Every finding on record at Villa St. Vincent

Based on observation, interview, and document review, the facility failed to protect residents' rights to be free from sexual abuse by failing to complete a comprehensive assessment for capacity to consent to sexual activity for 2 of 2 residents (R58, R61) with cognitive impairment who engaged in sexual activity. In addition, the facility failed to investigate unexplained bruising and vaginal bleeding for 1 of 1 resident (R58) in the context of known sexual activity. These failures resulted in an Immediate Jeopardy (IJ) as the facility did not determine whether either resident possessed the capacity to knowingly and voluntarily consent to sexual activity, creating a likelihood that one or both residents were subjected to non-consensual sexual contact and placing them at risk for serious harm, impairment, or injury. The immediate jeopardy began on [DATE] when the facility became aware of sexual activity between two residents with cognitive impairment and failed to immediately determine whether either resident possessed the capacity to consent or implement measures necessary to protect the residents from the likelihood of non-consensual sexual contact. Despite knowledge that sexual activity was occurring, the facility allowed continued unrestricted access between the residents and facilitated privacy for the relationship without first determining whether either resident possessed the capacity to consent to sexual activity. In addition, the facility failed to investigate unexplained bruising and vaginal bleeding in the context of known sexual activity, preventing the facility from determining whether the injuries were related to abuse, coercion, trauma, or other adverse outcomes associated with the relationship. Further, R58 and R61 had rooms next to each other farthest away from the nursing station, leaving more opportunity for sexual activity, that could have gone unnoticed by staff and was not documented. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:30 p.m. The IJ was removed on [DATE], at 7:00 p.m. when the facility successfully implemented a removal plan; however, noncompliance remained at the lower scope and severity level 2 [D] isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R58:R58's annual Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and R58 wandered one to three days a week. R58 required supervision with dressing and moderate assistance with grooming and bathing. R58 was independent with transfers and ambulation. Diagnoses included Alzheimer's disease, neurocognitive disorder with Lewy bodies, dementia and anxiety. R58's Brief Interview and Staff Assessment for Mental Status (BIMS) identified the following:[DATE], R58 scored 11[represented moderate cognitive impairment]. R58 was able to immediately report three words she was asked to remember but could not recall one of the words without cueing and unable to recall the second word at all, after a few minutes. R58 was able to correctly identify the current year, the month, within five days and was unable to correctly identify what day it was. During the assessment, R58 asked about getting things done, needed a bust and a desire to drive and leave the facility. [DATE], identified R58 scored 5 [represented severe cognitive impairment]. R58 was able to immediately report three words she was asked to remember but was only able to recall one of the three words with cueing after a few minutes. R58 was unable to correctly identify the current day, month or yearXXX[DATE], identified R58 scored 11. R58 was able to immediately report three words she was asked to remember but could not recall the words without cueing after a few minutes. R58 was able to correctly identify the current day, month and year. R58 became tearful during the assessment and stated her spouse was divorcing her but could not recall her spouse's name when asked. When R58 was shown a picture of her 50th wedding anniversary, R58 was no longer tearful and correctly stated her spouse had passed away. The social services assessment documentation noted R58 had been having hallucinations and had a recent medication increase. R58's Care Area Assessment (CAA) summary for Cognitive Loss dated [DATE], identified R58 had a diagnosis of dementia and had poor vision. R58's cognition had declined due to natural progression and R58 had episodes of hallucinations. R58 was followed by psychiatry, and staff would continue to monitor. R58's CAA summary for Behavioral Symptoms dated [DATE], identified R58 had a diagnosis of dementia and would wander and walk laps in the unit. R58 was usually easily redirected. R58 had hallucinations and staff would continue to monitor. R58's care plan dated [DATE], identified R58 had cognitive loss due to dementia and became confused to her surroundings at times. R58 exhibited behavior symptoms of wandering, intrusive in others space, history of hallucinations or delusions. The care plan identified R58 had developed a relationship with a male peer a goal identified R58 was to have supportive monitoring to ensure all social or physical interactions were safe and appropriate. Staff were directed to monitor and document any changes in R58's sleep patterns which included wandering, restless, or unusual interactions with peers. Staff were to note any behavioral changes or signs of distress. Staff were to notify the social worker or director of nursing (DON) of any new or escalating concerns regarding the residents' interactions. Staff were to respect resident rights and provide privacy during interactions unless there were concerns about safety and updating family as appropriate. Further, R58 was a vulnerable adult and needed assistance to remain safe within the community. Approaches included observing and documenting changes in mood or behaviors that may increase R58's risk for abuse, implement interventions to minimize risk of harm to self and others if became violent or aggressive and to report, investigate any allegations or suspected abuse, neglect or exploitation.R58's progress notes [DATE] to [DATE], identified the following behavior and cognitive status concerns:On [DATE], R58 was wandering in and out of other resident's rooms looking for her baby. Resident was redirected and returned to her room each time.On [DATE], R58 appeared anxious at times and needed reassurance on what she needed to be doing at any given point. On [DATE], R58 wanted to talk with her physician about having another baby.On [DATE], R58 was noted to intermittently engage in conversation when no one else was present, while ambulating in the unit. R58 was also observed standing in the dining room and appeared to speak and gesture toward unseen stimuli. R58 started seeing dancers and their instruments. On [DATE], R58 requested water for her baby and gestured to a blanket rolled inside of her coat. An NA provided R58 with a sippy cup and R58 was observed pouring water from the cup into her hand and making motions toward the blanket. R58 showed no signs of distress and behaviors were consistent with R58's baseline. [DATE], R58 was concerned about the babies and showed staff the baby on her bed. R58 stated the baby looked just like the orphaned baby in the next room. On [DATE], R58 stated she and her husband were heading to the hospital to see her nephew. R58 was asked to come out to the common area and watch television. R58 stated she had to go pick up all the kids to take care of them. On [DATE], a nursing assistant (NA) reported R58 had walked up to the vitals machine and started taking notes on her paper and went looking for her children. R58 went to her room and fell asleep after 2:00 a.m.On [DATE], R58 was observed reaching for pictures hanging on the walls. R58 stated she was not sure how it was done, should she just take the pictures. R58 stated [NAME] told her to take the pictures but could not recall who [NAME] was and stated she would go back to her room and ask him. On [DATE], R58 was found kneeling on the floor by the exit door near her room. R58 was holding a winter jacket and stated she had to get on the floor so she could give her jacket to her daughter. R58 stated it was cold outside, and she did not want her daughter going outside without it. On [DATE], An NA reported R58 was very confused during bedtime cares. R58 kept reaching for something on the floor when there was nothing there. R58 was observed talking to the vitals machine, the bladder scanner and the mechanical lift. On [DATE], R58 was distraught over a project that she was left in charge of. R58 then discussed how to get the employees paid.On [DATE], R58 was pacing and stated she was worried people were coming to steal things. R58 was observed talking to herself as if talking with another person. R58 asked an NA if she could get into the dirty linen room to get the baby that was crying. On [DATE], R58 stated she thought her cross just died and asked staff to go to her room and look. Staff entered room and R58 lifted the blanket on her bed and stated well I guess it was not there. On [DATE], an NA reported R58 had come out of her room three to four times to look for her children.On [DATE], R58 was observed going into another resident's room and lying down on the bed. R58 was easily redirected. R58's progress notes [DATE] to [DATE], identified the following: On [DATE], R58 was found with a male resident (R61) in bed together. Both residents were not clothed and asked staff to leave them alone. Neither resident seemed uncomfortable or unhappy per the unidentified staff member who witnessed the incident. There were no signs of distress, coercion, or injury. The residents were provided with privacy. On [DATE], family member (FM)-D called and notified the facility the family wanted R58 to remain with her clothes on when in company of other residents and to sleep in her own bed every evening. After consultation with the director of nursing (DON), registered nurse (RN)-A notified the family that they understood the family's wishes, but the residents retained their right to autonomy and R58 could not be forced to comply with the family's request if it was against her wishes. The facility's plan was to continue to ensure R58's safety and dignity, while respecting her rights and preferences. On [DATE], scattered bruises were noted to both of R58's forearms in various stages of healing. R58 stated she occasionally bumped into things and bruised easily. On [DATE], an unidentified activity aide reported finding R58 in R61's bed. Both residents were undressed and in bed. When RN-A arrived at the resident's room, both residents were seated on the edge of the bed fully clothed. R58 was putting on her shoes, and when asked, agreed to return to her room. R58 was noted to be calm and cooperative with no signs of distress, however, was unsteady and complained she felt dizzy. Vital signs were obtained and were normal. FM-D was notified and requested to be called whenever those types of incidents occurred. On [DATE], an unidentified NA reported R58 had reported some bloody [vaginal]discharge. Staff checked toilet and room with no signs of blood. The NA assisted R58 with peri care and had not noted blood. On [DATE], bruising was noted on R58's right front anterior and inside of right thigh, both of which were the size of a nickel. On [DATE], licensed practical nurse (LPN)-A was notified by an unidentified housekeeper R58 was in bed with R61, both residents were not clothed. When LPN-A entered R61's room, both residents were standing in the R61's bathroom. R61 was just pulling up his pants and R58 was standing without pants on, and her brief was around her foot. LPN-A took R61 out of room to walk with him in the hallway and an unidentified nurse trainee assisted R58 to dress and then brought her out to the dining room. R58's medical record lacked evidence R58 was assessed following the first documented incident and subsequent incidents to determine her understanding and capacity to consent during each of the incidents. Further, the record lacked evidence R58 had been physically assessed following her reports of vaginal bleeding to the NA or if the bruises of unknown source had been investigated for potential cause of the injuries and if they were related to any of the sexual activity. R61:R61's quarterly MDS dated [DATE], identified R61 had severe cognitive impairment. No wandering, hallucinations, delusions, physical or verbal behaviors were documented. R61 was independent with all activities of daily living (ADLs) and was independent with transfer and ambulation. Diagnoses included Alzheimer's disease and dementia with psychotic disturbance, R61's BIMS assessments identified the following:[DATE], identified R61 scored 4 [represented severe cognitive impairment]. R61 was able to immediately report three words he was asked to remember but was only able to recall one of the words with cueing and unable to recall the other two words at all, after a few minutes. R61 was unable to correctly identify the current day, month or year, It was noted that R61 was usually pleasant with other residents. [DATE], identified R61 scored 4. R61 was able to immediately report three words he was asked to remember but was unable to recall any of the words after a few minutes. R61 was able to correctly identify the current day, however, was unable to identify what the current month or year was, it was noted that R61 did not wander but had a history of exit seekingXXX[DATE], identified R61 scored 3 [represented severe cognitive impairment]. R61 was able to immediately report three words he was asked to remember but was unable to recall any of the words after a few minutes. R61 was unable to correctly identify the current day, month or year, It was noted R61 stated he knew what staff were asking him and denied pain or concern and stated he loved it at the facility. R61's CAA summary for Cognitive Loss dated [DATE], identified R61 had a diagnosis of dementia and Alzheimer's disease. R61s cognition had declined due to natural progression but did not appear distressed due to not remembering. R61 was no longer agitated when asked cognitive questions and staff would continue to monitor. R61's care plan dated [DATE], identified R61 had cognitive loss related to dementia. A goal was listed to receive services and assistance needed to his specific level of cognitive function. Staff were directed to help keep R61 orientated and provide him with reminders as needed. R61 had behaviors of a history of wandering and checking doors. Approaches included a mesh screen to his door to deter other wanderers from entering and that R61 enjoyed visiting with others and playing guitar. The care plan identified R61 had developed a relationship with a female peer with a goal identified as R61 would have supportive monitoring to ensure all social or physical interactions were safe and appropriate. Staff were directed to monitor and document resident interactions and observe for signs of distress coercion, confusion or changes in behavior related to interactions with female peer. Night staff were to monitor any changes in R61's sleep patterns which included wandering, restless, or unusual interactions with peers. Staff were to note any behavioral changes or signs of distress. Staff were to notify the social worker or director of nursing (DON) of any new or escalating concerns regarding the residents' interactions. Staff were to respect resident rights and provide privacy during interactions unless there were concerns about safety and updating family as appropriate. Further, R61 was a vulnerable adult and needed assistance to remain safe within the community. Approaches included observing and document changes in mood or behaviors that may increase R61's risk for abuse, implement interventions to minimize risk of harm to self and others if became violent or aggressive and to report, investigate any allegations or suspected abuse, neglect or exploitation.R61's progress notes from [DATE] to [DATE] identified the following for behavior and cognitive concerns:On [DATE]. R61 tried going into a female residents' room and stated he was going for a night cap. Staff redirected R61 four times, and he eventually went to a male's room to visit. On [DATE], R61 had several bug bites to his arms from standing outside. R61 refused to leave his shirt on when outside. On [DATE], R61 had flipped his mattress off the bed and stated he was looking for a part. NA reassured him his bed was put together correctly and did not have missing parts. R61 had a hard time communicating what he intended to say and often said he was looking for a part and then stated no that was not it while grabbing his head. On [DATE], R61 was given his medications and asked if he could get something to get him going. When asked what for, R61 replied, oh you know what for and winked. On [DATE], another resident kept telling R61 that supper was at 6:00 p.m. R61 became upset and told him to shut up and stated to staff if the resident did not shut up R61 was going to punch him. R61's progress notes from [DATE] to [DATE], identified the following: [DATE], R61 attempted to enter R58's room and stated he was going for a nightcap. Staff redirected R61 away from R58's room four times before R61 left to visit with another male resident. [DATE], R61 was found with another resident in his bed. Both residents were unclothed. R61 requested staff leave as soon as they entered the room. Both residents appeared to be enjoying each other's company. No signs of coercion or distress were noted. The residents' contact had been notified. [DATE], R61 brought an unidentified female resident to his room for a night cap. The female resident looked confused/worried, so staff redirected residents with no issues. [DATE], an unidentified aide reported R61 and R58 were in bed undressed. When RN-A entered resident room, both residents were seated at the edge of the bed and fully clothed. R61 was observed putting on his shoes. R61 appeared calm and cooperative and displayed no signs of distress. R61 was alert and responsive and did not verbalize any discomfort or concerns. R61 stated he wished to remain in his room. Based on direct observations at the time of assessment, the interaction between R61 and R58 appeared consensual. R61's emergency contact was notifiedXXX[DATE], LPN-B was notified by an unidentified trained medication assistant (TMA) that R61 and R58 were in R58's room together. LPN-B checked on residents and redirected R61 back to his own room. Later, R61 was seen with R58 holding hands and touching her buttocks. After a few laps around the secured unit, the two residents entered R58's room. Staff were unable to redirect them. LPN-A was called to assist staff with redirection. [DATE], R61 entered female resident room and was attempting to get around the bed to reach the blinds. Staff reminded R61 they would help the female resident. R61 asked what was wrong with him helping her, R61 was redirected back to his room. [DATE], LPN-A was notified by an unidentified housekeeper R61 was in R58's room and both were lying in bed without clothing on. LPN-A entered R58's room and both residents were standing in the bathroom. R61 was just pulling up his pants and had t-shirt and socks on. R61 returned to his room with LPN-A and stated he was good. No concerns were noted. Another staff member stayed to help R58.R61's medical record lacked evidence that R58 was assessed following the first documented incident and subsequent incidents to determine his understanding and capacity to consent during each of the incidents. On [DATE], at 4:09 p.m. R58 was observed fully dressed, seated in a recliner in her room. R58's room was located on the secured unit furthest down the hall from the nurse's station. R61's room was located directly next to R58's room. Both rooms had a double panel of magnetic mosquito netting over the doorway on the outside of the doors. No other rooms on the secured unit had magnetic netting over their doorways. R58 stated she was unable to think of her neighbor's name or the name of the town in which she resided. R58 stated she had met a lot of people and did have friends here, but it was years ago. R58 was unable to form full sentences in response to any general questions. R58 stood up and walked out into the hallway. R58 pointed to R61's room and stated that it was her room. R58 stated she was going to go back to her room and ambulated a short distance away from her room before stopping and looking around. R58 turned back and ambulated to her own room and recliner. During interview on [DATE], at 8:16 a.m. housekeeper (HSK)-A stated she had entered R58's room on [DATE], saw that R61 was on top of R58 in bed and they were both naked. She saw that he was on top of her and did not really pay attention to her and just went out of the room to find help. She had been told that it had happened a lot, but that was the only time she had seen it. She reported it to the first nursing staff she found, which was LPN-A and LPN-A went to talk to the residents. When interviewed on [DATE], at 8:21 a.m. NA-B stated she knew R61 and R58 would go into either room, in the past the facility said that was ok. NA-B stated lately they had been told to separate them. NA-B had never witnessed any incidents. The two residents used to sit together in the dining room for meals but now they separated them to different tables. NA-B was unsure why it changed or when it changed and why they were separated in the dining room for meals. When interviewed on [DATE], at 8:29 a.m. NA-C stated he had heard of the incidents that had occurred but had never witnessed any. NA-C stated they had just been told they would go into each other's rooms occasionally and to redirect them if possible and let the nurse know. During interview on [DATE], at 8:30 p.m. LPN-C stated she was aware there had been some inappropriate behaviors and was told to just keep an eye on both. Typically staff just tried to keep the two residents apart or to make sure they were not alone. R61 was good about knowing where his room was. R58 usually knew where her room was but there had been times when she would ask where her room was and have to be directed. When interviewed on [DATE], at 10:11 a.m. RN-A stated R58 and R61 had interactions in the past, but they were sporadic in nature. RN-A did not know who found the two residents together on [DATE] as she had only talked to the nurse that had been notified. LPN-A was the nurse that had been first notified of the incident and did the follow up. The plan going forward was the same as the other incidents that had occurred, try to preserve the resident's autonomy to make their own decisions while at the same time maintaining safety for both the residents. RN-A did not know if there were any investigation or assessments completed after the incidents. Regarding the first documented incident on [DATE], RN-A stated she had done an assessment of R58's overall status, such as if any harm occurred, although she had not documented the assessment, as it was and informal assessment. RN-A had just checked on R58 to make sure she was not frightened RN-A had spoken with R58's FM-D to discuss the families wishes and understanding of the relationship. The family wanted R58 to remain with her clothing on and to sleep in her own bed every night. The consensus was that the residents had the right to their autonomy, give them privacy while attempting to honor the family wishes. RN-A thought the R58's bruises that were documented on [DATE] were in relationship to a fall she had at around that time. R58 had told her she bumped into things frequently and bruised easily. RN-A stated she should have followed up more, related to the bruises, but at the time had just accepted R58's explanation. RN-A was unsure if R58's physician had been notified of the report of vaginal bleeding and the bruises on her thigh on [DATE], were attributed to a recent fall. RN-A thought R58's physician (MD)-C was notified of the incidents at some point as it was important to notify the MD when resident interactions occurred. RN-A thought she had talked to R58 at the level of her disease and mental capacity, to see if she felt any fear. When this had been addressed, R58 had been able to recall the incidents and had reported that she had made love, but she would have to look back in the medical record to see if there was any documentation of her discussion with R58, no documentation was found.When interviewed on [DATE], at 11:00 a.m. LPN-A stated HSK-A had approached her on [DATE], when she was giving a new employee a tour and notified her the two residents were in bed together without any clothing on. So, they knocked on R58's door and was told ok to enter. R58 and R61 were in the bathroom and R61 was just pulling his pants up. R58 did not have pants on, and her brief was wrapped around one of her feet. The new employee took R58 by hand and assisted her to redress and LPN-A took R61 to his room, which was right next door. R61 stated he was fine, and the new employee told her R58 had said she was fine as well. LPN-A did not do any type of assessment with either of the residents and reported the incident to the unit manager and documented the incident in each resident's medical record. LPN-A did not fill out any type of incident report. She had been told the family was aware of the relationship and were ok with it. During telephone interview on [DATE], at 11:40 a.m. MD-C stated she was R58's primary care provider and the medical director for the facility. MD-C had never been notified of any sexual interactions between R58 and R61. It was very much news to her and very alarming. R58 was pleasant, however, was not orientated. R58 would likely respond to questions with a smile and ok. She has always been that way and would always be agreeable and pleasant. When MD-C last saw R58, she seemed less happy than her usual self, her affect seemed more blunted when she was seen on [DATE], a week after the last resident to resident incident. MD-C did not feel R58 would be able to consent in any way and had concerns with R58's ability to consent. The facility usually faxed information to her if they were aware of it but she had looked back in R58's record and there was no notification documented. The last time she saw R58 the only mention was of a fall that had occurred. During interview on [DATE], at 11:57 a.m. the DON stated she was aware of the incidents of the residents being in an intimate position. Staff informed her of the October incident, and she had directed the staff to make sure both residents were consenting and to notify the families to let them know what was occurring. The staff knew the residents were consenting by their actions. If R58 did not want or like the interaction, she would push him away or tell him to get out. R58 was physically and verbally able to demonstrate when she was not comfortable with a situation. She is not sure if R58 had ever been asked if she knew the male resident or knew the risk or benefits of the incidents. The DON knew there had been comments made to R58 such as that is not your husband and R58 would get agitated or frustrated by the comment like she felt they were demeaning her and would respond she knew that. The DON did not know when that conversation had happened but knew a discussion had taken place after each incident, however she was not sure if any specific assessment had been completed. The DON was not aware of any type of assessment that could be used for a situation such as that. The facility had monitored the residents to make sure they were not uncomfortable with the situation. In the past, R58 had an altercation with another female resident on the secured unit and had been very verbal that she did not like that resident and would tell staff she did not want that resident in her room. The DON stated she felt R58 would react the same way with R61 if she was uncomfortable with the incidents. The interdisciplinary team (IDT) discussed the interactions each time they occurred and how the residents were at the time, prior and after each incident. Staff were able to document there were no signs of discomfort or fear. It was the DON's understanding that if the resident was able to demonstrate they did or did not want something to happen the facility would honor that. The DON did not have any documentation that staff had conversations with R58 that she denied feeling coerced and that she knew R61 was not her spouse. The DON was not aware that the resident primary physicians and psychiatric providers had not been notified of the incidents when they occurred, she would have expected the RN to have notified them both. The DON had not been aware of R58 bruises that were documented on [DATE] and [DATE]. The DON was not aware that bloody vaginal discharge had been reported, and she would have expected R58 would have been assessed and physician notification as bloody vaginal discharge would not be normal for a resident of R58's age. During telephone interview on [DATE], at 12:50 p.m. FM-A stated she had been told by the facility R58 had an interest in a male resident who also resided on the secure unit. FM-A had told the facility that she wanted R58 to be safe. FM-A was concerned with issues regarding balance, transferring in and out of bed and falls as well as spending time alone in a male resident's room as safety issues. FM-A initially told the facility that she did not want R58 to have any interactions with the male resident but had been told it was R58's right and R58 was able to make those decisions on her own. The staff were doing their best and trying to navigate the situation as best as they could, but FM-A was uncomfortable with it. FM-A stated R58 was able to communicate if she was hurting or if something did not feel good, but she was not sure if R58 had the ability to give consent. There are times FM-A would get phone calls and ask if R58 should take the flu shot and FM-A gave permission for that. Prior to having Alzheimer's, incidents of that nature would have been very upsetting to R58, and FM-A did share that information with the facility staff. FM-A did not know if R58 had the capacity to say if she wanted or did not want the gentleman to enter her bed. Nighttime could be a confusing time for R58. R61 was a nice, friendly man and FM-A knew they were friends. FM-A did not think R58 mistook him for her spouse. During interview on [DATE], at 2:30 p.m. RN-A stated she had been told the residents had the right to consent and follow up was only needed if injury was noted. Both residents had dementia and their capacity to consent may be on different levels. If the residents were able to verbalize or demonstrate no, get away from them, then they were able to process in their head whether they want to give consent or not. R58 and R61 were able to tell her if they do not want to do something or want to refuse the attention. R58 could not sign for medical treatments. The facility called on family to consent to any medical treatment or appointments and did not ask R58 for their consent. Some days R58 was more aware and verbal with the staff and usually was pretty good at communicating. The staff judged is she was consenting by the way she communicated with them and how she responded to the situation. RN-A stated the reported vaginal bleeding had never been confirmed to have happened, it had only been reported by R58, and staff had not actually saw any bleeding. RN-A stated it depended on the day if R61 was able to give consent to sexual activity. RN-A stated she had been following direction and was told that both residents had the ability to consent. The last time RN-A spoke with R61's contact person, he was not overly keen on the idea but understood and basically told the staff to do what they could do. RN-A did not remember if there had been any discussion about moving the resident rooms further apart. During interview on [DATE], at 3:40 p.m. social worker (SW)-A stated R58 and R61 were becoming friends. Staff had reported there were no signs of distress or crying when any of the incidents occurred. The facility knew they were consensual actions by the residents' actions. The residents sought each other out, not just any female or male. There was an incident SW-A had witnessed when another male resident, not R61, had touched R58's shoulder and she clearly said no to him and moved away

