Every finding on record at William E Christofferson Salt Lake Veterans Home

Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine washing temperature was not meeting manufacturer requirements and sanitizer solution was not at required levels for sanitizing. In addition, there were soiled areas in the kitchen. Findings included: 1. On 3/16/26 at 9:21 AM, an initial kitchen tour of the kitchen was conducted. The following was observed: Dietary Aide (DA) 1 stated the sanitizer solution located by the 3 compartment sink was made at 8:30 AM. DA 1 stated the sanitizer was quats ammonia and needed to be between 250-260 Parts Per Million (PPM). DA 1 was observed to test the solution and stated it was at 500 PPM. DA 1 stated the sanitizer was fine if it was too high but it could not be too low. A sign hanging by the sanitizer solution revealed the sanitizer solution should test between 150-400 PPM. DA 1 was observed to wipe the trayline with the sanitizer solution. At 9:37 AM, [NAME] 1 stated DA 1 made his sanitizer solution about an hour prior. The sanitizer solution was in the food preparation area. [NAME] 1 tested the sanitizer solution and the testing strip did not change color. [NAME] 1 stated the sanitizer was at 0 PPM. [NAME] 1 was then observed to wipe the food preparation area with the solution. There was a sanitation bucket log for March 2026 which revealed staff documented 300 to 400 PPM. At the bottom of the log it revealed sanitizer was to be at 200-300 PPM and changed every 4 hours. The shelf over trayline was observed to be soiled underneath. Food was served from below the shelf. There was dust on the piping behind the stove, fryer and oven. There was food splatter on the ceiling over the trayline. 2. On 3/16/26 at 9:42 AM, an observation was made of [NAME] 1 wearing gloves and touching raw meat. [NAME] 1 was observed to remove his gloves and no hand hygiene was observed. [NAME] 1 was observed to touch cutting boards without hand hygiene after removing gloves. 3. On 3/16/26 at 9:48 AM, an interview was conducted with DA 2. DA 2 stated the dishmachine needed to be above 150 degrees Fahrenheit and the rinse above 180 degrees Fahrenheit. The following was observed: [Note: All temperatures were in degrees Fahrenheit.] At 9:50 AM, the washing cycle was 145 and the rinse cycle was above 180. There were plate bases and 1 tray that went through the cycle. The items were observed to be put away with clean dishes. At 9:51 AM, the washing cycle was 145 and the rinse was 190. There were trays and bases which were observed to be put away with clean dishes. DA 2 confirmed the washing temperature was 145. At 9:52 AM, the washing cycle was 140 and the rinse was 189. DA 2 confirmed the washing temperature reached 140 and stated she doesn't know why it does this. There were trays in the cycle and were observed to be put away with clean dishes. At 9:54 AM, the washing cycle was 140 and the rinse cycle was 190. There were trays in the cycle and were observed to be put away with clean trays. DA 2 was immediately interviewed and stated she did dishes once a week and she did not know what to do if the washing temperature was not over 150. DA 1 was immediately interviewed and stated that DA 2 needed to continue washing dishes so the temperature would rise. 4. On 3/19/26 at 1:33 PM, the dish machine was observed. The washing cycle was 145 and the rinse was 190. The dishes were observed to be put away with the clean dishes. At 1:35 PM, an observation was made of a DA documenting the washing temperature of 150 and rinse of 185 on the dishmachine temperature log. 5. On 3/19/26 at 1:41 PM, a follow up kitchen tour was conducted. The following was observed: Behind the fryer, stove and over there were pipes with dust and debris. The shelf above the trayline was soiled underneath. The shelf was above prepared food. There was food splatter on the ceiling above the trayline. On 3/19/26 at 1:42 PM, an interview was conducted with the Dietary Manager (DM). The DM stated staff were to test the dish machine prior to meals. The DM stated the dish machine needed to run 2 to 3 times for it to reach 150 for the washing cycle and 180 for the rinse. The DM stated the ceiling tiles were cleaned by maintenance monthly. The DM stated the steam table was cleaned daily and deep cleaned weekly. The DM stated the shelf above the tray line was not on the cleaning list. The DM stated the pipes behind the fryer, ovens and stove needed to be cleaned.

Based on interview and record review, for 2 of 32 sampled residents, the facility did not obtain laboratory services only when ordered by a physician. Specifically, a resident had a Complete Blood Count (CBC) with differential and Vitamin D, 25-Hydroxy drawn without a physician's order. Resident identifier 5. Findings included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia, abnormal findings of blood chemistry, post traumatic stress disorder and major depressive disorder. Resident 5's medical record was reviewed 3/19/26. Resident 5 had laboratory results for Vitamin D, 25-Hydroxy and CBC with differential on 12/8/25. There were no physician's orders for the laboratory draws. It should be noted resident 5 had a physician's order dated 7/8/26 that revealed CBC, Comprehensive Metabolic Panel (CMP) and Vitamin D level every 6 months starting on the 8th for 1 day for routine labs. There was a Vitamin D, 25-Hydroxy and CBC with manual differential completed on 1/8/26. Resident 5 received 2 blood draws which were on 12/8/25 and 1/8/26. On 3/19/26 at 2:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she was unable to find a physician's order for the CBC and Vitamin D, 25-Hydroxy for 12/8/25. The DON stated she thought the nurse calculated 6 months from July 2025 as 12/8/25 instead of 1/8/26.

Based on interview and record review, the facility failed to ensure that laboratory reports were accurately maintained and readily available within the medical record. Specifically, for 2 out of 32 sampled residents, laboratory results were not located in their medical record. Resident identifiers: 3 and 4. Findings included: 1. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypo-osmolality, hyponatremia, and anxiety. A review of Resident 3's medical record was conducted on 3/16/26 through 3/19/26. A physician's order dated 12/28/25, revealed Additional labs for 12/29/25: ferritin level, serum iron, transferrin, and TIBC [Total Iron-Binding Capacity] one time only for anemia for 1 Day. The laboratory tests dated 12/29/25, were not located in resident 3's medical record. On 3/19/26 at 11:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the laboratory provider had changed their systems in October 2025. The DON stated the transitioning process was, a nightmare. The DON stated that some laboratory results had to be manually printed from an external portal and scanned into the resident's medical record. The DON stated that lab results for ferritin level, serum iron, transferrin, and TIBC dated 12/29/25, were not located in resident 3's medical record. 2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, depression, post traumatic stress disorder, constipation and prediabetes. A physician's order dated 1/26/26 revealed a Thyroid-Stimulating Hormone (TSH) with reflux to free Thyroxine (T4). Resident 4's laboratory results revealed T4 was completed on 1/26/26. There were no TSH results in the medical record. On 3/19/26 at 11:10 AM, an interview was conducted with the DON. The DON stated resident 4's TSH was completed but was not in the medical record. The DON stated resident 4's TSH needed to be manually printed from an external portal and then scanned into the medical record. The DON stated the TSH results should have been in the medical record.

