Msm Brigham City Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sampled residents, that the facility did not immediately consult with the resident's physician when there was a need to alter treatment. Specifically, the physician was not notified when a resident's Donepezil and Levothyroxine was held for multiple days due to unavailability. Resident identifier: 8.Findings included:Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included dementia and hypothyroidism.On 12/8/25 through 12/11/25 resident 8's medical records were reviewed.On 9/23/25, resident 8's physician ordered Levothyroxine Sodium Tablet 25 micrograms, give 1 tablet by mouth one time a day for Hypothyroidism.On 10/16/25, resident 8's physician ordered Donepezil Hydrochloride Tablet 5 milligrams, give one tablet by mouth in the evening. Resident 8's November 2025 Medication Administration Record (MAR) revealed the following: a. On 11/3/25 and 11/4/25 the Levothyroxine was documented with a code 9 (see progress note). The progress note documented that the medication was not in the facility and they would reorder from the pharmacy. b. On 11/9/25 and 11/11/25 the Levothyroxine was not documented as administered. c. On 11/17/25 through 11/19/25 the Donepezil was documented as not available. No documentation could be found that resident 8's physician was notified that the medications were not administered as ordered. On 12/11/25 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that if medications were unavailable for administration she would notify the resident, the resident representative, and the physician. RN 3 stated that she would document in the progress note that linked to the MAR that these notifications were made. On 12/11/25 at 10:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a medication was not available for administration staff should find out why it was not there and then notify the pharmacy and notify the physician. The DON stated that staff should document the notification to the physician in a progress note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 3 out of 25 sampled residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, a resident had conflicting Metoprolol Tartrate and Metoprolol Succinate documentation, a resident had conflicting International Normal Ratio (INR) laboratory orders, and a resident had a diagnosis of diabetes mellitus for the use of intravenous antibiotics. Resident identifiers: 6, 14, and 34.Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation, repeated falls, and unspecified tremor.Resident 14's medical record was reviewed 12/9/25 through 12/15/25.A review of resident 14's orders revealed: a. On 8/13/25 an order to Check PT( Prothrombin Time)/INR in the morning every Tue [Tuesday] b. On 8/15/25 an order for INR-notify provider of results every day shift for INR for 2 days c. On 8/15/25 and order for INR one time only for INR for 1 Day Check INR notify providers if INR outside of 2.0-3.0 range d. On 8/16/25 an order for INR-notify provider of results every day shift for INR for 1 DayA review of the facility's incident report dated 8/16/25 revealed that INRs were not checked on 8/16/25 and 8/17/25 as ordered. The immediate action was to notify the providers that an INR was not drawn. A review of resident 14's progress notes revealed: a. On 8/19/25 at 7:39 AM, a nurse's note documented, Late Entry: INR 7.4 this morning. Coumadin has been held since 8/16 per orders from providers. Providers notified of the above. Providers ordered the following labs to be drawn tomorrow: CBC [complete blood count], CMP [comprehensive metabolic panel], PTT [partial thromboplastin time], PT [prothrombin time], INR, vitamin k and factor 7 clotting factors. Continuing withhold order and daily INR checks. b. On 8/19/25 at 9:59 AM, a plan of care note documented, Reviewed in weekly therapy meeting. Resident has had several falls since she admitted . INR elevated, checking INR daily and holding coumadin indefinitely.On 12/10/25 at 1:47 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that if a resident's INR was above 6 then she would be concerned and notify the medical provider for orders. RN 2 stated if there were multiple lab orders then she would contact the medical provider for clarification. On 12/11/25 at 8:22 AM, an interview was conducted with the Medical Doctor (MD) via text message. The MD texted that he had ordered resident 14's Coumadin to be held for two days and to be redrawn on 8/18/25.On 12/11/25 at 9:06 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MD should be notified of all INR results and that a normal range for INR was between 2-3. The DON stated that on 8/15/25 resident 14's INR was 6.5. The DON stated that the provider was notified of the results and gave the order to hold Coumadin for two days and to draw INR for two days. The DON stated that on 8/18/25 the INR was obtained and the first level was greater than 8 and the INR was redrawn and came back at 7. The DON stated the provider ordered to hold warfarin and to check the INR daily. The DON stated that the INR on 8/16/25 and 8/17/25 were missed and not drawn.On 12/11/25 at 10:17 AM, an interview was conducted with the Administrator (ADM). The ADM stated the INR was checked on 8/15/25 and it was 6.4. The ADM stated that the normal range for INR was 2-3. The ADM stated that one progress note was to hold Coumadin for two days and recheck daily for two days. The ADM stated the other progress note was to hold Coumadin and then recheck the INR in hopes that the level would come down. The ADM stated that she had talked with the MD this morning and he stated that the facility was to hold the Coumadin and to recheck the INR in two days. The ADM stated that the unit clerk and the nurse had put in two orders that conflicted with each other. The ADM stated that a progress note should have been entered with the correct physician order information. The ADM stated that the lack of accuracy with the orders actually was the correct order and that resident 14 had not needed her INR checked on 8/16/25 and 8/17/25. The ADM stated that she completed an incident report because she was confused about the INR order and thought that staff had not completed the INR on 8/16/25 and 8/17/25 in error. 2. Resident 34 was admitted to the facility on [DATE] with diagnoses which included brief psychotic disorder, unspecified atrial fibrillation, and age-related physical debility.Resident 34's medical record was reviewed 12/9/25 through 12/15/25.A review of resident 34's orders revealed the order dated 11/19/25 for Metoprolol Tartrate Oral Tablet 50 MG (milligram) Give one tablet by mouth in the morning for hypertension.On 12/9/25 at 8:21 AM, during facility medication pass an observation was made of resident 34's morning medications. Resident 34 was administered one tablet of Metoprolol Succinate ER 50 mg by Certified Medication Technician (CMT) 1.On 12/9/25 at 9:32 AM, an interview was conducted with CMT 1. CMT 1 stated that resident 34 was administered Metoprolol Succinate because that was what the pharmacy sent to the facility. CMT 1 stated that she did not know the difference between Metoprolol Tartrate and Metoprolol Succinate. On 12/11/25 at 12:39 PM, an interview was conducted with the DON. The DON stated that when a resident was admitted to the facility either the unit clerk or nurse would enter the medications for residents and that a second person double checked the orders for accuracy. The DON stated that the pharmacy received a fax copy of the medication list when a resident was admitted to the facility. The DON stated that resident 34's hospital discharge orders were for Metoprolol Succinate which was the extended version of the medication and it was incorrectly entered as an order. The DON stated that resident 34 had been given the correct medication and it was just the order that was an error. 