Based on interview and document review, the facility failed to investigate potential resident-to-resident sexual abuse for 2 of 2 residents (R58, R61) reviewed for abuse. The facility became aware of repeated sexual activity between two residents with significant cognitive impairment but failed to assess either resident's capacity to consent to sexual activity. As a result, the facility was unable to determine whether the encounters were consensual and failed to complete a thorough abuse investigation. Additionally, the facility failed to investigate bruising and reports of vaginal bleeding experienced by R58 in relation to the known sexual activity. Findings include:R58R58's annual Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment. Diagnoses included Alzheimer's disease, neurocognitive disorder with Lewy bodies, and dementia.R58's care plan identified cognitive loss related to dementia, confusion, wandering, hallucinations or delusions, and identified R58 as a vulnerable adult. Staff were directed to report and investigate any allegations or suspected abuse, neglect, or exploitation.R58's progress notes identified the following:On 10/3/25, R58 and R61 were found together in bed unclothed and requested privacy.On 11/19/25, staff again found R58 and R61 undressed in bed together.On 5/7/26, staff found R58 and R61 in bed together without clothing.The record failed to contain evidence the facility assessed either resident's capacity to consent to sexual activity following any of the incidents.The record further identified:On 10/9/25, scattered bruises in various stages of healing were noted on both forearms.On 12/11/25, R58 reported bloody vaginal discharge.On 3/5/26, bruising was noted to the right anterior thigh and inner thigh.The record failed to contain evidence the facility investigated whether the bruising or report of vaginal bleeding were related to the known sexual activity involving R58 and R61.R61R61's quarterly MDS dated [DATE] identified severe cognitive impairment. Diagnoses included Alzheimer's disease and dementia with psychotic disturbance.R61's care plan identified cognitive loss related to dementia and identified R61 as a vulnerable adult. Staff were directed to observe for signs of distress, coercion, confusion, or behavioral changes related to interactions with R58 and to report and investigate any allegations or suspected abuse, neglect, or exploitation.R61's progress notes identified staff found R58 and R61 unclothed together on 10/3/25, 11/19/25, and 5/7/26.The record failed to contain evidence the facility assessed R61's capacity to consent to sexual activity or completed an abuse investigation to determine whether the encounters were consensual.On 6/2/26 at 10:11 a.m., registered nurse (RN)-A stated she did not know if any investigation or assessments had been completed following the incidents involving R58 and R61. RN-A stated she had not documented assessments related to the incidents or the bruising identified on R58.On 6/2/26 at 11:01 a.m., licensed practical nurse (LPN)-A stated she documented the 5/7/26 incident but did not complete assessments/investigations on either resident and was unsure whether any assessments/investigations had been completed by others.On 6/2/26 at 11:57 a.m., the director of nursing (DON) stated no assessments had been conducted following the incidents to evaluate physical injury or assess the residents' judgment or capacity to consent. The DON stated the facility believed the encounters were consensual based on the residents' behaviors and no further investigation had been conducted and the facility staff knew the incidents were consensual by how the residents behaved and their actions and no further investigation had been conducted. The DON further stated the facility did not complete a formal investigation process. At 5:00 p.m., the DON stated the facility did not conduct a formal investigation because staff believed the incidents were consensual. The DON further stated R58's bruising had not been investigated, and she was unaware of the reports of inner thigh bruising and vaginal bleeding.The facility's Abuse Prevention Plan directed staff to investigate allegations involving abuse and to monitor incident reports and medical records for indicators of possible abuse

Based on interview and document review, the facility failed to provide education regarding the benefits and potential side effects of pneumococcal vaccination and failed to document that education was provided prior to obtaining a vaccination decision from the resident representative for 1 of 5 residents (R42) reviewed for immunizations. Findings included:R42's Comprehensive Minimum Data Set (MDS) dated [DATE], identified R42 as [AGE] years old, had mild cognitive impairment and diagnoses that included heart failure, peripheral vascular disease, diabetes, and dementia. R42 was offered the pneumococcal vaccination but declined.R42's Immunization Report dated 3/23/26, identified R42 received pneumovax (PPSV23) on 5/20/09, and a pneumococcal conjugate vaccine (Prevnar 13) on 5/20/09. R42's Immunization Report dated 8/30/23, identified R42 received pneumovax (type unknown) on 4/28/14, and a pneumococcal conjugate vaccine (Prevnar 13) on 9/8/16. R42's medical record did not include evidence R42 or R42's representative received education regarding pneumococcal vaccine booster and there was no indication R42 was offered the pneumococcal vaccine per CDC guidance.R42's Immunization Consent form dated 3/23/26, identified R42's son declined the pneumococcal vaccination by phone. However, the form did not include evidence R42 or R42's representative received education regarding pneumococcal vaccine booster per CDC guidance.During an interview on 6/3/26 at 10:24 a.m., RN-B stated R42's family declined the pneumococcal vaccination by phone. Most family members didn't want to read the education, so RN-B didn't mail any education to anyone for review, nor did she document that.During an interview on 6/4/26 at 8:50 a.m., the director of nursing (DON) stated the resident and the resident representative need to be provided with all the education regarding vaccinations to ensure they understand what they are refusing or consenting to. Documentation should reflect their understanding of that education.The facility policy Pneumococcal Vaccines for Residents dated 1/9/25, identified the facility would provide education and administration of the PPSV23 and PCV13 to the residents according to CDC recommendations. CDC now recommended pneumococcal conjugate vaccine (PCV15 or PCV20) for adults who never received a prior pneumococcal conjugate vaccine (PCV13) if they are 50 years or older and have certain chronic medical conditions or other risk factors. For adults who have only received PCV13 but not PPSV23, CDC recommends vaccine providers give PPSV23 as previously recommended. The infection preventionist or designee will provide the resident and/or the responsible party

Based on observation, interview and document review, the facility failed to monitor and reevaluate the continued need for a wander guard utilized as a means to restrict the resident from accessing the outdoors for 1 of 1 resident (R17) reviewed for restraints. The facility failed to complete a reassessment despite changes in R17's behaviors and expressed desire to independently access the outdoors, resulting in the continued use of the intervention without documentation supporting ongoing need. Findings include:R17's quarterly Minimum Data Set, dated [DATE], identified R17 had moderate cognition, and was independent with activities of daily living. R17's diagnoses included dementia, anxiety, depression and diabetes. The assessment identified R17 used a wander/elopement alarm daily.R17's restraint/adaptive equipment assessment dated [DATE], identified R17 received antidepressants, antipsychotics, anxiolytics and narcotics, and recently experienced a decline in condition, although the type of decline was not included on the assessment. The assessment identified no other alternatives had been attempted prior to initiating the wander guard [device to alert staff to exiting secured areas of the building) and the wander guard was to be always utilized during all activities. The questions regarding whether the device met the definition of a physical restraint were not answered in the assessment.On 6/1/26 at 1:43 p.m., R17 was observed wearing a wander guard bracelet on her left wrist. R17 stated when she arrived at the facility staff had placed a wander guard on her wrist. R17 stated she was able to go outside although when she walked through the doors an alarm sounded, and staff came to check on her. R17 stated she did not like wearing the wander guard and wanted it removed. R17 stated the wander guard prevented her from enjoying the outdoors. Further, R17 stated she was told if she didn't go outside without a staff member eventually, she could have the wander guard removed. During interview on 6/3/26 at 4:05 p.m., nursing assistant (NA)-A stated if a resident had a wander guard and went out the doors an alarm sounded notifying staff, a resident had exited the doors. NA-A stated that when R17 first arrived around the beginning of the year, she had tried to go outdoors unattended but had not tried recently.During interview on 6/4/26, at 10:14 a.m., licensed social worker (LSW)-A stated wander guard assessments were completed on admission, quarterly, annually and with significant changes. The interdisciplinary (IDT) team met daily, Monday through Friday, and discussed residents who had wandering/elopement behaviors, the residents' safety concerns, and whether the wander guard should be continued. If the team determined a resident was at risk, social services completed an elopement risk assessment and nursing determined if a wander guard was appropriate. LSW-A stated R17 had an assessment completed on 1/22/26, however, was unable to find documentation that reassessments had been completed. LSW-A stated R17 should have been reassessed within three months of the initial assessment to determine if the wander guard was still needed.During interview on 6/4/26 at 1:23 p.m., LSW-B stated R17 had not shown a desire to leave the facility, and an elopement reassessment should have been completed at the quarterly mark, around April 2026.During interview on 6/4/26 at 1:44 p.m., the DON stated the facility policy identified that elopement risk assessments were to be completed on admission, quarterly, annually, with significant changes and as needed on an urgent basis. When a resident had elopement and/or wandering behaviors, the nurses were instructed to enter a progress note identifying the behaviors, interventions and outcomes. The DON stated residents with wander guards were encouraged to notify staff when they wanted to go outside because the alarm sounded when a resident passed a specific point and staff could turn the alarm off quickly. The DON stated R17 had an elopement risk assessment completed on admission and should have been reassessed quarterly to determine if the wander guard was still needed.The undated Elopement Alarm System policy identified the elopement alarm system is utilized to enhance safety for residents who wander or risk elopement from the facility. It is the facility policy to monitor the devices used for proper placement and for proper functioning of the door system as well as the resident signaling device. All residents determined at risk by the IDT team for wandering off units or with the potential for elopement from the facility will wear a signaling device. Assessment and consent will be completed on implementation and reviewed quarterly and with any significant change for continued need.

Based on interview and document review, the facility failed to report allegations and suspicions of resident-to-resident sexual abuse to the State Agency for 2 of 2 residents (R58 and R61) reviewed for abuse after becoming aware that the residents, who had significant cognitive impairment, were engaging in sexual activity without a determination of their capacity to consent. The facility also failed to report potential injuries of unknown source for 1 of 2 residents (R58) who exhibited unexplained bruising and vaginal bleeding.Findings include: R58's annual Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and wandered one to three days a week. R58 required supervision with dressing and moderate assistance with grooming and bathing. R58 was independent with transfers and ambulation. Diagnoses included Alzheimer's disease, neurocognitive disorder with Lewy bodies, heart disease, anxiety, and dementia. R61's quarterly MDS dated [DATE], identified R61 had severe cognitive impairment. No wandering, hallucinations, delusions, physical or verbal behaviors were documented. R61 was independent with all activities of daily living (ADLs) and was independent with transfer and ambulation. Diagnoses included Alzheimer's disease, dementia with psychotic disturbance, and atrial fibrillation (irregular heartbeat). R58's care plan with review date 5/20/26, identified R58 had cognitive loss due to dementia and became confused to her surroundings at times. R58 exhibited behavior symptoms of wandering, intrusive in others space, history of hallucinations or delusions. The care plan identified R58 had developed a relationship with a male peer a goal identified R58 was to have supportive monitoring to ensure all social or physical interactions were safe and appropriate. Staff were directed to monitor and document any changes in R58's sleep patterns which included wandering, restless, or unusual interactions with peers. Staff were to note any behavioral changes or signs of distress. Staff were to notify the social worker or director of nursing (DON) of any new or escalating concerns regarding the resident's interactions. Staff were to respect resident rights and provide privacy during interactions unless there were concerns about safety and update family as appropriate. Further, R58 was a vulnerable adult and needed assistance to remain safe within the community. Approaches included to observe and document changes in mood or behaviors that may increase R58's risk for abuse, implement interventions to minimize risk of harm to self and others if became violent or aggressive and to report, investigate any allegations or suspected abuse, neglect or exploitation.R58's medical record lacked an assessment identifying the resident had the capacity to consent to a sexual relationship.R61's care plan with review date 5/20/26, identified R61 had cognitive loss related to dementia. A goal was listed to receive services and assistance needed to his specific level of cognitive function. Staff were directed to help keep R61 orientated and provide him with reminders as needed. R61 had behaviors of a history of wandering and checking doors. Approaches included a mesh screen to his door to deter other wanderers from entering and that R61 enjoyed visiting with others and playing guitar. The care plan identified R61 had developed a relationship with a female peer with a goal identfied as R61 would have supportive monitoring to ensure all social or physical interactions were safe and appropriate. Staff were directed to monitor and document resident interactions and observe for signs of distress coercion, confusion or changes in behavior related to interactions with female peer. Night staff were to monitor for any changes in R61's sleep patterns which included wandering, restless, or unusual interactions with peers. Staff were to note any behavioral changes or signs of distress. Staff were to notify the social worker or director of nursing (DON) of any new or escalating concerns regarding the resident's interactions. Staff were to respect resident rights and provide privacy during interactions unless there were concerns about safety and update family as appropriate. Further, R61 was a vulnerable adult and needed assistance to remain safe within the community. Approaches included to observe and document changes in mood or behaviors that may increase R61's risk for abuse, implement interventions to minimize risk of harm to self and others if became violent or aggressive and to report, investigate any allegations or suspected abuse, neglect or exploitation.R61's medical record lacked an assessment identifying the resident had the capacity to consent to a sexual relationship.R58's progress notes 10/1/25 to 6/2/26, identified the following: 10/3/25, R58 was found with a male resident (R61) in bed together. Both residents were not clothed and asked staff to leave them alone. The residents were provided privacy. 10/9/25, scattered bruises were noted to both of R58's forearms in various stages of healing. R58 stated she occasionally bumped into things and bruised easily. 11/19/25, an unidentified activity aide reported finding R58 in R61's bed. Both residents were undressed and in bed. 12/11/25, an unidentified nursing assistant (NA) reported R58 had reported some bloody discharge. Staff checked toilet and room with no signs of blood. The NA assisted R58 with peri care and had not noted blood. There was no further documentation. 3/5/26, bruising was noted on R58's right front anterior and inside of right thigh, both of which were the size of a nickel. 5/7/26, licensed practical nurse (LPN)-A was notified by an unidentified housekeeper R58 was in bed with R61, both residents were not clothed. R61's progress notes 9/20/25 to 6/2/26, identified the following: 10/3/25, R61 was found with another resident in his bed. Both residents were unclothed. 11/19/25, an unidentified aide reported R61 and R58 were in bed undressed. 5/7/26, LPN-A was notified by an unidentified housekeeper R61 was in R58's room and both were lying in bed without clothing on. During interview on 6/2/26, at 11:01 a.m. LPN-A stated she had documented the incident in each of the resident's medical records and reported the incident to the unit manager RN-A. She did not fill out an event report, just documented in the resident progress notes because she had been told the family were aware of the incidents and were ok with them. When interviewed on 6/2/26, at 2:30 p.m. registered nurse (RN)-A stated regarding the first documented incident on 10/3/25, RN-A stated she had done an assessment of R58's overall status, such as if any harm. Regarding filing a Vulnerable Adult (VA) report, she would have to look at the policy, but her understanding was if there were incidents of coercion, or concerns with safety, such as physical harm, slapping, biting hitting, she would elevate the concerns to the director of nursing (DON) or the administrator. She had been told in these incidences, was that the resident's had a right to consent and follow up would only be needed if there were injury. RN-A had never filed a VA report herself but had discussed the incidents with the team for guidance. RN-A stated with bruises of unknown origin, staff were to notify the physician and fill out an event report. RN-A had documented R58's bruised forearms on 10/9/25. R58 had stated she bumped into things, RN-A took her word for it, but thought now she should have followed up more on it. It was not assessed in relation to the sexual relationship.During interview on 6/2/25, at 11:57 a.m., the DON stated the facility had not reported the intimate incidents that had occurred between R58 and R61 because, when discussed with the facility interdisciplinary team (IDT), it was felt the incidents were consensual in nature and not abuse. The DON stated she was not aware of the bruises on R58's forearms, documented 10/9/25. It was the facility's process that bruises of unknown origin were reported to the state agency. When bruises of unknown injury were reported an incident report was filled and a vulnerable adult (VA) report was completed. When interviewed on 6/2/25, at 3:40 p.m. the social worker (SW)-A stated the incidents between the residents were not reportable as the resident's had a right to intimacy. As far as R58's bruises, R58 was unsteady and bumped into things. The bruises would be for nursing to evaluate. SW-A stated she was not involved in VA reports any longer. She used to be but now submission of VA reports fell to nursing and the DON, as they were the ones completing the investigations. Bruises would need to be reported if there were no explanation for them or no other way they could have occurred other than abuse. SW-A did not get notified of incidents and/or injuries any longer. Those sorts of reports went to the DON. SW-A was more involved in the financial side of things and if any nursing issues, would go to the DON. It was usually determined by the DON or unit manager if an incident needed follow up or further investigation. During joint interview with the administrator, corporate RN (CP)-F and the DON on 6/2/26, at 5:00 p.m., the DON stated based on the resident's mood and behaviors, it was felt the incidents were consensual and not abuse and so the facility decided not to report the incidents to the state agency (SA). R58's bruises had never been reported because she walked around holding on to her arms, bumped into things and was on aspirin, so the facility staff came to the conclusion that was the cause. The facility's policy was to report bruises of unknown origin, fill out an incident report and complete a VA report. The DON was not sure if she had been notified of the bruises found on R58's inner thigh.The facility policy Abuse Prevention Plan with review date 7/21/22, identified the facility would develop an individual abuse prevention plan for each vulnerable adult who received services in the facility. The plan would include the resident's susceptibility to abuse, risk of abusing other vulnerable adults and specific measures to be taken to minimize the risk of abuse. Resident incident reports and medical records would be routinely monitored for indicators of possible abuse. Any allegations involving abuse would be investigated whether they caused injury or harm or no injury or harm. Staff would notify the facility administrator, DON and director of social services. If the event involved abuse or resulted in serious bodily injury, staff were required to report to the SA immediately, but no later than two hours after forming the suspicion. If the event did not involve abuse and did not result in bodily injury, staff were required to report to the SA no later than 24 hours after forming the suspicion.

Based on interview and document review, the facility failed to support a resident's expressed choice regarding smoking for 1 of 1 resident (R17) reviewed for resident choices. The facility failed to assess R17's request to smoke, evaluate options to accommodate the preference, and involve the interdisciplinary team after R17 repeatedly expressed a desire to resume smoking. Findings include:R17's quarterly Minimum Data Set, dated [DATE], identified R17 had moderate cognition and was able to make her needs known. R17's diagnoses included dementia, anxiety, depression and diabetes.R17's smoking risk assessment dated [DATE], identified R17 had a history of smoking but did not plan on smoking during the stay at the facility.R17's care plan printed on 4/25/26, failed to address R17's smoking preference.R17's progress notes identified the following:On 5/5/26 at 8:56 a.m., R17 reported to licensed social worker (LSW)-A she wanted to go outside and have a cigarette. On 5/18/26 at 9:07 a.m., R17 reported to LSW-A she missed smoking and wished she could still smoke.The facility failed to provide evidence of assessing R17 for ability to smoke safely off campus, since R17 expressed an interest in smoking.R17's care conference note dated 5/7/26 failed to identify discussions regarding R17's desire to smoke.On 6/2/26 at 10:30 a.m. R17 attended a resident council meeting held by the state agency (SA). R17 stated she wanted to smoke although she was told by staff that she couldn't.During interview on 6/2/26 at 11:12 a.m., R17 stated she had smoked for over 50 years prior to admission, was forced to quit smoking to be admitted to the nursing home and was not given the option to go off-site to smoke.During interview on 6/4/26 at 10:14 a.m., LSW-A stated all new residents were informed they could not smoke because the facility was a smoke-free campus and only two residents were grandfathered in and allowed to smoke. LSW-A stated R17 requested the desire to smoke on two occasions; however, LSW-A stated she had not documented follow up discussions with the interdisciplinary (IDT) team and the IDT team did not evaluate options to accommodate R17's preference.On 6/4/26 12:57 p.m., registered nurse (RN)-A stated residents with a history of smoking were assessed on admission by nursing and social services. The nursing assessment included questions regarding the resident's smoking history, whether they planned to smoke while a resident at the facility, and if they were provided information regarding being a non-smoking facility. RN-A stated she was aware that R17 wanted to smoke although had not completed a smoking assessment since admission.The facility maintained a blanket practice prohibiting smoking by new residents and failed to conduct the individualized assessment and consideration of options required by its own policy after R17 repeatedly expressed a desire to smoke.The undated facility Non-Smoking - Tobacco Free/Smoke Free Campus policy identified residents that wished to smoke were to sign in/out of the facility and leave the property to smoke. Upon admission, residents would be evaluated/assessed for safe smoking practices and ability to smoke independently if they chose to do so when they were off campus. Based on the assessment, the residents may be provided with equipment to aid in safety (such as a smoking apron) when they chose to smoke while off campus. The assessment further identified the facility would consult with the resident and/or the resident representative for alternate assistance to use off campus smoking options.

Based on observation, interview, and document review, the facility failed to honor a resident's right to make choices regarding daily activities by implementing a blanket requirement that residents be accompanied by staff when accessing a secured outdoor courtyard, without an individualized assessment of the resident's safety, abilities, or need for supervision. This affected 1 of 2 residents reviewed for resident rights (R42), who expressed a desire to independently access the courtyard as part of his customary routine.Findings include: R42's admission MDS dated [DATE], identified R42 and intact cognition and was independent with most ADLs and transfers. R42 was unable to ambulate and independently used a wheelchair for mobility. R42 had not exhibited any physical, verbal behaviors toward others and no wandering had occurred during the observation period. R42 had not exhibited any hallucinations, delusions, however, did have documented rejection of care. Diagnoses included paranoid schizophrenia, dementia, congestive heart failure, above the knee amputation, delusional disorders, generalized anxiety and post-traumatic stress disorder. R42's care plan revised 4/17/26, identified R42 was a pleasant man who was able to make his needs known. R42 was private and preferred his independent activities versus group programs. R42's interests included model cars, watching movies, music and going outside. Staff were directed to offer and escort R42 outdoors for programs or pleasure as weather allowed. R42's customary routine was identified that he enjoyed watching movies, working on his model cars, older music and smaller groups, but may not be able to stay if feeling anxious. R42 also enjoyed being outside. R42 had impaired mobility related to a right above the knee amputation, however, R42 was independent with transfer and activities of daily living (ADLs).On 6/1/26, at 12:32, R42 was observed seated in his wheelchair in his room. R42 was alert and able to move his wheelchair around his room and in the hallway independently. R42 stated he was not happy because he had always been able to go outside to the locked unit's fenced and secure courtyard whenever he liked to and now, he had been told he would not be able to go outside unless he was accompanied by a staff member. R42 stated it was because another resident had fallen out in the courtyard a few weeks ago and had been injured, but that resident should never have been allowed out there on her own in the first place. R42 stated he liked to go outside in the mornings when the weather was cooler and there was less wind but staff was not available to take him outside because they were busy with other resident cares. When the staff did take him outside, it was afternoon and hotter and he liked to sit out there alone, not with a group of people. R42 stated he had complained to the unit nurse, activities, social worker and administration but they just told him it was the rule for the unit. On 6/3/26, at 1:33 p.m. R42 was observed seated in the outside courtyard, in his wheelchair, visiting with R61. An unidentified staff member was seated nearby. The outside courtyard had a cement walkway and patio and a gazebo as well as grassy areas. The courtyard was fenced with a high fence and the gate was locked. R42 was listening to music on his phone and R61 was playing along on his guitar. The unidentified staff member stood up and notified the two residents she had other things to do, and the residents needed to return inside the facility. The two residents were observed complaining and stated they wanted to stay outside and why did they have to go in but they eventually went inside the facility with continued verbal complaints. R42 returned to his room. When interviewed on 6/2/26, at 10:38 a.m. registered nurse (RN)-A stated residents were never really allowed to go to the outside courtyard without supervision, but staff only recently started to reinforce the rule, when a resident recently fell in the outer courtyard. The outside courtyard was a closed fenced area with a locked gate. The door to the outside area was locked and could only be accessed by a staff members badge or family could take a resident outside. There had been some conversation regarding if more cognitive intact residents could be assessed to go out on their own, but she had been told that staff should be with the residents at all times. So far, no residents had been assessed to see if they could safely go out to the secured courtyard independently. Another problem was the door to come inside was locked and so the resident would not have access back into the building. During interview on 6/4/26, at 9:10 a.m. the social worker (SW)-A stated she was struggling with the issue as well. There was no call system since the facility had changed how the door operated. She had questioned if there was some type of call, they could give the resident to use outside or if the resident could just use their cell phone to call. The facility used to have a different door that they could lock but a resident outside could still get in. SW-A had brought up R42's complaint to the interdisciplinary team (IDT) and they were working on it, attempting to figure out a way more cognitively intact residents could go outside without supervision. The other problem was there was no shade. The facility had thought of putting an umbrella up but there was a concern it could blow over in the wind. On 6/4/26, at 1:44 p.m. a joint interview was conducted with the administrator and the director of nursing (DON). The DON stated the facility recently updated their locks to make the building more secure. The facility had also identified a concern with the current staff practices of allowing residents to out into the secured courtyard unsupervised. The ground was uneven and an accident risk, so the facility implemented that staff needed to be out with the residents in that area to ensure safety. It had always been that way, and staff had just gotten lax on the rule. They had not had a chance to evaluate each resident to see if they could be deemed safe to go out to the courtyard. One resident had recently fallen into the courtyard and because of that fall, it was discovered that staff were allowing resident's go to outside alone. If R42 were to wheel out there and go off the sidewalk, there was a risk he could tip his chair. The facility did not have therapy or nursing to assess how safe residents were when they were outside. The facility policy Resident Rights and Notification of Resident Rights, last reviewed 8/28/25, identified the facility acted to protect and ensure the rights of residents. Social services or designee would inform the residents of the Resident Rights at the time of admission and with changes to regulatory statute. Any time state or federal laws relating to resident rights or facility rules changed during the residents' stay, the residents would be promptly informed of the changes. The policy listed 45 resident rights which included exercise of rights, planning and implementing care, accommodation of needs, and grievances.The facility policy Chemical and Physical Restraints last reviewed 8/31/23, identified medical symptoms that warrant the use of restraints would be documented in the resident's medical record. Before a restraint was used the IDT would determine the presence of a medical symptom that required a restraint and how the restraint would treat the medical symptom, protect the resident's safety and assist the resident in attaining or maintaining their highest practicable level of physical and psychological wee-being. Alternative to the restraint and the risk benefits would be discussed with the residents. For the residents to be fully informed, the IDT would explain the context of the resident's condition and circumstances, and the potential risks and benefits of options under consideration. Alternatives would be considered and discussed with the resident or resident representative.