Based on interview and record review, for 1 of 3 sampled residents, the facility failed to ensure each resident received food prepared in a form designed to meet individual needs. Specifically, a resident had a diet order for soft and bite-sized texture and was served a sandwich for a snack which resulted in the resident choking and passing away. Resident identifier: 1.It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, S483.60(d)(3) Food prepared in a form designed to meet individual needs, F805, at a scope and severity of G. However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance.The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by 10/16/25 included the following measures: The facility implemented staff education, limited access to sandwiches in the memory care unit, and increased locations to access resident diet orders and education for staff. The survey team verified that all these interventions were completed before the survey start date.Findings included:Resident 1 was admitted to the facility on [DATE] with diagnoses which included pyelonephritis, vascular dementia, hypertension, atrial fibrillation, cerebral infarction, chronic cough, dysphagia oropharyngeal phase, age-related cognitive decline, cognitive communication deficit, and adult failure to thrive.The facility reported to the State Survey Agency on 10/16/25 at 4:55 PM that resident 1 had passed away. The report revealed on 10/16/25 at 12:50 AM, resident 1 was provided a snack which he started to consume and then started to cough. It further indicated staff administered the Heimlich maneuver in response to his coughing and that chest compressions were provided when he became unresponsive.An Investigation Checklist packet dated 10/16/25 indicated, Unexpected death.Summary of Event or Allegation: [Resident 1] was provided with a snack which he started to consume while interacting with the RN [Registered Nurse] Supervisor next to him. [Resident 1] stood from a chair and walked with assistance to his wheelchair then began to cough. Staff worked to help him clear the cough with some success, and he settled back into his wheelchair. [Resident 1] appeared to be breathing with some difficulty, and the nurse called 911. Prior to the arrival, he became non-responsive, and staff assisted him to the floor to continue to provide care. A Witness Statement from RN Supervisor indicated, .[RN 2] gave half a sandwich, a ham and cheese sandwich, He ate several bites of the sandwich and appeared to be eating with no concerns. He almost completed the sandwich and he started to cough. A Witness Statement from RN 2 indicated, .I offered both residents a snack and provided [resident 1] a half of a ham and cheese sandwich. [Resident 1] sat in a common area eating the snack. He took multiple bites with no distress noted. He then began to cough. He was able to clear some food while coughing and [RN Supervisor] put on a glove and swept his mouth. [Resident 1] stood up and was showing some unsteadiness (his baseline is unsteady) and was assisted back to a sitting position. He had more coughing noted, and I provided the Heimlich maneuver with three abdominal thrusts. At this time, [resident 1] was breathing but did show some signs of decline. [RN Supervisor] called 911 and [staff name omitted] came with oxygen as requested and after it was placed, I went to get the crash cart. RN Supervisor and CNA [Certified Nursing Assistant] continued to monitor and provide care for [resident 1]. When I returned to the common room area, the CNA was providing CPR [Cardiopulmonary Resuscitation], and the RN supervisor was on the phone with EMS [Emergency Medical Services]. When EMS arrived, they assessed [resident 1] with the AED [Automated External Defibrillator], and no heart rate could be found. EMS called time of death at 12:50am. It further indicated that on 10/16/25 at 2:00 AM, [RN 2] was educated by [DON] and [Administrator] on the level six soft and bite-sized diet texture. It further indicated, [RN 2] was educated that level six soft and bite-sized foods are soft tender and moist, but with no thin liquid leaking/dripping from the food. Residents must have the ability to chew 'bite-sized' pieces so that they are safe to swallow. Bite-sized pieces are no bigger than 1.5cm [centimeters] x 1.5cm in size. Food can be mashed/broken down with pressure from a fork; a knife is not required to cut this food. No regular dry breads are allowed.Resident 1's medical record was reviewed on 11/12/25.A Physician's Order dated 7/16/25 at 12:35 PM indicated, 'Regular Diet diet Soft & Bite-Sized SB6 texture, Thin consistency.A Nursing Note dated 7/16/25 at 1:48 PM indicated, .He ate breakfast with supervision and assistance eating. He was coughing with eating. His wife was stating that he coughs when he eats too fast or takes bites that are too big. Able to cough and clear food.A Nursing Note dated 7/17/25 at 8:00 AM indicated, .He eats a soft bite size diet and coughs with food. He is supervision/touch assist in the common dining area.A Skilled Nursing Note dated 7/26/25 at 4:30 PM indicated, .He is on a soft and bite size diet. Speech therapy has recommended that staff sit by him to encourage small bites and slow down when eating. He will listen to prompts and is able to feed himself with set up assistance. Fluids are encouraged at meals and in between meals.A Speech-Language Pathologist (SLP) Evaluation and Plan of Treatment dated 8/14/25 indicated a diet recommendation of a Mechanical Soft/Ground textures (IDDSI (International Dysphagia Diet Standardization Initiative)-6) with close supervision, small bites, slow rate, and to take drinks frequently during the meal.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident 1 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. It further indicated he coughed or choked during meals or when swallowing medications and required a mechanically altered diet.A Nursing Note dated 10/6/25 at 5:29 PM indicated, .[Resident 1] has a soft and bite size diet. He has a good appetite. Staff sit by resident to encourage small bites and to eat slowly as per speech therapy. No difficulty swallowing if speech therapy recommendations are followed.A Nursing Note dated 10/16/25 at 1:53 AM indicated, .After a few minutes he had stated he was hungry and wanted something to eat. He had refused pudding a few minutes earlier and refused a chocolate cookie from me. [RN 2] offered him a sandwich and he agreed. After [resident 1] had taken a few bites of sandwich and had started to cough. I took his sandwich and asked him to spit out what he had in his mouth. he spit some out but took a huge breathe [sic] and started to cough. His breathing changed, then stopped so the Heimlich was tried for 3 thrusts. a small amount was dislodged. He was then placed on the floor, chest compressions started, 911 was called. The call did not go through, a call was then placed on facility phone. Information was given, the 911 person then asked to call on my cell phone to speak to person giving chest compressions. Chest compressions continued then switched to another person. First responders arrived and took over the situation. First responders could not dislodge item and called his time of death.A Nursing Note dated 10/16/25 at 9:51 AM indicated, .Resident passed away on 10/15/2025 [sic] at 0050 [12:50 AM].A Care Plan Report dated 10/16/25 indicated a Focus of, [Resident 1] has a swallowing problem; he is noted to cough and take too big bites and sips of drinks. He is at risk for aspiration or choking.; and Interventions/Tasks which included, Monitor/document/report PRN [as needed] any s/sx [signs or symptoms] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. A Care Plan Report dated 10/16/25 indicated a Focus of, [Resident 1] has an ADL [activities of daily living] self-care performance deficit related to his cognition and mobility; his walk is unsteady and unsafe. He relies on staff to assist him with all his self-cares and mobility using a w/c [wheelchair]. D; and Interventions/Tasks which included, Eating: [Resident 1] requires supervision/touch to partial/moderate assistance of (1) staff for eating.On 11/12/25 at 11:46 AM, an interview was conducted with the Assistant Dietary Manager (ADM). The ADM stated residents on a Soft & Bite-Sized diet could not have any bread or sliced sandwich meat because it could cause choking. The ADM stated resident 1 was on a Soft & Bite-Sized diet. The ADM stated sandwiches were no longer stocked in the snack refrigerator in the memory care unit. The ADM stated there were two residents in the memory care unit that requested sandwiches and if a sandwich was sent down it would be labeled with the resident's name. The ADM stated that after the choking incident, they ordered more soft snacks than they previously had and stocked items like canned tomato soup, canned diced fruits, yogurts, and applesauce so they were available for residents on modified diets. The ADM stated at least once a week and as needed, he and the DON updated a list that included all residents who were on a modified textured diet which was available in all of the nursing stations and that nurses were expected to reference that list before providing snacks to residents.On 11/12/25 at 11:58 PM, an interview was conducted with CNA 2. CNA 2 stated she served meals to residents and checked the meal card to ensure they received the correct ordered diets and textures. CNA 2 stated if she was unsure what diet a resident had ordered she asked a nurse or supervisor before providing food to the resident. On 11/12/25 at 12:17 PM, an interview was conducted with the Speech-Language Pathologist (SLP). The SLP stated resident 1 had inefficient chewing, difficulty breaking down food, and was on the recommended Soft and Bite-Sized diet. The SLP stated that they provided some recommendations after resident 1's choking incident and that they implemented the diet information packets that were now found in the memory care unit.On 11/12/25 at 12:26 PM, an interview was conducted with RN 1. RN 1 stated that resident 1's family was very involved with his care and would be present during meals. RN 1 stated that when family was not present during meals, staff would supervise and sometimes he would be okay on his own. RN 1 stated there were sandwiches available in the snack refrigerator, but after the choking incident, a new protocol was put into place where a resident had to ask for something, like a sandwich, and then it was sent down from the kitchen labeled with their name. RN 1 stated if the intended resident did not eat the labeled food, it had to be thrown away. RN 1 stated they had received a lot of education after the incident.On 11/12/25 at 12:35 PM, a telephone interview was conducted with CNA 1. CNA 1 stated that she had seen resident 1 eat sandwiches before the incident. CNA 1 stated she was not involved with resident 1's care on 10/15/25 but she was there and after the incident the Administrator and DON investigated what happened. CNA 1 stated there was a binder at the nurses station and on the electronic medical record where staff could find out what diet and texture a resident was on. CNA 1 stated staff received education the following day that included information on different types of diet textures and what to do if a resident choked. CNA 1 was unable to describe what a Soft and Bite-Sized diet was but stated that if she had questions she asked the nurse or looked at a binder that was available on the snack refrigerators.On 11/12/25 at 1:36 PM, a telephone interview was conducted with the Registered Dietician (RD). The RD stated that she, the speech therapist, and the dietary manager reviewed what new snacks would be provided after the choking incident.On 11/12/25 at 1:59 PM, an interview was conducted with the DON. The DON stated she received a phone call the night of the incident and was told that resident 1 had expired. The DON stated anytime there was an unexpected death, she and the Administrator (ADMIN) would go in, so they went to the facility that night. The DON stated that when they got there the paramedics were on their way out. The DON stated they went through the steps of what happened with the nurses that were there and then they went home. The DON stated that they had a morning trigger call with corporate to discuss what happened. The DON stated two 4-step action plans were put into place. The DON stated staff were provided education on diets, altered diets, and what that entails. The DON stated in-person or video conference call education was provided to all staff members by 10/24/25. The DON stated binders were made available to staff that contained names of residents on altered texture diets in the front along with recommendations and education on diet textures. The DON stated sandwiches were not made available in the memory care unit anymore unless they have a name labeled on it so it will not be given to a resident who should not have it. The DON stated they looked at all of their processes in the building which included changing the accessibility of snacks during activities to ensure residents received the correct ordered diets. The DON stated more CPR with simulation training had been implemented. The DON stated the SLP had done a lot of training with staff. The DON stated any change in diet orders went through her office and dietary and then it was updated in the electronic medical record, staff were informed of changes verbally,on the communication board, and it was updated in all of the binders. The DON stated staff were expected to check the communication board when they started their shift.On 11/12/25 at 2:19 PM, an interview was conducted with the ADMIN. The ADMIN stated she was alerted by the RN supervisor the night of the choking incident that resident 1 had passed away and that she went to the facility. The ADMIN stated she talked to the paramedics, law enforcement, resident 1's family, and debriefed with the team that provided the Heimlich maneuver and CPR. The ADMIN stated the next morning they had a QAPI (Quality Assurance and Performance Improvement) meeting and talked about diet textures to make sure staff knew where to find that information and education was implemented for all staff that covered IDDSI diets, where diets were located, and the expectation of knowing what food was provided to residents that lived there. The ADMIN stated diet orders were updated and were available in the binders and the electronic medical record. The ADMIN stated previous education on diets was done through a program but they implemented a new orientation with staff and they would speak with the Director of Rehabilitation, who was a Speech Therapist, and the Dietary Manager. The ADMIN stated prior to the incident there was no other diet information than what was available in the medical record and in the care plan. The ADMIN stated the binders were located on the snack refrigerators and they provided at-a-glance information and some other tools to help identify appropriate foods for certain diets. The ADMIN stated this information was also available in the nursing communication book. The ADMIN stated everyone was involved in creating the education, including the staff developer, SLP, nursing supervisors, the corporate nursing consultant, and the DON. The ADMIN stated they started providing different sandwiches that were softer to chew for the residents who could have sandwiches and that they would not be available to everyone. The ADMIN stated proper diet compliance was reviewed in QAPI and that education would continue to be provided to all new staff with remote options.On 11/13/25 at 8:38 AM, an email was received from the ADMIN that indicated: 1. An All Staff Meeting was held on 10/16/25 and education on diet textures was provided. All resident diet textures could be found in the medical record and diets were also printed on meal tickets. 2. A new process was introduced for alternative diet textures on 10/16/25: A printed list of residents who had orders for texture modified diets were placed in the nurse report books. 3. IDDSI diet information sheets were placed in the dining coordinator communication binder and in the nurse report books for quick reference. 4. As of 10/16/25, changes in diet textures were communicated to staff on PCC's communication board and lists were updated, printed and distributed. 5. Diet texture compliance was a facility initiative and the focus was shared in break rooms and would be discussed at All Staff again on 11/13/25. New staff members would be educated on diet textures during orientation.

Based on observation, interview, and record review it was determined, for 1 of 23 sampled residents, that the facility failed to ensure that a resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Specifically, individualized accommodations to keep a resident's telephone and radio within reach was not provided. Resident identifier: 50. Findings include: Resident 50 was admitted to the facility on [DATE] with diagnoses which included dementia, neurocognitive disorder with lewy bodies, pain, insomnia, hypertension, major depressive disorder, anxiety, type 2 diabetes mellitus, post-traumatic stress disorder, glaucoma, and fibromyalgia. On 2/26/24 at 9:50 AM, an observation was made of resident 50's room. Resident 50 was in bed. Resident 50's bed was placed against a wall that had peeling paint and 4 screws with nothing attached to them. There was a telephone, a radio, and a large cup of fluid with a lid on it sitting on the bed between the resident and the wall. On 2/26/24 at 9:50 AM, an interview was conducted with resident 50. Resident 50 stated his radio and telephone were on his bed because they got knocked off when they were put on his bedside table. Resident 50 stated he had requested to have a shelf placed on the wall to put his items on, so they were not on his bed. Resident 50 stated he had asked facility staff and put in a ticket for maintenance about three months ago, but that it had not been put up yet. Resident 50 further stated he was blind and needed his items within reach. Resident 50's medical record was reviewed from 2/26/24 through 2/28/24. A quarterly Minimum Date Set (MDS) dated [DATE] revealed resident 50 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated cognitive status was intact. It further indicated that resident 50 required extensive assistance with bed mobility. Bed mobility was how resident moved to and from lying position, turned side to side, and positioned body while in bed or alternate sleep furniture. On 2/28/24 at 12:04 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated resident 50 liked to have his tape player and radio on a shelf on the right side of his bed. CNA 2 stated that the facility needed to leave them within reach because he was blind. CNA 2 stated resident 50 had a shelf on the wall but it fell off approximately four to five months ago and had not been put back up. CNA 2 stated resident 50 requested to have the shelf replaced about two to three months ago and that they filled out a work order for the shelf to be put back up. On 2/28/24 at 1:06 PM, an interview was conducted with the Maintenance Manager. The Maintenance Manager stated he had put items up on resident 50's wall, which included a shelf, but that resident 50 ripped them down. The Maintenance Manager stated he did not have a request to replace his shelf. The Maintenance Manager stated resident 50's phone was hung directly on the wall, but it was ripped down too. The Maintenance Manager stated he was aware of the wall missing paint and having screws but that he had not told his helper to paint it. On 2/28/24 at 2:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the shelf had been fixed several times but that it had been pulled off the wall because resident 50 tried to reposition himself with it. The DON stated that if a work order was placed it should have been fixed and that the shelf should have been reaffixed to resident 50's wall.

