/15, timed 12 PM, showed resident #21 was complaining of pain with ADLs with "Obvious pain noted especially to lower back/hip area." The note further showed the nurse would "request pain intervention from MD (medical doctor)." Review of physician orders [REDACTED]. Review of the March 2015 MAR indicated [REDACTED]. There was no evidence the physician was contacted on 3/22/15 about the resident's pain. Further review of the March 2015 MAR indicated [REDACTED]. 2. Review of the March 2015 MAR indicated [REDACTED]. Review of the medical record showed no evidence the resident's physician was contacted about this high pain level. 3. Review of the 3/25/15 Physician's Record of Visit showed the resident had experienced a decline in condition and a mental status change, was complaining of pain, and had a swollen and painful right ankle. Further review showed new physician orders [REDACTED]. 4. Review of the March 2015 MAR indicated [REDACTED]. Further review showed no Alleve or Tylenol was administered to the resident to treat pain during the AM shift. 5. Observation of the resident on 3/25/15 beginning at 5:15 PM showed the following: a. At 5:15 PM the resident was seated in a wheelchair in the dining room of the secure unit. The resident said, "Ow!" several times and was grimacing and rubbing the area at the top of his/her right thigh. b. At 5:22 PM, RN #1 asked the resident if s/he was okay. The resident did not respond to the question. c. At 5:23 PM, the resident again said, "Ow!" and CNA #1 walked over to the resident and checked to ensure the resident's feet were not being bumped. d. At 5:28 PM the resident again said, "Ow!" and RN #1 told CNA #2 that she thought someone was going to need to feed the resident. e. At 5:30 PM, CNA #1 and CNA #2 repositioned the resident in her wheelchair. At 5:47 PM the resident stated s/he needed to go to the toilet, and CNA #1 and CNA #2 took the resident from the dining room to his/her room where the aides transferred the resident from the wheelchair to the toilet. During the transfer, the resident repeatedly stated, "Ow!" and CNA #2 stated the resident had been "saying that an awful lot lately." f. The resident was returned to the dining room at 6:02 PM, where s/he would not eat dinner. At 6:08 PM, CNA #2 asked the resident "Are you in any kind of pain?" The resident did not respond verbally but continued to fidget, grimace and and periodically say, "Ow!" g. Observation at 6:38 PM showed RN #1 was ending her shift, and RN #2 was her replacement. h. Interview with RN #2 at 7:30 PM revealed he had received report from RN #1 the resident was complaining of pain and had new orders for pain medication. i. Observation at 7:42 PM showed RN #2 administered medications to the resident. Interview with RN #2 at that time revealed the medications administered did not include medication for pain. j. Observation at 7:45 PM showed the resident was taken to his/her room and prepared for bed. The resident moaned, grimaced and said, "Ow!" and "Ow-oh-oh-oh!" with transfer from wheelchair to bed, and grimaced and moaned when s/he was rolled from side to side in the bed for incontinence care. CNA #2 stated, "I think (s/he) just hurts all over." k. Further review of the March 2015 MAR indicated [REDACTED]. l. Interview with the DON on 3/26/15 at 10:45 AM confirmed the resident should have been treated for [REDACTED].