Based on interview and document review, the facility failed to ensure eligible residents received COVID-19 vaccination after consent was obtained for 1 of 5 residents (R30); and the facility failed to provide current Centers for Disease Control and Prevention (CDC) COVID-19 vaccine education regarding the potential benefits and risks of vaccination to resident representatives prior to obtaining a refusal for 2 of 5 residents (R16, R42) reviewed for COVID-19 vaccination status. These failures resulted in one resident not receiving a consented-to vaccination and had the potential to affect residents' ability to make informed vaccination decisions. Findings include:Unadministered VaccinesR30R30's admission Minimum Data Set (MDS) dated [DATE], identified R98 as [AGE] years old, cognitively aware and had diagnoses that included Multiple Sclerosis, congestive heart failure (CHF), Rheumatoid Arthritis, and Parkinson's disease. R30 was not up to date for COVID-19 vaccination. The MDS did not identify if R30 was offered a COVID-19 vaccination.R30's Immunization Consent form dated 2/17/26, identified R30 consented to receive the COVID-19 vaccination.R30's medical record failed to identify R30 had received the corresponding COVID-19 vaccination.During an interview on 6/3/26 at 10:21 a.m., registered nurse (RN)-B stated she was responsible for the facility's infection prevention program and the resident vaccinations. RN-B stated she was unsure why R30 had not received the COVID-19 vaccination as R30 had consented. RN-B stated the facility did not currently have any COVID-19 vaccine, however, RN-B stated when she ordered the vaccine the facility would have the COVID-19 vaccine available. RN-B usually ordered vaccines once per year in the fall. R30 consented to receive the COVID-19 vaccine on 2/17/26. Review of the medical record through 6/4/26 failed to identify the vaccine had been administered or documentation explaining why it was not administered despite approximately three, and one-half months having elapsed since consent was obtained.EducationR16R16's admission MDS dated [DATE], identified R16 as [AGE] years old, had a mild cognitive impairment and diagnoses that included CHF and atrial fibrillation (irregular heartbeat). R16 was not up to date for COVID-19 vaccination. The MDS did not identify if R16 was offered a COVID-19 vaccination.R16's Immunization Consent form dated 3/23/26, identified R16's son declined the COVID-19 vaccination by phone. However, the form failed to identify the education provided to R16's son.R42R42's admission MDS dated [DATE], identified R42 as [AGE] years old, had a mild cognitive impairment and diagnoses that included heart failure, peripheral vascular disease, diabetes, and dementia. R42 was not up to date for COVID-19 vaccination. The MDS failed to identify if R42 was offered a COVID-19 vaccination.R42's Immunization Consent form dated 3/23/26, identified R42's son declined the COVID-19 vaccination by phone. However, the form failed to identify the education provided to R42's son.During an interview on 6/3/26 at 10:24 a.m., RN-B stated R16 and R42's family declined the COVID-19 by phone. Most family members didn't want to read the education, so RN-B doesn't mail any education to anyone for review, nor does she document that.During an interview on 6/4/26 at 8:50 a.m., the director of nursing (DON) stated there was no documentation in R30's medical record that reflected R30 was given the COVID-19 vaccination nor why R30 had not received it. The DON stated should have received the vaccination as R30 had consented to. The DON also stated the resident and the resident representative need to be provided with all the education regarding vaccinations to ensure they understand what they are refusing or consenting to. Documentation should reflect their understanding of that education.The facility policy COVID-19 Vaccine and Booster for Residents dated 5/11/21, identified the facility would assure all residents that are eligible are offered the COVID-19 vaccination and booster doses when available.

Based on interview and document review the facility failed to ensure residents remained free from significant medication errors. This resulted in actual harm to R1 who was administered opioid medications prior to the prescribed date resulting in hypoxia, confusion and unresponsiveness and required the use of Narcan (used to reverse the effects of an opioid overdose).Findings include: A report to the state agency dated 7/1/25, indicated R1 had a visit with the palliative care provider on 6/27/25. The provider was informed that the R1's insurance had denied Oxycontin which R1 had been receiving for management of significant pain from fractures that occurred prior to admission to SNF (skilled nursing facility). R1's provider, nurse practitioner (NP)-A, stated that she made numerous calls regarding this patient on Friday afternoon once she received notification of the denied coverage of the Oxycontin from the insurance. After lengthy calls with the insurance provider and pharmacy it was determined the Oxycontin would be extended until they could work through a prior authorization of Morphine for pain management. The provider had to write an order for Morphine to initiate the prior authorization process. However, the order indicated not to fill until on or after 6/30/25. The night nurse received Morphine from the pharmacy on 6/28/25, around 1:00 a.m. A call was placed to the pharmacy as the facility did not have an order. The pharmacist confirmed the order, indicated the signed order would be sent to the facility. Upon receipt, the night nurse entered the order into the electronic record on 6/28/25 at 1:34a.m. R1 received Morphine while continuing to receive OxyContin. R1's Resident Face Sheet indicated she admitted to the facility on [DATE], diagnosis of osteoporosis with fractures of left and right lower leg and left clavicle. R1's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment, dependent on staff for transfers and had almost constant severe pain. R1's care plan dated 6/27/25, identified the use of high-risk medications for pain. The care plan directed staff to administer medications as ordered and assess for side effects. R1's Physician Order Report dated 6/1/25 through 6/30/25, identified the following medications. -6/6/25, OxyContin 15 milligrams (mg) by mouth every 12 hours.-6/17/25, Oxycodone 5mg every six hours as needed for severe pain.-6/28/25, MS Contin (morphine) 30mg every twelve hours. Discontinued 6/29/25. Provider note dated 6/27/25, indicated Oxycontin had been denied due to health care plan. An emergency refill was approved through the weekend. A prescription dated 6/27/25, indicated do not fill until 6/30/25. MS Contin 30 mg oral tablet extended release by mouth every 12 hours. R1's Medication Administration History dated 6/1/25 through 6/30/25, indicated the following medications were administered. -MS Contin 30mg, 6/28/25 at 12:00 p.m., 6/29/25 at 12:00 a.m. and 6/29/25 at 12:00 p.m.-OxyContin 15mg, 6/2825 at 8:00 a.m., 6/28/25 at 8:00 p.m., 6/29/25 at 8:00 a.m. 8:00 p.m. dose not administered due to condition. R1's Resident Progress Notes identified the following:-6/28/25, Fax received from pharmacy for MS Contin. Order placed in electronic record. MS Contin 30 mg oral tablet extended release every 12 hours.-6/29/25, 2:52 p.m., R1 was very groggy and not eating or drinking. Writer noted R1 was receiving both OxyContin and MS Contin. Call placed to pharmacy who confirmed R1 should not be receiving both medications at the same time. MS Contin was not supposed to be started unless payment authorization was not received for OxyContin.-6/29/25, 4:07 p.m., R1 resting in bed. She would respond by opening her eyes a little with gentle touch and calling her name.-6/30/25, 2:20 a.m., R1 was semi-alert but unresponsive verbally and only able to open eyes partially. R1's pulse was 116 beats per minute; oxygen saturation level was 56 percent on room air (normal range for oxygen saturation is 95-100). On-call nurse practitioner (NP) was updated and directed staff not to call 911 due to resuscitation status. Family was updated and came to see R1 and requested she be sent to the emergency department (ED). R1's hospital notes dated 6/30/25, indicated R1 admitted for altered mental status and hypoxia (a condition where the body, or a specific part of it, doesn't receive enough oxygen). Apparently had both oxycodone and morphine last afternoon for pain. No Narcan was given and R1 was hypoxic on arrival to ED and barely responded to verbal commands. Her baseline was alert and awake. The current episode started from one to two hours ago and the problem had not changed. Associated symptoms included confusion, somnolence (excessive sleep or drowsiness) and unresponsiveness. R1 responded to three doses of Narcan. Was alert and awake after Narcan but continued to be hypoxic. Started antibiotic to cover aspiration pneumonia secondary to obtundation from opioid overdose. During interview on 7/9/25 at 2:14 p.m., pharmacist (P)-A stated the potential negative effects of too much opioid medication included respiratory distress, increased sedation, Tachycardia (a condition where the heart beats faster than normal, typically over 100 beats per minute), unresponsiveness and hypoxia. During interview on 7/9/25 at 4:57 p.m., registered nurse (RN)-A stated prior to the medication error R1 had been alert and was able to make her needs known. During interview on 7/9/25 at 5:03 p.m., nursing assistant (NA)-A stated R1 had been alert and fairly oriented. NA-A said before the medication error happened, R1 had been coming out of her room more. During interview on 7/10/25 at 9:04 a.m., LPN-A stated early Saturday (6/28/25) morning, a tote arrived from the pharmacy. LPN-A said when she saw the morphine she called the pharmacy and was told they had a prescription. LPN-A said the pharmacy sent a copy of the prescription and she entered the order into the electronic record and had a second nurse verify the order. LPN-A said the prescription had said do not give until 6/30/25, but she had missed it. LPN-A said she had received education following the medication error. During interview on 7/9/25 at 5:09 p.m., the director of nursing (DON) stated when licensed practical nurse (LPN)-A found out the order for the MS Contin had been obtained, she should had read the physical prescription prior to entering the order into and medication record. The DON stated the nurse who verified the order should have compared the prescription with the order. The DON said the facility policy was to have all orders verified by two staff. The DON stated the nurses did not follow the process for entering and verifying orders. The DON stated the nurses involved in the medication error had been immediately educated following the identification of the medication error. In addition, auditing of medical records had been initiated for other residents. During interview on 7/10/25 at 8:46 a.m., nurse practitioner (NP)-A stated R1 had significant pain, and the OxyContin needed insurance authorization. NP-A wrote the order for the MS Contin to start on 6/30/25, if the insurance did not authorize the Oxycontin. NP-A said the potential concerns related to R1 having received both medications at the same time included respiratory distress and said, that is what happened. NP-A said the medication error was significant and said she had not written the order while at the facility because she did not want staff to administer the MS Contin to R1. Facility policy related to significant medication errors was requested but not received.

Based on interview and document review the facility failed to ensure timely reporting to the state agency (SA) of a significant medication error for 1 of 3 residents (R1) reviewed for medication errors and failed to ensure timely reporting of an incident of resident to resident abuse for 2 of 3 residents (R2,R3) reviewed for abuse.Findings include:R1's care plan dated 6/27/25, identified the use of high-risk medications for pain. The care plan directed staff to administer medications as ordered and assess for side effects. R1's Physician Order Report dated 6/1/25 through 6/30/25, identified the following medications. -6/6/25, OxyContin 15 milligrams (mg) by mouth every 12 hours.-6/17/25, Oxycodone 5mg every six hours as needed for severe pain.-6/28/25, MS Contin (morphine) 30mg every twelve hours. Discontinued 6/29/25. Provider note dated 6/27/25, indicated Oxycontin had been denied due to health care plan. An emergency refill was approved through the weekend. A prescription dated 6/27/25, indicated do not fill until 6/30/25. MS Contin 30 mg oral tablet extended release by mouth every 12 hours. R1's Medication Administration History dated 6/1/25 through 6/30/25, indicated the following medications were administered:-MS Contin 30mg, 6/28/25 at 12:00 p.m., 6/29/25 at 12:00 a.m. and 6/29/25 at 12:00 p.m.-OxyContin 15mg, 6/2825 at 8:00 a.m., 6/28/25 at 8:00 p.m., 6/29/25 at 8:00 a.m. 8:00 p.m. dose not administered due to condition. -6/30/25, 2:20 a.m., R1 was semi-alert but unresponsive verbally and only able to open eyes partially. R1's pulse was 116 beats per minute; oxygen saturation level was 56 percent on room air. On-call nurse practitioner (NP) was updated and directed staff not to call 911 due to resuscitation status. Family was updated and came to see R1 and requested she be sent to the emergency department (ED). R1's hospital notes dated 6/30/25, indicated R1 admitted for altered mental status and hypoxia (a condition where the body, or a specific part of it, doesn't receive enough oxygen). Apparently have both oxycodone and morphine last afternoon for pain. No Narcan was given and R1 was hypoxic on arrival to ED and barely responded to verbal commands. Her baseline was alert and awake. The current episode started from one to two hours ago and the problem had not changed. Associated symptoms included confusion, somnolence (excessive sleep or drowsiness) and unresponsiveness. R1 responded to three doses of Narcan. Was alert and awake after Narcan but continued to be hypoxic. Started antibiotic to cover aspiration pneumonia secondary to obtundation from opioid overdose. A report to the SA indicated the medication error was reported on 7/1/25, at 6:43 p.m. During interview on 7/10/25 at 11:00 a.m., the director of nursing (DON) stated when a significant medication error was identified it should be reported to the SA. The DON said she felt like she had to do a little more digging do determine if the medication error was significant and when she determined it was, she reported the error. The DON said when she learned R1 had been admitted to the hospital it was determined to be a significant error. R2's Resident Face Sheet indicated diagnosis included Alzheimer's disease, insomnia and dementia with behavioral disturbance. R2's Resident Progress Notes dated 6/30/25, indicated R2 was found on the floor of another residents (R3) room. The other resident (R3) stated R2 came to her door, and she tried to push her out and said R2 pushed her back. R2 had a bump on the back of her head. R3's Resident Face Sheet indicated diagnosis included dementia without behavioral disturbance, agitation, Alzheimer's disease and anxiety. R3's Resident Progress Note dated 6/30/25, indicated per trained medication aide (TMA), R3 came out of her room asking for assistance. TMA and another caregiver noted R3's right eye was black and blue and swollen and her lip was swollen with a small amount of blood noted. R3 brought the staff to her room where another resident (R2) was lying on the bathroom floor. When asked what happened, R3 stated the other resident was trying to come into her room so she pushed her away and said the other resident pushed back and they both fell on the floor. An additional Progress Note dated 6/30/25, indicated the incident occurred at 6:40 a.m. A report to the SA indicated the resident-to-resident altercation had been reported 6/30/25 at 3:16 p.m. During interview on 7/10/25 at 1:29 p.m., the DON stated the incident had not been reported to the SA in the required two-hour time frame. The DON said staff had called her at home and she went to the facility and reported as soon as she could. Facility policy Abuse Prevention Plan dated 7/21/22, indicated staff would notify building charge immediately any reports of possible abuse, neglect, misappropriation or exploitation. The charge would immediately notify the administrator, DON and social services. If the event that caused suspicion involves abuse or results in serious bodily injury the individual is required to report to the SA immediately, but no later than two hours after forming the suspicion. Abuse was described as: the willful infliction of injury. Neglect described as: Failure of the facility, employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain or emotional distress.

Based on observation, interview and document review the facility failed to protect the residents right to be free from physical abuse by other residents for 2 of 3 residents (R2, R3) when care plan intervention to adequately increase supervision to protect residents from abuse were not implemented and behaviors were not investigated or documented with detail to assist in determining possible antecedents of the negative behavior. Additionally, the facility failed to monitor R3 for mood and behavioral changes following a resident-to-resident abuse incident which resulted in minor injuries and increased withdrawal. R2's Resident Face Sheet indicated she admitted to the facility 10/19/23. R2's diagnosis included Alzheimer's disease, insomnia and dementia with behavioral disturbance.R2's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed wandering behaviors 4-6 days during the assessment period. The MDS indicated R2 ambulated independently.R2's Vulnerable Adult assessment dated [DATE], indicated she did not have a history of abuse toward others or self abuse. R2 had physical limitations and cognitive deficits that made her susceptible to abuse. R2 had behaviors that made her susceptible to abuse to self or others and had communication limitations. R2's care plan dated 6/30/25, identified her as a vulnerable adult and indicated if she became violent or aggressive staff should implement interventions to minimized risk to herself or others. The care plan indicated she had exhibited physical aggression toward others and indicated she had slapped another resident on 10/4/24 and 10/11/24, had pinched another resident on 10/6/24, and pushed another resident on 6/30/25. The care plan directed staff to provide close supervision and gently guide her away if she was observed in close proximity to peers, especially when entering others personal space or rooms and observe her closely to identify specific triggers that may lead to aggression. The care plan further directed staff to provide sensory items and/or baby doll and stroller when R2 became agitated. The care plan indicated R2 exhibited inappropriate behaviors such as wandering into other residents rooms and taking things that didn't belong to her. R2's Resident Progress Notes identified the following:5/11/25, R2 had family visit. After they left R2 appeared to be upset. R2 had been in and out of other residents rooms, tried to take a blanket off someone who was using it and was walking around the dining room trying to take food and drinks off of other residents trays.6/19/25, R2 was standing in the dining room to the left of a male resident. R2 was observed interacting with newspapers on the table and not engaging with male resident. Male resident reached out and struck R2 on the elbow with a closed fist. Staff removed R2 from the area. 6/30/25, R2 found on the floor of another residents (R3) room. The other resident stated R2 came to her door and she tried to push her out and said R2 pushed back. R2 had a bump on the back of her head. 6/30/25, Due to resident to resident altercation, R2 would remain under constant supervision due to ongoing boundary intrusiveness.7/3/25, R2 remained one to one with staff. During observation on 7/10/25 at 11:13 a.m., R2 was ambulating independently on the unit. R2 was following a female resident. R2 had newspapers in her hand and was touching the other resident with them. The other resident repeatedly stated, don't touch me. A staff member was standing with her back to the room, down the hall. Two other staff walked out of the bathroom with a different resident. No staff were in the area to intervene. At 11:20 a.m., the other resident propelled herself out of her room. R2 walked over and placed her hands on the other residents wheelchair. The other resident stated, no, no, no, don't touch me. R3's Resident Face Sheet indicated she admitted to the facility on [DATE]. Diagnosis included dementia without behavioral disturbance, agitation, Alzheimer's disease and anxiety. R3's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she displayed physical, verbal and other behaviors 4-6 days of the assessment period and wandering behaviors 1-3 days. The MDS indicated R3 ambulated independently.R3's care plan dated 6/30/25, identified her as a vulnerable adult. The care plan indicated if R3 got violent or physically aggressive staff would implement interventions to minimize risk to self or others. Facility to report and investigate any allegations of suspected abuse. The care plan indicated R3 had been a victim of another residents physical aggression. The care plan directed a mesh screen to her door and directed staff to monitor for behavioral changes indicating fear, withdrawl or anxiety and adjust care accordingly. The care plan identified behavioral symptoms that included hallucinations/delusions. R3's Vulnerable Adult assessment dated [DATE], indicated she did not have a history of any type of abuse toward others or self. R3 did not have physical limitation which made her susceptible to abuse, but did have cognitive deficits. The assessment further indicated R3 did not display behaviors that made her susceptible to abuse. R3's Resident Progress Notes identified the following:6/30/25, Per trained medication aide (TMA), R3 came out of her room asking for assistance. TMA and another caregiver noted R3's right eye was black and blue and swollen and her lip was swollen with a small amount of blood noted. R3 brought the staff to her room where another resident (R2) was lying on the bathroom floor. When asked what happened, R3 stated the other resident was trying to come into her room so she pushed her away and said the other resident back and they both fell on the floor. 7/1/25, R3's family member called regarding incident and inquired about plan to keep R2 out of her room as she felt it startled R3 and she wanted R3 to feel secure. Informed family of stop sign and mesh screen type door and R2 currently being one to one with staff.7/1/25, R3 had been in her room most of the shift.7/1/25, R3 had been following another female resident (R2) consistently for about two hours. Staff had been one to one with other resident (R2). After supper R3 went to her room and stayed in the room. 7/6/25, R3 was seated at the breakfast table and noticed female resident (R2) near her room. R3 stated, that's my room and immediately got up and walked at a fast pace toward the other resident. Staff was able to intercept. When asked where she was going, R3 said that women is too close.7/8/25, R3 had been staying in her room throughout most of shift. Did go out to eat dinner.7/9/25, R3 stayed in room for most of shift. During observation and interview on 7/9/25 at 4:15 p.m., R3 was seated in a recliner chair in her room. R3 had a bruise above her right eye, and a scab on her lip. When asked about her eye, R3 stated a fight. R3 said it was the person who for some time would take things from her room. R3 said, finally, I just said no more of this. R3 remembered the fight and said it happened over there, pointing to the window. R3 said, I had a bruise, a black eye, and the other. When asked if she was afraid of the other resident R3 said, Yes and said as time goes by it's less and less, then said, that's not right. R3 said, it just so much and so long, then said, no, for a short time. R3 said she wouldn't sleep. R3 said, this is how I look at it, she hit me here, and pointed to her eye, and said, it came from the south. R3 said, it wasn't just you hurt me, I'll hurt you, it was real fighting. R3 said it lessened as time went by but said that doesn't mean it goes away either.During interview on 7/9/25 at 4:30 p.m., nursing assistant (NA)-B stated since the incident R3 had not been out of her room as much. NA-B said normally R3 would walk around the unit. NA-B said she had not seen any issues between R2 and R3 since the incident but said R3 stayed in her room. NA-B said if R3 was out walking, staff tried to keep R2 away. During interview on 7/10/25 at approximately 7:00 a.m., TMA-A stated R3 liked to walk around the unit but said, I know she did not come out of her room much after the incident with R2. TMA-A said R3 would come to an activity then go right back to her room. During interview on 7/10/25, at approximately 7:15 a.m., NA-D said she worked the day after the incident between R2 and R3. NA-D said the only thing she had noticed was one time R3 walked past a table where R2 was seated and R2 said there she is, in Spanish and seemed very agitated. NA-D said R3 was staring at R2 very deeply but had not said anything. During interview on 7/10/25 at 11:36 a.m., NA-C said staff tried to keep an eye on R2 but said sometimes they got busy. NA-C said R3 had been in her room a lot lately and did not come out as much. During interview on 7/10/25 at 1:03 p.m., registered nurse (RN)-B stated after the incident between R2 and R3, staff kept R2 in their visual field and if they saw R2 near other residents they tried to direct her away. RN-B said staff were not assigned to R2 but they worked together to provide supervision to R2. RN-B said they did not have any increase in staffing to supervise following the incident. In regard to the weekend and evening staffing, RN-B said she was not sure what the plan was. RN-B said when she started at the facility they had a designated extra staff person called a safety staff but said they had not had the extra staff for a month or so. RN-B said she had seen some signs of fear/anxiety from R3 but had not asked her if she was afraid of R2. She said she felt R3 had a good recollection of what had happened. During interview on 7/10/25 at 1:29 p.m., the director of nursing said prior to the incident between R2 and R3 they had implemented an extra safety staff member due to a previous resident, The DON said after that resident declined they felt they could pull that position and provide increased supervision when it appeared someone was more agitated. The DON said they provided one to one supervision of R2 the day of the incident and throughout the investigation but no longer had the one to one. The DON said currently they provided more eyes on supervision.Facility Policy Abuse Prevention Plan dated 7/21/22, indicated Prevention of abuse, neglect, misappropriation of resident property the facility should do the following: Ensure sufficient staffing and appropriate supervisory staff on each shift to meet the needs of the residents. Ensure concerns, incidents and grievances are investigated and steps taken to minimize the likelihood of re-occurrence.

Based on observation, interview and document review the facility failed to ensure care planned interventions to reduce the risk for falls were followed for 2 of 4 residents (R1, R3). This resulted in actual harm for R1 who fell and sustained a vertebral fracture. Findings include: R1's Resident Face Sheet indicated she admitted to the facility 1/30/24. Diagnosis included dementia, fracture of T (thoracic) 11- T12 vertebrae, difficulty walking, muscle weakness and age related osteoporosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. The MDS indicated R1 required partial to moderate assistance and did not ambulate due to medical condition or safety concerns and had no falls since the prior assessment. R1's assessment for Fall Risk and Functional Limitation dated 4/22/25, identified intermittent confusion, balance problem while standing, impaired mobility and indicated R1 utilized a wheelchair. The assessment score of 16 indicated a high risk for falls. R1's care plan dated 5/16/25, identified a self-care deficit and indicated she needed assistance with bed mobility, transfers, ambulation and locomotion due to a history of a fall with hip fracture. The care plan identified a high risk for falls and indicated all standard fall interventions were in place. An undated, untitled nursing assistant (NA) care guide directed staff to provide extensive assistance of one to two staff with transfer and directed staff to utilize a wheelchair for transport. R1's Resident Progress Notes indicated the following: -5/30/25, Nurse was called to the hallway outside of R1's room where she was on the floor sitting with NA-A behind her, and both legs in front of her. Per NA-A, R1 fell around the corner. R1 complained of pain to her buttocks. -5/31/25, R1 was experiencing severe back pain rated 9/10 on pain scale. R1 was clenching her fists and grimacing and refused to roll over due to pain. New order received to increase Tramadol (used for the management of moderate to moderately severe pain) to 50 milligrams (mg) every four hours as needed. -6/1/25 at 10:58 a.m., R1 continued to complain of pain in her back. Family member requested R1 be sent to the emergency department (ED) for further evaluation. 6/1/25 at 1:45 p.m., received call from ED staff who reported R1 sustained a T12 compression fracture (a type of fracture where a vertebra in the spine is compressed or collapses). 3:05 p.m., R1 returned from ED with the following orders: Start taking Hydrocodone-acetaminophen (combination prescription medication used to treat moderate to severe pain) 5 mg-325 mg, 1 tablet every six hours as needed for moderate or severe pain if not controlled by Tramadol. R1's ED Provider Note dated 6/1/25, indicated she presented to the ED for pain. The note indicated R1 experienced constant pain that started two days prior as a result of a fall. Pain was present in the lumbar spine and symptoms were aggravated by bending, twisting and certain positions. Tramadol provided no relief. Lumbar computed tomography scan (a medical imaging test that uses X-rays and computers to create detailed images of the lower spine) showed a T12 compression fracture. During interview on 6/4/25 at 6:33 p.m., registered nurse (RN)-A stated staff had reported R1 was in the hallway and started to slowly fall so NA-A lowered R1 to the ground. RN-A stated R1 did not typically ambulate, but NA-A had been walking with her at the time of the fall. RN-A stated NA-A had not used a transfer belt when walking with R1. RN-A said R1's family did not want her walking after she sustained a hip fracture the previous year and said the NA care sheet directed staff to utilize a wheelchair. During interview on 6/4/25 at 6:50 p.m., the assistant director of nursing (ADON) stated NA-A should have known not to ambulate with R1 and should have utilized a transfer belt. The ADON said NA-A received education following the incident and all staff received training on following resident fall interventions. During interview on 6/5/25 at 8:18 a.m., NA-A stated on 5/30/25, at approximately 5:00 p.m., she had been doing rounds on the unit. NA-A said she went to R1's room to bring her to the dining room and said she had been distracted and forgot about the transfer belt. NA-A said she got R1 up and out to the hallway and said R1 was holding on to the walker with one hand and the hand rail with the other hand. NA-A said after they got about four feet from R1's room, R1 stopped and said it was too far, then let go of the railing. NA-A said that was when she realized she had forgotten the gait belt so she somewhat grabbed R1 and went to the floor with her. NA-A stated she had been working at the facility for almost four months and said she had not been trained on the care plan when she started but was trained following the fall incident. During interview on 6/5/25 at 9:05 a.m., NA-B stated she had been working the night of R1's fall. NA-B said NA-A went to get R1 up for dinner and said NA-A did not look at the care guide and thought R1 could walk. NA-B said R1 had not walked with staff since she had broken a bone in the past. NA-B said NA-A also had not used a transfer belt when walking with R1. During interview on 6/5/25 at 12:07 p.m., NA-E stated R1 participated in a range of motion program but said she did not ambulate with staff. NA-E said the last time he had seen R1 walk with staff was the previous year. During interview on 6/5/25 at 12:13 p.m., NA-F said R1 fell because the staff person walking with her did not use a transfer belt. NA-F said he had never seen staff walk with R1 and said the care guide said to use the wheelchair for long distances. R3's Resident Face Sheet indicated he admitted to the facility 4/17/25. Diagnosis included traumatic subdural hemorrhage with loss of consciousness, Alzheimer's disease, maxillary fracture (a break in the bones surrounding the maxillary sinus, which are air-filled spaces in the cheekbones), fracture of lateral orbital wall (break in the outer wall of the eye socket) of right eye, muscle weakness and repeated falls. R3's assessment for Fall Risk and Functional Limitation dated 5/5/25, indicated he was disoriented, required the use of assistive devices and had impaired mobility. The assessment identified a fall score of 20 which indicated high risk. R3's 5-day MDS dated [DATE], identified severe cognitive impairment and indicated he required supervision for transfers and partial to moderate assistance for toileting. The MDS indicated ambulation was not attempted due to medical condition or safety concerns and indicated he had one fall since the prior assessment. R3's care plan dated 5/20/25, identified impaired physical mobility related to cognitive decline secondary to dementia. The care plan directed staff to provide assistance from two caregivers during all transfers and ambulation. The care plan further identified a high risk for falls due to a history of falls. Fall interventions included; remove leg rests when not pushing R3 in the wheelchair, auto lock brakes on wheelchair, and transfer belt at all times. R3's NA care guide, undated identified fall interventions that included slip grip to wheelchair and recliner chair. R3's Resident Progress Notes indicated the following: -5/1/25, progress note indicated, R1 had been leaning to his right side in the wheelchair and slid out of the chair. (no time indicated) -5/1/25, R3 had a second fall, progress note indicated at approximately 2:40 p.m., R1 had an unwitnessed fall from his wheelchair, landing on the floor and striking his head. R3 was found lying on his left side the hallway. R3 verbalized pain to his forehead. Staff noted a raised area on R3's forehead. 5/1/25, Interdisciplinary team (IDT) reviewed the falls. Intervention to ensure slip grip was applied when in wheelchair. -5/5/25, progress note indicated R3 returned from the hospital where he had been admitted on [DATE]. Hospital diagnosis included acute subdural hematoma (a life-threatening condition where blood collects between the brain and its outer lining, the dura mater, following a head injury), acute non-displaced fractures of right maxillary sinus and right lateral orbit, and metabolic encephalopathy (a change in how your brain works due to an underlying condition), likely due to urinary tract infection. -5/6/25, progress note indicated IDT reviewed fall and implemented Slip Grip to recliner chair. -5/16/25, progress note indicated R3 experienced a fall from a wheelchair. Staff determined the wheelchair utilized at the time of the fall did not belong to R3. -5/18/25, R3 had an unwitnessed fall in his room. -5/25/25, R3 had a fall in the dining room. -5/27/25, R3 had two falls, the first fall, R3 was found on the floor in his room. The second fall R3 fell attempting to ambulate in the television room. -6/1/25, R3 fell after attempting to stand up from his wheelchair and sustained a laceration above his right eye. -6/2/25, R3 had an unwitnessed fall and was found on his back with his leg tangled in the footrest of his wheelchair. During interview on 6/5/25 at 11:47 a.m., NA-C stated R3 required one person to transfer and could walk using a gait belt. When asked about fall interventions, NA-C was not sure where to look. NA-C pulled the resident care guide out of her pocket, looked at it and said, I'm not really seeing a lot, then said no interventions were listed on the care guide. (interventions were listed on the back of care guide) During interview on 6/5/25 at 11:51 a.m., NA-D said they used two staff to assist R3 due to behaviors. Regarding fall interventions, NA-D said staff just monitored him closely and said he had a motion detection device in his room. During observation and interview on 6/5/25 at 11:59 a.m., R3 was seated in a chair in the television area of the unit with his legs crossed and his eyes closed. R3 was seated on a soaker pad and did not appear to have slip grip underneath him. RN-B was interviewed and acknowledged no slip grip had been placed under R3 in the chair. RN-B stated R3 was care planned to have slip grip in his wheelchair and his recliner chair. RN-B said he should have it in any chair he was sitting in. RN-B stated fall interventions were on the NA care guides. The care guide was reviewed with RN-B and fall interventions, including the slip grip were listed on the backside of the paper. Facility policy Comprehensive Assessment and Care Planning dated 9/27/23, indicated the facility should use the results of the assessment to develop, review and revise the residents person-centered comprehensive care plan. All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.