Based on interview and record review, the facility did not send a copy of resident 30-day discharge notices or hospitalization s to the Long-Term Care Ombudsman. Resident identifiers: 30. Findings include: 1. Resident 30 was admitted to the facility on [DATE] with diagnoses which included Schizophreniform disorder, dementia, heart failure, nausea and neuromuscular dysfunction of bladder. A nursing progress note dated 5/3/23 at 6:15 AM revealed, .Sent to ER [emergency room ] for uro-sepsis .decision made to send to ER for further evaluation . A nursing progress note dated 5/4/23 at 3:45 PM revealed, [Resident 30] returned from the VA hospital this afternoon . On 2/28/24 at 2:04 PM, an interview was conducted with the Office Specialist. The Office Specialist stated the facility Licensed Clinical Social Worker (LCSW) was the staff member in charge of notifying the Ombudsman of discharges. On 2/28/24 at 2:15 PM, an interview was conducted with the LCSW. The LCSW stated if there were concerns about a residents, then she contacted Adult Protective Services (APS) or ombudsman. The LCSW stated she did not notify the Ombudsman about discharges. On 2/28/24 at 2:17 PM, an interview was conducted with the Administrator. The Administrator stated she was not aware the Ombudsman needed to be notified of a residents transfer or discharge.

Based on observation, interview and record review, for 1 of 23 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who required substantial two person assistance for transfers was left unattended on the side of her bed and sustained a fall. Resident identifier: 6. Findings include: Resident 6 was admitted to the facility initially on 11/29/21, and readmitted on [DATE] with diagnoses that included cerebral infarction due to embolism, fracture left lower leg, anxiety disorder, hemiplegia and hemiparesis, aphasia, multiple sclerosis, age related osteoporosis, major depressive disorder and Post Traumatic Stress Disorder (PTSD). On 2/26/24 at 10:07 AM, an interview was conducted with resident 6 who stated she had fallen earlier on that day. Resident 6 stated she was on the floor for a while and was unable to push her call light due to it being on the bed and she was on the floor. Resident 6 stated she fell on her right side. Resident 6 was observed to have large contusion above her right eye, bruising and swelling on the right side of her face. Resident 6 stated she was experiencing pain. Resident 6's medical records were reviewed. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 6 required 2 person physical assistance to move between surfaces. A fall risk evaluation dated 1/13/24 revealed that resident 6 was at risk for falls related to having had multiple falls, decreased muscular condition, and that the resident was non-ambulatory. An additional fall risk assessment dated [DATE] revealed that resident 6 was at risk for falls related to having had multiple falls, decreased muscular condition, and that the resident was non-ambulatory. Resident 6's care plan included that resident 6 had an ADL [activities of daily living] self-care performance deficit related to left middle cerebral artery stroke. The goal was, Will improve current level of function being able to go from substantial to moderate to minimal with part of her upper body dressing through the review date. Interventions included, .Transfer: [resident 6] relies on one to two-person substantial to total assist with gait belt for transferring safety from bed to w/c [wheelchair] and back . Initiated on 10/28/22 and revised on 12/12/23. Resident 6's care plan also included that, [Resident 6] has limited physical mobility r/t [related to] her left sided stroke. She does not walk and is moderate to total assist for mobility and transfers. The goal was, [Resident 6] will remain free of complications related to decreased mobility, including contractures, thrombus formation, skin break-down, fall related injury through the next review date. Interventions included, LOCOMOTION: [Resident 6] uses a motorized wheelchair. She relies on staff to put her in the chair and take her out for her safety. Initiated on 10/28/22 and revised on 7/6/23. The Certified Nursing Assistant (CNA) Kardex for informing CNA's of resident's care needs included, Safety .11/6/23 Education provided to staff on safe transfers. [Resident 6] needs two person max assist with transferring on to scale or use of wheelchair .4/27/23 Staff to remain with [resident 6] when she is attempting to get up on her own and call for more assistance if needed. [Resident 6] often will not wait for staff to get more assistance and will continue to attempt to get up on her own. In the CNA task management, documentation for transfers revealed that within the past 30 days, resident 6 received supervision or touching assistance 1 time, partial to moderate assistance 12 times, substantial to maximal assistance 28 times, and was completely dependent 8 times. A progress note dated 2/26/24 at 8:43 AM revealed, Patient was found face down on the floor bedside. CNA left patient unattended sitting up in bed and went looking for extra help to transfer patient into wheelchair. Patient states she lost balance and fell over to the floor. [Family member's name removed] was left a voicemail. No emergency contacts answered. Patient's right upper quadrant of face, temporal, and eyebrow area swollen. Patient says she feels pain in her shoulder and general pain on right side due to falling on it. ROM [range of motion] intact. No other injuries found. Neurology checks initiated. A progress note dated 2/27/24 at 1:42 PM revealed, Follow-up note in regard to recent ground fall. Patient's right upper face/eyebrow/eye/temple continues to be swollen and appears bruised. No open areas noted. Patient continues to verbalize discomfort and pain in right neck/shoulder/arm region. Regular pain medications and pain relieving gel applied . A progress note dated 2/27/24 at 1:46 PM revealed, Resident had a previous fall. A new bruise was noted from post fall assessment on the top right of her lip . A physician progress note dated 2/27/24 at 4:35 PM revealed, Reason for visit/cc: fall, head trauma. Medical necessity visit to evaluate patient after unwitnessed GLF [ground level fall] where patient hit right side of head. Found face down on floor at bedside. NO LOC [loss of consciousness]. Sustained contusion to right temple and cheek, as well as right upper lip. Patient states she lost balance and fell over to the floor. Neurology checks initiated .HEENT [head, ears, eyes, nose, and throat examination]: Contusion of right eye, right temple, right zygomatic arch. Eyelids swollen but still able to keep eye open. Area is swollen and tender to touch. Right upper lip with bruising but minimal swelling .Assessment and Plan: #GLF; #Head trauma; #Hx [history] of CVA [cerebral vascular accident] on DOAC [Direct Oral Anticoagulant] and ASA [Aspirin]; #Headache .Alerted both floor RN [Registered Nurse] and nurse supervisors to monitor headache and for focal neurologic findings, increased irritability or lethargy, notify provider immediately to send to ED [emergency department] for trauma eval. On 2/28/24 at 12:40 PM, an interview was conducted with CNA 1. CNA 1 stated if she found a resident who had an un-witnessed fall she would go and get a nurse before moving the resident to ensure there were no injuries. CNA 1 stated she would complete her part of the incident report and check the resident's vital signs. CNA 1 stated that resident 6 was a 2 person transfer. On 2/28/24 at 2:14 PM, an interview was conducted with CNA 2 who stated resident 6 needed a 1 to 2 person extensive assistance depending on how she was doing or if she was feeling weak. CNA 2 stated sometimes resident 2 was not very steady. CNA 2 then stated resident 2 needed 2 staff members to assist with transfers so that she would not fall. On 2/28/24 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNAs should ensure that a resident was in a safe position before going to get another staff member for assistance with transferring a resident. The DON stated, related to resident 6's fall on 2/26/24, a new aid was working with resident 6. The DON stated the new CNA was provided education on how to use the KARDEX and review the fall interventions for residents. The DON stated that most of the things in the care plan transferred over to the KARDEX for the CNAs. On 2/28/24 at 2:34 PM, a follow-up interview was conducted with the DON. The DON stated, in the CNA task management area for transfers, if it was checked under supervision/touching assistance or partial/moderate that it indicated the resident had received a 1 person assist. The DON stated if it was checked under substantial/maximal or dependent that it indicated the resident had received a 2 person assist.

Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 23 sampled residents, a staff member was observed to touch the resident's medications with their bare hand during medication administration. Resident identifiers: 62 and 70. Findings included: 1. On 2/28/24 at 8:34 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during medication administration. LPN 1 was observed preparing medications for resident 70. LPN 1 was observed to dispense the medications from medication bottles. LPN 1 opened each bottle and shook the medication bottle until a tablet was near the edge of the bottle. LPN 1 took a bare finger and touched the medication, assisting the tablet into the bottle lid, and then placing the tablet into the medication cup. No hand hygiene was observed prior to touching cholecalciferol tablet 1000 units, famotidine tablet 40 milligrams (mg), and multivitamin with minerals tablet. LPN 1 was observed to administer the medications to resident 70. 2. On 2/28/24 at 8:40 AM, an observation was made of LPN 1 preparing medications for resident 62. LPN 1 was observed to dispense the medications from medication bottles. LPN 1 opened each bottle and shook the medication bottle until a tablet was near the edge of the bottle. LPN 1 took a bare finger and touched the medication, assisting the tablet into the bottle lid, and then placing the tablet into the medication cup. No hand hygiene was observed prior to touching acetaminophen 1000 mg, ascorbic acid 500 mg, cyanocobalamin 1000 micrograms, and senna docusate sodium 8.6-50 mg. LPN 1 was observed to administer the medications to resident 62. On 2/28/24 at 10:47 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she would sanitize her hands prior to preparing resident medications and between resident medication preparations. RN 1 stated that she would sanitize her hands with alcohol based hand rub (ABHR) up to three times unless she touched the resident or administered insulin then she would wash her hands with soap and water. RN 1 stated that she would never bring other resident's medications in resident rooms or leave the medications anywhere. RN 1 stated if she needed to handle resident medication she would put gloves on. RN 1 stated she did not want to handle any resident medications with bare hands nor would she want any of her medications touched. On 2/28/24 at 10:55 AM, an interview was conducted with LPN 1. LPN 1 stated that she would wash her hands and use ABHR between residents. LPN 1 stated if a medication fell on the medication cart she would throw the medication away. LPN 1 stated she would try not to touch a resident's medications. LPN 1 stated if she needed to touch a resident's medications with her bare hand she would put on a glove I guess. On 2/28/24 at 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the staff used barriers like cups and paper towels to pass medications and not breach infection control. The DON stated that each resident had their own glucometer that the staff cleaned between each use. The DON stated that staff should not touch resident medications with their bare hands and hand sanitization should be done between each resident.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety, Specifically, food service staff were not wearing hair restraints while preparing and serving food. Findings include: On 2/27/24 at 11:19 AM, an observation of trayline was conducted. Cook 1 was observed to be wearing a mask and gloves, and was preparing to serve the lunch meal at the steam table. Cook 1 was not wearing any type of hair covering. On 2/27/24 at 11:19 AM, an observation was made of the Maintenance Manager. The Maintenance Manager was observed walking through the kitchen with no hair covering. On 2/27/24 at 12:18 PM. an observation was made of the Assistant Dietary Manager. The Assistant Dietary Manager was observed walking throughout the kitchen, into and out of the walk-in refrigerator, and preparing a dessert item with no hair covering. On 2/28/24 at 3:17 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she did not require male kitchen staff to wear hair coverings if their hair was very short, and had not required staff who had a beard to wear hair coverings for their beards. The DM stated the Maintenance Manager came into the kitchen occasionally and did not wear hair coverings while in the kitchen. The DM stated kitchen staff with longer hair could wear a ball cap as a hair covering as long as they were clean shaven.