3. Resident 6 was admitted to the facility on [DATE] with diagnoses which include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, dysphagia, type 2 diabetes mellitus and vascular dementia. Resident 6's medical record was reviewed 12/8/25 through 12/15/25. A physician's order dated 10/29/25 revealed Vancomycin HCl Intravenous Solution Reconstituted 1 GM (gram) (Vancomycin HCl) Use 1 dose intravenously two times a day related to type 2 diabetes mellitus without complications for 6 Weeks. Another physician's order dated 10/28/25 revealed cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM (Ceftriaxone Sodium) Use 1 dose intravenously two times a day related to type 2 diabetes mellitus without complications for 6 Weeks. A nursing progress note dated 10/29/25 at 10:12 AM, revealed resident 6 had osteomyelitis and Vancomycin was ordered. On 12/10/25 at 3:36 PM, an interview was conducted with the DON. The DON stated Vancomycin and Ceftriaxone were antibiotics and would not be used for type 2 diabetes mellitus. The DON stated the diagnoses for the antibiotics should have been osteomyelitis. The DON stated nurses or unit clerks entered the orders into the residents medical record. The DON stated the unit clerks were medication technicians. The DON stated usually the unit clerk put the order in and the nurse double checked the order for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine was not at the required temperature for sanitation, there were soiled areas in the kitchen, and domes over food were tarnished with a white substance. Findings included: A. On 12/8/25 at 10:16 AM, an initial tour of the kitchen was conducted. The following was observed: 1. There was a substance on the floor in the freezer. 2. The ice machine had dust on the vent in the front. The Cleaning Schedule revealed Tuesday night the ice machine was to be cleaned inside and out. There was no signature on the schedule. 3. There were food particles and dried substances under the shelf that was above the steam table. 4. The warming drawer was soiled on the outside and the wall by the grill had a dried white substance on it.B. On 12/8/25 at 10:39 AM, an observation was made of the refrigerator in the activities room. The following was observed: 1. A container labeled Boost glucose control had a use by date of 10/30/25. 2. There was an unlabeled container with a white substance in it with no date. 3. A McDonalds bag open to air with date of 12/7 with room [ROOM NUMBER] written on it. 4. There were 4 plastic grocery bags with food and no dates.C. On 12/11/25 at 1:40 PM, a follow-up kitchen tour was conducted. The following was observed: 1. Dietary Aide (DA) 1 was observed in the dishmachine area. DA 1 was observed to place a dishmachine basket full of dishes into the dishmachine 4 times. The following temperatures were observed: [Note: All temperatures were in degrees Fahrenheit.] a. Washing temp was at 140 and rinsing temp was 140. DA 1 was observed to replace plates without dipping them in a sanitizer solution. b. Washing temp was 135 and rinsing temp was 140. DA 1 was observed to replace plate lids without dipping them in a sanitizer solution. c. Washing temp was 138 and rinsing temp was 140. DA 1 replaced meal trays without dipping them in a sanitizer solution. d. Washing temp was 138 and rinsing temp was 140. DA 1 replaced bases and plates without dipping them in a sanitizer solution. DA 1 was immediately interviewed. DA 1 stated the dishmachine needed to have a washing temperature of 155 and rinsing temperature of 180. DA 1 stated the dishmachine repair company had been to the facility because the temperatures were low on the dishmachine. DA 1 stated the dishes needed to be dipped in a sanitizer solution after going through the dishmachine. DA 1 was observed to point to a 3 compartment sink with 1 basin full of a clear liquid. DA 1 stated there was sanitizer in that sink. There was a cart in front of the sink, thus creating a barrier to put dishes in the sink to sanitize. DA 1 stated the temperatures had been low for a month or 2. DA 1 stated there was a high limit warning on the machine because it was getting too hot.The Dishmachine Temperature Log for December 2025 was reviewed. On 12/4/25 for lunch the wash temp was 155 and rinse temp was 174. On 12/9/25 for dinner, there were no temperatures documented. On 12/10/25 for breakfast, the wash temp was 145 and rinse temp was 140. There was a hand written note that the dishmachine repair company was notified and coming on 12/10/25. On 12/11/25 for breakfast, the wash temp was 149 and rinse temp was 170. On 12/11/25 for lunch, the wash temp was 148 and rinse temp was 172 with 20 PPM (parts per million) and 350 for the INT (initials) column. DA 1 stated that the PPM column was plates per minute that were washed and he was able to wash 20 per minute. DA 1 stated he timed himself washing plates. DA 1 stated the INT column was for the sanitizer in the 3 compartment sink. DA 1 stated he used Quats strips to test the sanitizer and it was 350. 2. There was a substance on the floor in the freezer 3. The ice machine had dust on the vent in the front. The Cleaning Schedule revealed Tuesday night the ice machine was to be cleaned inside and out. There was no signature on the schedule. 4. There was dust on the ceiling around a vent. There was a table for food preparation under the vent. There were pots and pans hanging from the ceiling under the vent. There was dust on the pots and pans and on the rack they were hanging from. The table had a shelf under it for storage. There was debris and white splatter on it. 5. There was a white substance on the wall by the grill. 6. There were food particles and dried substances under the shelf that was above the steam table. 7. Inside the microwave the top of it was soiled with dried food. 8. There were 2 plastic drawers with utensils in it. The drawers were dirty on the outside and one was broken. 9. There was a dried brown liquid substance on the ceiling and walls by the soda boxes. On 12/11/25 at 2:22 PM, a phone interview was conducted with the Dietary Manager (DM). The DM stated she was in the facility when they needed help. The DM stated the facility was without a Dietary Manager for a few weeks. The DM stated she had helped out for approximately 36 hours total in the last 3 weeks. The DM stated there was a work order put in for the dishmachine because the soap was not going through correctly. The DM stated she was not aware of any temperature issues. The DM stated the dishmachine repair company was there the first week of November and were waiting for a part. The DM stated the dishmachine was a high temperature so the washing cycle needed to reach 155 and the rinsing cycle needed to reach 175-180. The DM stated if the dishmachine was not reaching the required temperatures, then staff needed to wash dishes in the 3 compartment sink. The DM stated the 3 compartment sinks required a wash compartment, rinse compartment and a sanitizer compartment. The DM stated the washing water needed to be hot so the staff needed to boil water to put into the sink. The DM stated she would not recommend the staff to put the dishes through the dish machine and then dip into the sanitizer compartment of the sink. On 12/11/25 at 2:12 PM, an interview was conducted with the Administrator. The Administrator stated the dishmachine was so hot it was melting the dishes, so they called the dishmachine repair company. The Administrator stated the dishes should be dipped in the sanitizer in the 3 compartment sink after going through the dishmachine. The Administrator stated the facility was between DM's and a DM from another facility was overseeing the kitchen.