Based on observation, interview and document review, the facility failed ensure their infection control surveillance contained all data to effectively track, trend, analyze infections with the potential to affect all residents residing in the facility; and the facility failed to ensure enhanced barrier precautions and standard precautions for 1 of 2 residents (R140) reviewed for wound care; and failed to ensure contact precautions were followed for 1 of 3 residents (R75) reviewed for transmission-based precautions. Findings include: Surveillance: The Infection Prevention Line Listing dated March 2025, identified columns labeled the following: all units, ID number, resident name, age, sex, room, infection site, date/lab pathogen, date/symptoms, predisposing factors, date isolation began, date isolation ended, date/treatment, appropriate yes/no, in-house acquired, resolved yes/no. However, the line listing identified twelve resident names, age, sex and room number but failed to identify any other information. The Infections excel spreadsheet dated 3/4/25 to 3/20/25, identified the following: Two carbuncles (Norovirus infection can cause severe vomiting and diarrhea that start suddenly. Noroviruses are highly contagious. They commonly spread through food or water that is contaminated during preparation or through contaminated surfaces. Noroviruses can also spread through close contact with a person who has norovirus infection.) - 8 UTIs. - 1 septic arthritis - 1 bronchitis - 2 respiratory infections - 1 pneumonia All listed were treated with medication. R21: R21's admission Minimum Data Set (MDS) dated [DATE], identified R21 was cognitively intact and had diagnoses that included irregular heart rate, left femur fracture, fibromyalgia, left arm fracture, and right wrist fracture. R21 was frequently incontinent of bladder and had a colostomy (a surgical procedure that creates an opening for the colon through the abdominal wall. It is done when there is a problem with the colon or a disease affecting it). R21's nursing progress notes on 3/01/25 at 10:38 a.m., R21 was complaining of being weak, tired, nauseated, diarrhea, stomach pains. R21 was having the dry heaves. Colostomy bag was emptied. Toileted and put in bed per her request. R21 did try to eat oatmeal but that wasn't what she wanted or worked with her stomach. Has refused her morning medications. During an interview on 3/25/25 at 5:01 p.m., licensed practical nurse (LPN)-B stated that weekend R21 complained of diarrhea, abdominal pain and a low-grade temperature. Staff treated it like it was norovirus (Norovirus infection can cause severe vomiting and diarrhea that start suddenly. Noroviruses are highly contagious. They commonly spread through food or water that is contaminated during preparation or through contaminated surfaces. Noroviruses can also spread through close contact with a person who has norovirus infection.) The first day R21's diarrhea was frequent; sometimes every hour with some watery and some formed feces. R75: R75 discharge return anticipated MDS dated [DATE], identified R75 had a mild cognitive impairment and had diagnoses that included traumatic head injury and chronic obstructive pulmonary disease (COPD). R75 was frequently incontinent of bladder and bowel. R75 required substantial to maximum assistance with toileting. R75's nursing progress note dated 3/21/25 at 4:59 p.m., identified R75 returned to the facility after a hospitalization . R75 had been admitted to the hospital on 3/14/25 due to right lower lobe pneumonia and a complicated urinary tract infection (UTI). R75 tested positive for norovirus on 3/20/25 due to diarrhea. Contact precautions were initiated. The Infection Prevention Line Listing dated March 2025 and The Infections excel spreadsheet dated 3/4/25 to 3/20/25 , failed to identify R21 nor R75's symptoms and treatments. During an interview on 3/26/25 at 2:36 p.m., registered nurse (RN)-A stated she was the facility's infection prevention nurse as well as the Station 240-unit manager. RN-A dedicated eight hours a week to the infection prevention program but tried to keep up with infection signs/symptoms surveillance daily. The facility used an excel spreadsheet where any licensed staff could enter information when a resident was started on an antibiotic or antiviral. From there, RN-A would enter that information on the line listing form and do mapping of the infections at the end of the month. Additionally, the unit managers would read nursing progress notes daily to look for signs of infection. RN-A stated she was unaware of R21's symptoms but staff were generally aware of residents with symptoms such as nausea, vomiting and/or diarrhea. Rarely would the facility have a diagnosis correlating to the symptoms unless there were laboratory tests to confirm it. However, unless a resident was prescribed a treatment, such as antibiotics, the resident would not be added to the surveillance. During an interview on 3/27/25 at 12:09 p.m., the director of Nursing (DON) stated all signs and symptoms of potential infections should be tracked and evaluated timely to find trends earlier to try to prevent the spread of infection and keep it contained. The facility policy Surveillance Reporting revised 8/2023, identified once surveillance was completed, the data was collected and analyzed, and the significance was summarized. The resulting information should be shared with those who assist in the infection prevention and may include internal and external sources. 1. The IP performs on-going surveillance and investigation into all infections within the facility. 2. Once the surveillance is completed, the data collected is analyzed and summarized. It is then shared with the parties that assist with infection prevention in facilities, or if indicated external agencies. 3. If infection trends are noted, or there has been a break in infection prevention standards, the 1P will educate the associates noted in the trend or break, put an action plan in place to monitor for adherence lo standards, and report the results of both the trend and/or break in standards, as well as the action plan to tile Quality Council for further recommendations/comments. 4. Internal reporting may include, but is not limited to: a. Resident and /or their significant support systems and family members b. Nursing c. Admitting d. Therapy e. Life enrichment/activities f. Environmental Services g. Maintenance h. Culinary i. Administration j. Quality Council 6. The IP must know what to report, how to report, and who must be informed. 7. Repo11ing requirements vary by state and may include reporting healthcare associated infections, community-associated infections, and infectious/communicable diseases. 8. As part of public reporting, each IP will make contact with the public health professionals who may assist the facility in time or need. Enhanced Barrier and Standard Precautions: R140 R140's admission MDS dated [DATE], identified R140 was cognitively aware and had diagnoses included osteomyelitis of sacral and sacrococcygeal vertebra (a rare infection in your spine. It happens when bacteria or fungi infect your vertebrae (spine bones). The infection can start in your spine if the germs get in a wound or surgery site. It can also spread to your spine from somewhere else in your body. You'll need medication for several weeks to kill the infection. Vertebral osteomyelitis can damage your affected vertebra and the tissue around it in your spine.), type 2 diabetes, chronic kidney disease and weakness. R140 was at risk for pressure ulcers and had one stage 4 pressure ulcer. R140's care plan revised 3/13/25, identified R140 was at risk for alteration of skin status due to weakness, pain, type 2 diabetes and current treatment for osteomyelitis. Interventions included a special mattress, offloading when in bed, barrier cream applied to dry areas as needed, and a wheelchair cushion. R140 require a wound care treatment plan as follows: wound vac per orders and wet to dry dressings as needed. However, the care plan failed to identify R140's need for enhanced barrier precautions. R140's physician order dated 3/22/25, identified R140 had a wound vac to sacrum, change Tuesday, Thursday and Saturday and pressure set to -125. During an interview on 3/24/25 at 4:35 p.m., R140 stated he had a sore on his butt that was awful. R140 stated the wound went all the way to the bone and the nurses were not really trained in how they take care of it. R140 had to direct staff, or staff got to a point and would have to start over. During an observation on 3/25/25 at 9:41 a.m., R140's door to his room had an enhanced barrier precautions (EBP) sign on his door with a personal protective equipment cart outside his room. RN-B changed R140's wound vac dressing while licensed practical nurse (LPN)-A assisted. Prior to starting the dressing change RN-B and LPN-A entered R140's room without putting on a gown. Without gloves, RN-B removed R140's catheter bag from under R140's wheelchair and placed it on R140's bed frame. - At 9:43 a.m., LPN-A placed R140's walker in front of R140. With verbal cues and stand by assistance, R140 stood, turned and sat on his bed. - 9:45 a.m., RN-B nor LPN-A put on a gown. RN-B placed R140's wound vac on bed and removed the wound vac cover. RN-B put on gloves then clamped and disconnected the wound vac tubing. RN-B and LPN-A assisted R140 to pull down his pants. - 9:49 a.m., RN-B removed R140's soiled dressing. RN-B stated the dressing had bloody, brown drainage. RN-B removed her gloves, but did not use hand sanitizer before putting on new gloves and pulled foam from R140's wound. RN-B removed her gloves, but did not use hand sanitizer before putting on new gloves and cleansed the wound with a 4 inch by 4 inch gauze and wound cleanser. RN-B stated the wound was 25% slough (Slough in wound healing refers to dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material) with some granulation (Granulation tissue heals the wound by filling in the wound from the base, moving upward) and a new undermined( caused by erosion under the wound edges, resulting in a large wound with a small opening) area. - 9:52 a.m., RN-B put on new gloves without using hand sanitizer and a portable electronic tablet to take photos of R140's wound, LPN-A used a gloved hand to pull back R140's right buttock to allow for a clear wound photo. RN-B was leaning on R140's bed with the linens touching RN-B's forearms and the front of RN-B's uniform. RN-B removed her soiled gloves but did not use hand sanitizer and used a clipboard and pen to write down R140's wound measurements. - 9:54 a.m., RN-B opened the new wound vac dressing and laid it on R140's bed. RN-B did not place a clean surface for the dressing to lie on. - 9:55 a.m., RN-B put on clean gloves and replaced R140's wound vac dressing. RN-B nor LPN-A wore a gown and hand sanitizer was not used between soiled and clean gloves. - 10:18 a.m., RN-C entered R140's room without a gown or gloves, looked at R140's wound dressing and left the room. RN-B disposed of the dressing packaging, removed her soiled gloves and fastened R140's incontinence brief. RN-B and LPN-A assisted R140 to pull up his pants. - 10:22 a.m., RN-B and LPN-A exited R140's room. RN-B took the electronic tablet, clipboard and pen without using a sanitizing wipe. During an interview on 3/25/25 at 10:29 a.m., LPN-A stated R140's EBP were only for catheter/ostomy care. Staff did not need to wear a gown any other time. During an interview on 3/25/25 at 10:29 a.m., RN-B stated R140's EBP were for catheter cares and not for the wound care because R140 had a wound vac. RN-B stated gowns should be worn during wound care yea, probably. During an interview on 3/25/25 at 10:29 a.m., RN-C stated staff were expected to wear a gown and gloves when entering R140's room, to perform hand hygiene (hand washing or hand sanitizer) when removing soiled gloves and were expected to clean all equipment when exiting the room to prevent potential infections. During an interview on 3/26/25 at 2:57 p.m., RN-A stated staff were educated that when a sign was on a resident's door and there was a PPE cart there, staff were expected to put on PPE. The facility even implemented reference cards for the staff name badge, so staff always had access to what was needed and when. RN-A could not say why staff did not wear the appropriate PPE during a wound vac change because it just screams the need for PPE. During an interview on 3/25/25 at 10:31 a.m., the DON stated staff were expected to put on a gown and gloves when entering R140's room, use hand sanitizer between clean and dirty gloves and either leave the equipment in the room or clean it when leaving the room to prevent possible infections. The facility policy Hand Hygiene revised 2/5/20, identified there are situations in nursing homes and assisted living which may lead to a higher rate of infectious disease than a person living in their own home. Therefore, associates in these settings have a special concern to prevent the spread of infection through proper hand hygiene. All associates are accountable including those not involved in direct care. Clean hands are the single most important factor to stop the spread of infection. Hand must be washed with soap and water when hands are visibly soiled, after skin contact with blood or body fluids and after exposure to infectious materials. The CDC dated 6/28/24, identified Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The facility policy Enhanced Barrier Precautions undated, identified Enhanced Barrier Precautions (EBP) is a strategy in nursing homes to decrease transmission of CDC-targeted and other epidemiological important multidrug-resistant organisms (MDROs). EBP will be used for residents actively infected or colonized with CDC-targeted and other epidemiologically important MDROs. Additionally, residents at risk for MDROs, specifically those with an indwelling medical device and/or chronic wounds requiring a dressing will be required to use EBP. Transmission Based Precautions Centers for Disease Control and Prevention (CDC) Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions updated 2/7/25, identified norovirus required the use of contact precautions for a minimum of 48 hours after the resolution of symptoms or to control institutional outbreaks. Persons who clean areas heavily contaminated with feces or vomitus may benefit from wearing masks since virus can be aerosolized from these body substances; ensure consistent environmental cleaning and disinfection with focus on restrooms even when apparently unsoiled. Hypochlorite (Common examples include sodium hypochlorite (household bleach) and calcium hypochlorite (a component of bleaching powder, swimming pool chlorine) solutions may be required when there is continued transmission. Alcohol is less active, but there is no evidence that alcohol antiseptic handrubs are not effective for hand decontamination. R75 R75 discharge return anticipated MDS dated [DATE], identified R75 had a mild cognitive impairment and had diagnoses that included traumatic head injury and chronic obstructive pulmonary disease (COPD). R75 was frequently incontinent of bladder and bowel. R75 required substantial to maximum assistance with toileting. R75's nursing progress note dated 3/21/25 at 4:59 p.m., identified R75 returned to the facility after a hospitalization . R75 was admitted to the hospital on 3/14/25 due to right lower lobe pneumonia and a complicated urinary tract infection (UTI). R75 tested positive for norovirus on 3/20/25 due to diarrhea. Contact precautions were initiated. R75's care plan revised 3/21/25, failed to identify R75's need for contact precautions. During an observation on 3/25/25 at 10:44 a.m., R75 was sitting in his wheelchair in his room. There was a contact precautions sign and PPE cart outside R75's room. Housekeeping (HK)-A entered R75's room with a hand-held basket with cleaning supplies. HK-A put on a pair of gloves but did not put on a mask or gown. HK-A cleaned R75's bathroom. High touch areas of R75's room and swept/mopped the floor. During an interview on 3/25/25 at 11:05 a.m., HK-A stated R75 was on contact precautions but that was only for cares, when staff had to touch R75. During an interview on 3/26/25 at 2:57 p.m., RN-A stated staff were educated that when a sign was on a resident's door and there was a PPE cart there, staff were expected to put on PPE. The facility even implemented reference cards for the staff name badge, so staff always had access to what was needed and when. When RN-A observed housekeeping not following precautions, RN-A educate them. RN-A stated housekeeping should have cleaned R75's room last and should have worn PPE while doing so. During an interview on 03/25/25 12:09 a.m., the DON stated housekeeping staff were expected to follow contact precautions while cleaning a room to prevent the potential transmission of infection. The facility policy Environmental Services - Cleaning dated 2020, identified the following: 1. Standard cleaning procedures will be used in isolation rooms; however, isolation rooms will be cleaned last or the equipment and water changed before going into another room to clean. 2. Special attention will be paid to cleaning of environmental surfaces in the isolation room, as these surfaces are frequent sources of person-to-person transmission of infection. 3. If mop and bucket solution are contaminated with feces or bloody fluids, they will be changed. 4. Appropriate personal protective equipment (PPE) will be worn: a. Contact precautions - Gloves and gown will be worn when in the room - Must be removed with proper hand hygiene performed before leaving the room.

Based on interview and document review, the facility failed to ensure use of an as-needed (PRN) psychotropic medication was limited to a 14-day period and/or obtain justification for continued use by the provide for 1 of 5 residents (R68) reviewed for unnecessary medication use. Findings include: R68's significant change Minimum Data Set (MDS) dated [DATE], identified R68 had severe cognitive impairment and did not exhibit behaviors during the assessment period. Diagnoses included Alzheimer's disease, dementia and bipolar disorder. R68's undated prescription fax request identified an order for diazepam 5 mg/ml liquid concentrate; administer 2.5 mg oral every 6 hours - PRN for anxiety/agitation, start date 2/19/25. The order failed to identify a justification of use beyond 14 days and did not provide an end date and/or re-evaluation date. R68's Medication Administration Record (MAR) dated 2/1/25 through 2/28/25, identified R68 received diazepam on 2/20/25, 2/23/35 (two doses), 2/25/25 and 2/28/25. R68's MAR dated 3/1/25 through 3/27/25, identified R68 received diazepam on 3/3/25. R68's medical record failed to identify a justification of continued use past the initial 14 days and failed to provide an end date for use and/or re-evaluation date. R68's Medication Regimen Review (MRR) dated 3/5/25, identified the consulting pharmacist recommended either discontinuing PRN use of diazepam for R68, or reorder for a specific number of days, per federal guidelines. On 3/27/25 at 11:13 a.m., registered nurse (RN)-D stated PRN psychotropic orders, including diazepam, were ordered by the provider for 14 days or required an end date with a rationale for use. RN-D stated R68's diazepam order did not have an end date or a rationale for use longer than 14 days and the order should've been discontinued until discussed with the provider. On 3/27/25 at 11:45 a.m., the director of nursing (DON) stated the nurses were aware if a PRN psychotropic order did not include an end date it was their responsibility to reach out to the provider. The order should also include a rationale for use if the provider ordered the medication for longer than 14 days, including orders for residents on hospice. On 3/27/25 at 1:16 p.m., the consulting pharmacist (CP) stated medication regimen review were completed on every resident on a monthly basis. PRN psychotropic medications required an end date of 14 days and/or a documented rationale for a longer period with an end date. On 3/27/25 at 1:31 p.m., a message was left for the hospice provider. The undated Psychotropic Medication Use policy (POL_NS712) identified psychotropic medication are given upon a medical provider order. PRN orders for psychotropic drugs are limited to 14 days. PRN anti-psychotic orders are limited to 14 days and cannot be renewed unless the attending provider evaluated the resident for the appropriateness of that medication.

Based on interview and document review, the facility failed to follow through on a grievance regarding missing clothing for 1 of 1 resident (R9) reviewed for grievances. Findings include: R9's admission Minimum Data Set (MDS) dated [DATE], identified R9 had a severe cognitive impairment and diagnoses included Alzheimer's disease and dementia. During a phone interview on 3/24/25 at 3:07 p.m., family member (FM)-A stated half of R9's clothing and slippers were missing. The first thing staff asked FM-A was if FM-A labeled the clothing. FM-A stated she was unaware she needed to label the clothing prior to bringing it to the facility and was told to bring R9's clothing to the nurses' desk so that's what FM-A did. The clothing and slippers went missing from there. FM-A stated she had to re-buy all the missing items, was not reimbursed and would no longer allow R9's clothing to be washed at the facility. During an interview on 3/27/25 at 11:05 a.m., licensed practical nurse (LPN)-B stated FM-A did report R9 had missing clothing. LPN-B called the laundry and asked that laundry staff look for the missing items, but they were not found. FM-A stated she would wash R9's clothing from then on. LPN-B had never heard of anyone ever making a report or anything for missing items. During an interview on 3/27/25 at 11:07 a.m., registered nurse (RN)-E stated when a resident or family member reported missing items. Staff should start looking for it and report it to the social worker or the unit manager. For clothing, staff notified laundry and housekeeping, so everyone was looking for the missing item. Also, there was a rack of unlabeled clothing that they can look through and usually the missing item is found. During an interview on 3/27/25 at 11:47 a.m., the social services (SS)-A stated staff usually contacted SS-A or send an email to all staff so the item could be searched for. Then, SS-A went to laundry and/or took the family member or resident to the laundry to look through the lost and found to see if the item could be found. SS-A did not necessarily fill out a grievance form. SS-A would ask the resident or family member if they wanted to file a grievance, but they usually say they just want to keep an eye out for it. SS-A stated she was aware R9 had some missing clothing items. SS-A brought FM-A to the laundry to look through the lost and found and some items were found, and some items weren't. FM-A had given the clothing to a nurse who said they were bringing the clothing to laundry to get labeled, but the items went missing from there. SS-A did not fill out a grievance for R9. During an interview on 3/27/25 at 1:29 p.m., the director of nursing (DON) stated missing items was an area where the facility had room to improve. Usually, an email was sent out for all staff that indicated what was missing and staff responded with what was or wasn't found. The DON's understanding was the social worker brought that information to the administration or, at least, reached out to the family with how the family wanted to proceed. Usually, the administration instructed to replace those items, bring the receipt and the administration would reimburse those funds. The DON stated there was no documentation to show that was done for R9 and/or FM-A. All missing items are personal to the residents and staff needed to do their due diligence to find those items or to see if there was a pattern in a specific area. It was important to the residents and staff needed to be mindful of that. The facility Missing Items policy reviewed 8/4/17, identified the following: 1. All personal were responsible for reporting missing items to the supervisor staff prior to their end of shift. 2. Any items found that could not be identified, were reported to the supervisory staff and stored until the owner could be determined. 3. Staff worked to locate the missing items. 4. If items were not located, staff worked with the resident or resident representative to determine next steps.