Based on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air, and food items in the walk-in refrigerator were past the manufacturers use-by date. Findings included: On [DATE] at 9:06 AM, an initial walk-through of the kitchen area was conducted. In the walk-in refrigerator, a container of sour cream with an open date of [DATE], and a use-by date of [DATE], was observed. A container of cottage cheese was also observed with a use-by date of [DATE]. On [DATE] at 9:15 AM, an observation was made of the walk-in freezer. A box of frozen doughnut-holes were observed open to air. A box of pre-made omelets were also observed open to air. On [DATE] at 3:00 PM, a second walk-through was conducted of the kitchen. In the walk-in refrigerator, the sour cream container with a use by date of [DATE], and the cottage cheese container with a use by date of [DATE], were observed to still be in the refrigerator. In the walk-in freezer, an observation was made of the doughnut-holes open to air, the pre-made omelets open to air, and a box of ready to cook turkey breast open to air. On [DATE] at 3:11 PM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated when she would pull an item out of the refrigerator, she would check the date before using the item. DA 1 stated the open date and the use by date were supposed to be wrote on the food item. DA 1 stated food items needed to be covered with a lid, cling wrap, or in a sealed container. DA 1 stated she was not sure what to do with food items that were in boxes. DA 1 stated she would not feel comfortable using food items if they were past the use by date but would ask the Dietary Manager (DM) before throwing the food item away. On [DATE] at 3:15 PM, an interview was conducted with the DM. The DM stated she was the person who checked the dates of food items in the refrigerator and freezer. The DM stated she was especially watching the dates on salad dressings as they had been receiving items that were close to the expiration date. The DM stated she would refuse items that were delivered past their use by date or expired. The DM stated once a food item was opened a use by date of 7 days out from the open date was wrote on the food item container. The DM stated this was especially for dairy products. The DM stated if food items were expired or past the use by date, they did not use the food item. The DM stated an open date should be wrote on boxed food items also, and food items in the refrigerator and freezer should be closed or put in a zip-lock baggies for storage. The DM stated food items in boxes could also be taped back up to prevent contamination. The DM stated she went through the refrigerator every couple of days to ensure food items were not expired. The DM was shown the sour cream and cottage cheese in the walk-in refrigerator and acknowledged that they were past the use by and expiration dates and should have been thrown away. The DM removed the items from the walk-in refrigerator. The DM stated she would check the freezer to ensure the food items were all sealed.

Based on observation and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there were four chairs with missing seat cushions on the Memory Care Unit (MCU). Findings included: On 6/6/22 at 1:28 PM, an observation was made of four blue padded chairs without seat cushions. Two of the chairs were located in the MCU television room and the other two chairs were located in the MCU alcove. On 6/7/22 at 1:37 PM, an observation was made of the same four blue padded chairs on the MCU without seat cushions. On 6/7/22 at 1:44 PM, an interview was conducted with Registered Nurse (RN) 1 and Speech Therapist (ST) 1 on the MCU. RN 1 and ST 1 stated that the seat cushions from the four padded blue chairs on the MCU had been soiled and removed by housekeeping. RN 1 and ST 1 further stated that the seat cushions had been missing from the MCU for about a month. On 6/8/22 at 9:16 AM, an observation was made of the same four blue padded chairs on the MCU without seat cushions. On 6/8/22 at 11:33 AM, an interview was conducted with the Housekeeping Manager (HM). The HM stated that the four seat cushions from the MCU had become soiled and she had taken them to the laundry area to clean them. The HM stated she had removed the four seat cushions from the MCU about a week ago. The HM stated she was going to clean and return the seat cushions later today. On 6/8/22 at 12:47 PM, an interview was conducted with the Administrator. The Administrator stated she expected soiled furniture to be cleaned and returned within a day or two.

Based on interview and record review, it was determined, that the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F812 which was cited within the facility's 2017, 2018, and 2019 recertification survey. In addition, the facility was found to be in non-compliance with F584 which was cited within the facility's 2019 recertification survey. Findings included: An annual recertification survey was completed on 9/27/17. During the survey deficiency F371 (F812) was cited. An annual recertification survey was completed on 12/12/18. During the survey deficiencies F641, F697, F732, F756, F760, and F812 were cited. An annual recertification survey was completed on 12/19/19. During the survey deficiencies F554, F580, F584, F600, F609, F656, F676, F689, F695, F759, F760, F761, and F812 were cited. 1. Based on observation and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there were four chairs with missing seat cushions on the Memory Care Unit. [Cross Reference F584] 2. Based on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air, and food items in the walk-in refrigerator were past the manufacturers use-by date. [Cross Reference F812] On 6/8/22 at 3:36 PM, an interview was conducted with the Administrator. The Administrator stated that all of the leadership team and both Certified Nursing Assistant coordinators attended the monthly QAA meeting. The Administrator stated that the Medical Director attended the QAA meeting monthly and the Pharmacist was invited. The Administrator stated that QAA concerns would come from the floor or the nursing department. The Administrator stated that what ever concerns were sent to her were sent to Quality Assurance and Performance Improvement. The Administrator stated that the kitchen had been discussed in the QAA meeting. The Administrator stated a Manager was responsible for assisting with serving all meals and eating a meal tray once a day. The Administrator stated a Manager would inspect the kitchen once a month. The Administrator stated a Manager was scheduled to be in the facility six days a week.

Based on interview and record review it was determined, for 5 of 5 sampled facility staff members, that the facility did not ensure that testing of all facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on the county positivity rate, was not completed two times a week. Staff identifiers: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5. Findings include: On 10/18/21, a list of staff that were unvaccinated were provided. Staff 1, Staff 2, Staff 3, Staff 4 and Staff 5 were indicated as unvaccinated. According to the Center for Disease Control and Prevention (CDC) the community transmission was red for the weeks of 9/20/21, 9/27/21, 10/4/21, 10/12/21 and 10/18/21. https://covid.cdc.gov/covid-data-tracker/#county-view|Utah| |Risk|community_transmission_level On 10/18/21 the facility surveillance testing log for September 2021 and October 2021 were reviewed. Staff testing was reviewed for the following unvaccinated staff members: a. Staff 1 testing was completed on 9/12/21 using [MEDICATION(S)] testing. Staff 1 testing was completed on 9/23/21 with an [MEDICATION(S)] test, 9/24/21 with polymerase chain reaction (PCR) test, 10/8/21 with PCR test, and 10/15/21 with [MEDICATION(S)] test. Staff 1 was not tested the week of 9/26/21 through 10/2/21 and during the week of 10/3/21 though 10/9/21, staff 1 was only tested on ce that week. Staff 1 was also tested on ce the week of 10/10/21 through 10/17/21. b. Staff 2 testing was completed on 9/15/21 and 9/19/21 with [MEDICATION(S)] tests. Staff 2 was tested during the weeks of 9/21/21 and 10/4/21 with PCR tests. Staff 2 was tested [DATE], 10/7/21 and 10/10/21 with [MEDICATION(S)] tests. Staff 2 was tested [DATE] with a PCR test. Staff 2 was not tested twice the week of 9/26/21 through 10/2/21. c. Staff 3 testing was completed on 9/14/21 with an [MEDICATION(S)] test, 9/21/21 with PCR test, 10/4/21 with PCR test, 10/5/21 with [MEDICATION(S)] test, 10/7/21 with [MEDICATION(S)] test, 10/10/21 with [MEDICATION(S)] test, and 10/12/21 with PCR test. Staff 3 was not tested twice weekly during the weeks of 9/12/21 through 9/18/21, and 9/19/21 through 9/25/21. Staff 3 was not tested the week of 9/26/21 through 10/2/21. d. Staff 4 testing was completed with [MEDICATION(S)] testing on 9/30/21. Staff 4 did not have twice weekly testing from the start of the outbreak on 9/19/21 through 10/18/21. e. Staff 5 was hired on 9/14/21. Staff 5 testing was completed with [MEDICATION(S)] testing on 9/14/21 and 9/22/21. Staff 5 did not have additional testing. Review of the staff schedules for September 2021 and October 2021 revealed the following: a. Staff 1 was scheduled to work on 9/23/21, 9/24/21 ,9/25/21, 9/30/21, 10/1/21, 10/2/21, 10/7/21, 10/8/21, 10/9/21, 10/14/21, 10/15/21, 10/16/21. The schedule revealed calloff sick on 10/15/21. b. Staff 2 was scheduled to work 9/19/21, 9/20/21, 9/21/21, 9/22/21, 9/23/21, 9/26/21, 9/27/21, 9/28/21, 10/3/21, 10/4/21, 10/5/21, 10/6/21, 10/10/21, 10/11/21, 10/12/21, 10/13/21, 10/17/21 and 10/18/21. c. Staff 3 was scheduled to work 9/30/21, 10/1/21, 10/5/21, 10/7/21, 10/12/21 and 10/14/21. d. Staff 4 was scheduled to work on 10/1/21, 10/2/21, 10/3/21, 10/8/21, 10/13/21, 10/14/21, 10/15/21, and 10/17/21. The schedule revealed that staff 4 was a no call, no show on 10/3/21 and on 10/17/21 staff 4 calloff. e. Staff 5 was scheduled to work on 9/30/21 and 10/6/21. On 10/19/21, The Infection Preventionist (IP) provided information that Staff 4 had been vaccinated. On 10/19/21 at 1:50 PM, an interview was conducted with the IP. The IP stated that she was unable to find PCR testing for staff 4 and 5. The IP stated that staff 4 and 5 were part time and as needed. On 10/20/21 at 11:23 AM, an interview was conducted with the IP and Administrator. The IP stated that on 9/1/21 the community transmission rate was above 10.0%, so unvaccinated staff were to test twice weekly for COVID-19. The IP stated that on 9/6/21 the percent dropped to 9.7%, on 9/14/21 was 9.1%, on 9/21/21 was 9.0%, on 9/28 was 8.9%, on 10/5 was 9%, on 10/12 was 9.6% which rate was for unvaccinated to be tested weekly. The IP stated that testing was done from Sunday to Saturday for the twice weekly status. The IP stated that twice weekly testing for unvaccinated staff was required when transmission rates were over 10%. The IP stated there was an outbreak that started on 9/19/21 with 2 residents that tested positive. The IP stated that she sent a text to staff that all staff, both vaccinated and unvaccinated, were to be tested twice weekly. The IP stated that there were supervisors available to test staff 24 hours per day 7 days a week. The IP stated that sometimes there were problems with the night supervisors getting the testing completed.