Based on observation, interview, and record review it was determined, for 4 of 25 sampled residents, each resident did not receive food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained about the food temperatures and palatability, the test tray was not palatable, and resident council minutes revealed concerns regarding food. Resident identifiers: 11, 21, 35 and 39. Findings included: On 12/8/25 at 10:16 AM, an interview was conducted with resident 39. Resident 39 stated that the food was sometimes cold. On 12/8/25 at 10:37 AM, an interview was conducted with resident 21, who stated that the taste of the food had good days and bad days. Additionally, resident 21 stated that the food was often cold and doesn't look appetizing.On 12/8/25 at 1:50 PM, an interview was conducted with resident 35. Resident 35 stated that the food items were not served at the correct temperature and sometimes the food was cold. Resident 35 stated the taste of the food and the way it was cooked was not appealing. Resident 35 stated the food could be improved. Resident 35 stated the oatmeal was served without milk. On 12/8/25 at 2:43 PM, an interview was conducted with resident 11. Resident 11 stated that sometimes the flavor of the food was bland. On 12/10/25 at 12:05 PM, an observation was made of the posted meal. The meal was Cranberry Glazed Turkey Roast, Fresh Cooked Yams, [NAME] Bean Casserole, Baked Roll and Pumpkin Cheesecake Bars.On 12/10/25 at 12:13 PM, the food was taken to the hallway in a cart to be served to residents. A test tray was obtained. The plate of food was covered with a stainless steel cover that was tarnished with a white substance. There was no warmer under the plate. The Last meal served was at 12:29 PM, the temperatures were obtained from the test tray. [Note: All temperatures were in degrees Fahrenheit.] a. A white meat with a light brown gravy with carrots and celery was 122.7. b. Yellowish orange cubed vegetables were 110.1. c. [NAME] Bean Casserole was 116.7 d. An individual container of vanilla ice cream was runny and 29.7. The meat was lukewarm to the taste and did not have cranberry glaze. The vegetables were squash which were lukewarm to the taste. The green bean casserole had green beans with a crispy texture and was not palatable. The vanilla ice cream was warm to the taste and was melted to a liquid consistency. On 12/10/25 at 1:29 PM, [NAME] 1 brought a slice of pie to the surveyors and stated pie was the dessert but not everyone liked pie so it was not served with the food. [NAME] 1 stated pie was never served with the food trays but was offered later. [NAME] 1 stated she offered the residents in the dining room pie and was planning to go room to room and ask who wanted pie. An observation was immediately conducted of the dining room. There were 3 residents in the dining room. The pie temperature was 22 and the middle of the pumpkin pie was frozen. On 12/15/25 at 10:07 AM, an interview was conducted with [NAME] 2. [NAME] 2 stated pie was served with the meal when it was on the menu. [NAME] 2 stated pie was not served 2 hours later by going room to room to see who wanted pie. Resident Council Minutes were reviewed and revealed the following: a. On 2/13/25, Some of the residents stated that some of the meals are not great and that some of the meals are not hot or they do not receive what they have ordered. b. On 6/19/25, Meals are not always hot when delivered and cold meals are delivered on hot plates. c. On 8/13/25, Salads needed to be larger when it was the main meal, condiments were not being sent out, residents liked more mashed potatoes and less rice, and they stated fries have not been fully cooked and sent out cold. d. On 10/15/25, breakfast was served cold, residents were playing What is this during meal times trying to figure out what they were eating, some items on the residents plates were not what was written on the menu, no one knew what the pot pie was because there was no crust or roll, there was no sauce on the beef stroganoff and fries were not being cooked/raw/cold. On 12/15/25 at 10:12 AM, an interview was conducted with the Administrator (ADM). The ADM stated food had been discussed in the Quality Assurance and Performance Improvement (QAPI). The ADM stated the DM was recently terminated because of lack of response to residents regarding food. The ADM stated there were concerns about updating resident dietary profiles for preferences and that the DM was trying to help update those and the DM had altered the menu to accommodate preferences.

Based on interview and record review it was determined the facility did not employ a full-time, designated person to serve as the director of food and nutrition services. Specifically, the facility did not have a qualified food service director. Findings included: On 12/8/25 at 10:16 AM, an interview was conducted with the Dietary Manager (DM). The DM stated she worked at a sister facility and helped in the kitchen since there was no full-time DM. The DM stated she was a Certified Food Manager (CFM). An observation was made of the CFM which expired on 8/1/26. On 12/11/25 at 2:14 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the previous DM had been terminated and they had hired a new DM. The ADM stated the new DM was unable to start till 12/18/25, so the facility did not have a full-time DM but a DM from another facility was helping in the kitchen along with the Maintenance Director. The ADM stated the Maintenance Director was off this week. On 12/11/25 at 2:22 PM, a follow-up phone interview was conducted with the DM. The DM stated the facility had been without a DM since before Thanksgiving. The DM stated she stopped by in the mornings before going to her facility. The DM stated she had worked approximately 36 hours total in the last 3 weeks at the facility. (Cross Refer to F804 and F812)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 out of 25 sampled residents the facility did not file in the resident's clinical record radiologic reports. Specifically, a resident's head Computed Tomography (CT) results were not in the medical record. Resident identifier: 14.Findings included:Resident 14 was admitted to the facility on [DATE] with diagnoses which included, paroxysmal atrial fibrillation, repeated falls, and unspecified tremor.Resident 14's medical record was reviewed 12/9/25 through 12/15/25.On 8/18/25 at 5:27 PM, a nurse's note documented, Provider ordered a head CT scan due to increased confusion and high INR [International Normal Ratio]. Resident transported to and from appointment at [local hospital] by staff around 1500 [3:00 PM]. Resident now in room with husband.It should be noted that resident 14's head CT results could not be located in the medical record.On 12/11/25 at 9:06 AM, an interview was conducted with the Director of Nursing. (DON). The DON stated that she had to request the head CT results from the hospital for resident 14 because they were not in the medical record. The DON stated that radiology results should be uploaded into the medical record under the miscellaneous tab.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 5 out of 25 sampled residents that the facility did not file in the resident's clinical record laboratory reports. Specifically, urine culture and blood laboratory results were missing from the medical records for three residents, and the result for one resident's clotted laboratory sample was not located from the medical record. Resident identifiers: 3, 7, 8, 33, and 56.Findings included:1. Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, fracture of left femur, fracture of right femur, repeated falls, and overactive bladder.Resident 56's medical record was reviewed 12/9/25 through 12/15/25.On 9/5/25 at 4:28 PM, an infection prevention/control note documented, Urine dipped, MD [medical doctor] notified for possible UTI [urinary tract infection] , MD ordered Septra and urine C&S [culture and sensitivity].An order for resident 56 dated 9/5/25 documented, Send urine for c &s one time only for Possible UTI for 1 Day.It should be noted that urine culture results could not be located in resident 56's medical record.On 12/11/25 at 9:19 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was unable to locate the urine culture results for resident 56. The DON stated that Medical Records uploaded records to resident's medical charts and she expected results to be there within one business day. 2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypo-osmolality and hyponatremia and chronic kidney disease with heart failure. Resident 3's medical record was reviewed on 12/8/25 through 12/11/25. A physician's order dated 12/5/25 at 1:00 AM revealed UA with culture and sensitivity one time only for possible UTI. Pain with urination, increased frequency and lethargy with elevated temperature. Cloudy urine with a strong odor. Positive dip stick for nitrites, leukocytes, glucose and blood. On 12/7/25 at 10:58 AM, Received UA results back from [name of lab] notified providers.On 12/11/25, the surveyor requested the UA and C&S results. The Corporate Quality Assurance Nurse provided the laboratory results on 12/11/25 and the sample had mixed flora present, probably contamination and the C&S was not completed. The laboratory form was printed on 12/11/25. On 12/11/25 at 3:30 PM, an interview was conducted with the Corporate Quality Assurance Nurse. The Corporate Quality Assurance Nurse stated she obtained the UA and C&S from the laboratory website and that it was not in resident 3's medical record. 3. Resident 33 was admitted to the facility on [DATE] with diagnoses which included myopathy, sepsis, pneumonitis due to inhalation of food and vomit, Alzheimer's disease. Resident 33's medical record was reviewed 12/8/25 through 12/15/25. A physician's order dated 5/31/25 revealed to complete a CBC (complete blood count) and CMP (Comprehensive Metabolic Panel). A nursing progress note dated 5/31/25 at 1:29 PM revealed CMP and CBC drawn per nurse. Sent to the local hospital lab on STAT order for suspected pneumonia. The CBC was not located in resident 33's medical record. There was a CMP that was located. There were no nursing progress notes regarding the CBC results and physician notification. On 12/10/25, the surveyor requested the CBC. The Corporate Quality Assurance Nurse provided a copy of the CBC results which were run on 12/10/25 and revealed it was cancelled Sample was Clotted. On 12/10/25 at 3:08 PM, an interview was conducted with the Corporate Quality Assurance Nurse. The Corporate Quality Assurance Nurse stated that the CBC on 5/31/25 did not have results because it was clotted. The Corporate Quality Assurance Nurse stated she called the lab to get the results and the run date was when she printed the laboratory results. The Corporate Quality Assurance Nurse stated there were no nurses' notes about the sample being clotted and cancelled. The Corporate Nurse stated she would expect nurses to have contacted the physician and document if the physician wanted a new lab drawn or not. 4. Resident 7 was admitted to the facility on [DATE] with diagnoses which included an encounter for attention to colostomy, atrial fibrillation, schizophrenia, epilepsy, and neuromuscular dysfunction of bladder. Resident 7's medical record was reviewed on 12/8/25 through 12/15/25. A physician's order dated 11/26/25 revealed the following labs one time for one day only: CBC, Basic Metabolic Panel (BMP), and Vitamin D (VIT D).The results for a CBC, BMP, and VIT D collected on 11/26/25 could not be located on resident 7's medical record. On 12/10/25 at approximately 3:40 PM the surveyor requested the CBC, BMP, and VIT D results. On 12/11/25 at 10:18 AM, the DON stated that she called the laboratory and requested a copy of the labs ordered on 11/26/25. It should be noted that the laboratory forms were run on 12/10/25 at 4:22 PM.5. Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cutaneous abscess of chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia.On 12/8/25 through 12/11/25 resident 8's medical records were reviewed.On 1/17/25, the physician ordered a CBC, CMP, Erythrocyte Sedimentation Rate (ESR), and a C-reactive protein (CRP). The results for the CBC, CMP, ESR, and CRP could not be located in resident 8's medical records. On 12/11/25 at 10:18 AM, the DON stated that she called the laboratory and requested a copy of the labs ordered on 1/17/25. It should be noted that the copy of the results for the labs ordered on 1/17/25 was dated 12/10/25 at 4:21 PM. On 12/10/25 at 3:45 PM, an interview was conducted with the DON. The DON stated the lab process was for staff to obtain an order from the physician, determine if it was routine or state, fill out a lab form the day before the lab was to be drawn, and then the hospital lab faxed results to the facility. The DON stated the nurse notified the physician of the results and the results were uploaded into the residents medical record The DON stated if the staff did not get the results, then staff called the lab for the results. The DON stated the nurse was to enter a progress note that the physician was notified of the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25, the facility did not promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges. Specifically, the physician was not notified after a laboratory specimen was clotted and not completed as ordered. Resident identifier: 33.Findings included: Resident 33 was admitted to the facility on [DATE] with diagnoses which included myopathy, sepsis, pneumonitis due to inhalation of food and vomit, Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, and hereditary and idiopathic neuropathy. A physician's order dated 5/31/25 revealed to complete a CBC (complete blood count) and CMP (Comprehensive Metabolic Panel). A nursing progress note dated 5/31/25 at 1:29 PM revealed CBP and CMP drawn per nurse. Sent to the local hospital lab on STAT order for suspected pneumonia. The CBC was not located in resident 33's medical record. There was a CMP that was located. There were no nursing progress notes regarding the CBC results and physician notification. On 12/10/25, the surveyor requested the CBC. The Corporate Quality Assurance Nurse provided a copy of the CBC results which were run on 12/10/25 and revealed it was cancelled Sample was Clotted. On 12/10/25 at 3:08 PM, an interview was conducted with the Corporate Quality Assurance Nurse. The Corporate Quality Assurance Nurse stated that the CBC on 5/31/25 did not have results because it was clotted. The Corporate Quality Assurance Nurse stated she called the lab to get the results and the run date was when she printed the laboratory results. The Corporate Quality Assurance Nurse stated there were no nurses' notes about the sample being clotted and cancelled. The Corporate Nurse stated she would expect nurses to have contacted the physician and document if the physician wanted a new lab drawn or not. On 12/10/25 at 3:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the lab process was for staff to obtain an order from the physician, determine if it was routine or state, fill out a lab form the day before the lab was to be drawn, and then the hospital lab faxed results to the facility. The DON stated the nurse notified the physician of the results and the results were uploaded into the residents medical record The DON stated if the staff did not get the results, then staff called the