Based on observation, interview and document review the facility failed to implement interventions to protect 2 of 2 residents (R1, R2) from resident to resident abuse when R2, who had a history of pushing other residents, initiated an altercation with R1 which resulted in R1's transport to the Emergency Department (ED) for a scalp laceration repaired with sutures. This resulted in harm for R1. Findings include: R2's Resident Face Sheet indicated he admitted to the facility 11/3/22. R2's diagnosis included Alzheimer's disease, depression, dementia, obsessive compulsive disorder (OCD), unspecified head injury and disorientation. R2's care plan dated 8/2/24, identified a risk for impaired psychosocial well-being due to cognitive impairment and indicated he could become aggressive toward others. The care plan further identified a risk for harming others and indicated he had been aggressive (pushed) another resident. The care plan identified the use of a stop sign on R2's door to deter others from entering and directed staff to close door when appropriate and re-direct R2 or others away if showing agitation. R2's Observation Detail List, Behavior Conditions dated 8/2/24, identified Alzheimer's Disease, subarachnoid hemorrhage, OCD and depression. The observation indicated physical behaviors toward others occurred 1-3 of the past seven days and indicated the behaviors put others at significant risk for injury. R2's Resident Progress Notes identified the following: -7/25/24, R2 stated to nursing assistant (NA) he had had pushed another resident who had come into his room. -8/1/24, R2 was seen pushing another resident that morning. When approached R2 stated, she was taking his walker. Resident informed it was not appropriate to push residents. -8/4/24, 1:09 p.m. R2 noted to be entering other residents rooms. Denied when approached until staff mentioned he had been seen entering or leaving another's room. During observation on 8/8/24 at 12:22 p.m., R2 was observed leaving the dining room. He entered his room, re-applied a Velcro stop sign to his door, and shut the door. R1's Resident Face Sheet indicated she admitted to the facility 10/19/23. R1's diagnosis included Alzheimer's Disease, head laceration, dementia, anxiety and depression. R1's care plan dated 7/29/24, identified inappropriate behaviors exhibited by wandering into other residents rooms, taking things and becoming defensive/combative with directions. The care plan indicated R1 was unaware of personal boundaries and property and did not appear to comprehend direction. The care plan directed if R1 was wandering in potentially dangerous area or near residents known for agitation/aggression to escort away and provide diversional activity. The care plan further indicated she had been a victim of another resident's physical aggression. R1's Resident Progress Notes indicated the following: -8/4/24, 1:30 p.m. R1 was attempting to push residents around in their wheelchairs multiple times. Redirection attempted without success. -8/4/24, 4:37 p.m. R1 was found lying on her back on the floor in the common area with a pool of blood under her head. R1 complained of pain to her coccyx. Sent to ED. R1's ED visit note dated 8/4/24, indicated she was brought in by ambulance after an unwitnessed fall with scalp laceration. laceration repaired with sutures. A report to the state agency dated 8/4/24, indicated Resident (R1) was found on floor with head wound noted. Another resident (R2) was close to the scene and appeared to be leaving the area. On 8/8/24 at 11:10 a.m., video surveillance of the incident was viewed with the director of nursing (DON). The video showed R1 pushing a living room type chair across the television area of the unit. R2 was seated in a nearby chair and was speaking to R1 (no audio on video). R2 stood and began pushing the chair, with R1 still holding on to it, back across the room where it had been. As a result, R1 fell to the ground. As staff approached the area, R2 was seen talking and shaking his finger. During observation on 8/8/24 at 12:01 p.m., R1 was ambulating in the dining room. Staff assisted her to a table in the dining and R1 got up and followed staff. R1 then sat at a table with other residents at which time staff re-directed her back to a table by herself and put food in front of her. At 12:07, R1 was up wandering in the dining room again. At 12:43, R1 was observed ambulating in the television area of the unit where she set two pieces of bread on the arm of a chair and attempted to open the door to the kitchenette. During interview on 8/8/24 at 1:36 p.m., NA-A stated she was working the day of the 8/4/24, incident. NA-A stated she came out of another residents room and R1 was on the floor bleeding, adding she did not usually work on the unit and said she had been told R2 had pushed someone else recently and that resident had gotten seriously injured. NA-A said she had not been given any direction related to supervision of R1 or R2. During interview on 8/8/24 at 1:48 p.m., NA-B stated on 8/4/24 she had been in another room and heard a crash and went out to assist. NA-B stated she was familiar with the residents on the unit and said the week prior R2 had pushed R1 down in the dining room. NA-B said R2 got mad when R1 was pushing chairs around and he would react. NA-B stated staff tried to re-direct R2 and tell him to go to his room but said it did not always work. NA-B stated after the incidents there were no new interventions or direction related to supervision other than to try to keep an eye on R2. During interview on 8/8/24 at 2:06 p.m., licensed practical nurse (LPN)-A stated R2's behaviors had changed and he seemed to be getting more territorial with his room and his walker. LPN-A stated R2 went through phases of going into other residents rooms and taking things. LPN-A added she was aware of the incident on 8/4/24, but was not given any specific details and when she worked, she tried to keep staff close by the residents to step in if needed. LPN-A stated R1 walked around and would pick up things to carry around with her but said R1 was not aggressive and she had never heard her raise her voice. During interview on 8/8/24 at 2:11 p.m., NA-C stated she was on break when the 8/4/24 incident had occurred and said she also heard there had been a similar incident the week prior. NA-C said on the p.m. shift the facility had safety aides who worked and said they tried to keep and eye on the residents. During interview on 8/8/24 at 2:32 p.m., LPN-B stated on 8/4/24 when the incident between R1 and R2 had occurred he had been called over from another unit to assist. LPN-B said R1 had fallen and sustained a head laceration. LPN-B stated staff had reported that R2 had been in the area when the fall occurred and had been hurrying away. LPN-B said R2 had other situations with residents in the past and said someone had fallen when in R2's room recently. LPN-B said there was no specific supervision plan for R2 and said staff just tried to keep an eye on him. During interview on 8/8/24 at 3:41 p.m., the DON acknowledged R2 had been involved in other resident to resident altercations and said they had placed a stop sign on his door because he was triggered by others wandering into this room. The DON stated they had recently ordered a different type of screen for R2's room. In regard to the incident on 8/4/24, DON stated the facility investigated and did not feel R2 had pushed R1 and did not intend to harm her. The DON said she felt R2 was only pushing the chair back to where it had come from. The DON said staff were monitoring R2 more closely since the incident but was not able to state what that meant and said she would have to talk with registered nurse (RN)-A. The DON further stated she was not aware R2 had pushed someone on 8/1/24. During interview on 8/8/24 at 4:01 p.m., RN-A stated she had written the progress note on 8/1/24, when R2 had pushed another resident and said the other resident was R1. RN-A said no one had witnessed the incident on 8/4/24 until the video surveillance had been reviewed. RN-A said R2 was not on one to one supervision but staff we really trying to keep an eye on him. RN-A stated after the incident on 8/4/24, nothing new had been implemented in regard to supervision. Facility policy Abuse Prevention Plan dated 9/5/19, identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and described Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated once suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation has been identified, safety measures will be implemented to ensure the safety of the suspected vulnerable adult and other residents. Such safety measures may include the following: Responding immediately to protect the resident or alleged victim from further abuse and to protect the integrity of the investigation, Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment as needed, Moving a resident to another room or floor, Providing increased staff supervision of resident, as needed. Take any other appropriate corrective action not specifically listed above.

Based on interview and document review, the facility failed to ensure a gait belt was used when transferring/walking 1 of 5 residents (R296) reviewed for falls. This resulted in actual harm for R296 who fell while being transferring and received a lumbar fracture. The facility implemented corrective action prior to the investigation so the deficient practice was issued at past non-compliance. Findings include: R296's quarterly Minimum Data Set (MDS) dated [DATE], identified R296 had moderate cognitive impairment, used a wheelchair or walker with mobility and required maximum assistance with toilet hygiene, transfers and ambulation. Diagnoses included Alzheimer's disease and osteoarthritis. R296's care plan dated [DATE], identified R296 was at risk for falls. Interventions included to follow standard fall prevention policy and use walker or wheelchair. Approaches included to ambulate with a full wheeled walker, contact guard assist of one staff with gait belt and wheelchair to follow. R296 was on a scheduled toileting plan and approaches included to offer toileting assistance every morning and bedtime with cares and after the noon meal. Staff were instructed to provide incontinence care after each incontinent episode. R296's Emergency Department Provider Notes dated [DATE], identified R296 had a syncopal (fainting) episode while on the toilet and may have hit her head. R296 was taking the medication Eliquis (a blood thinner used to prevent clots) and R296 complained of pain all over. R296 was medicated for pain and returned to the facility with no change in orders. A Nursing Home Incident Report Summary dated [DATE], identified R296 had a witnessed fall on [DATE], at 12:00 p.m. when staff was assisting R296 in the common bathroom by the dining room. R296 was assisted up from the toilet for staff to assist her with peri care and adjust her clothing. R296 fell on the floor and was unresponsive for approximately ten minutes. R296 was sent to the emergency room (ER) for evaluation and returned to the facility the same day. The following day, R296 was sent to the ER a second time due to reports of continued significant pain. R296 returned to the facility the same afternoon with a diagnoses of lumbar compression fracture. R296's Riverview Health Transfer Note dated [DATE], identified R296 had a new diagnosis of lumbar compression fracture and muscle spasms. The invetigative report submitted to the state agency dated [DATE], identfied nursing assistant (NA)-C stated she was assisting R296 in the bathroom next to the dining room on the memory care unit. R296 stood up from the toilet without problems and NA-C was able to provide peri cares and pull up R296's pants without problem. Then R296 fell forward and hit her head on the safety bar while falling forward. Staff were educated to remain within hands reach at all times and to utilize a gait belt and all staff will participate in the training. R296's progress note(s) identified the following: - [DATE], A fax was sent to R296's primary provider to notify R296 had fell to the floor, hitting her head, when staff were assisting her with toileting hygiene. R296 left the facility by emergency medical services to be evaluated at the ER. - [DATE]. R296 continued to have extreme pain with movement and blood pressure was elevated. R296 was sent to the ER to be evaluated. R296 returned with diagnosis of lumbar fracture and pain medication was ordered. - [DATE], R296 had pain and discomfort with movement and repositioning. Grimacing and yelling out in pain. Did receive as needed pain medication which was effective for approximately two hours. R296 did not get out of bed and refused both breakfast and lunch. - [DATE], A physical therapy evaluation was completed, and therapy ordered three times per week. - [DATE], R296 was in bed until mealtime and then did not want to sit for very long. Refused breakfast or to get up for her noon meal. Stated she was in a lot of pain and would holler out in distress with movement of any kind. - [DATE], R296 had been in bed most of shift. R296 did go out for supper but refused to eat anything. R296 took some of her scheduled medications along with as needed medication for back pain which was effective. - [DATE], R296 was evaluated for hospice and admitted to hospice services with primary diagnosis of Alzheimer's disease. - [DATE], R296 passed away with her family at her bed side. When interviewed on [DATE], at 6:30 p.m. family member (FM)-D stated R296 had been on hospice at the facility and expired. A staff member had taken her to the bathroom, and she fell , hitting her head, and had gone downhill after her fall. During interview on [DATE], at 9:39 a.m. nursing assistant (NA)-A stated she always used a gait belt when walking or transferring patients. She remembered R296 transferred and ambulated with assist but would take off on her own sometimes. When interviewed on [DATE], at 9:53 a.m. NA-B stated R296 was assist of one with toileting and she had never noticed her trying to go to the bathroom on her own. NA-B always used a gait belt with transfers and when assisting anyone to ambulate. During interview on [DATE], at 10:00 a.m. registered nurse (RN)-C stated she was working when R296 fell . RN-C heard R296 fall and rushed into the bathroom to see what happened. RN-C found NA-C standing frozen and R296 was lying flat on her back with her head close to the door that was opposite of the toilet, her body at an angle with her feet between the toilet and sink. NA-C was standing between the toilet and R296. R296 was unresponsive and did not have a gait belt on. RN-C called for help and 911 was called. When R296 returned from the ER, no imaging had been done on her back. The following day RN-C sent her back in due to extreme pain and then they found the fracture in her back, which was a new fracture. RN-C thought NA-C could possibly have caught R296 as she fell backward and possibly slowed or prevented her fall if she had been using a gait belt with the transfer. When interviewed on [DATE], at 2:24 p.m. the director of nursing (DON) stated it was her understanding that a gait belt had not been in use when assisting R296 with toileting just prior to her fall and R296 had a syncope episode and fell , and a gait belt was not in use. Staff were expected to use a gait belt whenever there was hands on assist with any transfer or ambulation. After the investigation of the fall staff, including the NA involved were educated on signs and symptoms of syncope and interventions to use as well as use of a gait belt with transfer and ambulation. Observation of other residents transferring and ambulating were observed during the course of the survey and all staff utilized the transfer belt as appropriate. Staff interviews identified staff knew when to use a gait belt. The facility policy Transfer Belt dated [DATE], identified staff were to review the resident's care plan or assignment sheet for the resident's transfer and ambulation status. Fasten the transfer belt around the resident's waist, allow the resident to get and maintain balance after assisting to stand and ambulate resident with grasp on transfer belt at the resident's back, until assisting resident back to a sitting position.

Based on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 4 of 5 residents (R3, R13, R70, R72) reviewed for immunizations. Findings include: R3's admission Face Sheet dated 4/22/24, identified R3's age of [AGE] years. Diagnoses included cerebral infarction (stroke), thrombocytopenia (low platelet count that could cause bleeding), endocrine disorder and malignant neoplasm of prostate (cancer)/ R3's Minnesota Immunization Information Connection (MIIC) report dated 12/15/23, identified R3's immunizations. R3 received the pneumococcal polysaccharide vaccine (PPSV23) 11/13/06, the pneumococcal vaccine Prevnar 13 (PCV13) on 7/1/15. R3's immunization record lacked evidence any other pneumococcal vaccinations, including the newer recommended pneumococcal conjugate (PCV 15 or PCV 20) had been offered in conjunction with their providers recommendation. R3's electronic medical record (EMR) lacked evidence R3 had been given information or offered the newer recommended PCV15 or PCV20 vaccination. R13's admission Face Sheet dated 3/2/23, identified R13's age of [AGE] years. Diagnoses included Alzheimer's disease, diabetes, and kidney failure. R13's MIIC report dated 3/1/23, identified R13's immunizations. R13 received the PPSV23 on 5/11/07, and PCV13 on 8/29/17. R13's immunization record lacked evidence any other pneumococcal vaccinations, including the newer recommended PCV15 or PCV20 had been offered in conjunction with their providers recommendation. R13's EMR lacked evidence R13 had been given information or offered the newer recommended PCV15 or PCV20. R70's admission Face Sheet dated 12/21/23, identified R70's age 74. Diagnoses included Stage four pressure ulcer, atrial fibrillation, kidney disease, heart failure and kidney disease. R70's MIIC report dated 7/31/24, identified R70's immunizations. R70 received the PPSV23 on 4/16/07, 10/31/07, and 8/30/17 and the PCV13 on 10/14/15. R70's immunization record lacked evidence any other pneumococcal vaccinations, including the newer recommended PCV15 or PCV20 had been offered in conjunction with their providers recommendation. R70's EMR lacked evidence R39 had been given information or offered the newer recommended PCV15 or PCV20 vaccination. R72's admission Face Sheet dated 7/18/23, identified R72's age 90. Diagnoses included dementia, polymyalgia rheumatica, obesity, heart disease and cerebral infarction (stroke). R72's MIIC report dated 7/31/24, identified R72's immunizations. R72 received the PPSV23 on 12/18/13, and the PCV13 on 12/18/14. R72's immunization record lacked evidence any other pneumococcal vaccinations, including the newer recommended PCV15 or PCV20 had been offered in conjunction with their providers recommendation. R72's EMR lacked evidence R39 had been given information or offered the newer recommended PCV15 or PCV20 vaccination. When interviewed on 7/31/24, at 1:36 p.m. registered nurse (RN)-B stated she was aware the residents were due for the updated pneumonia vaccinations but had not yet offered it to them. RN-B had R3, R13, R70 and R72 on her list to offer the new PCV20 vaccine but had not gotten around to offering it to them yet. RN-B had recently gotten back in to the position of infection preventionist and was trying to get a number of things caught up, including offering the PCV15 or PCV20 vaccination to residents. During interview on 7/31/24, at 2:59 p.m. the director of nursing (DON) stated she was not aware the PCV20/PCV15 was not being offered to residents and it should have been offered. The Centers for Disease Control (CDC) Pneumococcal Vaccination: Summary of Who and When to Vaccinate dated 9/22/23, identified for adults [AGE] years or older with immunocompromising conditions, the PCV15 or PCV20 should be given at least five years after the last pneumococcal vaccine. The facility policy Pneumococcal Vaccines for Residents dated 3/18/22, identified the facility would provide education and administration of the PPSV23 and PCV13 to the residents of the facility according to Center for Disease Control (CDC) recommendations. The policy identified the CDC recommended PCV15 or PCV20 to adults who had never received PCV13 if they were [AGE] years or older with certain chronic medical conditions. The facility had failed to update their policy to reflect the new CDC recommendations.

Based on interview and document review, the facility failed to ensure a significant change in status Minimum Data Set (MDS) was completed as directed for 2 of 2 residents (R64, R296) reviewed for significant change in status. Findings include: R64's quarterly Minimum Data Set (MDS) dated [DATE], identified R64 had moderate cognitive impairment and required supervision or touch assistance with toileting hygiene, bed mobility, transfers and ambulation. Diagnoses included dementia, Alzheimer's, repeated falls, heart disease and diabetes. R64's discharge assessment MDS dated [DATE], identified R64 required substantial to maximum assist with toileting hygiene, and bed mobility, partial to moderate assist with transfers and ambulation was not attempted. R64's quarterly MDS dated [DATE], identified R54 required substantial to maximum assist with toileting hygiene and bed mobility and was dependent on staff with transfers. R64 was unable to ambulate. R64's quarterly MDS dated [DATE], identified R64 was dependent with toileting hygiene, required substantial to maximum assist with bed mobility and was dependent on staff with transfers. R64 was unable to ambulate. When interviewed on [DATE], at 10:23 a.m. registered nurse (RN)-C stated she completed R64's MDS when it was due. Licensed practical nurse (LPN)-C notified her when a resident was due for an MDS and also tracked when significant changes needed to be done. RN-C did not track that sort of thing and just followed the list she was provided. During interview on [DATE], at 11:22 a.m. LPN-C stated whenever new dependencies were coded a significant change MDS needed to be completed. R64 should have had one done. Therapy had been working with him and so she had not recognized that R64 was no longer ambulating. It was important to complete significant change MDS when changes occur with residents so there was further discussion regarding that resident's care, the care plan was brought up to date and staff were providing care accordingly. When interviewed on [DATE], at 2:34 p.m. the director of nursing stated she would have expected a significant change MDS be completed for R64 when he was newly coded dependent with transfers and non ambulatory. It was important to complete the significant change MDS so the resident's care plan was update and accurate and staff were providing the care the resident needed. R296's quarterly MDS dated [DATE], identified R296 had moderate cognitive impairment and required substantial or maximum assistance with toileting hygiene, dressing, bed mobility and transfers. R296 required partial to moderate assist with ambulation. Diagnoses included dementia, osteoarthritis, anxiety, muscle weakness, kidney disease, heart disease and diabetes. R296's care plan problem with start date [DATE], identified a problem with mobility due to R296 was limited with bed mobility, transfers and toileting with goal to receive extensive assistance of one to two people to steady for transfers and toileting and two people to boost up in bed. The newly identified care plan problem with mobility on [DATE], indicated the facility was aware of the significant decline with R296's mobility, however, the medical record lacked evidence a significant change assessment had been initiated. R296's Physical Therapy Discharge Summary dated [DATE], identified R296 was discharged due to had reached her highest practical level. R296's had participated with therapeutic activities for wheelchair mobility and transfers. Refused to exercise or walk due to back pain with diagnosis of fracture at L1. R296's progress notes [DATE] through [DATE], identified the following: On [DATE], R296 had experienced a fall that resulted in a lumbar fracture. On [DATE], physical therapy had evaluated R296 and order received for therapy three times per week. On [DATE], R296 was admitted to hospice services. A death in facility MDS tracking record dated [DATE], identified R296 expired at the facility under hospice care During interview on [DATE], at 11:13 a.m. registered nurse (RN)-C stated she was responsible for completing R296's MDS but was not aware a significant change MDS was needed. LPN-C notified her when MDS were due and if significant changes were needed. When interviewed on [DATE], at 11:15 a.m. LPN-C stated she was aware when residents required a significant change at the facility daily interdisciplinary team (IDT) meetings. LPN-C identified a hospice admission would be an automatic reason to complete a significant change MDS, and she had not schedule an MDS assessment. There should have been a significant change MDS assessment completed for R296 with her decline in condition as well as her hospice admission. When interviewed on [DATE], at 2:24 p.m. the DON stated she would have expected a significant change MDS assessment to have been completed for R296 related to her decline in mobility as well as her hospice admission. It was important to complete the significant change MDS assessments to identify and capture when a resident has a change for the good or the bad and ensure the staff were providing the care to the resident to meet their needs. The facility's undated Comprehensive Assessments and Care Planning policy, identified the RN coordinator with input from the IDT would determine if it was necessary to complete a significant change MDS. A significant change assessment would be appropriate if there were a consistent pattern of changes with two or more areas of decline or improvement or one area that required extensive care plan revision.

Based on interview and document review, the facility failed to ensure the provider documented a thorough rationale for continued use of medications for 1 of 5 residents (R64) reviewed for unnecessary medication use. Findings include: R64's undated Active Orders report identified R64 had current physician orders for sertraline (an antidepressant medication) 50 milligrams (mg) every morning with start date 10/21/22. A previous order for trazadone (an antidepressant medication) 50 mg one-half tablet every bedtime, had been ordered with start date 10/20/22, and discontinued date 3/26/24. R64's Consultant Pharmacist Recommendation to Physician dated 8/24/23, identified the consulting pharmacist (CP) identified R64 was receiving sertraline 50 mg and trazadone 25 mg every day. R64's medical record lacked evidence of depression symptoms. The CP recommended according to practice guidelines; a trial reduction may be reasonable. R64's primary physician responded, continue antidepressant therapy, a dose reduction was contraindicated and to see progress note below or in chart with no further notation. R64's medical record was reviewed and lacked any other documentation or dictation from R64s provider regarding the justification of continued use of the antidepressant medications. When interviewed on 7/31/24 at 10:23 a.m., registered nurse (RN)-C stated R64's trazadone was stopped in March because a narcotic had been ordered. RN-C would have to talk to R64's primary provider about the need for rationale to deny a gradual dose reduction for his antidepressant medications. RN-C was not aware it was ever brought up again since the pharmacist made the recommendation in August the previous year. When the physician sends back something indicating no changes, she never questioned it. The director of nursing (DON) had a recent meeting with the providers group and the need to address pharmacist recommendations and provide rationale for dosing decisions was brought up to them as it was recognized as a problem for the facility. When interviewed on 7/31/24 at 2:34 p.m., the DON stated usually when CP-E made recommendations that were not properly addressed, he would send follow up recommendations the following month. The facility had been having some struggles with certain providers addressing the pharmacy recommendations. The DON had just met with the providers the previous month and physician response to pharmacy recommendations was discussed. The DON felt the providers had a better understanding of the issues and were now aware of what the facility expectations were. During telephone interview on 7/31/24 at 3:00 p.m., CP-E stated he had made recommendations to taper R64's antidepressant medications in August 2023. CP-E usually brings the issue up every few months when a provider declines a recommendation. R64 had experienced a number of falls and medication changes in March 2024 and so by the time he was going to readdress the issue with the provider again, the antidepressant medications were the least of his worries. CP-E verified the time between his recommendations in August until R64 had change in condition was seven months. On 7/31/24 at 3:27 p.m., a telephone interview was attempted with the medical director (MD)-F with no answer. A message was left for return call. On 8/1/24 at 3:15 p.m., MD-F returned call. MD-F stated he was aware of the issues with some of the primary providers failing to respond adequately to pharmacist recommendations. It had been discussed during the last quality assurance performance improvement (QAPI) meeting and the pharmacist had provided a list of the providers who frequently did not address medications recommendations. MD-F was planning to set up a meeting with the providers to find out what the issues were and why they were not responding appropriately to the pharmacist recommendations.