Based on interview and record review it was determined, for 3 of 28 sampled residents, that the facility did not consult with the residents physician when there was a need to alter treatment significantly. Specifically, the physician was not notified when 1 resident's insulin was held, 1 resident refused insulin, one resident's blood pressure was elevated, and medication was substituted for another medication without Medical Doctor (MD) notification. Resident identifiers: 29, 40, and 41. Findings include: 1. Resident 41 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 12/18/19, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 41. RN 1 stated that resident 41 would always refuse the Humalog insulin. RN 1 was observed to document a refusal on the Medication Administration Record [REDACTED]. Resident 41 stated yes just the [MEDICATION NAME] at this time. A record review for resident 41 was completed on 12/18/19. A physician's orders [REDACTED]. A start date of 2/28/19 to be administered at 7:30 AM. A review of the October, November, and (MONTH) 2019 MAR indicated [REDACTED]. No documentation could be located in the medical record of MD notification of refusals. A physician's orders [REDACTED]. A start date of 2/28/19 to be administered at 11:30 AM. A review of the October, November, and (MONTH) 2019 MAR indicated [REDACTED]. No documentation could be located in the medical record of MD notification of refusals. A physician's orders [REDACTED]. A start date of 2/27/19 to be administered at 4:30 PM. A review of the October, November, and (MONTH) 2019 MAR indicated [REDACTED]. No documentation could be located in the medical record of MD notification of refusals. A physician's orders [REDACTED]. If 0-59 give juice and notify MD, 60-149 give 0, 100-250 give 1, 251-300 give 2, 301-350 give 3, 351-400 give 4, and 401-999 give 5 and call MD subcutaneously 4 times a day for diabetes mellitus. No nightly sliding scale insulin unless above 250 give 1 unit for every 50 above 250. Administer insulin after eating with a start date of 11/2/19. A review of the October, November, and (MONTH) 2019 MAR indicated [REDACTED]. In addition, resident 41's blood glucose was above 508 on 12/3/19. No documentation could be located in the medical record of MD notification of refusals. 2. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review for resident 40 was completed on 12/18/19. A physician's orders [REDACTED]. Notify MD if blood glucose was below 70 or above 350. With a start date of 10/18/2019. A review of the October, November, and (MONTH) 2019 MAR indicated [REDACTED]. No documentation could be located in the medical record of MD notification when the insulin was held. 3. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [NAME] On 12/18/19, RN 1 was observed to prepare and administer medications to resident 29. RN 1 was observed to use a battery operated wrist blood pressure cuff to obtain resident 29's blood pressure and pulse. RN 1 stated she was obtaining these vital signs to determine if resident 29's [MEDICATION NAME] should be administered. Resident 29's blood pressure was 181/93 and a pulse of 44. RN 1 was observed to not administer the [MEDICATION NAME] to resident 29. A record review for resident 29 was completed on 12/18/19. A review of physician's orders [REDACTED]. i. [MEDICATION NAME] extended release (ER) tablet 25 milligrams (mg). Give 12.5 mg by mouth one time a day related to essential (primary) hypertension. Hold for Systolic blood pressure (SBP) <100 and/or Apical pulse of <50. Apical pulse per MD order needs to be counted for a minimum of 30 seconds. Notify MD if pulse <35. A start date of 12/18/19. ii. [MEDICATION NAME] ER tablet 25 mg. Give 12.5 mg by mouth one time a day related to essential (primary) hypertension. Hold for SBP <100 and/or Apical pulse of <50. Apical pulse per MD order needs to be counted for a minimum of 30 seconds. A start date of 11/21/19 and an end date of 12/17/19. A review of the (MONTH) 2019 MAR indicated [REDACTED]. (Note: Resident 29's blood pressures were hypertensive all 15 days they were recorded in the month of December. The SBP ranged from 136 to 181 and the diastolic blood pressure ranged from 72 to 98. No documentation could be located in the medical record of MD notification when the [MEDICATION NAME] was held, or for elevated blood pressures.) On 12/18/19 at 12:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would only hold insulin after speaking to a supervisor and a physician with her reasoning. On 12/18/19 at 1:07 PM, an interview was conducted with LPN 2 . LPN 2 stated some medications have parameters to hold. LPN 2 stated that if a medication did not have parameters to hold she would not hold the medication on her own and would notify the MD for permission to hold. LPN 2 stated that she would notify the MD if a medication was refused 2 or 3 times and would ask the MD to review the medication for readjustment. LPN 2 further stated that if insulin was refused she would notify the MD. LPN 2 stated that if a resident was having hypertension frequently she would notify the MD and have the MD reevaluate the residents medications. On 12/18/19 at 1:23 PM, an interview was conducted with RN 1. RN 1 stated that a physician would be notified if a resident refused medications more than a couple of times. On 12/19/19 at 7:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that the MD should be notified if a medication needed to be held without parameters. ADON 1 stated that medication should not be held unless there was an order to hold it based on the vital signs. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that medication with parameters were located in the physician's orders [REDACTED]. The DON stated that if a blood pressure was really high, or out of range, the physician should definitely be notified. On 12/19/19 at 9:01 AM, an interview was conducted with MD 1. MD 1 stated that her expectation would to be notified if insulin had been held or refused. MD 1 stated that she would expect to be notified of hypertension, and if she would have been notified of resident 29's elevated blood pressure on 12/18/19, and the trend of elevated blood pressures she would have reviewed his medications. B. On 12/16/19 at 11:41 AM, an interview was conducted with resident 29. Resident 29 stated he had pain in his lower back because he had 7 operations with a tumor on his sacrum. Resident 29 stated that his C2 and C7 were fused, 3 Lumbar's were fused, and L3 had been fractured. Resident 29 stated that he also had scoliosis. Resident 29 stated that he had surgery on a pinched nerve in his neck. Resident 29 stated that his pain was usually a 7 to 8 and down to a 0 if he was sitting still after taking pain medications. (Note: The pain scale was 0 no pain and 10 excruciating pain.) On 12/17/19 at approximately 2:00 PM, an observation was made of resident 29 telling RN 1 that he was having pain in his neck. RN 1 asked resident 29 if he wanted his cream rubbed on his neck. Resident 29 stated he wanted the cream rubbed on his neck. RN 1 was observed to pump cream from a large container labeled biofreeze and rubbed it into resident 29's neck using a gloved hand. Resident 29 was observed to thank RN 1 and stated his neck felt better. Resident 29's medical record was reviewed on 12/18/19. A physician's orders [REDACTED]. On 12/18/19 at 9:10 AM, an interview was conducted with RN 1. RN 1 stated that she applied biofreeze to resident 29's neck on 12/17/19. RN 1 stated that resident 29 had a physician's orders [REDACTED]. On 12/18/19 at 10:40 AM, an interview was conducted with LPN 4. LPN 4 stated that resident 29 requested Biofreeze on his neck. LPN 4 stated that resident 29 received Biofreeze as he requested it. LPN 4 stated that she rubbed Biofreeze into his neck this morning. LPN 4 stated that she was not aware that the order was for [MEDICATION NAME] Cream. LPN 4 stated that she had not reported that resident 29 was requesting Biofreeze instead of [MEDICATION NAME] Cream. LPN 4 was observed to look for the [MEDICATION NAME] Cream for resident 29. LPN 4 stated she did not have [MEDICATION NAME] Cream available for application. On 12/18/19 at 12:14 PM, an interview was conducted with Pharmacist 1. Pharmacist 1 stated that Biofreeze and [MEDICATION NAME] cream were very different medications. Pharmacist 1 stated that the [MEDICATION NAME] 4% would last longer for pain relief. Pharmacist 1 stated the the two creams had different active ingredients for pain relief. On 12/18/19 at 12:20 PM, an interview was conducted with Pharmacy Technician (PT) 1. PT 1 stated that the pharmacy did not have a history of delivering [MEDICATION NAME] 4% cream for resident 29. PT 1 stated that a 5% [MEDICATION NAME] was delivered on 9/11/17. PT 1 stated that [MEDICATION NAME] cream was specific for resident's so an individual tube with the resident's name would be delivered to the facility. On 12/18/19 at 2:24 PM, an interview was conducted with the DON. The DON stated that biofreeze and [MEDICATION NAME] were different medications. The DON stated that he had not contacted the Nurse Practitioner regarding interchanging the creams. On 12/19/19 at 9:23 AM, an interview was conducted with MD 1. MD 1 stated that she had not been notified that resident 29 was receiving Biofreeze instead of [MEDICATION NAME] cream. MD 1 stated that staff should notify her if the resident requested a change in creams or if the resident was experiencing pain.