lab for the results. The DON stated the nurse was to enter a progress note that the physician was notified of the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined for 3 of 25 sampled residents, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, insulin pens were not dated with an open date or had expired past 28 days. Resident identifiers: 1, 3, and 15.Findings included: On [DATE] at 8:40 AM, an observation of medication cart 2 was conducted. Inside the cart resident 1 had an opened Lispro insulin pen that did not have an opened date. Resident 3 had a Lispro insulin pen with an opened date of [DATE].On [DATE] at 8:50 AM, an observation of medication cart 1 was conducted. Inside the cart resident 15 had a Lispro insulin pen with an opened date of [DATE].On [DATE] at 8:45 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that opened insulin pens were good for 28 days once opened and then should be discarded. On [DATE] at 8:53 AM, an interview was conducted with Certified Medication Technician (CMT) 1. CMT 1 stated that insulin was good for 28 days once opened. CMT 1 stated that it was the nursing staff that inspected the dates on insulin and should send the expired pens back to the pharmacy and order new pens.On [DATE] at 9:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that insulin was good for 28 days once it had been opened. The DON stated that unit clerks and nurses should check the medications weekly through an audit to ensure they were not expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 25 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, the resident's Levothyroxine and Donepezil were not available from the pharmacy for administration. Resident identifier: 8.Findings included: Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cutaneous abscess of chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia.On 12/8/25 through 12/11/25 resident 8's medical records were reviewed.On 9/23/25, resident 8's physician ordered Levothyroxine Sodium Tablet 25 micrograms, give 1 tablet by mouth one time a day for Hypothyroidism.On 10/16/25, resident 8's physician ordered Donepezil Hydrochloride Tablet 5 milligrams, give one tablet by mouth in the evening for Psychotropic.Resident 8's November 2025 Medication Administration Record (MAR) revealed the following: a. On 11/3/25 and 11/4/25 the Levothyroxine was documented with a code 9 (see progress note). The 11/3/25 progress note documented that the medication was not in the facility and they would reorder from the pharmacy. The 11/4/25 progress note documented that the medication did not come from the pharmacy and they would reorder the medication. b. On 11/9 and 11/11 the Levothyroxine was not documented as administered. c. On 11/17/25 through 11/19/25 the Donepezil was documented as not available. On 12/11/25 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that the nurses were to reorder medications from the pharmacy when the medication blister pack got past the refill date indicated on the pack, and typically that was the last week that medications were available. RN 3 stated that everyone was responsible for reordering medications. RN 3 stated that the nurse who did the reordering should label the blister pack with the date it was reordered so that the other nurses could see that it had been done. RN 3 stated that the nurse should also check the medication cart to see if there were any other blister packs already available for use prior to ordering more medication. RN 3 stated that if medication was unavailable she would check the Pixus to see if the medication was available in the overstock, and then she would enter a stat order from the pharmacy for the medication. RN 3 stated that stat medication orders would be delivered by the pharmacy approximately 4 hours later. RN 3 stated that if a medication did not have documentation it was not easy to tell if it was given so she would check with the previous nurse to see if it was administered. On 12/11/25 at 10:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if medication was not available then the nursing staff should find out why it was not at the facility. The DON stated that the nurse should notify the pharmacy of any needed medication, then check the stat safe and the Over the Counter (OTC) supply for any inventory availability. The DON stated that an empty spot on the MAR meant that it was not signed out, but that signature was the proof that the medication was administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out 25 sampled residents, that the facility did not ensure that the resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, a resident developed a UTI following the use of a PureWick, which had been implemented without a physician's order or usage instructions. In addition, a resident had no follow-up after a urine culture was contaminated. This resulted in harm for resident 56. Resident identifiers: 3 and 56.Findings included: 1. Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, fracture of left femur, fracture of right femur, repeated falls, and overactive bladder.Resident 56's medical record was reviewed on 12/9/25 through 12/15/25.A review of resident 56's progress notes revealed: a. On 9/8/25 at 12:30 PM, a nurse's note documented, Resident reviewed in IDT [interdisciplinary team] meeting. Resident states tried getting out of bed and couldn't stand and fell. Providers and family were notified. Intervention: Staff report they increased checks on residents after fall and put purewick on to help resident feel like they didn't have to get up until staff arrived to assist her. b. On 9/11/25 at 5:42 PM, a nurse's note documented, .family has purewick [sic] brought from home and purewick [sic] was placed upon arrival. resident's urine is dark at this time. c. On 9/15/25 at 4:46 PM, a nurse's note documented, CNA [Certified Nursing Assistant] reported to nurse that the family was continually wanting pure wick [sic] on resident, due to it starting to cause redness in peri [perineal] area. Nurse talked with family about not putting pure wick [sic] on resident 24 hours a day to allow area to heal. Cream is being applied to area. Family agreed to not put it on for the full day. d. On 9/17/25 at 10:33 PM, a nurse's note documented, .Redness to groin and labia. Continuing to monitor and apply barrier cream with brief changes. e. On 9/23/25 at 5:09 PM, a communication note documented, Resident was c/o [complaining of] pain this morning gave tylenol and Ibprophen [sic] and the pain went away. This evening she was c/o pain and said there was a smell. Collected a urine sample and did a urnie [sic] dip, sent to providers. Providers got back to the nurses and said send over for culture and sensitivity f. On 9/26/25 at 8.27 PM, a nurse's note documented, N.O. [new order] for UA [urinalysis] results. 