Based on observation, interview and document review, the facility failed to adequately assess 1 of 1 resident (R1) who was at risk for elopement prior to discharging him from the secured unit and failed to provide supervision while outside smoking on the facility property which led to R1 eloping. This resulted in an immediate jeopardy (IJ) situation for R1 who eloped from the facility on two separate occasions. The IJ began on 7/14/21, when R1 was transferred from the secured unit of the facility and was allowed to go outside the facility independently to smoke. The director of nursing (DON) and licensed social worker (LSW)-A were informed of the IJ on 8/12/21, at 1:39 p.m. The IJ was removed on 8/13/21, at 1:45 p.m. but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's Resident Face Sheet indicated he admitted to the facility on [DATE], with diagnosis that included [CONDITION(S)] with behavioral disturbance, history of falls and history of a [CONDITION(S)]. Review of R1's records revealed an untitled, undated document which indicated unit manager recommendations: R1 mildly cognitively impaired, exit seeks and is a major elopement risk. An Admission Screening undated, indicated R1 had lots of behaviors due to not being able to smoke. R1's Care Area Assessment (CAA) dated 5/7/21, identified cognitive loss/dementia and indicated R1 wandered at times and displayed exit seeking behaviors. The CAA further identified behavioral symptoms and indicated R1 tended to wander and exit seek and verbalized that he wants to get out of here. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated R1 displayed behaviors that included verbal behavioral symptoms, rejection of care and wandering. The MDS indicated R1 required supervision or oversight when ambulating. R1's care plan dated 7/14/21, indicated a potential for injury related to his choice to smoke. The care plan indicated R1 could smoke independently. The care plan identified vulnerabilities that included dementia and a history of a [CONDITION(S)]. R1's care plan further identified a risk for elopement related to dementia, wandering and impulsive behaviors and indicated R1 wore a WanderGuard device (WanderGuard devices alert the caregiver whenever a resident breeched a perimeter or strayed too far) on his wrist. An Elopement Risk assessment dated [DATE], indicated R1 verbalized statements about leaving the facility, resided on the secured memory care unit and was at moderate risk for elopement. An Elopement Risk assessment dated [DATE], one month after moving off the secured unit, identified a high risk for elopement. The designated smoking area was observed on 8/12/21, at 7:12 a.m. There was a set of doors leading to a short hallway with doors that opened to the outside of the building. A wander alert system was visible on the interior doors. Outside the door and to the left was a shed designated for smoking. The area was not enclosed and was between two buildings of the campus in the parking lot designated for vendors/deliveries. Accessible from the parking lot was a neighborhood with multiple houses and side streets which allowed R1 to leave the area unnoticed by staff. R1's records indicated he was moved from the secured unit to the general care unit on 7/14/21. R1's records lacked evidence of an elopement re-assessment, justification for care changes, care plan revisions or physician records indicating support of the care change. R1's Resident Progress Notes identified the following: - 7/14/21, R1 tried to go outside and set off the alarm at door number four. - 7/14/21, R1 had a WanderGuard placed due to moving out of the secured memory care unit. R1 had a history of threats of leaving the facility and had been breaking facility property. - 7/15/21, R1 was wandering around the area behind the smoke shack and was very resistant to returning inside. Later the same day R1 attempted to go out and was told it was too late and dark then attempted to go out a different door. - 7/16/21, R1 was walking down the hallways and needed directions to his room. - 7/17/21, R1 needed frequent reminders on how to get to his room, was easily turned around. Note written at 11:16 p.m. indicated R1 walked out the dining room doors and his Wanderguard set off the alarm. Later the same day R1 was spoken to about the smoking agreement and again made the statement that if he couldn't smoke you can say goodbye to me. - 7/17/21, at 11:16 p.m. R1 walked out the dining room doors and set off the alarm. Staff spoke with R1 outside and asked him to come back in. R1 stated he did not want to. R1 asked if he could have a cigarette and staff provided it. Staff directed R1 toward the smoke shack as he appeared unsure which direction he had to go. When the alarm sounded at the door to the smoke shack R1 stated he was pissed off at that damn alarm. - 7/18/21, R1 was found walking around with no Wanderguard and said he broke it off. R1 was on the phone with his son and was heard saying that when he went out to the smoke shack he could leave whenever he wanted to without a staff member with him. - 7/19/21, registered nurse (RN)-A visited with R1 about his multiple trips to the smoke shack the previous night and removal of his Wanderguard. RN-A wrote a new smoking agreement which allowed R1 to go out to the smoke shack whenever he wanted and stay out there for up to an hour each time and tell staff when he came back. - 7/23/21, R1 was observed by staff turning off the Wanderguard system leading to the smoke shack. - 7/24/21, R1 was pacing the halls and asking for cigarettes past midnight. R1 set off the alarm by dining room door then punched in the code and turned off the alarm. Later note indicated staff spoke to R1 about shutting off the alarms and educated him not to do it. - 7/26/21, R1 was not wearing his Wanderguard and said he ripped it off because it got caught on a nail. R1's Wanderguard was on a meal tray in his room. Later note indicated R1 was outside in the employee smoke shack and was told he should not be in there. Another note that day indicated R1 was walking around without his Wanderguard and when staff asked about it R1 said he did not care, mumbled and swore under his breath and kept walking away out to the smoke shack. - 7/27/21, R1 had a new Wanderguard placed. - 7/28/21, R1 was found going out the doors to the smoke shack around 2:00 a.m. R1 made the statement what would happen if they couldn't find me because that will happen real soon if they can't. - 7/29/21, R1 attempted to go out the door at 1:30 a.m. Directions were provided back to his room and snack offered but R1 refused. - 7/30/21, R1 had left the building and was across the street behind the cathedral church and refused to return. Staff called the police and remained by resident. R1 did return with police officer and stated, I have warned them. R1 stated he had fallen outside and had blood running down his forearm. R1 had a nick on his wrist and later noted to have a 2.4 centimeter (cm) x 1.5 cm skin tear on his left elbow. -7/30/21, a second note indicated R1 had reported to the nurse manager that he had gone out before midnight and had walked around until his legs and knees started hurting. R1 said if he had not been hurting, he would have been gone. Safety checks were increased to hourly and R1 had a wander guard on both wrists now. - 7/30/21, a third progress note indicated R1 was independent with ambulation and able to take himself to the designated smoking area. - 7/31/21, at 9:40 p.m. staff received a call from a member of the community who had been approached by R1 in the driveway of his home. When staff went to look for R1 he was sitting outside the smoke shack. R1 agreed to stay on the property but refused to make eye contact with the staff. R1's records lacked evidence of re-assessment, interventions or care plan revisions to address elopement concerns after significant events on 7/15/21, 7/23/21, 7/30/21 and 7/31/21. An untitled document dated 7/19/21, indicated R1 agreed to the following: There would be no smoking schedule, may smoke whenever he liked, would ask nurse for a cigarette when he wanted one and return his lighter at the end of the day. He would be allowed to remain in the smoke shack for an hour at a time and would notify staff when he returned and may stay outside until midnight. He would wear Wanderguard at all times and not remove or cut the strap. The document was amended on 7/29/21, to include R1's failure to follow the agreement may result in having staff supervision while smoking (if staffing allowed), losing privileges or moving back to the memory care unit. Review of the medical record indicated R1 was moved back to the secured unit on 8/3/21. On 8/11/21, at 1:25 p.m. nursing assistant (NA)-C stated R1 had just moved back to the secured unit two weeks prior. NA-C stated R1 liked to go out and smoke and said R1 had a Wanderguard that would alarm if he tried to go out alone. NA-C stated he did not know why R1 was moved off the unit and did not know why he was moved back but stated he understood R1 needed supervision due to potential elopement. -At 1:29 p.m. RN-B stated R1 was alert, sometimes he knew where he was at, sometimes with it and sometimes not so much and would ask why he was at the facility. RN-B stated R1's cognition fluctuated. RN-B stated when R1 was moved off the unit he would go and smoke but did not always remember where he was supposed to be. RN-B said R1 would ask what would happen if he walked away and over to a house and had moments when he would wander off the grounds. RN-B stated R1 made poor decisions. RN-B further stated someone had mentioned that R1 had learned the code for the door alarms and was able to deactivate them. -At 1:46 p.m. RN-A stated R1 had been off the unit a few weeks but was moved back to the memory care unit. RN-A stated when R1 first moved to the general care unit there was a verbal agreement that he would go out to smoke three times a day after meals, but he would become agitated, so the nurses allowed him extra times to smoke. RN-A said if the nurses did not give R1 his cigarettes he would go out and smoke butts out of the ashtray, so they started allowing him to go smoke as often as he wanted to as long as he was in the building by midnight. RN-A said R1 would smoke outside the shack so he would not be visible on the monitor that was inside the smoke shack. RN-A said one of the nurses had reported that R1 had figured out the code to deactivate the alarm and he had a tendency to rip off his Wanderguard. RN-B said R1 was not fully capable of understanding the smoking contract due to his dementia and [CONDITION(S)]. RN-B said R1 had a good memory for past events but had trouble with short term. RN-B said R1 had impaired decision making and said most of his decisions were not well thought out and said he was very impulsive. RN-B said an elopement risk assessment had not been completed when R1 moved off the secured unit and said when he first moved, she was not aware he was an elopement risk. RN-B said an elopement assessment should have been completed after the first elopement, but it was not done. The DON and LSW-B were interviewed on 8/11/21, at 3:18 p.m. LSW-B stated when R1 had resided on the secured unit a staff member had discovered R1 had been loosening boards on the courtyard fence when sitting outside and had asked staff for a hammer. LSW-B stated R1 said he felt like a prisoner. LSW-B stated R1 had been a smoker and had not been allowed to smoke while he was on the secured unit and said all he would express was a desire to smoke. LSW-B stated the interdisciplinary team had met and discussed concerns about other residents if R1 were to remain on the secured unit and said they felt his quality of life would improve if he was moved off the unit to a less secure area of the facility, however, was not sure if the physician had been involved in the discussion. LSW-B stated they came up with an agreement to move R1 off the secured unit and place a Wanderguard bracelet on him. LSW-B said R1 started smoking the day he was moved and had a smoking plan that staff would keep his cigarettes and he would need to smoke in the designated smoke shack where there was a camera. However, the camera was only visible if staff were present in the charting office located behind the nurses station and was not continuously monitored. LSW-B stated staff did not go outside with R1 when he smoked. LSW-B stated the Wanderguard was not placed for elopement but so staff would be alerted when R1 went outside. LSW-B also stated she did not think R1 was unsafe to be outside alone. She said he was impulsive and did not always display good judgement, but she felt his elopements were purposeful. She stated the smoking contract was developed to establish a schedule and some boundaries. LSW-B stated after R1 eloped the first time, more frequent checks were added and a second Wanderguard was placed on R1's other wrist. The DON stated the reason for placing an additional alarm was because the closer the bracelet was to the sensor the more effective it became. Regarding the elopement on 7/31/21, LSW-B stated she had come in the next morning and read the progress notes. LSW-B said R1 had walked across the street and asked a man if he had a lighter. The man called the facility and R1 had returned. The DON stated R1 had not gone far, even though he had crossed a street, and said R1 was not wandering or lost and said, it was purposeful. On 8/12/21, at 6:08 a.m. nursing assistant (NA)-A stated R1 would get up and walk around the building and liked to go outside between 1:30 a.m. and 2:00 a.m. NA-A stated R1 had a Wanderguard so staff had to keep an eye on him. NA-A said R1 would walk out to the smoke shack and staff would turn off the alarm. NA-A further stated R1 knew how to turn off the alarm. NA-B who was also present during the interview and confirmed staff were never given any instructions in terms of supervision when R1 moved to the unit. NA-B stated they were initially told R1 could not go outside alone but then it changed because R1 would get mad if staff followed him out. NA-B stated she was working the morning of 7/30/21, when R1 eloped. NA-B said the nurse was busy getting someone ready to go out to an appointment and said, we don't know when or how he got out because no alarm went off. -At 6:15 a.m. licensed practical nurse (LPN)-A stated the morning R1 eloped she was coming on to her shift and saw another employee in the parking lot who said to her, Isn't that [R1]? LPN-A stated R1 would not return to the facility so staff stayed with him until he was brought back by the police. LPN-A said when R1 moved to the unit he had a Wanderguard put on but he was allowed to go outside and smoke by himself without staff supervision. LPN-A said she had no idea how R1 had gotten out that morning. -At 6:18 p.m. LPN-B stated she worked the overnight shift and R1 would go outside and smoke by himself and staff were supposed to keep an eye on him until he came back inside. LPN-B stated the Wanderguard alerted staff he was outside but said R1 knew how to turn of the alarm. LPN-B said she had seen R1 turn off the alarm and said the code had not been changed after he learned and said it still had not been changed (8/12/21). LPN-B said even after R1 eloped the first-time staff were not told he could not go outside alone. LPN-B further stated the hourly checks that had been implemented were not documented anywhere and said staff documented once per shift that they had checked on him. A facility policy Elopement-Resident dated 9/2018, indicated the facility ensured residents were safe through the implementation of systems for monitoring care delivery and location within the facility premises. The policy indicated residents who were known to wander may wear a signaling divide which activated an alarm should they leave the facility. When the Wanderguard system signaled staff were to go and visualize the area to ensure no resident had left the building safe area. The IJ was removed on 8/13/21, at 1:45 p.m. when it was verified through interview and document review the facility had updated their policy on elopements, including assessment of elopement risk, changing of alarms codes, and included processes so that any resident at risk for elopement does not leave the facility without immediate supervision of staff or responsible guardians. In addition, the facility educated all staff on procedures related to residents who were at risk for elopement and/or wore a Wanderguard.

Based on observation, interview and document review, the facility failed to implement the Centers for Disease Controls (CDC) guidance for individualized transmission-based precautions including appropriate personal protective equipment (PPE) and isolation precautions to prevent the spread of COVID-19 for 1 of 1 resident (R6) who displayed symptoms of COVID-19, resided on the dementia unit, wandered throughout the unit and subsequently tested positive for COVID-19. This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death for 2 of 23 residents (R7, R8) who resided on the memory care unit and were not fully vaccinated; 2 of 67 residents (R9, R10) who were not fully vaccinated against COVID-19 and resided in other units of the facility, whose staff included unvaccinated employees who were assigned to alternating units throughout the building. In addition,this deficient practice had the potential to affect all 85 remaining vaccinated residents residing in the the facility that did not rise to the level of immediate jeopardy. The IJ began on 7/19/21, when R6 displayed symptoms of COVID-19 including fever, harsh, dry cough, nasal drainage and swollen, painful lymph nodes in her neck. A rapid [MEDICATION(S)] (screening) test was obtained with presumptive negative results. While awaiting a confirmatory COVID-19 test, the facility failed to implement individualized interventions for transmission-based precautions and isolation for R6, who continued to wander throughout the unit and subsequently tested positive for COVID-19. Further, staff present on the memory care unit were not wearing appropriate eye protection, N95 respirators, gowns or gloves prior to the facility obtaining a confirmatory COVID-19 test. The administrator, director of nursing (DON) and registered nurse(s) (RN)-A, RN-B, RN-C, RN-D, and RN-E were notified of the IJ on 7/22/21, at 2:30 p.m. The IJ was removed on 7/23/21, at 6:00 p.m. but noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance People with Certain Medical Conditions dated 5/13/21, identified older adults were more likely to get seriously ill from COVID-19. More than 80 percent of COVID-19 deaths have occurred in people over the age of 65, and more than 95 percent of COVID-19 deaths have occurred in people older than 45. Further, among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. The CDC guidance [CONDITION(S)]-CoV-2 [MEDICATION(S)] Testing in Long Term Care Facilities dated 1/7/21, directed symptomatic people who test [MEDICATION(S)] negative should have a confirmatory test performed. Confirmatory test should be performed with nucleic acid amplifications tests (NAAT) such as reverse transcriptase polymerase chain reaction (RT-PCR). If an [MEDICATION(S)] test is presumptive negative, perform NAAT immediately (e.g., within 2 days). Symptomatic residents should be kept on transmission-based precautions until NAAT results return. The CDC guidance Interim Infection Prevention and Control Recommendation to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 3/29/21, directed residents with suspected [CONDITION(S)]-CoV-2 infections should be prioritized for testing, should be cared for by healthcare personnel (HCP) using an N95 or higher-level respirator, eye protection (i.e. goggles or a face shield that covers the front and sides of the face) gloves and a gown. Ideally, the resident should be moved to a single-person room with a private bathroom while test results were pending. In general, it was recommended the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. However, in some circumstances such as memory care units, keeping the door closed may pose safety risks and the door might need to remain open. If doors remain open, implement strategies to minimize airflow into the hallway. Increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptom, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least three times daily and quickly manage serious infection. The CDC guidance Considerations for Memory Care Units in Long-term Care Facilities dated 5/12/20, recommended facilities dedicate personnel to work only on memory care units when possible and try to keep staffing consistent. Limit personnel on the unit to only those essential for care. Limit the number of residents or space residents at least 6 feet apart as much as feasible when in a common area, and gently redirect The guidance directed when residents on a memory care unit are suspected or confirmed to have COVID-19: As it may be challenging to restrict residents to their rooms, implement universal use of eye protection and N95 or other respirators (or facemasks if respirators are not available) for all personnel when on the unit to address potential for encountering a wandering resident who might have COVID-19. Consider potential risks and benefits of moving residents out of the memory care unit to a designated COVID-19 care unit. During entrance conference on 7/19/21, at 10:00 a.m. the licensed social worker (LSW) stated the facility census included 90 residents and there were no active or suspected COVID-19 cases in the building. During interview on 7/19/21, at 4:21 p.m. documentation provided was reviewed with the infection preventionist, RN-A who indicated it included undated lists of vaccinated and unvaccinated residents and staff. The resident list identified 93% of the facility residents had received the COVID-19 vaccine and identified five residents (R7, R8, R9, R10 and R6) who were not vaccinated as of 7/19/21. A handwritten note on the report indicated staff were to wear surgical masks at all times and eye protection if they were not vaccinated. Facility staff were not required to wear eye protection if they were vaccinated. The note also indicated a county positivity rate of 1.3%. The employee list identified 93 employees had declined vaccination, 111 employees received vaccination and 17 employees entries on the report were blank with no declination or vaccination status identified. R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's medical record identified R7 was not fully vaccinated. R8's quarterly MDS dated [DATE], indicated R8 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's R7's medical record identified R7 was not fully vaccinated. R9's quarterly MDS dated [DATE], indicated R9 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's medical record identified R7 was not fully vaccinated. R10's admission MDS dated [DATE], indicated R10 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated R10 had shortness of breath or trouble breathing when lying flat. R7's medical record identified R7 was not fully vaccinated. R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 was greater than [AGE] years of age, had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 did not display behavioral symptoms or rejection or care but did experience delusions and wandering behaviors which occurred 1-3 days of the assessment period. R6 required extensive assistance with all activities of daily living except only required supervision with eating. R6's medical record identified R6 was not fully vaccinated. R6's behavioral symptoms Care Area Assessment (CAA) dated 6/21/21, indicated R6 had recently admitted from assisted living to memory care. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's care plan dated 6/14/21, identified R6 was at risk for infection due to COVID-19 pandemic with confirmed cases reported in the community and directed staff to observe for, document, and promptly report signs and symptoms of COVID-19, follow facility protocols for COVID-19 screening/precautions, and educate staff, resident, family and visitors of COVID-19 signs, symptoms and precautions. The care plan also identified R6 was non-compliant with wearing a mask for protection from COVID-19 due to cognitive deficits and directed staff to attempt to provide another mask if the fit was contributing to non-compliance; educate on the importance of wearing a mask; provide frequent reminders and assistance to wear a facemask; adhere to federal and state visiting restrictions and staff in the community were to wear appropriate PPE. R6's Resident Progress Notes dated 7/19/21 to 7/20/21, included the following: -7/19/21 at 7:58 p.m. Noted to have a dry harsh cough. Resident was flushed, had clear drainage from nose. Temperature (T) 100.6, would not allow any other vital signs to be taken. Lymph nodes in the neck were swollen, and R6 reported they were painful. Rapid COVID test was negative. -7/20/21 at 10:49 a.m. R6 continued to have a runny nose and occasional cough. T 98.8, O2 [oxygen saturation] 90% on room air. -7/20/21 at 2:54 a.m. Return fax from PCP [primary care physician]. She can be evaluated. I believe I'll be there a.m. 7/22. -7/20/21 at 2:55 p.m. Call placed to daughter to update her to status. Daughter will take R6 into clinic to be evaluated -7/20/21 at 3:03 p.m. Would not be able to get in until tomorrow, plan is to continue to monitor status, update family and PCP with any changes. Will be seen by PCP on 7/22. -7/20/21 at 5:17 p.m. COVID-19 nasopharyngeal test completed at 4:40 p.m. -7/20/21 at 5:30 p.m. Called the lab to ask about COVID-19 PCR, test results was positive. Update to team leader immediately, directed R6 to her room, enhanced respiratory precautions initiated. R6's Event Report dated 7/19/21 at 8:12 p.m. Infection Control - Potential Upper Respiratory Tract Infection SBAR (Situation Background Assessment Recommendation) Nurse to IP Communication completed by LPN-C identified R6 met criteria for upper respiratory tract infection with symptoms of runny nose or sneezing, dry cough and swollen or tender glands in neck. The form also included sections to indicate if lab, imagine, anti-infective medications, or isolation precautions were ordered or initiated; however, all sections were blank. R6's medical record lacked documentation of any additional special accommodations made by the facility or individualized interventions implemented due to R6 residing on a memory care unit and her need for transmission-based precautions and isolation. Further, R6's medical record lacked evidence R6 was fully vaccinated from COVID-19. During observations of the Memory Care Unit on 7/20/21, from 1:30 p.m. until approximately 2:00 p.m. approximately twelve unmasked residents were seated in chairs which lined the perimeter of the common entry area of the unit, along the wall of the nursing office, the sitting area by the courtyard door and along a curved wall in front of the enclosed television room. The chairs were placed side by side and were touching each other. Chairs were not spaced for adequate social distancing. R7 who was unvaccinated, and not wearing a facemask, was seated in a wheelchair near the door to the nursing office in the sitting area near the door to the outside courtyard. Other residents were seated in the area; however, were not wearing masks. R8 who was also unvaccinated and not wearing a mask, was seated in a wheelchair sleeping. R8's wheelchair was positioned very close to another vaccinated resident's chair along the curved wall. The chair was within touching distance without R8 having to extend her arm. - R6 ambulated with the use of a walker through the common area. R6 wore a mask which was positioned underneath her chin. RN-B approached R6, touched her shoulder and prompted her to pull the surgical mask over her nose and take a seat in a chair in the row of chairs along the wall in front of the nursing office. R6 was hard of hearing so RN-B leaned forward closely, approximately 8 inches from R6's face, and gestured, as well as, verbally again prompted her to raise the mask over her nose and mouth. RN-B wore a laboratory jacket over street clothing, a surgical mask over her mouth and nose and prescription glasses; however, was not wearing any other form of PPE such as gown, gloves or eye protection (i.e. goggles or a face shield that covered the front and sides of the face) or an N95 respirator. RN-B prompted R6 to sit in a chair directly next to a female vaccinated resident. The chairs were touching and R6 and the resident could touch each other by just extending their hands. R6 was the only resident in the common area wearing a face mask. RN-B did not direct R6 back to her room to isolate her from the other residents in the unit, nor were any prompts to encourage social distancing attempted with R6 or any of the residents seated in the area. - During interview on 7/20/21, at approximately 1:40 p.m. RN-B stated when she saw a mask around the neck, she automatically prompted the resident to pull it up. She wasn't sure why R6 had a surgical mask on but would check. RN-B guessed R6 just liked to wear a surgical mask as R6 came from a family of nurses that come and go and R6 just preferred to wear a mask. - At approximately 1:45 p.m. R6 stood up independently from her chair with the use of her walker and crossed the common area and sat next to R11, another unvaccinated, unmasked resident. There were no staff in the area to intervene or provide redirection. R6 pulled her surgical mask beneath her nose and fell asleep in the chair. NA-Q and NA-R were observed working throughout the unit assisting other residents to lay down. Both NAs were dressed in scrubs and wore surgical masks, they were not wearing gowns, gloves or appropriate eye protection. - During the observation, a tour of the unit there was no signage of any kind R6's room door, nor were there any isolation carts for PPE storage and disposal, to identify transmission-based precautions were in place or any isolation or quarantine measures had been implemented. Nor were there any signs anywhere on the unit. No carts with PPE such as gowns, gloves, or eye protection, were noted to be available in patient care areas. Residents moved throughout the unit, in the common areas, or in their rooms, per their usual manner. During interview in the common sitting area, on 7/20/21, at approximately 1:50 p.m. LPN-C stated R6 came from the assisted living, and they had to wear masks there, so R6 was used to wearing a mask. R6 had a cough yesterday, so they were trying to have her wear the mask all the time. The doctor had been notified of her cough. LPN-C was dressed in scrubs and wore a surgical mask with no other PPE such a gown, gloves, or eye protection or N95 respirator. Upon completion of the interview, LPN-C returned to the nursing office and did not direct R6 to her room to isolate her from the other residents in the unit, nor were any prompts to encourage social distancing attempted with R6 or any of the residents seated in the area. - During this time, NA-R entered the common area on two separate occasions to assist two different residents from the sitting area back to their rooms. At no time did NA-R redirect R6 to her room to isolate her from the other residents in the unit, nor were any verbal prompts or reminders made to encourage social distancing among any of the residents including R6 and R8 who were unvaccinated and seated within close proximity to other residents. R6 remained seated next to R11 sleeping with her mask beneath her nose. R6 and R11's chairs were touching. The residents were seated in close proximity and could touch each other without extending their arms. On 7/20/21, at 4:11 p.m. the DON was notified of the need to obtain an PT-PCR test for R6. Then during interview outside the DON office RN-A was requested to obtain an RT-PCR test for R6 as soon as possible. RN-A stated she was not sure about the ability to obtain the test results today as the local hospital completed all their testing and she would have to check with them to see. She would try to get it in today if able. She felt R6's symptoms were related to the recent air quality issues and smoke haze rather than COVID-19 infection. R6's [CONDITION(S)] CoV2 (COVID-19) laboratory report dated 7/20/21, indicated the [CONDITION(S)]-CoV-2 (COVID-19) by NAAT (nucleic acid amplifications test) value was detected. The report indicated a detected result was positive and indicated a presence of target [CONDITION(S)] nucleic acids which were generally detectable in upper respiratory specimens during the acute phase of infection. The positive result was reported to the facility at 6:22 p.m. On 7/21/21 at 8:00 a.m. upon entry to the facility, the DON was observed at the facility entrance. Signage was in place in the entrance announcing no visitation was allowed due to positive COVID-19 status in the building. DON was conducting education with staff as they entered the building which included a post-test. Additional nursing staff conducted symptom screening and rapid [MEDICATION(S)] testing on all in-coming staff. The DON stated R6 had tested positive on her PCR test so they were educating staff and going into outbreak mode. During interview on 7/21/21, at 11:16 a.m. nursing assistant (NA)-P stated staff were to wear a mask, gown, and goggles if a resident had COVID-19. NA-P did not identify the type of mask staff were supposed to wear. During interview on 7/21/21, at 11:22 a.m. trained medication assistant (TMA)-A stated she would report symptoms such as fever, cough or chills to the unit manager or nurse so they could swab the resident (obtain a test for COVID-19) and have them stay in their room until they were tested . Residents who had symptoms were to stay in their room. She also stated they had a lot of staff that worked in both the memory care unit and on the long-term care units of the facility. During interview on 7/21/21, at 11:30 a.m. NA-G stated they watched residents for symptoms such as cough, monitored their oxygen saturations every shift, signs of them not being themselves or fever and would report these findings to the nurse. She indicated they performed a rapid test on these residents and kept them in their room and used PPE such as gown, gloves, mask, and eye protection until the test results were back and they were cleared to use less stringent measures. During interview on 7/21/21, at 11:37 a.m. RN-J stated if residents displayed respiratory or other symptoms of potential COVID-19 she would expect staff to put the resident in respiratory isolation, obtain a rapid test, notify the physician, resident family, and administration. Pending the results would then do a follow up PCR test and would confer with the infection preventionist. During interview on 7/21/21, at 11:53 a.m. licensed practical nurse (LPN)-B stated if a resident displayed potential symptoms of COVID-19 she would complete an assessment, obtain vital signs, notify the nurse, and obtain a test if indicated. She also stated she would quarantine the resident and implement transmission-based precautions. During interview on 7/21/21, at 1:56 p.m. NA-S stated she worked in the memory care unit and they had three unvaccinated residents in that unit. They tried to keep the residents away from others. R7 and R8 were better than R6 at staying in their room. R6 was not good about staying in her room and they had to redirect her or sit with her or provide her with one-to-one supervision. She was working with R6 all week. R6 developed symptoms on Monday evening (7/19) and they had tried to keep her away from others as much as possible. R6 didn't understand why she had to stay in her room, so it was difficult to get her to do so. The next day she was out like every other day. After they learned of R6's positive COVID test they were told to move her to an empty room on the unit; however, she didn't really sleep or even go in her room and usually slept in a recliner in the main area. There were a couple of residents on the unit who would wear masks but didn't know why they were wearing them so weren't consistent. NA-S normally worked in the memory care unit; however, other staff floated between units frequently. During interview on 7/21/21, at 2:03 p.m. NA-A stated she was working 7/19/21, when R6 began showing symptoms. LPN-C did a rapid test and the result were negative and they had a difficult time getting an assessment. R6 was fatigued, having behaviors, a runny nose, a dry, bad cough and was running a temperature. They put a mask on her and tried to give her Tylenol, but she would not take it. She kept pacing and wouldn't sit down. They tried to put her in her room, but she wouldn't go in there and kept pacing. The other residents on the unit were pretty much in their rooms at this time, only two other residents were up so they kept her away from everyone. You could tell she was sick. The next morning (7/20), she remembered seeing her when she walked in for her shift. She was seated in the common area and was tired and was wearing a mask but would take it off. NA-A reminded her to keep it on. R6 was very sleepy. She didn't like staying in her room and was still out and about in the unit because her test had come back negative. She added without prompting that she knew there could be false negatives with the rapid test. She also indicated she had been picking up extra shifts and worked in both the memory care unit and long-term care units of the facility. NA-A did not identify any interventions implemented upon the onset of R6's illness to address transmission based precautions other than attempted social distancing of R6 from the other residents on the unit the evening of 7/19/20. During interview on 7/21/21 at 4:10 p.m. RN-A stated R6 became symptomatic on Monday night, 7/19/21, at approximately 8:00 p.m. Staff completed a rapid [MEDICATION(S)] test which was negative. She had a temperature of 100.6. R6 usually always wore a mask. They did try to redirect her to her room; however, it was very difficult for her. They would ordinarily try to quarantine with a symptomatic resident but was very difficult in the memory care unit. After they had received R6's positive test results, they had talked about moving her to an empty room; however, they ended up moving the roommate instead due to R6's behaviors. Further, the facility had not obtained the confirmatory PCR test on 7/20/21, prior to surveyor request. The plan had been to do that during an appointment with R6's primary care provider (PCP) on 7/22/21. She asked staff to arrange for an earlier appointment but was unaware they were not able to arrange an appointment prior to 7/22/21. - RN-A did not identify any updated interventions related to transmission-based precautions such as isolation carts for PPE storage and disposal, signage to identify precautions were in place or any isolation/quarantine measures had been implemented upon onset of R6's symptoms, nor were staffing practices changed at that time. She indicated they had utilized dedicated staff for the memory care unit for a while; however, after residents had received vaccinations, they had opened that up and allowed staff to work throughout the building. They stopped that practice as soon as R6's positive test result returned and again dedicated staff to the unit. During group interview with the administrator, DON, RN-B, RN-A, RN-K, and RN-C on 7/21/21 at 5:45 p.m. the DON stated R6 was symptomatic on Monday, 7/19/21, received a rapid screening test and was negative. She expected staff to observe the resident's vitals signs and ensure the resident was wearing a mask which was difficult on the unit, but they tried. R6 liked to wear a facemask sometimes; however, it was difficult with dementia residents. They could never stay put, it was a memory care unit and is all of their home. The [MEDICATION(S)] test was not a confirmatory test, so you get a PCR test to confirm. If a resident was symptomatic, you would also quarantine unless a physician has provided an alternative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, it was very difficult to quarantine in a memory care. The administrator stated it was impossible to quarantine in a memory care unit due to the wandering behaviors. RN-B stated they did the best they could to keep residents apart and tried to get them to wear a mask. DON stated she would expect them to do that. PCR should be obtained the next day and they had planned to do the test it had just not been done yet. It had been their intention all long to get the confirmatory PCR test. None of the faciliy staff present for the interview could identify what interventions discussed, attempted, or implemented in an effort to provide isolation status for R6 and minimize the risk of spread of COVID-19 on the unit. During follow-up interview on 7/22/21, at 5:17 p.m. NA-A stated LPN-C and NA-A obtained the rapid test on R6 and she really struggled with it. She kept turning her head and her eyes were watering. It was really hard to get it. R6 fought it. R6 was in the common area and there were about 4 other residents there throughout the night to NA-A's knowledge. The residents didn't like staying in their rooms and the masks really made their behaviors worse. When NA-A came in the a.m. R6 was sleeping in the chair in common area. Her mask was down and laying on her chest. Another resident was in the common area at that time too, but she could not recall if the other resident wore a mask. Normally, they put a symptomatic person in isolation for 14 days. During follow up interview on 7/22/21, at 6:15 p.m. NA-S stated the night R6 became ill was like any other night. After supper, R6 started coughing more, getting more sniffily and she wouldn't eat her supper. They got a rapid test and that was negative. She really wasn't around the other residents, but she wouldn't stay in her room, and she wouldn't keep the mask on. NA-S was wearing their surgical mask and goggles like usual. NA-S did not identify any interventions implemented after the onset of R6's symptoms. She was notified of R6's positive COVID-19 test result when she came to work the evening of 7/20/21. At that time, they moved R6 to an open room which made R6's behaviors worse, so they put her back and moved her roommate to the open room instead. They really didn't tell me to do anything different with her roommate or any of the other residents. When I was working with R6 I needed to wear a gown, surgical mask, goggles, and gloves, but anyone else it was just the surgical mask, goggles, and gloves but no gown. We put a cart outside R6's room. Otherwise for other residents it was nothing special. When someone was symptomatic, they tell us what to do. The 2019 Novel Coronavirus policy dated 5/8/20, directed if any resident were to present with fever or symptoms, implement recommended IP [infection prevention] practices: a. Standard, Contact and Droplet Precautions b. Restrict resident with respiratory symptoms to their room c. If they need to leave their room for a medical reason, they will have a facemask in place d. Contact primary provider for further direction on what tests to perform e. Contact family to notify them of change in condition. The policy identified preventive measures to include: remind residents to practice social distancing - maintaining a distance of 6 feet of another - while performing frequent hand hygiene. The policy did not address staffing considerations. The Guidance on Caring for a Confirmed Case of COVID-19 policy dated 7/2/20, directed if a resident was presenting with respiratory symptoms, the resident must remain in room on standard, contact and droplet precautions while waiting for diagnostic laboratory results. The policy also directed if a resident diagnosed with COVID or pending test results leaves room, they should have on a facemask, perform hand hygiene, limit their movement in the community, and perform soical distancing - staying a minimum of 6 feet away from others. The IJ which began on 7/19/21, was removed on 7/23/21 at 6:00 p.m. when it could be verified through observation, interview and document review the facility: conducted a general risk assessment for those potentially exposed to R6 and immediately closed the Memory Care Unit and converted it into a temporary COVID unit with dedicated staff, entrances and processes to ensure no traffic between the unit and the rest of the building. The facility reviewed the CDC's Considerations for Memory Care Units in Long Term Care Facilities dated 5/12/20, on how to best manage residents living in memory care units when there was a suspected or confirmed case of COVID-19 and adopt as necessary in accordance with the risks and benefits in how that would affect individual residents specific to their needs. The facility reviewed and revised their COVID-19 protocols for quarantine/isolation of symptomatic residents and use of appropriate PPE according to CDC guidance and updated their policy to include information for the Memory Care unit. The facility identified monitoring and testing plans for all facility residents, suspended all activities and visitation and educated their staff regarding this plan.