Based on interview, observation, and record review it was determined, for 7 of 28 sampled residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, the facility did not provide services to prevent one resident from having multiple resident to resident altercations that included physical contact with other residents. Resident identifiers: 4, 9, 11, 12, 21, 37, and 61. Findings include: Resident 11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/16/19 at 10:37 AM, an observation was made of resident 11 in the activity/TV room watching television. At 11:05 AM, resident 11 was observed to self-propel out of the TV room. Resident 11 encountered another resident. Resident 11 kept self-propelling towards the resident trying to get past, with wheelchair wheels in path and right next to another residents feet, hitting his wheelchair wheels into the other residents wheelchair wheel. The other resident then propelled his wheelchair back enough for resident 11 to pass. There was no staff present in the activity room during the 28 minute observation, or during the resident to resident interaction. Resident 11 was also observed in the activity/TV room with other residents and no staff present the following days and times: 12/16/19 at 12:20 PM, 12/16/19 at 1:15 PM, 12/18/19 at 9:35 AM, and 12/18/19 at 1:21 PM. Resident 11's medical record was reviewed on 12/18/19. The following resident to resident incidents were documented: a. On 1/8/19, resident 11 started swearing and struck resident 4 in the chest, resident 4 struck resident 11 back in the arm. b. On 1/12/19, resident 11 hit resident 9 several times in the back as witnessed by a staff member in the restorative dining room. c. On 1/24/19, resident 11 hit resident 37 2 times in the arm while in the activity room. d. On 3/31/19, resident 11 hit resident 12 two times in his right shoulder blade in the hallway. e. On 4/5/19, resident 11 ran over resident 61's toes while self-propelling during a musical performance activity. Resident 11 then started swinging at resident 61, resident 61 then held resident 11's hands down on wheelchair. f. On 5/8/19, resident 11 told resident 9 to shut up and swung to hit her. Resident 9 denied being hit. g. On 5/29/19, resident 11 was in his wheelchair in the hallway when resident 61 walked past. Resident 11 then started yelling profanities and struck resident 61 in the arm 3 times. h. On 8/10/19, resident 11 hit a resident in her left bicep while in the TV room in front of the bird's cage. i. On 9/27/19, resident 11 was observed in the activity/TV room swearing and kicking resident 21. A review of resident 11's progress notes revealed the following progress notes of additional aggressions towards other residents. a. On 9/24/19 at 8:22 PM, a progress note documented, continues to have verbally aggressive behaviors towards staff and other residents, he uses foul language and obscene gestures. NO physically aggressive behavior noted at this time. b. On 9/28/19 at 12:42 PM, a progress note documented, has had several outbursts today. Attempting to hit a resident, swatting at people walking by and shouting out cuss words. c. On 10/18/19 at 11:34 AM, a progress note documented, Behaviors today: This am (resident 11) .when he got close to the other resident, nurse pushed (resident 11) wheelchair away, and he yelled 'son of a [***] , I hate him', trying to swing at he (sic) other resident, but he was not close enough and didn't touch the other resident. d. On 11/3/19 at 10:06 AM, a progress note documented, (Resident 11) was rolling his wheelchair down the hall and one of the residents was sitting on the middle, facing the opposite side of him when (name removed) started yelling at the resident 'f you, f you, I hate you' while pushing his wheelchair towards the resident. Nurse interviewed before he hit the other residents. e. On 11/3/19 at 4:40 PM, a progress note documented, Behaviors: wife was called and she came. She stayed with him for a while. When she left (resident 11) was showing signs of aggression again towards any resident ahead of him Nurse removed him 2 times right before he punched another resident that was not looking at him. Resident had to be removed from the common area. MD (Medical Doctor) and family notified. A care plan Focus initiated on 2/23/16 and revised on 8/30/18, documented (Resident 11) uses anti-anxiety medications related to Anxiety disorder, and antidepressants for his tearfulness. He has verbally and physically aggressive behavioral symptoms attributed to his TBI ([MEDICAL CONDITION]). The Goal initiated on 2/23/16 and revised on 10/2/19, documented (resident 11) will be free from discomfort or adverse reactions related to anti-anxiety therapy and antidepressants through the review date. He will not have an increase in verbal or physical aggression towards others through next review. (resident 11) will not have an increase in banging on furnishings during the nighttime. Resident to Resident: 2/24/16, 3/7/16, 3/29/18, 5/16,18, 5/23/18, 7/22/18, 11/1/18, 12/9/18, 1/8/19, 1/12/19, 1/24/19, 3/31/19, 4/5/19, 5/8/19, 5/29/19, 8/10/19, 9/27/19. The Interventions developed were: a. Assist (resident 11) when he appears 'trapped' in common areas to prevent verbal or physical aggression towards others. He has cursed, yelled and hit others whom he observes as obstacles in his path. Date initiated 10/3/19. b. Assist (resident 11) with navigating the hallways as he will allow to prevent him from bumping into others and diffuse conflicts that arise. Date initiated 1/14/19. c. Calm Reassurance. Date initiated 5/23/19. d. Care partners will monitor (resident 11) and provide redirection as necessary to assist him with navigating his wheelchair safely in an effort to prevent conflict with others. Date initiated 4/12/19. e. Care partners will redirect (resident 11) away from others he has shown aggression toward in an effort to prevent further incidents. (Resident 11) has expressed dislike for another individual whom he dines in the same area with. Date initiated 1/17/19. f. Help create a clear path for (resident 11) to exit the therapy gym as he self-propels his wheelchair. Provide physical space between (resident 11) and other residents whom he has previously had physical aggression towards. Date initiated 5/23/18. g. Intervene and separate (resident 11) from others if he is showing verbal and/or physical aggression toward others to promote safety. Date initiated 12/13/18 and revised on 5/23/19. h. (Resident 11) cursing and verbal outburst may be distressing to others. Care partners will redirect him from common areas when he is visibly upset to prevent conflict with others. Date initiated 1/29/19. i. Maintenance of daily routine and caregivers as possible. Date initiated 5/23/17. j. Quarterly review with IDT (interdisciplinary) team. Date initiated 5/23/16. k. Quiet environment. Date initiated 5/23/17. l. Redirect (resident 11) from others when he is expressing frustration or imposing on their personal space or interfering with their dining experience. Helping him to his room to calm down may be effective. Date initiated 5/25/18. m. Separate (resident 11) from others if an argument occurs to prevent escalation as he may swear and threaten others. Date initiated 4/5/18. On 12/18/19 at 12:59 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 11 will go to bingo but was often agitated, and that he liked to watch football in the tv room. CNA 2 stated that resident 11 was aggressive with other residents. CNA 2 stated she did not know any preventative measures in place for resident 11 to prevent resident to resident altercations. CNA 2 stated that resident 11 behaviors just come out of nowhere, one second he is fine and the next swearing and yelling. On 12/18/19 at 1:01 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 11 attended music programs and watched music on tv in the tv room. CNA 3 stated that resident 11 had a history of [REDACTED]. CNA 3 stated that if resident 11 was trying to leave a room and someone was in the way resident 11 would just continue to keep running into other residents. CNA 3 stated that if resident 11 was doing this type of behavior he was taken to the nurse to sit one on one with him, and if an altercation was witnessed the nurse, and a supervisor was notified. On 12/18/19 at 1:07 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 11 had been combative in the past, but that he was doing better on his new medications. LPN 2 stated that resident 11 was sometimes agitated when he was constipated or in pain. LPN 2 stated that preventative measures for resident 11 to prevent resident to resident altercations was to be aware of who he is around, and if he was in the tv room it was best if someone was in there to watch, and keep him away from someone who triggers him. LPN 2 stated that mostly CNA staff and nurses knew where resident 11 was, and when he was getting agitated he would start swearing and the staff would intervene. LPN 2 stated that if a resident to resident occurred she removed residents, notified the family, MD, and supervisors. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident to resident altercation occurred the process was to dive in to see what the resident to resident was. The DON stated if there was any mental anguish or physical contact, then he would report to the state and come up with a solution to limit the altercation from happening again. The DON stated that it was a struggle with resident 11 because resident 11's wife would not let the staff use medication on resident 11. The DON stated that when the staff were able to get resident 11 on medication the resident to resident altercations had resolved. The DON stated that for resident 11 it required anticipation, and they usually put him close to have eyes on him so that he can be removed quickly. The DON stated that the supervisors usually had eyes on resident 11 or they would put resident 11 in an activities. The DON stated that often resident 11 would use the ipad or watch television. On 12/19/19 at 10:22 AM, an interview was conducted with the Administrator. The Administrator stated that the facility staff all watch resident 11 and removed resident 11 if he was getting agitated but the staff could not always catch resident 11. The Administrator stated that the facility tried some medication adjustments but the wife would always want the orders changed. The Administrator stated that she had spoke to resident 11's wife on several occasions about transferring resident 11 but the wife wanted nothing to do with it. The Administrator stated that during the last meeting with resident 11's wife and son she spoke to them about paying for a one on one staff member to sit with resident 11. The Administrator stated that the family did not want to pay for a one on one so the family agreed to let the staff adjust resident 11's medications. The Administrator stated that when stretching the facility to stay staffed it would be difficult to staff a one on one with a resident. The Administrator stated that staffing a one on one with resident 11 even if it were for 16 hours a day would not be logical, staffing with certified nursing assistants right now is so hard. The Administrator stated that if there had been an injury resulting from one of resident 11's resident to resident altercations that resident 11 would have been transferred out to a psych (psychiatric) facility.