1. Cipro 500 mg [milligram] po [by mouth] BID [two times a day] x [times] 5 days for UTI [urinary tract infection] 2. Septra DS 1 PO Qday [every day] x 5 days for UTI Both pulled from the stat safe and given this shift. Order faxed to pharmacy. g. On 10/2/25 at 11:55 PM, an orders administration note documented, May use purewick [sic] every shift Wet changing. [It should be noted that the resident had been using a PureWick for 8 days until a doctor order was received.]An order dated 9/16/25 revealed that resident 56 may use purewick [sic] every shift. [It should be noted that there were no treatment orders located in resident 56's medical record related to instructions for use and monitoring of PureWick.]A review of the facility's Specialized Medical Equipment Policy documented the following: PURPOSE: To ensure staff training and competency regarding identification and use of specialized medical equipment.POLICY: Maple Springs will ensure that all specialized medical equipment is identified and assessed for safety and necessity. Staff members will receive education on the use of specialized equipment and demonstrate competency.PROCEDURES:1. Facility charge nurse will identify specialized resident equipment.2. Specialized equipment will be assessed for safety/necessity prior to use.3. Resident and/or POA [Power of Attorney] will be notified of assessment findings.4. If deemed safe for use, a provider order for use will be obtained.5. Nurse educator will develop an education module and competency checklist specific to the identified equipment.6. Staff will receive necessary education and demonstrate competency prior to use of identified specialized equipment.On 12/10/25 at 9:17 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that before a PureWick was used, it required an order from the provider. RN 1 stated that the facility did not supply PureWicks and if a resident requested to use one they had to pay for it. RN 1 stated that he had not received any training from the facility on how to use a PureWick. RN 1 stated that he would not want a CNA to change a PureWick because they would not know how to use them. RN 1 stated that a PureWick could cause irritation and redness to the peri area if it was applied incorrectly.On 12/10/25 at 9:40 AM, an interview was conducted with CNA 1. CNA 1 stated that she had worked at the facility for about 3 months. CNA 1 stated that she had never heard of a PureWick and had not received training for the use of one. On 12/10/25 at 10:26 AM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that a resident would require a physician's order to use a PureWick. LPN 1 stated that she had not received training on how to use or care for a PureWick at the facility. LPN 1 stated that resident 56 had some irritation and redness in her peri area after continued use of the PureWick. LPN 1 stated that resident 56's family wanted resident 56 to use the PureWick all the time because they did not want her sitting in a wet brief. LPN 1 stated that resident 56's family brought in the PureWick and that the facility did not provide supplies. LPN 1 stated she was unsure how often a Purewick needed to be changed but thought probably at least once a shift. LPN 1 stated that using a PureWick could cause urinary tract infections and skin breakdown. LPN 1 stated that resident 56 could verbalize when she needed to use the bathroom and could use a call light when she needed assistance.On 12/10/25 at 10:53 AM, an interview was conducted with CNA 2. CNA 2 stated that PureWicks weren't used and the facility did not supply them. CNA 2 stated she did not know how long PureWicks were good for or how often they should be changed. On 12/10/25 at 11:07 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility did use PureWicks if the family supplied them. The DON stated that a resident would need a physician's order before a PureWick could be used. The DON stated that she believed that most nurses knew how to use a PureWick and then they would teach the CNAs. On 12/11/25 at 9:19 AM, a follow-up interview was conducted with the DON. The DON stated that resident 56 had an order for the use of the PureWick on 9/16/25. The DON stated that resident 56 had the PureWick placed on 9/8/25. The DON stated that the facility had not provided any training for staff on how to use a PureWick. The DON stated that the risks of using a PureWick included skin breakdown and urinary tract infections.On 12/11/25 at 12:32 PM, a follow-up interview was conducted with the DON. The DON stated that nursing staff should have training on how to apply a PureWick and how often a PureWick needed to be changed. The DON stated that she was not sure if nurses or CNAs were provided education on how to properly use a PureWick. The DON stated that resident 56 did have a couple of urinary tract infections while at the facility. The DON stated that education for the use of a PureWick was not provided to staff because she did not think about it.2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypo-osmolality and hyponatremia, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure. Resident 3's medical record was reviewed on 12/8/25 through 12/11/25.A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 3 was frequently incontinent of bladder. A nursing progress note dated 12/4/25 at 7:00 PM revealed a new order for Keflex 500 milligrams (mg) four times per day for 7 days for increased edema and redness to bilateral lower extremities (BLE).A physician's order dated 12/4/25 revealed Keflex Oral Capsule (Cephalexin), Give 500 mg by mouth four times a day for Possible cellulitis to BLE related to CHRONIC KIDNEY DISEASE, STAGE 4 until 12/11/25. A nursing progress note dated 12/5/25 at 12:59 AM revealed, resident reported pain with urination and increased frequency. Resident 3 had increased lethargy with elevated temperature. UA (urinalysis) obtained per physician's orders. Urine was white with gel-like consistency, cloudy with strong odor. Positive dip stick for nitrites, leukocytes, glucose and blood.A physician's order dated 12/5/25 at 1:00 AM revealed UA with culture and sensitivity (C&S) one time only for Possible UTI. Pain with urination, increased frequency and lethargy with elevated temperature. Cloudy urine with a strong odor. Positive dip stick for nitrites, leukocytes, glucose and blood. A nursing progress note dated 12/6/25 at 6:15 AM revealed, refused cares last night during last rounds. Resident 3 requested as needed medication. On 12/7/25 at 10:58 AM, Received UA results back from [name of lab] notified providers.The results of the UA and C&S on 12/5/25 were not located in the medical record. On 12/11/25, the surveyor requested the UA and C&S results. The Corporate Quality Assurance Nurse provided the laboratory results on 12/11/25 and the sample had mixed flora present, probably contamination and the C&S was not completed. The laboratory form was printed on 12/11/25. On 12/11/25 at 3:30 PM, an interview was conducted with the Corporate Quality Assurance Nurse. The Corporate Quality Assurance Nurse stated that the nurse was notified over the weekend that the urine sample was contaminated and the C&S was not done. The Corporate Quality Assurance Nurse stated the nurse told her that the physician was contacted and the physician did not want to do another UA because resident 3 was already on Keflex. The Corporate Quality Assurance Nurse stated the nurse told him the doctor was planning to see resident 3 on 12/12/25. The Corporate Quality Assurance Nurse stated there was no note in the progress note regarding what happened so the nurse put one in on 12/11/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 25 sampled residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident sustained multiple injuries while operating his power wheelchair after therapy evaluated the resident as needing supervision while operating the wheelchair. In addition, another resident was not provided two person assistance during repositioning for a brief change and sustained a fall. Resident identifiers: 4 and 33. Findings included: 1. Resident 33 was admitted to the facility on [DATE] with diagnoses which included myopathy, sepsis, pneumonitis due to inhalation of food and vomit, Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, and hereditary and idiopathic neuropathy. On 12/8/25 at 10:59 AM, an interview was conducted with resident 33. Resident 33 stated he had a power wheelchair that was taken away. Resident 33 stated he had some accidents with his power wheelchair, cut his leg wide open, and needed 19 stitches. Resident 33 stated he received a new bed after his leg was cut open.Resident 33's medical