Based on observation, interview and document review, the facility failed to test staff for COVID-19 according to Centers for Disease Control (CDC) guidance for outbreak and routine resting requirements. In addition, the facility failed to ensure a confirmatory, RT-PCR (real-time reverse transcription polymerase chain reaction [rRT-PCR] test) was obtained for 1 of 1 resident (R6) after a presumptive negative rapid [MEDICATION(S)] (screening) and was displaying signs and symptoms of COVID-19. This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death for 2 of 23 residents (R7, R8) who resided in the locked memory care unit and were not fully vaccinated against COVID-19; and 2 of 67 residents (R9, R10) who were not fully vaccinated against COVID-19 and resided in other units of the facility whose staff included unvaccinated employees who were assigned to alternating units throughout the building. In addition, this deficient practice had the potential to affect all 85 remaining vaccinated residents residing in the the facility that did not rise to the level of immediate jeopardy. The IJ began on 4/21/21, when the facility was notified a staff member tested positive for COVID-19 and the facility failed to ensure all active staff were immediately tested for COVID-19 prior to working (or removed from the schedule) and continued to work without testing; along with following ongoing outbreak testing to ensure no more active cases were circulating within the facility. In addition, the facility failed to ensure all unvaccinated staff were routinely tested at the minimum requirements per the county positivity rate. The administrator, director of nursing (DON) and registered nurse(s) (RN)-A, RN-B, RN-C, RN-D, and RN-E were notified of the IJ on 7/22/21, at 2:30 p.m. The IJ was removed on 7/23/21, at 6:00 p.m. but noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance People with Certain Medical Conditions dated 5/13/21, identified older adults were more likely to get seriously ill from COVID-19. More than 80 percent of COVID-19 deaths have occurred in people over the age of 65, and more than 95 percent of COVID-19 deaths have occurred in people older than 45. Further, among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. During entrance conference on 7/19/21, at 10:00 a.m. the licensed social worker (LSW) stated the facility census included 90 residents and there were no active or suspected COVID-19 cases in the building. Documentation regarding the facility's COVID-19 policies and procedures, resident and staff vaccination information and testing tracking records were requested. Outbreak and Routine Testing: The CDC Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated 4/27/21, identified COVID-19 testing was required regardless of vaccination status during an outbreak. In nursing homes with an outbreak of COVID-19, healthcare personnel (HCP) and residents regardless of vaccination status should have a [CONDITION(S)] test immediately and every 3-7 days until no new cases were identified for 14 days. The CDC expanded screening testing of asymptomatic HCP recommendations further identified in nursing homes located in counties with <5% positivity of [CONDITION(S)] tests in the past week, unvaccinated HCP should have a [CONDITION(S)] test once a month. If unvaccinated HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). During interview on 7/19/21, at 4:21 p.m. the infection preventionist, RN-A indicated the last positive COVID-19 case at the facility was for an employee in April which had placed the facility in outbreak testing which concluded the beginning of May. The facility had been in routine testing status since that time with the last round of testing completed 6/22/21, and the next round of routine testing due 7/27/21. Untitled, undated documentation was provided and was reviewed with RN-A who indicated it included undated lists of vaccinated and unvaccinated residents and staff. - The resident list identified 93% of the facility residents had received the COVID-19 vaccine and identified five residents (R6, R7, R8, R9 and R10) who were not vaccinated as of 7/19/21. A handwritten note on the report indicated staff were to wear surgical masks at all times and eye protection if they were not vaccinated. Facility staff were not required to wear eye protection if they were vaccinated. The note also indicated a county positivity rate of 1.3%. The employee list identified 93 employees had declined vaccination, 111 employees received vaccination and 17 employees entries on the report were blank with no declination or vaccination status identified. R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's medical record identified R7 was not fully vaccinated. R8's quarterly MDS dated [DATE], indicated R8 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's medical record identified R8 was not fully vaccinated. R9's quarterly MDS dated [DATE], indicated R9 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's medical record identified R9 was not fully vaccinated. R10's admission MDS dated [DATE], indicated R10 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated R10 had shortness of breath or trouble breathing when lying flat. R10's medical record identified R10 was not fully vaccinated. R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 was greater than [AGE] years of age, had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 did not display behavioral symptoms or rejection or care but did experience delusions and wandering behaviors which occurred 1-3 days of the assessment period. R6 required extensive assistance with all activities of daily living except only required supervision with eating. R6's medical record identified R6 was not fully vaccinated. During interview on 7/20/21, at 9:47 a.m. RN-A stated the facility had a contract with Mayo Clinic for their COVID-19 testing. They completed their testing onsite, sent the tests to Mayo and Mayo returned the results electronically. RN-A downloaded the lab results from Mayo, reviewed them and sent the results to Human Resources (HR). Due to a county positivity rate of 0.6% on 6/22/21, the facility met monthly routine testing requirements. The last routine testing was completed 6/22/21. RN-A opened the 6/22/21, testing spreadsheet with the attached clinical laboratory test results file and indicated the spreadsheet was color coded based on employee vaccination status and test result. Staff identified in purple were vaccinated and were not required to be tested . Staff identified in green were unvaccinated and had a negative test. Staff identified in red were unvaccinated and did not test. - Upon opening the untitled, undated spreadsheet, the spreadsheet was not up to date and RN-A began to make entries for staff not tested as she reviewed them and stated she knew the information in her head. RN-A also identified some of the employees on the spreadsheet worked solely at the assisted living facility as she made entries into the spreadsheet. RN-A stated they tested on a Tuesday; however, would test anytime between the scheduled date of testing and the day before. She tried to make it reasonable and convenient for staff to test and left testing kits at the facility so the night shift could test during their shift as staff had been trained to test themselves. She also tried to accommodate with multiple times for casual staff. She sent reminders of the testing times and if staff did not test would notify HR. - The untitled, undated spreadsheet identified 31 unvaccinated staff tested negative; however, there were 42 unvaccinated staff who were not tested . RN-A stated not all staff were available at the time of testing as some were on medical leave, some were on vacation and one staff member was not eligible for testing due to a previous positive test less than 90 days prior. If staff missed outbreak testing they were taken off the schedule until they were tested but she was not sure what the policy directed for the routine testing. They did not require staff to test for someone who traveled or took vacation unless they were symptomatic. Vaccinated staff were not required to be tested for routine testing. However, all staff would be tested for outbreak testing. During interview on 7/20/21, at 11:09 a.m. RN-A identified the last outbreak period was due to an employee positive test which occurred 4/20/21 and the outbreak ended 5/5/21. There was only one positive test result. All staff were clear prior to discontinuation of outbreak testing and staff were not allowed to work if they missed testing. During interview on 7/21/21, at 9:46 a.m. human resources manager (HRM) stated she assisted RN-A with tracking of declinations of staff vaccinations. She identified of the 17 blanks noted on the staff vaccination report, 8 of the staff members had not returned a declination, were not vaccinated and currently worked at the facility. During interview on 7/21/21, at 11:10 a.m. health unit coordinator (HUC)-A stated vaccinated employees were not required to test for COVID-19 and indicated they had been testing monthly prior to a recent outbreak. He was not aware of any make up days for missed tests; however, HUC-A never needed to make up a test. HUC-A thought RN-A notified staff to let her know if they couldn't make it for scheduled testing and arrangements could be made. HUC-A was not aware of any requirements which needed to be followed if staff missed testing. During interview on 7/21/21, at 11:16 a.m. nursing assistant (NA)-P stated staff were notified via text regarding testing times and indicated testing was offered on one day. Further, NA-P was vaccinated so was not required to test. During interview on 7/21/21, at 11:22 a.m. trained medication assistant (TMA)-A stated she had not received the COVID-19 vaccination and the testing frequency depended on the numbers. Staff were notified via email, on the board or by the phone tree of the testing date and they could test during certain hours but could not remember the specifics. TMA-A was not sure what would happen if testing was missed. She didn't think she had been present for the facility testing in June and was not required to complete a test prior to returning to work. She wore a face mask and goggles all the time while in the facility due to her unvaccinated status. During interview on 7/21/21, at 11:30 a.m. NA-G stated routine testing was once a month and was only for unvaccinated staff. The testing was only on one day and they were notified of the testing through their phone tree; however, they could go see RN-A and she would do a test in her office. She did not think they would let her go back to work without being tested if she had missed a test. During interview on 7/21/21, at 11:37 a.m. RN-J stated routine testing was based on county positivity rates and most recently was completed monthly. Staff would be notified via text, phone, and email and information was also posted next to the facility time clock. Testing was usually arranged over a couple of days. If staff couldn't make it RN-A would make arrangements to accommodate. All they would have to do is contact RN-A or RN-C and they would address getting the testing completed. RN-J didn't believe staff were allowed to work if they had not tested or neglected to test. During interview on 7/21/21, at 4:10 p.m. RN-A stated 48% of the staff were vaccinated and 52% of the staff were unvaccinated at this time. The unvaccinated, untested staff identified on the routine testing spreadsheet dated 6/22/21, were reviewed with RN-A, 30 of the previously identified 42 untested staff (RN-F, RN-G, RN-H, RN-I, trained medication aid (TMA)-A, nursing assistant (NA)-A, NA-B, NA-C, NA-D,NA-E,NA-F,NA-G,NA-H,NA-I,NA-J,NA-K,NA-L,NA-M,NA-N,NA-O, cook (C)-A, C-B, culinary services aid (CSA)-A, CSA-B, CSA-C, CSA-D, CSA-E, CSA-F, laundry assistant (LA)-A, and beautician (B)-A) were determined to have required testing. RN-A stated she did not do any type of follow-up with staff who missed testing, nor did she ensure these staff received a test prior to returning to work. During group interview with the administrator, DON, RN-B, RN-A, RN-K, and RN-C on 7/21/21 at 5:45 p.m. the administrator and DON both stated that while formal COVID-19 testing was offered on a specific day, staff could come in for testing at any time. The administrator indicated it was her understanding the facility needed to provide testing per the county positivity rate but not that staff had to be tested as staff had the right to refuse testing. She indicated their facility policy allowed for staff to continue to work after refusal to test when in routine testing status and she believed these aforementioned 30 staff had refused testing. - When asked if all staff would have been tested at the time of the facility's last outbreak from 4/20/21 to 5/5/21, the administrator stated yes. When asked if staff, last tested during outbreak (which ended 11 weeks prior) yet continued to work in the facility, had met the minimum monthly testing requirements, the administrator reiterated staff's right to refuse testing and stated they could not force staff to test. When asked if she would expect monitoring of staff testing adherence and follow up of staff who had not tested , she stated yes. Individual Mayo Clinic Laboratories [CONDITION(S)] Coronavirus 2 RNA, PCR, V reports for the 30 aforementioned employees who were not tested during the round of routine testing on 6/22/21, were reviewed with the facility master schedules and identified the following information: Kitchen staff: CSA-A: no previous test result provided, worked 6 days during the outbreak period CSA-B: no previous test result provided, worked 5 days during the outbreak period CSA C: last tested [DATE], worked 8 days during the outbreak period CSA-D: last tested [DATE], worked 5 days during the outbreak period CSA-E: last tested [DATE] worked 7 days during the outbreak period C-B: last tested [DATE] worked 9 days during the outbreak period Laundry Staff LA-A: no previous test result provided, worked 2 days during the outbreak period Nursing Staff RN-F: last tested [DATE], worked 4 days during the outbreak period RN-G: last tested [DATE], worked 2 days during the outbreak period RN-H: last tested [DATE], worked 8 days during the outbreak period During group interview with RN-A, RN-B, culinary services manager (CSM) and DON on 7/23/21, at 4:31 p.m. RN-A stated all staff were required to be tested during outbreak status and if staff did not show up for testing, they were not supposed to work while the facility remained in outbreak status. The facility campus included a nursing home and attached assisted living which were both serviced by a single kitchen. Kitchen staff may have duties primarily assigned to the nursing home or assisted living; however, all kitchen staff worked out of the same kitchen space. - RN-A stated CSA-A and CSA-B never completed a COVID-19 test yet continued to work at the facility and worked during the most recent outbreak and were not removed from the schedule as required. CSM stated kitchen staff were not tested and had worked during the outbreak as described above. CSM and DON stated exposure to the nursing home would be limited for kitchen staff identified due to assignments in the assisted living, never leaving the kitchen or only brief deliveries in the nursing home. However, RN-A indicated no risk assessment for kitchen staff had been completed. RN-B and DON stated the nursing staff were not tested during outbreak as required and had worked the identified dates. The DON stated the facility policy directed staff could not work if they had not completed testing during a COVID-19 outbreak. The Centers for Medicare and Medicaid (CMS) QSO-20-38-NH memo revised 4/24/21, directed, An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. For outbreak testing, all staff and residents should be tested , regardless of vaccination status, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested . Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Routine testing intervals should be conducted as follows: less than 5 percent, once a month- 5 to 10 percent, once a week and greater than 10 percent twice a week. The guidance above represents the minimum testing expected. Facilities must have procedures in place to address staff who refuse testing. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing. However, the state and local jurisdiction have no guidance on refusing routine testing. Resident PCR Testing: The CDC guidance [CONDITION(S)] CoV-2 [MEDICATION(S)] Testing in Long Term Care Facilities dated 1/7/21, identified symptomatic people who test [MEDICATION(S)] negative should have a confirmatory test performed. Confirmatory test should be performed with nucleic acid amplifications tests (NAAT) such as reverse transcriptase polymerase chain reaction (RT-PCR). As the sensitivity of [MEDICATION(S)] tests is generally lower than RT-PCR, negative POC [MEDICATION(S)] tests should be considered presumptive. Testing of symptomatic residents or HCP If an [MEDICATION(S)] test is presumptive negative, perform NAAT immediately (e.g., within 2 days). Symptomatic residents should be kept on transmission-based precautions until NAAT results return. If a confirmatory NAAT is performed within 2 days, people should be assumed to be infectious until the confirmatory test results are completed. For instance, in general, if a symptomatic resident tests presumptive negative by [MEDICATION(S)] test and a NAAT is performed, the resident should remain in Transmission-Based Precautions until the NAAT result is available. R6's Behavioral Symptoms Care Area assessment dated [DATE], indicated R6 had recently admitted from assisted living to memory care. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's care plan dated 6/14/21, identified R6 was at risk for infection due to COVID-19 pandemic with confirmed cases reported in the community and directed staff to observe for, document, and promptly report signs and symptoms of COVID-19, follow facility protocols for COVID-19 screening/precautions, and educate staff, resident, family and visitors of COVID-19 signs, symptoms and precautions. The care plan also identified R6 was non-complaint with wearing a mask for protection from COVID-19 due to cognitive deficits and directed staff to attempt to provide another mask if the fit was contributing to non-compliance, educate on the importance of wearing a mask, provide frequent reminders and assistance to wear a facemask, adhere to federal and state visiting restrictions and staff in the community were to wear appropriate PPE. R6's Resident Progress Notes dated 7/19/21 to 7/20/21 included the following: -7/19/21 at 7:58 p.m. Noted to have a dry harsh cough. Resident was flushed, had clear drainage from nose. Temperature (T) 100.6, would not allow any other vital signs to be taken. Lymph nodes in the neck were swollen, and R6 reported they were painful. Rapid COVID test was negative. -7/20/21 at 10:49 a.m. R6 continued to have a runny nose and occasional cough. T 98.8, O2 (oxygen saturation) 90% on room air. -7/20/21 at 2:54 a.m. Return fax from PCP (primary care physician). She can be evaluated. I believe I'll be there a.m. 7/22. -7/20/21 at 2:55 p.m. Call placed to daughter to update her to status. Daughter will take R6 into clinic to be evaluated -7/20/21 at 3:03 p.m. Would not be able to get in until tomorrow, plan is to continue to monitor status, update family and PCP with any changes. Will be seen by PCP on 7/22. -7/20/21 at 5:17 p.m. COVID-19 nasopharyngeal test completed at 4:40 p.m. -7/20/21 at 5:30 p.m. Called the lab to ask about COVID-19 PCR, test results was positive. Update to team leader immediately, directed R6 to her room, enhanced respiratory precautions initiated. R6's Event Report dated 7/19/21 at 8:12 p.m. Infection Control - Potential Upper Respiratory Tract Infection SBAR (Situation Background Assessment Recommendation) Nurse to IP Communication completed by LPN-C identified R6 met criteria for upper respiratory tract infection with symptoms of runny nose or sneezing, dry cough and swollen or tender glands in neck. The form also included sections to indicate if lab, imagine, anti-infective medications, or isolation precautions were ordered or initiated, however, all sections were blank. R6's medical record lacked documentation of any additional special accommodations made by the facility or individualized interventions implemented due to R6 residing on a memory care unit and her need for transmission-based precautions and isolation or need for a follow up PCR test. During observations of the Memory Care Unit on 7/20/21, from 1:30 p.m. until approximately 2:00 p.m. approximately twelve unmasked residents were seated in chairs which lined the perimeter of the common entry area of the unit and was in close proximity of R7 and R8. R6 ambulated with the use of a walker through the common area. R6 wore a mask which was positioned underneath her chin and at times staff approached her to put the mask up over her nose, but was not redirected to isolate, nor were any prompts to encourage social distancing attempted with R6 or any of the residents seated in the area. During a tour of the unit there was no signage of any kind R6's room door, nor were there any isolation carts for PPE storage and disposal, to identify transmission-based precautions were in place or any isolation or quarantine measures had been implemented. Nor were there any signs anywhere on the unit. No carts with PPE such as gowns, gloves, or eye protection, were noted to be available in patient care areas. Residents moved throughout the unit, in the common areas, or in their rooms, per their usual manner. On 7/20/21, at 4:11 p.m. the DON was notified by the surveyor of the need to obtain an PT-PCR test for R6, as she was symptomatic and had not had a confirmation test completed. RN-A who was outside the DON's office was also informed of the need for a PCR test for R6 as soon as possible. RN-A stated she would collect the sample today; however, she was not sure about the ability to obtain the confirmatory test results today as the local hospital completed all their testing and she would have to check with them to see. Further, RN-A felt R6's symptoms were related to the recent air quality issues and smoke haze rather than COVID-19 infection. R6's [CONDITION(S)] CoV2 (COVID19) laboratory report dated 7/20/21, identified the [CONDITION(S)]-CoV-2 (COVID-19) by NAAT (nucleic acid amplifications test) value was detected. The report indicated a detected result was positive and indicated a presence of target [CONDITION(S)] nucleic acids which were generally detectable in upper respiratory specimens during the acute phase of infection. The positive result was reported to the facility at 6:22 p.m. On 7/21/21, at 8:00 a.m. upon entry to the facility, the DON was observed at the facility entrance. Signage was in place in the entrance announcing no visitation was allowed due to positive COVID status in the building. DON was conducting education with staff as they entered the building which included a post-test. Additional nursing staff conducted symptom screening and rapid [MEDICATION(S)] testing on all in-coming staff. DON stated R6 had tested positive on her PCR test so they were educating staff and going into outbreak mode. During interview on 7/21/21, at 11:37 a.m. RN-J stated if residents displayed respiratory or other symptoms of potential COVID-19 she would expect staff to put the resident in respiratory isolation, obtain a rapid test, notify the physician, resident family, and administration. Pending the results would then do a follow up PCR test and would confer with the infection preventionist. During interview on 7/21/21 at 4:10 p.m. RN-A stated R6 became symptomatic on Monday night, 7/19/21, at approximately 8:00 p.m. Staff completed a rapid [MEDICATION(S)] test which was negative. She had a temperature of 100.6. R6 usually always wore a mask. They did try to redirect her to her room; however, it was very difficult for her. They would ordinarily try to quarantine with a symptomatic resident but was very difficult in the memory care unit. After they had received R6's positive test results, they had talked about moving her to an empty room, however, they ended up moving the roommate instead due to R6's behaviors. They had not obtained the confirmatory PCR test on 7/20/21, prior to surveyor request. The plan had been to do that during an appointment with R6's primary care provider (PCP) on 7/22/21. She had asked staff to arrange for an earlier appointment but was unaware they were not able to arrange an appointment prior to 7/22/21. During group interview with the administrator, DON, RN-B, RN-A, RN-K, and RN-C on 7/21/21 at 5:45 p.m. the DON stated R6 was symptomatic on Monday, 7/19/21, received a rapid screening test and was negative. The DON expected staff to observe the resident's vitals signs and ensure the resident was wearing a mask which was difficult on the unit, but they tried. The resident liked to wear one sometimes however, it was difficult with dementia residents. They could never stay put, it is a memory care unit and is all of their home. The [MEDICATION(S)] test was not a confirmatory test, so you get a PCR test to confirm. If a resident was symptomatic, you would also quarantine unless a physician has provided an alternative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, it was very difficult to quarantine in a memory care until. The administrator stated it was impossible to quarantine in a memory care unit due to the wandering behaviors. RN-B stated they did the best they could to keep residents apart and tried to get them to wear a mask. DON stated she would expect them to do that. PCR should be obtained the next day and they had planned to do the test it had just not been done yet. It had been their intention all long to get the confirmatory PCR test; however, the facility did not implement transmission based precautions and isolation while awaiting a confirmatory test. The Benedictine COVID-19 Testing Procedure dated 10/12/20, directed outbreak testing would be performed for all residents and associates and weekly testing repeated of all previously negative residents and associates until no new cases were identified over a period of at least 14 days. Associates refusing to participate in outbreak testing would be restricted from the building until procedures for outbreak testing were completed. Routine (screening) testing of associates was required by CMS (and state) regulation in the SNF [skilled nursing facility] with frequency based on county positivity rate and not required in the ALF [assisted living facility]. When an associated routinely worked in both the SNF and ALF (crosses over), the associate should be included in routine SNF testing. When an associate worked only in the ALF the associate did not need to be included in routine SNF testing. Further the minimum testing frequency for a county positivity <5% was identified as monthly. The COVID-19 Testing of Associates - Protocols for When Associates Choose Not to Test dated 9/14/20 directed when a community was conducting routing COVID-19 testing, but there was no outbreak within the community, associates who refused to participate in the testing may do so and continue to work provided they complied with all health screening protocols and utilized all prescribed PPE during their work hours on campus. The policy also directed in situations where there was an active outbreak of COVID-19 on campus, either with associates or residents, associates still had a choices of whether to be tested . However, those associates who refused to be tested would not be allowed to reenter the community during the outbreak testing timeframe. The community must go 14 days without a positive COVID test before the associate could return to work. This may result in extended time off of work if there was a positive case in either associate or resident during outbreak testing. The undated Benedictine Preferred Testing Approach for Residents and Associates flow diagram identified if a resident point of care POC [point of care] nasal [MEDICATION(S)] test was negative, confirm with PT-PCR. Then if positive, begin outbreak testing. The 2019 Novel Coronavirus policy dated 5/8/20, directed if any resident were to present with fever or symptoms, implement recommended IP [infection prevention] practices: a. Standard, Contact and Droplet Precautions b. Restrict resident with respiratory symptoms to their room c. If they need to leave their room for a medical reason, they will have a facemask in place d. Contact primary provider for further direction on what tests to perform e. Contact family to notify them of change in condition. The policy identified preventive measures to include: remind residents to practice social distancing - maintaining a distance of 6 feet of another - while performing frequent hand hygiene. The policy did not address staffing considerations. The Guidance on Caring for a Confirmed Case of COVID-19 policy dated 7/2/20, directed if a resident was presenting with respiratory symptoms, the resident must remain in room on standard, contact and droplet precautions while waiting for diagnostic laboratory results. The policy also directed if a resident diagnosed with COVID or pending test results leaves ro