Based on interview and record review it was determined, for 8 out of 28 sampled residents, that the facility did not ensure that the violations involving abuse including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury. Specifically, an injury of unknown origin was initially reported to the State Survey Agency 7 hours and 30 minutes after the incident was reported to the Administrator. In addition, resident to resident altercations were not reported timely to the State Survey Agency and Adult Protective Services (APS). Resident identifiers: 4, 9, 11, 12, 21, 37, 51, and 61. Findings include: 1. Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/16/19 at 11:24 AM, resident 51 was observed in a wheelchair in the day room. Resident 51 was observed to have a splint on his left foot and a cast on his right arm. Resident 51's medical record was reviewed on 12/17/19. A review of the Progress Notes documented the following entries: a. On 10/30/19 at 3:23 PM, Resident has complaints that his right forearm is hurting. There is no bruising or redness noted. MD (Medical Doctor) notified. b. On 10/30/19 at 5:25 PM, New order per (Name of MD): x-ray 2 views of the right elbow and of the right radius and ulna. c. On 10/30/19 at 8:50 PM, a Nursing Progress Situation, Background, Assessment, Recommendations (SABR) Note documented, (Resident 51) reports c/o (complaints of) Guarding his right arm, cries out in pain if it is moved. XRAY tech (technician) came-angle fx (fracture) is visible to nurse who in (sic) not trained in reading xrays. There is actually a corresponding bump on his arm, that began on 10/30/2019 12:00 AM and have (sic) gotten worse since the onset. Moving make (sic) the symptoms worse, while Not moving improve the symptoms. These symptoms have not occurred before. Severe Osteopenia was dx (diagnosis). last fx. d. On 10/30/19 at 9:40 PM, (Family member name) was contacted about FX in Rt (right). Ulna and that he would probably go to (Hospital name) ER (emergency room ) for treatment. e. On 10/31/19 at 12:18 AM, Finally got xray report. Mildly angulated, comminuted fx. of the mid-distal right ulna with medical angulation of the distal fragment relative to the proximal fragments. (MD name) notified. Order to send to ER to manage pain-cast/splint. Nurse called (transportation company name) r/t (related to) displaced fx. and risks for displacing fx. further with transport. EMT's (emergency medical technicians) had a splint they formed to his arm, and placed in sling. HE tolerated transport well. He had been given his nightly tylenol and and [MEDICATION NAME] as ordered. Plus we had pillow splinted for comfort while he was in bed. Res. (residents) bones fragile. f. On 10/31/19 at 1:39 AM, ER called they have placed a 'sugar toned (sic) splint' they are sending resident back by ambulance d/t (due to) fragility. He will have an f/u (follow up) appt. (appointment) with ortho (orthopedics). g. On 10/31/19 at 8:07 AM, a Geriatric Nurse Practitioner (GNP) Medical Necessity/focus Visit Note documented . Yesterday he seemed to indicate pain at the right elbow area. Mechanism of injury is not known. Symptoms: immediate pain, delayed swelling, inability to use arm directly after injury. Symptoms have been waxing and waning since that time. Prior history of related problems: no prior problems with this area in the past. h. On 11/1/19 at 6:31 PM, a Physician/Practitioner Note documented . Right ulnar fragility fracture: per staff report that I have knowledge of and the radiology reading of a spiral fracture I suspect this may have occurred while he was grabbing something (bar or door or aid's ((Certified Nursing Assistants)) arm are all possible) as aides were trying to bathe/shower him. He has known severe [MEDICAL CONDITION] with several previous fragility fractures. In the setting of his dementia goals of care have been to focus on palliative approach with treatment focused on management of pain and prioritizing comfort. An Incident Report for Injury of Known Cause dated 10/29/19 at 7:30 AM, documented Nursing Description: Aide reported to nurse that Resident was agitated, trying to hit the aide and refused his shower. Aide also reported that while trying to go into the shower room, the resident had grabbed the doorway and clung on to it as he tried to go through. So he took the resident back to his room and laid him down. Ralph continued to try to hit the aide and yelled at the aide so he reported to the nurse. A review of the facility reported incident investigation documented the following entries: a. On 10/31/19 at 9:30 AM, the Administrator was notified. b. On 10/31/19 at 5:00 PM. the State Survey Agency was notified. On 12/18/19 at 12:14 PM, an interview was conducted with the Social Services Assistant (SSA). The SSA stated that the Administrator was the abuse coordinator. The SSA stated that she would complete the investigation and the documentation. The SSA stated that she would notify Adult Protective Services and start the process of the Investigation Checklist. The SSA stated that she would review the nursing documentation and interview anyone that might have knowledge of the incident. The SSA stated that as soon as the incident was reported to her, she would investigate the incident, and the final document was reported to the State Department of Health within 5 working days. The SSA further stated that the Administrator notified the State Department of Health and that was how she would get the complaint number for the investigation. On 12/18/19 at 12:22 PM, an interview was conducted with the Administrator. The Administrator stated that the notification to the State Department of Health regarding the incident with resident 51 was reported late. The Administrator stated that the staff were unsure if the incident with resident 51 was abuse. The Administrator stated that resident 51 was very brittle and she did not think the incident was abuse. The Administrator stated that the incident was reported late and there were no excuses. The Administrator stated that the incident was an injury of unknown origin and it should have been reported timely. 2. Resident 11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11's medical record was reviewed on 12/16/19. A review of the incident reports revealed the following incidents, and the following date and times reported to the applicable agencies. a. On 1/8/19, resident 11 started swearing and struck resident 4 in the chest, resident 4 struck resident 11 back in the arm. This event occurred on 1/8/19 at 6:15 PM. i. Notification to the State Survey Agency occurred on 1/8/19 at 7:30 PM. ii. Notification to APS occurred on 1/9/19 at 12:30 PM. (Note: The APS reporting occurred more than 2 hours after the incident initially occurred and was reported to the facility administrator.) b. On 1/12/19, resident 11 hit resident 9 several times in the back as witnessed by a staff member in the restorative dining room. This even occurred on 1/12/19 at 6:15 AM. i. Notification to the State Survey Agency occurred on 1/12/19 at 9:14 AM. (Note: The State Survey Agency reporting occurred more than 2 hours after the incident initially occurred and was reported to the facility administrator.) ii. Notification to APS occurred on 1/14/19 at 12:00 PM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator.) c. On 1/24/19, resident 11 hit resident 37 2 times in the arm while in the activity room. This event occurred on 1/24/19 at 4:40 PM. i. Notification to the State Survey Agency occurred on 1/24/19 at 4:40 PM. ii. Notification to APS occurred on 1/25/19 at 10:30 AM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. d. On 3/31/19, resident 11 hit resident 12 two times in his right shoulder blade in the hallway. This event occurred on 3/31/19 at 1:00 PM. i. Notification to the State Survey Agency occurred on 3/31/19 at 2:51 PM. ii. Notification to APS occurred on 4/1/19 at 11:40 AM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. e. On 4/5/19, resident 11 ran over resident 61's toes while self-propelling during a musical performance activity. Resident 11 then started swinging at resident 61, resident 61 then held resident 11's hands down on wheelchair. This event occurred on 4/5/19 at 7:08 PM. i. Notification to the State Survey Agency occurred on 4/5/19. ii. Notification to APS occurred on 4/8/19 at 10:10 AM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. f. On 5/8/19, resident 11 told resident 9 to shut up and swung to hit her. Resident 9 denied being hit. This event occurred on 5/8/19 at 4:25 PM. i. Notification to the State Survey Agency occurred on 5/8/19 at 5:49 PM. ii. Notification to APS occurred on 5/9/19 at 4:54 PM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator.) g. On 5/29/19, resident 11 was in his wheelchair in the hallway when resident 61 walked past. Resident 11 then started yelling profanities and struck resident 61 in the arm 3 times. This event occurred on 5/29/19 at 7:01 PM. i. Notification to the State Survey Agency occurred on 5/29/19 at 7:07 PM. ii. Notification to APS occurred on 5/30/19 at 2:05 PM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. h. On 8/10/19, resident 11 hit a resident in her left bicep while in the TV room in front of the bird's cage. This event occurred on 8/10/19 at 10:15 AM. i. Notification to the State Survey Agency occurred on 8/10/19 at 5:45 PM. (Note: The State Survey Agency reporting occurred more than 2 hours after the incident initially occurred and was reported to the facility administrator.) ii. Notification to APS occurred on 8/12/19 at 9:00 AM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. i. On 9/27/19, resident 11 was observed in the activity/TV room swearing and kicking resident 21. This event occurred on 9/27/19 at 10:00 AM. i. Notification the State Survey Agency occurred on 9/27/19 at 11:41 AM. ii. Notification to APS occurred on 9/24/19 at 12:57 PM. (Note: The APS reporting occurred more than 2 hours after incident initially occurred and was reported to the facility administrator. ) On 12/19/19 at 11:07 AM, an interview was conducted with the Administrator. The Administrator stated that the state agency was notified of potential abuse allegations by herself, the Director of Nursing, or the charge nurses at night. The administrator stated that the social worker notified APS and the Ombudsman of potential allegations of abuse the next time she was at the facility, and that APS had not been notified on off hours, but that they can change that process.

Based on observation, interview, and record review it was determined, for 2 of 28 sampled residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 46 medication opportunities on 12/18/19, revealed 5 medication errors which results in a 10.87 % medication error rate. Specifically, one resident was given the wrong dose of medication, one resident was given a substitute medication, one resident was given the wrong medication, and one residents physician's order for administration was not followed. Resident identifiers: 41 and 29. 1. Resident 41 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 12/18/19 at 8:08 AM, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 41. RN 1 administered one 5 milligram (mg) tablet of memantine to resident 41. Resident 41's medical record was reviewed for the reconciliation of medications on 12/18/19. According to the Physician's order, resident 41 was to receive Memantine 5 mg, give 10 mg. 2. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/19 at 8:27 AM, RN 1 was observed to prepare and administer medications to resident 29. The following observations were observed: a. [MEDICATION NAME] cream 4% was marked refused on the Medication Administration Record [REDACTED]. No physician's order for Biofreeze could be located in resident 29's medical record. On 12/18/19 at 8:43 AM, an interview was conducted with resident 29. Resident 29 stated that he did not refuse his [MEDICATION NAME] cream, and that he did want it. b. [MEDICATION NAME] 2 plastic spoons of [MEDICATION NAME], mixed in 4 ounces of water with [MEDICATION NAME]. According to the physician's order, resident 29 was to receive [MEDICATION NAME] Fiber Packet ([MEDICATION NAME]) Give 1 packet by mouth one time a day for constipation. c. [MEDICATION NAME] 12.5 mg was not administered and was held for a pulse of 44. RN 1 obtained resident 29's blood pressure and pulse with an electronic wrist blood pressure cuff. According to the physician's order, resident 29 was to receive [MEDICATION NAME] Extended Release Tablet 25 mg. Give 12.5 mg by mouth one time a day related to Essential (primary) Hypertension. Hold for Systolic Blood Pressure <100 and/or Apical pulse of <50. Apical pulse per physician's order needs to be counted for a minimum of 30 seconds. Notify Medical Doctor if pulse <35. d. Prosight one tablet was administered. According to the physician's order, Resident 29 was to receive [MEDICATION NAME]-[MEDICATION NAME] Capsule (multivitamin- minerals) Give 1 capsule by mouth two times a day for eye vitamins. On 12/18/18 at 10:33 AM, an interview was conducted with Pharmacist 1. Pharmacist 1 stated that there were several manufactures that produce eye vitamins with [MEDICATION NAME]. Pharmacist 1 stated that if the Prosight medication had [MEDICATION NAME] in it, it would be a suitable substitute for the [MEDICATION NAME]-[MEDICATION NAME]. On 12/18/19 at approximately 11:00 AM, an observation was made. The Prosight vitamin that was administered to resident 29 was observed to have the following active ingredients which included Vitamin A, Vitamin C, Vitamin E, Calcium, Phosphorus, Zinc, [MEDICATION NAME], and [MEDICATION NAME]. The Prosight Vitamin did not include any [MEDICATION NAME] in the ingredient list. On 12/19/19 at 9:01 AM, an interview was conducted with Medical Director (MD) 1. MD 1 stated that resident 29's pulse should be checked with an apical pulse as the order reads for administration of the [MEDICATION NAME]. MD 1 stated that when a blood pressure and pulse was taken with a blood pressure cuff it can give an artificial low pulse if a resident has [MEDICAL CONDITION], and that was why resident 29 required an apical pulse for medication administration. On 12/19/19 at 9:51 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she had obtained the pulse for resident 29 prior to the medication administration. LPN 4 stated that she obtained resident 29's blood pressure and pulse with a blood pressure cuff. LPN 4 stated that the physician's order for resident 29's [MEDICATION NAME] had not stated to take an apical pulse. LPN 4 stated that an apical pulse would be obtained with a stethoscope listening to the resident's chest.