record was reviewed 12/8/25 through 12/15/25. A nursing progress note dated 3/25/25 at 4:49 AM revealed resident 33 stated that he ran into his bed while in his wheelchair. The nurse assessed his leg and noticed blood coming down his leg and skin torn. The nurse applied gauze and stopped the bleeding then wrapped it. The nurse called emergency medical services. At 7:30 PM, a nursing note revealed resident 33 was brought back to the facility. A nursing progress note dated 3/27/25 revealed resident 33 had 13 staples to his left lateral lower leg. The progress note further revealed a telephone order for Physical Therapy (PT) to complete a wheelchair safety evaluation was written. A power-mobility indoor driving assessment dated [DATE] revealed that resident 33 was not able to drive independently with no restrictions. There were comments that resident 33 had a diagnosis of Alzheimer's, resident also has a new diagnosis of pneumonia potentially affecting cognition. An Interdisciplinary (IDT) note dated 3/28/25 revealed PT completed an evaluation assessment and was working on wheelchair driving with resident 33. [It should be noted, the results of the power-mobility indoor driving assessment, which concluded resident 33 could not drive independently without restrictions, was not addressed.] A nursing progress note dated 4/4/25 at 6:52 PM revealed resident 33 had a laceration to his right lower leg, and that resident 33 stated to the nurse he had banged it against the bed. The nurse provided education to resident 33 on power chair safety. A physician's note dated 4/10/25 revealed that resident 33 had a new laceration to right lower leg from running into an object in his wheelchair. A Power-Mobility Indoor Driving Assessment form dated 4/16/25 revealed Pt [patient] demonstrates cognitive impairments & has a dx [diagnosis] of dementia. Pt demonstrates improvements in PWC [Power Wheelchair] driving when under observation, but pt observed to have poor safety awareness & bumps [sic] into objects often when driving IND [independently]. The form further revealed resident 33 had poor safety awareness, bumped into multiple things, and did not slow down. Resident 33's total score was 64%. The PT's opinion was resident 33 was unable . to drive independently with no restrictions. Resident 33 was in need of training because he was able to drive with some difficulty. An in-service was provided to the staff on 5/2/25, addressing the topic of accident hazards, with a focus on blunt force trauma from high-powered wheelchairs. A nurses progress note dated 5/2/25 at 8:05 PM revealed resident 33 had 2 large hematomas that were bleeding with skin tears to bilateral lower extremities. A nurses progress note dated 5/8/25 at 2:29 PM revealed staff reported multiple incidents where resident 33 had run into things or almost ran into staff when driving his electric wheelchair. Resident 33 has had two incidents where he ran into things and cut open his legs. Therapy has been working on patients ability to drive WC safely and wheelchair tests show he is not safe. The speed on his WC was turned down lower, but resident is still able to adjust the speed within the lower range. At this time IDT removed electric WC, and resident will be using a manual WC. Resident was educated on this. Resident will be re-evaluated by therapy in the future to test residents capabilities to drive electric WC. A nurses note dated 5/21/25 at 11:14 AM, revealed that an IDT meeting was completed with family and patient regarding his electric wheelchair. Resident 33 was allowed to operate the electric wheelchair when supervised by family. A plan of care note dated 6/30/25 at 3:18 PM revealed resident 33's electric wheelchair usage was reviewed in an IDT meeting. Staff were able to get a different company to lower the wheelchair speed and lock the low speed so resident 33 was unable to adjust it. Resident 33 was educated that he could have his wheelchair back for a trial period since the speed was lowered. A nurses note dated 7/20/25 at 12:42 AM revealed that resident 33 came to the nurses station and the nurse noticed blood on the sock of right foot. Resident 33 stated he had hit a soda machine cabinet while in his wheelchair. A nurses note revealed on 7/21/25 at 10:18 AM the IDT met to discuss an abrasion to the top of resident 33's right foot from running into a soda machine. The intervention was to educate resident 33 to be careful when driving and therapy would do another wheelchair evaluation. A communication note dated 7/24/25 at 12:02 PM, revealed resident 33 had an x-ray of left foot due to increased pain. A nurses note dated 7/24/25 at 4:14 PM revealed, staff discussed a behavior contract with resident 33 and his daughter regarding power wheelchair safety. A nurses note dated 7/25/25 at 6:52 PM revealed resident 33 came to nurses station and told the nurse he had accidentally bumped into his bed. The nurse looked at resident 33's left leg and it was bleeding down the leg. There were 2 skin tears with blood pooling and bruising. The nurse asked resident's daughter to bring in shin guards. Resident 33 stated he had bumped into his bed and asked the nurse not to tell anyone. Resident 33 was concerned his power wheelchair would be taken away. Resident 33 was educated on being more careful with the power chair and his surroundings.A care plan dated 7/29/25 initiated the focus area: [Resident 33] uses an electric wheelchair for mobility. [Resident 33] has has [sic] incidents of running into furniture and walls when driving electric wheelchair. [Resident 33] will often not report injuries to the staff. The goal was resident 33 will drive his wheelchair safely through the review date. An intervention on 7/25/25 was for resident 33's daughter to get resident 33 shin guards. Interventions on 7/29/25 included therapy as ordered; wheelchair speed was turned down; and staff provide education as needed on wheelchair safety. On 7/31/25, an intervention was electric wheelchair to be taken away, therapy to do evaluation. A nurses note dated 7/29/25 at 10:18 AM revealed resident 33 asked staff to help him transfer to the toilet. Resident 33 was frantic and drove his chair into the bathroom walls which pinned his left foot between his foot board on the power wheelchair and the wall. Resident continued to yell I fucked up my foot, an x-ray was ordered and waiting for results. Resident 33 was provided a manual wheelchair. A nurses note dated 7/31/25 at 4:59 PM revealed resident 33 was reviewed in an IDT meeting related to driving his wheelchair into the bathroom. The power wheelchair had been taken away. A Power-Mobility Indoor Driving assessment dated [DATE] revealed resident 33 bumped into a bed at high speed and had small bumps into the dresser and closet. Resident 33 scored at 72% and continued to have poor safety awareness and had difficulty determining appropriate speeds when navigating small spaces. Resident 33 was showing improved safety when backing up but had difficulty with looking back over his shoulder. Resident 33 had a diagnosis of dementia which contributed to his safety awareness. A Power Wheelchair Contract was signed on 9/1/25 by the resident, family, and the facility. The contract revealed resident 33 would stay on the right side of the hallway; speed would be less than two miles per hour in the facility, reduce speed in congested areas; check over his shoulder and use his horn before backing up; use a seatbelt; not use pillows or cushions on the seat; be aware of people coming out of rooms and around corners; would not intentionally block or run into residents, staff or equipment; safely navigate crosswalks and intersections, sign himself out if he left the property; the facility could continually assess