Based on observation, interview and document review, the facility failed to assess and evaluate causal factors of falls, and failed to ensure adequate supervision and interventions were implemented in order to minimize falls and/or injury for 1 of 5 resident (R1) who sustained multiple falls resulting in injury including a pelvic fracture. This deficient practice resulted in actual harm for R1. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. The assessment indicated R1 required extensive assistance with all activities of daily living including bed mobility, transfers and ambulation. The assessment also indicated, R1 had sustained a fall with injury in the past month and had fallen one time since her admission to the facility. R1's Falls Care Area Assessment (CAA), dated 8/28/18, indicated R1 was at risk for falling due to impaired mobility and altered cognition secondary to dementia. R1 sustained a fall at home which resulted in a left [MEDICAL CONDITION]. R1 was able to bear weight as tolerated and was working with therapy to regain strength. The CAA further indicated R1 displayed impulsivity and had been attempting to self transfer in her room. R1 had sustained a fall while at the facility, which resulted in a laceration to the back of her head. The interventions to reduce resident risk for falls included not leaving R1 in her room alone, safety checks every two hours, staff to anticipate her needs, and the call light and personal items to be kept within reach at all times. R1's 30 day Medicare MDS, dated [DATE], indicated R1 had severe cognitive impairment, and required extensive assistance with all activities of daily living. R1 was not ambulating at the time of the assessment and had not sustained falls during the assessment review period. R1's care plan, dated 8/21/18, identified R1 at risk for falls related to impaired mobility and weakness. The plan indicated R1 had poor safety awareness and could be very impulsive at times. The care plan approaches included a low bed, fall mat next to the bed, not to leave R1 alone in her room unattended, proper foot wear, assist with toileting after the administration of suppositories, grab bars at the head of the bed, personal items within reach and hourly checks. Review of the Safety Events/ Incident reports and Post Fall Assessment revealed the following information: 1. On 8/17/18, at 11:15 a.m. R1 was found in her room on the floor with blood on the back of her head and a few drops on the floor. The report indicated R1 had reported she was out shopping and could not recall what happened. R1 was noted to have a small abrasion (exact size not identified) to the back of the her head which required first aide. The immediate interventions initiated following the fall was: R1 was not to be left alone in room. R1's Post Fall Assessment, dated 8/28/18, indicated R1 had a 6 centimeter (cm) by 5 cm bruise to the back of her head with a 1.1 cm x 0.5 cm scabbed area in the middle. R1 did not complain of pain related to the fall and the immediate interventions directed the staff to ensure R1 was not left in her room unattended. 2. On 9/3/18, at 6:11 a.m. R1 was found on the floor in her room between the dresser and the foot of the bed. R1's back was against the dresser. R1 stated she was attempting to get to the bathroom as she had received a suppository earlier. R1 did not sustain an injury and was assisted to the restroom. R1's Post Fall Assessment, dated 9/4/18, directed the staff to assist with toileting after the administration of a suppository. 3. On 9/14/18, at 11:03 a.m. R1 was found on the floor alone in her room by the bathroom door. R1 was noted to have blood on her right shoulder and on the floor. R1 was noted to have a 1 cm cut on the right side of her head and complained of pain in her right leg. R1 had been in her bed prior to the fall. R1 was transferred via ambulance to the local hospital and was hospitalized with a pelvic fracture. R1's clinical record did not contain a Post Fall Assessment following the fall which occurred on 9/14/18. R1's Fall Risk (Acuity) - Balance and Functional Limitations assessment, dated 9/16/18, indicated R1 had returned to the facility after hospitalization for a closed displayed [MEDICAL CONDITION] pubis sustained from a fall. R1 was alert and disorientated and yelled out in pain with movement. R1 was to be on bed rest until further evaluation from therapy. 4. On 10/20/18, at 9:19 p.m. R1 was found on the floor in her room next to her recliner. R1 had been in the recliner prior to the fall. R1 stated she had tripped on her pants. No injuries were noted. R1's Post Fall assessment dated [DATE], indicated R1 fell while in the room and R1 was not to be left alone in her room while awake. On 11/14/17, at 4:00 p.m. R1 was observed alone in her room, seated in a recliner in her room with her feet in an elevated/reclined position. R1 was noted to have a personal call light, a blanket over her lap, and was reading a magazine. R1's door was open, however, no staff members were observed to be within eyesight of R1. - At 4:15 p.m. nursing assistant (NA)-A entered R1's room and shut the door. - At 4:21 p.m. R1 was wheeled out of the room and escorted to the television (TV) lounge area. R1 was observed to remain in the common areas of the facility within staff sight from 4:21 p.m. to 7:00 p.m. While in the common areas, R1 was not observed to attempt to stand or self transfer. - At 7:00 p.m. R1 wheeled herself to her room. Licensed practical nurse (LPN)-B was observed standing next to R1's room with the medication cart. LPN-B was within eyesight of R1. - At 7:10 p.m. R1 asked for assistance to use the restroom. Registered nurse (RN)-A was observed to wheel R1 into the restroom, applied a transfer belt and directed R1 to reach for the bathroom safety bars and pull herself up. R1 was observed to be able to pull herself into a standing position with stand by assistance as RN-A assisted to remove R1's pants, incontinent brief and to transfer R1 onto the toilet. - At 7:20 p.m. R1 requested to transfer off of the toilet. RN-A directed R1 to stand. R1 was able to stand utilizing the bathroom safety bars independently with stand by assistance. RN-A completed perineal cares, replaced R1's pants and guided her back into the wheelchair. - At 7:29 p.m. RN-A wheeled R1 from the bathroom to her bedside. RN-A turned the television on, placed an over the bed table in front of R1 and provided an evening snack. RN-A pulled the privacy curtain between R1 and her roommate. The privacy curtain prevented staff from observing R1 from hall/doorway. - At 7:38 p.m. RN-A left the room. R1 was alone in her room, seated in her wheelchair and behind the privacy curtain. R1 was not within eyesight of the staff. - At 8:10 p.m. RN-A entered R1's room. - At 8:25 p.m. the director of nurses (DON), RN-A and RN-D entered R1's room and closed the door. - At 8:30 p.m. R1 was observed seated in her recliner in her room. On 11/15/18, at 7:05 a.m. R1's room was observed dark and the privacy curtain was pulled. R1 was resting in a low bed with a fall mat next to the bed. LPN-A was observed at the medication cart outside of R1's room. - At 7:46 a.m. NA-B, a NA student and RN-D entered R1's room to perform morning cares. - At 7:51 a.m. NA-B and NA student assisted R1 to sit on the edge of the bed. NA-B applied a transfer belt and transferred R1 from the bed to the wheelchair with minimal stand by assist. R1 was wheeled into the bathroom and cued to transfer onto the toilet. R1 was able to transfer from the wheelchair to the toilet with stand by assist. - At 8:23 a.m. NA-student wheeled R1 from her room to the dining room for breakfast. - At 8:46 a.m. NA-C stated R1 was able to ambulate with restorative nursing, and did not require any type of special fall interventions. - At 8:54 a.m. housekeeper (HSKP)-A stated R1 usually spent the majority of her day in the TV lounge. HSKP-A was unaware of any special interventions for R1. - At 8:57 a.m. LPN-A stated R1's fall interventions included a low bed, fall mat and frequent checks if she was left alone in her room. - At 9:19 a.m. RN-A was observed to assist R1 to transfer from her wheelchair to a recliner in the TV lounge with stand by assistance. Once in the recliner, R1 was reclined in the chair and was within eyesight of the staff. - At 10:50 a.m. NA-E stated R1 was not to be left alone in her room. The staff were to stay with her or encourage her to be in common areas within eye sight. - At 10:50 a.m. NA-F stated R1 was to be kept in common cares and receive frequent visual monitoring. R1 was a fall risk and was to have frequent checks while in her room. - At 11:00 a.m. health unit coordinator (HUC)/NA-G stated R1 was able to be left in her recliner alone in her room, but was not to be left in her wheelchair in her room alone. - At 11:02 a.m. NA-B reviewed the undated Team 2 (nursing assistant care guide) and pointed out the first notation related to R1 which read/instructed the staff Do not leave alone in room when awake! - At 11:30 a.m. DON, RN-A, RN-B, RN-C and LPN-A reviewed R1's falls. The DON confirmed R1 had sustained a fall resulting in a head injury on 8/27/18, at 11:15 a.m. while alone in her room. The intervention was to ensure R1 was not left alone in her room. R1's second fall on 9/3/18, at 6:11 a.m. occurred after R1 had requested a suppository at 5:30 a.m. and R1 attempted to self transfer out of the bed to go to the bathroom. R1 was awake and alone in her room at the time of the fall and the intervention was to ensure R1 was assisted to the restroom after receiving a suppository. The third fall occurred on 9/14/18, at 11:03 a.m. R1 was alone in bed in her room and began looking for food. R1 sustained a head injury and a fractured pelvis which required hospitalization . R1's interventions following the fall included the initiation of a low bed and a fall mat being placed by the bed. R1's fourth fall occurred on 10/20/18. R1 was in her wheelchair alone in her room and did not sustain an injury. No new interventions were initiated and the intervention to ensure R1 was not left alone in the room was continued. The DON stated following each fall the facility was focused on what possible intervention could be put into place to prevent further falls. The DON stated R1 enjoyed sitting in her recliner in her room with her feet up reading or listening to the TV and verified on 11/14/18, at 8:30 p.m. she had assisted R1 into the recliner and left R1 alone. The DON confirmed the facility had reviewed the falls, however, they had focused their post-fall evaluations on new interventions rather than why R1's current interventions had not been followed. The facility had not determined why R1 had been in the room unattended, or if the care plan interventions were effective for the prevention or to minimize R1's risk for falls. The DON confirmed R1 had sustained injury while at the facility as the direct result of falls and the fall interventions were in need of re-evaluation. On 11/15/18 at 1:49 p.m. RN-A completed a Fall Assessment Update which indicated R1 had the ability to transfer with extensive assist of one person. R1 was disorientated but was able to answer questions appropriately and make her needs known most of the time. R1's improved ability to communicate her needs had decreased her anxiety and decreased her attempts to self transfer. R1 was now able to be left alone in her room to sit in her recliner or to sit in her wheelchair to watch TV. R1 was to receive thrifty minute checks to ensure safety. The undated Falls Investigation Policy directed the staff to investigate in an attempt to establish the cause of falls by the LPN/RN and interventions were to be put into place to proactively prevent further falls. Monthly evaluations of interventions were to be reviewed and a determination of there effectiveness and proper changes were to be made by the resident care coordinators. Weekly review of the investigation process were to be followed by the interdisciplinary (IDT) team / DON to determine compliance with the weekly policy.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning in accordance with the care plan for 1 of 1 resident (R1) identified at risk for the development of pressure sores. In addition, the facility failed to ensure a pressure redistribution cushion (Roho cushion) was appropriately utilized. This failure resulted in actual harm for R1 due to the development of a recurrent pressure ulcer. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. The assessment indicated R1 required extensive assistance with all activities of daily living including bed mobility, transfers and ambulation. The assessment also identified R1 was at risk for the development of pressure ulcers. R1's Pressure Ulcer Care Area Assessment (CAA) dated 8/28/18, indicated R1 was at risk for skin breakdown due to impaired mobility and altered nutritional status. R1 had sustained a recent left [MEDICAL CONDITION] and required assistance with repositioning every two hours, along with a pressure redistribution cushion on her bed and wheelchair. R1's CAA indicated a Braden Scale (instrument for the prediction of pressure ulcer) identified R1 was at moderate risk for the development of pressure ulcer. R1's 30 day Medicare MDS dated [DATE], indicated R1 had severe cognitive impairment, and required extensive assistance with all activities of daily living. R1 did have a stage two pressure ulcer at the time of the assessment. R1's Care Plan identified start date of 8/21/18, indicated R1 was at risk for alteration in skin status due to impaired mobility and weakness. The care plan indicated R1 had a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister) pressure ulcer on her coccyx. The plan directed the staff to provide assistance with repositioning every two hours and ensure R1's bed and wheelchair were equipped with a pressure redistribution cushion. The care plan indicated R1 was to have a Roho cushion (a wheelchair cushion filled with 1 x 2 x 2 inch air filled rubber squares that while a person was seated on the cushion, their buttocks is suspended on the air, which deters direct pressure on the hips and buttocks). R1's Fall Risk Acuity - Balance and Functional Limitation form, dated 9/16/18, indicated R1 had a duoderm (thick protective dressing) over her coccyx for protection upon returning from the hospital on [DATE]. The documentation did not identify any type of alteration in the skin at the time of the assessment. R1's Skin Integrity Event - Pressure Sore/Stasis Ulcer report dated 9/25/18, indicated R1 had been identified with a 2 centimeter (cm) x 1.5 cm open area on the coccyx which appeared red with yellow slough wound bed. A protective dressing was applied. R1's progress notes revealed the following information: - 9/27/18, at 1:16 p.m. R1 was at risk for skin breakdown due to impaired mobility, incontinent loose stools and impaired nutritional status, due to poor appetite. R1's Braden Score was 12 (high risk for the development of pressure sores) and R1 had an unstageable (scabbed) area to her coccyx. R1 was to receive assistance with repositioning every two hours. - 9/27/18, at 1:35 p.m. R1's coccyx wound was an unstagable pressure area measuring 2 cm x 1.5 cm. The wound had 45 percent (%) eschar (black scab) and 45% yellow slough. There was a 3 cm reddened area around the wound, which was blanchable. - 10/2/18, R1's coccyx was noted to have a Stage 2 ulcer which measured 1.4 cm x 0.8 cm with 100% pink granulation tissue (new tissue growth). - 10/9/18, R1's coccyx wound was 1.4 cm x 0.75 cm. The wound bed was pink. - 10/12/18, R1's coccyx wound was 1 cm x 0.8 cm. The wound bed continued to be pink - 10/23/18, R1's coccyx wound was 0.5 cm, with a dry scab which covered it. - 10/30/18, R1's coccyx was healed. - 11/14/18, at 9:03 p.m. RN-A documented R1 had two pin point open areas. A calloused area measured 0.5 cm x 0.2 cm, which was surrounded by blanchable redness. Barrier cream was applied to the area. On 11/14/18, from 4:21 p.m. to 7:10 p.m. R1 was continuously observed to remain seated in her wheelchair without assistance with repositioning. - At 4:21 p.m. nursing assistant (NA)-A was observed to wheel R1 out of her room via a wheelchair. R1 was positioned in front of the television (TV) in the TV lounge. - At 4:52 p.m. R1 was wheeled to the dining room by nursing assistant partner (NAP)-A. - At 5:23 p.m. R1 was seated in wheelchair at the dining room table waiting for the evening meal. - At 5:53 p.m. R1 was served the evening meal and began to eat independently. - At 6:25 p.m. NAP-A assisted R1 to wheel from the dining room back to the TV lounge. - At 6:57 p.m. R1 wheeled herself from the TV lounge to her room. - At 7:10 p.m. R1 asked to use the rest room. Registered nurse (RN)-A assisted R1 to the the rest room and cued her to stand utilizing the bathroom assist bars. Once up, RN-A removed R1's pants and incontinent brief. R1's bottom was observed red with an approximate one centimeter (CM) calloused area directly on the coccyx with two small openings noted within the calloused area. R1's wheelchair was observed equipped with a Roho cushion, however, the cushion was not fully inflated (approximately half flat/low on air). - At 7:42 p.m. RN-A stated R1 had a history of [REDACTED]. At this time, RN-A stated R1's coccyx had reopened and confirmed she was to be repositioned every two hours while in the wheelchair. - At 8:20 p.m. nursing assistant (NA)-A verified R1 had sat in her wheelchair from 4:20 p.m. to 7:10 p.m. a total of 2 hours and 50 minutes. NA-A confirmed R1 was to receive assistance with repositioning every two hours. On 11/15/18, at 8:10 a.m. R1's wheelchair cushion was checked by RN-D. RN-D stated R1's wheelchair cushion was in need of additional air to ensure R1's bottom did not rest directly on the chair but rather supported by the Roho cushion. - At 9:22 a.m. RN-A was observed to transfer R1 from the wheelchair to a recliner in the TV lounge. RN-A proceeded to add air to R1's Roho cushion. RN-A stated it seems a little flat. - At 12:15 p.m. the director of nurses (DON) confirmed R1's coccyx wound had been healed and reopened. R1 should have received assistance with repositioning every two hours as directed by the care plan and the Roho cushion should have had the appropriate amount of air to minimize pressure areas on R1's buttocks. The DON confirmed R1 had not received assistance in accordance to the care plan. The Skin Integrity Assessment/ Documentation policy dated 7/2016, directed the staff to ensure residents determined to be at risk or having loss of skin integrity review aggressive/appropriate preventive measure and care specific to address the resident's unique risk factors and approbate treatment. The policy directed that pressure relieving equipment be utilized appropriately and ensure the resident received assistance with repositioning as directed by the care plan.

Based on interview and document review, the facility failed to ensure 1 of 8 residents (R1) reviewed for abuse was free from physical and verbal abuse by staff. This failure resulted in harm for (R1) who sustained bruises to both arms. Findings include: R1's medical record was reviewed. R1's face sheet indicated R1 resided on the secure dementia unit, diagnosed with [REDACTED]. R1's care plan last revised 7/19/16, indicated R1 required one to two staff for transfers and ambulation with a walker. R1 required extensive assistance of one staff for dressing and personal hygiene. R1's cognitive assessment dated [DATE], indicated R1 had severe cognitive impairment. R1's event report dated 10/25/16, at 7:43 p.m. documented by licensed practical nurse (LPN)-E, indicated R1 sustained a light blue/black bruise on the right thumb which measured 2 centimeters (cm) by 2 cm. R1 also sustained a dark purple bruise on the left elbow which measured 1 cm by 1 cm. R1's nursing progress notes dated 10/25/16, at 8:19 p.m. documented by LPN-E indicated R1 had been refusing to take R1's medications. R1 stood up from the wheelchair and ambulated without assistance. When staff approached R1, R1 yelled at staff and hit out. The staff attempted to redirect R1 and R1 became upset with the staff's approach. The staff lifted R1 and placed R1 in bed. Two staff assisted R1 to remove R1's clothing and change R1's incontinent pad. R1 continued to be resistive with cares. An interview with LPN-E was conducted on 11/29/16, at 1:23 p.m. LPN-E stated on 10/25/16, trained medication aide (TMA)-I stated he had lost his temper when R1 ambulated independently so he picked up R1 and carried R1 to bed. LPN-E stated TMA-I told her R1 was getting physical with him so he held R1's hands and arms. An interview with NA-F was conducted on 11/29/16, at 3:05 p.m. NA-F stated on 10/25/16, at approximately 5:45 p.m. TMA-I attempted to give R1 medications, R1 refused and questioned what the medications were for. TMA-I told R1 she could not leave the table or go to bed unless R1 took the medications. NA-F came out of a resident's room and saw R1 ambulating independently and TMA-I told R1 multiple times to be seated. NA-F stated TMA-I told her to get a nightgown for R1 and then TMA-I picked up R1 under R1's knees and behind R1's neck. NA-F stated R1 pulled TMA-I's hair and called him a pig. NA-F stated TMA-I was about 2 1/2-3 feet away from the bed when he tossed R1 onto the bed. R1 was seated on the edge of the bed with both feet touching the floor. NA-F stated TMA-I then put his left forearm on R1's neck and forced R1 onto R1's back. NA-F stated TMA-I then forcefully removed R1's pants and threw them across the room, while keeping his left forearm on R1's neck. NA-F stated R1 told TMA-I to get off as R1 tried to get to a seated position. TMA-I tried to remove R1's shirt and R1 pulled TMA-I's hair and called him a pig. R1's shirt was over the top of R1's head and TMA-I had his right hand inside R1's shirt to remove it and hit R1 in the face with a closed fist. TMA-I then threw R1's shirt across the room. TMA-I put his right knee on R1's upper abdomen and grabbed R1's wrists to pull them through the nightgown. NA-F stated TMA-I then removed R1's incontinent brief and rolled R1 to the left side. NA-F stated she applied the new brief and R1 tried to get to an upright position when TMA-I laid across R1's chest and face area. TMA-I then placed his left forearm on R1's neck and called R1 a nasty [***] and an old hag. NA-F stated TMA-I then pulled the blankets up over R1's face. NA-F stated she immediately went and reported the incident to LPN-H. An interview with TMA-I was conducted on 12/1/16, at 12:05 p.m. TMA-I stated on 10/25/16, at about 5:30 p.m. he offered R1 four pills and R1 asked what the pills were for TMA-I stated he told R1 the pill was to help R1 sleep and after 10 times of approaching R1, R1 continued to refuse to take the medications. TMA-I stated he noticed R1 was out of the wheelchair so he picked R1 up and carried R1 to the bed. TMA-I stated due to R1's weight he dropped R1 onto the bed. TMA-I stated he asked NA-F to get a nightgown and TMA-I stated he did restrain R1's arms from hitting him. TMA-I stated R1 was pulling his hair at the time he removed R1's long sleeve shirt. TMA-I stated he and R1 were yelling at each other. TMA-I stated he laid over R1 and leaned on the bed and R1 could still move both arms. TMA-I stated he told R1, R1's husband did not give two[***] about R1. TMA-I stated he was arguing with R1 and held R1's wrists for three to four minutes while removing R1's shirt and placing the nightgown. TMA-I stated he smacked R1's hands away when R1 tried to hit TMA-I. TMA-I stated he hit R1's right hand two or three times on the top of the hand or the palm of the hand. TMA-I stated he was more forceful with R1 when he was turning R1 to remove R1's pants. An interview with NA-F was conducted on 12/1/16, at 2:11 p.m. NA-F stated TMA-I had his hand inside R1's shirt to remove it up and over R1's head when TMA-I's fist hit R1's face. An interview with NA-G was conducted on 12/1/16, at 2:34 p.m. NA-G stated on 10/25/16, she stayed with R1 in R1's room when NA-F left to notify LPN-H. NA-G stated R1 told her that R1's arm hurt and NA-G noted bruises on R1's arms. R1 asked NA-G are you going to hit me again. NA-G stated R1 was very scared. An interview with family member (FM)-J was conducted on 1/3/17, at 10:38 a.m. FM-J stated the day after the incident he visited R1 and R1 stated being scared to stay at the facility. FM-J stated R1 was scared for about a month after the incident. The facility's undated Vulnerable Adult Mistreatment Policy indicated each resident had the right to be free from mistreatment.