Based on observation, interview, and record review it was determined, for 3 of 28 sampled residents, that the facility did not ensure residents were free of any significant medication errors. Specifically, 2 residents with diabetes were not administered insulin per the physician's orders [REDACTED]. Resident identifiers: 29, 40, and 41. Findings include. 1. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 40's medical record was reviewed on 12/18/19. A physician's orders [REDACTED]. Notify Medical Doctor (MD) if blood glucose below 70 or above 350. A start date of 10/18/19. (Note: Resident 40's Insulin [MEDICATION NAME] Solution did not include parameters to hold.) A review of the October, November, and (MONTH) 2019 Medication Administration Record [REDACTED] a. On 10/20/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 89. b. On 10/20/19 at 11:40 AM, insulin was held for vitals out of parameters. Blood glucose 100. (Note: Resident 40's subsequent blood glucose was 284.) c. On 10/26/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 91. (Note: Resident 40's subsequent blood glucose was 209.) d. On 11/2/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 74. (Note: Resident 40's subsequent blood glucose was 332.) e. On 11/15/19 at 11:30 AM, insulin was held, with a code of 5 hold see nurse notes. Blood glucose 72. f. On 11/16/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 100. g. On 11/17/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 98. h. On 11/23/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 78. i. On 11/24/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 90. (Note: Resident 40's subsequent blood glucose was 230.) j. On 11/27/19, insulin was held with a code of 5 hold see nurse notes. Blood glucose 78. k. On 11/28/19, insulin was held with a code of 5 hold see nurse notes. Blood glucose 84. (Note: Resident 40's subsequent blood glucose was 232.) l. On 11/30/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 100. (Note: Resident 40's subsequent blood glucose was 348.) m. On 12/1/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 92. n. On 12/5/19 at 7:30 AM, insulin was held with a code of 5 hold see nurse notes. Blood glucose 84. (Note: Resident 40's subsequent blood glucose was 235.) o. On 12/6/19 at 7:30 AM, insulin was held with a code of 5 hold see nurse notes. Blood glucose 72. (Note: Resident 40's subsequent blood glucose of 268.) p. On 12/7/19 at 4:30 PM, insulin was held for vitals out of parameters. Blood glucose 78. (Note: Resident 40's subsequent blood glucose was 212.) q. On 12/8/19 at 7:30 AM, insulin was held for vitals out of parameters. Blood glucose 87. 2. Resident 41 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A record review for resident 41 was completed on 12/18/19. A physician's orders [REDACTED]. A start date of 2/28/19 to be administered at 7:30 AM. A physician's orders [REDACTED]. A start date of 2/28/19 to be administered at 11:30 AM. A review of the (MONTH) 2019 MAR indicated [REDACTED] a. On 12/6/19, resident 41 received a partial dose of 4 units. b. On 12/13/19, resident 41 received a partial dose of 4 units. A physician's orders [REDACTED]. A start date of 2/27/19 at to be administered at 4:30 PM. A review of the (MONTH) 2019 MAR indicated [REDACTED]. A physician's orders [REDACTED]. If 0-59 give juice and notify MD, 60-149 give 0, 200-250 give 1, 251-300 give 2, 301-350 give 3, 351-400 give 4, and 401-999 give 5 and call MD subcutaneously 4 times a day for diabetes mellitus. No nightly sliding scale insulin unless above 250 give 1 unit for every 50 above 250. Administer insulin after eating with a start date of 11/2/19. (Note: There was no sliding scale for a blood glucose between 150 and 199.) A review of the (MONTH) and (MONTH) 2019 MAR indicated [REDACTED] a. On 11/4/19 with the administration time of 6:00- 10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 238. (Note: Resident 41 should not have received insulin per the order for the nightly sliding scale.) b. On 11/7/19 with the administration time of 6:00-10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 204. (Note: Resident 41 should have not received insulin per the order for the nightly sliding scale.) c. On 11/10/19 with the administration time of 6:00-10:00 PM, resident 41 received 3 units of insulin for a blood glucose of 347. (Note: Resident 41 should have received 2 units per the order for nightly sliding scale.) d. On 11/11/19 with the administration time of 6:00-10:00 PM, resident 41 received 2 units for a blood glucose of 272. (Note: Resident 41 should have received 1 unit per the orders for nightly sliding scale.) e. On 11/20/19 with the administration time of 6:00 PM- 10:00 PM, resident 41 received 3 units of insulin for a blood glucose of 311. (Note: Resident 41 should have received 2 units per the orders for nightly sliding scale.) f. On 11/23/19 with the administration time of 6:00-10:00 PM, resident 41 received 2 units for a blood glucose of 258. (Note: Resident 41 should have received 1 unit per the orders for nightly sliding scale.) g. On 11/26/19 with the administration time of 6:00-10:00 PM, resident 41 received 4 units of insulin for a blood glucose of 370. (Note: Resident 41 should have received 3 units per the orders for nightly sliding scale.) h. On 11/27/19 with the administration time of 6:00-10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 212. (Note: Resident 41 should not have received any insulin per the order for nightly sliding scale.) i. On 12/1/19 with the administration time of 6:00 PM- 10:00 PM, resident 41 received 1 unit for a blood glucose of 221. (Note: The resident should have not received insulin per the order for nightly sliding scale.) j. On 12/8/19 with the administration time of 6:00 PM-10:00 PM, resident 41 received 1 unit of insulin for a blood glucose of 231. (Note: The resident should have not received insulin per the order for nightly sliding scale.) k. On 12/9/19 with the administration time of 6:00 PM-10:00 PM, resident 41 received 2 units of insulin for a blood glucose of 257. (Note: The resident should have received 1 unit for every 50 above 250 per the order for nightly dose of sliding scale.) l. On 12/13/19 with the administration time of 6:00 PM-10:00 PM, resident 41 received 1 unit of insulin with a blood glucose of 245. (Note: The resident should have not received insulin per the order for nightly sliding scale.) 3. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/19 at 8:27 AM, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 29. Resident 29's [MEDICATION NAME] 12.5 milligrams (mg) was not administered and was held for a pulse of 44. RN 1 obtained resident 29's blood pressure and pulse with an electronic wrist blood pressure cuff. A record review for resident 41 was completed on 12/18/19. A physician's orders [REDACTED]. Hold for Systolic Blood Pressure <100 and/or Apical pulse of <50. Apical pulse per Dr. (doctor) order needs to be counted for a minimum of 30 seconds. Notify MD if pulse is <35. Start date of 11/21/19. On 12/18/19 at 12:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would only hold insulin after speaking to a supervisor and a physician with her reasoning. On 12/18/19 at 1:07 PM, an interview was conducted with LPN 2. LPN 2 stated that some medications have parameters to hold. LPN 2 stated that if a medication did not have parameters to hold she would not hold the medication on her own and would notify the MD for permission to hold. LPN 2 stated that she would notify the MD if a medication was refused 2 or 3 times and would ask the MD to review medication for re adjustment, but if it was insulin that was refused she would notify the MD. LPN 2 stated that if a resident was having hypertension frequently she would notify the physician, and that the physician would re-evaluate the residents medications. On 12/19/19 at 7:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that the MD should be notified if a medication needs to be held without parameters. ADON 1 stated that medication should not be held unless there was an order to hold it based on the vital signs. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that a medication with parameters was located in the physician's orders [REDACTED]. On 12/19/19 at 9:01 AM, an interview was conducted with MD1. MD 1 stated that her expectation would to be notified if insulin had been held or refused. MD 1 stated that she would expect to be notified of hypertension. MD 1 stated if she would have been notified of resident 29's elevated blood pressure on 12/18/19, and the trend of elevated blood pressures she would have reviewed his medications. MD 1 stated that resident 29's pulse should be checked with an apical pulse as the order reads for administration of the [MEDICATION NAME]. MD 1 stated that when a blood pressure and pulse was taken with a blood pressure cuff it could give an artificial low pulse if a resident had [MEDICAL CONDITION], and that was why resident 29 required an apical pulse for medication administration. On 12/19/19 at 9:51 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she had obtained the pulse for resident 29 prior to the medication administration. LPN 4 stated that she obtained resident 29's blood pressure and pulse with a blood pressure cuff. LPN 4 stated that the physician's orders [REDACTED]. LPN 4 stated that an apical pulse would be obtained with a stethoscope listening to the resident's chest.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration dates on the medication. Specifically, drugs were not labled correctly and one resident was administered expired medication. Resident Identifier: 9. Findings include: On 12/18/19 at approximately 10:00 AM, the medication cart for the west hall was inspected, the following items were discovered: a. A clear cup with no labeling, contained 2 white pills, and was located in the top of the medication cart. An immediate interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the pills were [MEDICATION NAME], and it was not supposed to be in there so she was going to through it away. b. A bottle of [MEDICATION NAME] 100 milligrams/5 milliliters was in the narcotic drawer of the medication cart. The bottle of [MEDICATION NAME] did not have a Pharmacy label and a resident name was written on the bottle in black marker. c. An insulin pen with the medication [MEDICATION NAME] was in the top drawer of the medication cart. There was no open date or use by date located on the insulin pen. d. A bag with 12 syringes of [MEDICATION NAME], and [MEDICATION NAME] (ABH) cream with an expiration date of 12/14/19, for resident 9. A record review of Resident 9's controlled substance record was completed on 12/18/19. The controlled drug record documented that the expired ABH cream was administered to resident 9 on 12/16/19 at 3:00 PM and 12/17/19 at 3:00 PM. On 12/19/19 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the medication room and medication carts were checked weekly for expired medications by the graveyard supervisors. The DON stated that expired medications should not be administered to residents. The DON stated that insulin should be labeled with a use by or open date and should be used or discarded within 28 days. The DON stated that all medications other than over the counter (OTC) medications in the OTC bottles should have a label.

Based on observation, interview, and record review it was determined, for 1 of 28 sampled residents, that the facility did not determine if a resident was clinically appropriate to self-administer medications. Specifically, a resident was self-administering medication without being evaluated for safety. Resident identifier: 74. Findings include: Resident 74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/19, Licensed Practical Nurse (LPN) 1 was observed to prepare and administer medications to resident 74. LPN 1 stated that resident 74 kept at bedside and self-administered the [MEDICATION NAME] medication. LPN 1 was observed to document on resident 74's Medication Administration Record [REDACTED]. LPN 1 was observed and did not ask resident 74 about the administration of the [MEDICATION NAME] medication. A record review for resident 74 was completed on 12/18/19. A self-administration of medication assessment dated [DATE], documented that resident 74 would like to self-administer medications. The form documented that resident 74 had no impairment in visual ability, was alert and oriented to person, place and time, and was physically able to self-administer medications. The form further documented that there was no other reason that resident 74 should not self-administer medications and resident 74 was capable of self-administration. A physician's order dated 9/27/18, documented [MEDICATION NAME] Allergy Relief Suspension 2 sprays in both nostrils one time a day from allergies [REDACTED].) A care plan Focus dated 10/3/18, documented that Resident 74 had a physician's order for unsupervised self-administration of the following medications: [REDACTED]. The Interventions developed was to assess resident 74's ability to safely self-administer medications specified on admission and re-admission, quarterly, with a change in medication orders, and with significant changes of condition. Discuss medications with each supervised administration. Demonstrate correct administrations as required. Review each medication as necessary with the client. (Note: The self-administration assessment was last completed on 4/23/19, which was over 7 months since the last assessment. This does not meet the quarterly requirement as specified in the care plan.) On 12/18/19 at 12:37 PM, an interview was conducted with LPN 1. LPN 1 stated that if a resident self-administered medications a physician's order to self-administer medications would be in the resident medical record. LPN 1 stated a nurse would assess the resident to determine safety for self-administration of medications. LPN 1 stated that she did not know how often the assessments were completed. On 12/18/19 at 1:07 PM, an interview was conducted with LPN 2. LPN 2 stated that if a resident requested to self-administer medications the facility did an assessment to ensure the resident was safe to self-administer medications. LPN 2 stated that if a resident was self-administering medications it would be located on the care plan. On 12/18/19 at 1:23 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if a resident self-administered medications it would be located in the physician's orders and an assessment would have been documented. RN 1 stated that the assessment should be completed yearly or every 6 months, and that one of the supervisors completed the assessments. RN 1 stated if a resident was self-administering medications it would also be located on the care plan. On 12/18/19 at 3:11 PM, an interview was conducted with resident 74. Resident 74 stated that he did not self-administer any medications, and that staff gave him all his medications. Resident 74 stated that he did not have any medications at bedside. Resident 74 further stated that he had nasal spray at the bedside. Resident 74 stated the he did not take the nasal spray, but if the staff asked he would just lie and tell them that he had taken it. On 12/19/19 at 7:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that she did not know if any residents self-administered medications. ADON 1 stated that she thought resident 74 might self-administer his medications but if he did he does not administer them alone, he does it with supervision and guidance of a nurse. ADON 1 stated that if a resident self-administered medications there must be a physician's order to self-administer, an assessment to determine if the resident was safe to self-administer medications, a care plan, and a consent form. ADON 1 stated she did not know how often a self-administration assessment should be completed, she thought it was either quarterly or annually. On 12/19/19 at 7:51 AM, an interview was conducted the Director of Nursing (DON). The DON stated that for a resident to self-administer medications an assessment should be completed. The DON stated that he believed the assessment should be updated every 6 months. The DON stated that there would be an order for [REDACTED].