and modify wheelchair rights; use of the wheelchair could be limited or ceased if he was injured, others or property; and the speed capacity could be reduced. It should be noted that there were no additional nursing notes located in resident 33's medical record that documented his use of the power wheelchair after 7/31/25.On 12/11/25 at 11:00 AM, an interview was conducted with the Director of Nursing (DON) and Administrator (ADM). The DON stated resident 33 injured himself multiple times when using his power wheelchair. The DON stated on different occasions resident 33 had injured his foot and had required stitches on his shin when using his power wheelchair. The ADM stated the staff felt like he had a notable injury from running into a therapy desk. The ADM stated that was when management questioned resident 33's ability to use his power wheelchair. The ADM stated therapy was asked to do extra wheelchair training. The ADM stated she talked to the ombudsman about resident rights versus resident safety. The ADM stated the facility developed a power wheelchair safety assessment with goals that therapy staff were looking for to determine safety. The ADM stated resident 33 did the assessment and he was unsafe to drive it. The ADM stated resident 33 was reassessed because staff wanted him to be safe and able to use his power wheelchair. The ADM stated an IDT meeting was done since resident 33 was assessed as not being safe and they tried to allow resident 33 to have it as long as possible. The DON stated resident 33 had an accident on 7/14/25, 7/20/25, 7/21/25, 7/24/25 and 7/29/25. The ADM stated she could not remember when resident 33's power wheelchair was taken away. The DON stated that there were some incidents where resident 33 almost hit staff but had not hit any residents. The ADM stated therapy assessed the resident and felt that he was safe when he was being observed but when he was not he had more risky behaviors. The ADM stated family were allowed to supervise him while he was using the power wheelchair. The ADM stated there was no documentation of how staff supervised resident 33 when he was using his power wheelchair. The ADM stated resident 33 currently had a manual wheelchair and he was unable to propel himself very far. The ADM stated they had not thought of a power assist manual wheelchair for him to maintain his independence and be safe. On 12/15/25 at 10:47 AM, a follow-up interview was conducted with the ADM. The ADM stated that after resident 33 had an accident with the power wheelchair, staff did not immediately remove it because an infection was determined to be interfering with his cognition. The ADM stated that the Maintenance Director examined resident 33's bed and confirmed there were no sharp areas. The ADM stated they presume the date the bed was checked was around 3/26/25. The ADM stated after resident 33 injured himself on 3/25/25 by running into his bed, a power wheelchair assessment was done on 3/27/25. The ADM stated resident 33 hurt himself on 4/10/25 and education on operating the power wheelchair was provided and he was treated for pneumonia. The ADM stated that on 4/16/25 another power wheelchair assessment was completed. The ADM stated he hurt himself 5/2/25 and had a hematoma and an all staff education was provided on accident prevention. The ADM stated they removed his power wheelchair on 5/5/25. The ADM stated she did not know why there was a 3 day delay in removing his wheelchair but thought there were conversations with management on how to keep him as safe as possible. The ADM stated on 5/8/25 the wheelchair speed was lowered but resident 33 was able to adjust it back up and education was provided to the resident to keep his speed low. The ADM stated an IDT meeting was completed on 5/21/25 and the decision was to remove the power wheelchair again except when family were there to supervise him. On 5/30/25, the ADM stated that a different wheelchair company successfully lowered and locked the device's speed, allowing resident 33 to use his wheelchair on a trial. However, the ADM stated she was unsure what the 'trial' status specifically entailed and stated that no information was available regarding the specific monitoring or observations staff were performing for resident 33. The ADM stated resident 33 was treated for pneumonia on 6/6/25. The ADM stated resident 33 got lost when he left the faciity on 7/13/25 so the ombudsman was contacted on 7/13/25. The ADM stated there was another IDT meeting with family on 7/14/25, where they discussed resident 33's Brief Interview for Mental Status (BIMS) and reviewed incidents of him running into objects. The ADM stated the IDT discussed resident 33's power wheelchair being taken away if he continued to injure himself. The ADM stated staff were to supervise resident 33, if he went outside or he needed to use a manual wheelchair. The ADM stated that resident 33 injured himself on 7/20/25 and was provided education on 7/21/25, as he was determined to be cognitively intact. The ADM stated therapy did another power wheelchair assessment. The ADM stated that on 7/25/25, resident 33's daughter was asked to bring shin guards for him. The ADM believed the daughter had brought them in, but was not sure when The ADM stated resident 33 injured his foot on 7/29/25. The ADM stated another IDT meeting was held on 7/31/25, after which resident 33's power wheelchair was taken away and it had not been returned to him. 2. Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dysphagia, streptococcal sepsis, depression, chronic pain, polyneuropathy, aphasia, generalized anxiety disorder, seizures, and adjustment disorder with depressed mood.On 12/8/25 through 12/11/25, resident 4's medical records were reviewed. On 7/2/25, state optional Minimum Data Set (MDS) assessment documented resident 4's functional status as 2 person extensive assist for bed mobility and toileting. The resident was assessed as total dependence with 2 persons for transfers.On 9/4/25 at 12:20 AM, the Nurse's Note documented, CNA's [Certified Nurse Assistant] were in resident room changing resident's brief. Resident was rolled onto her left side when she lifted her leg and rolled off of the bed. Resident was lowered to the floor by CNA's. CNA's immediately called nurse in to assess resident. Provider, family, DON, Administration notified. Resident has small scratch above right eye. Resident complaining of pain in right wrist. Pain medications administered, will continue to monitor resident.On 9/3/25 at 7:20 PM, the incident report documented that CNAs were providing incontinence care and the resident was rolled onto her left side and subsequently rolled off the bed. The resident was lowered to the floor. The report documented that resident 4 sustained an abrasion to the face. The report did not document the names of the CNA witnesses.On 11/24/24, resident 4's care plan for Activities of Daily Living self care performance deficit was initiated. The interventions documented that resident 4 was totally dependent on one staff for toilet use. It should be noted that this care plan intervention was not updated to reflect the MDS assessment on 7/2/25 that assessed the resident as requiring 2 person extensive assistance for toileting. On 10/5/22, resident 4's care plan for at risk for falls related to Cerebrovascular Accident, muscle weakness, and difficulty walking was initiated. The interventions identified on the care plan included that clinical staff were educated to use 2 staff when changing the resident's brief. It should be noted that this intervention was initiated on 9/4/25 after resident 4's fall. On 12/11/25 at 2:39 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 4 was totally dependent on staff for everything. CNA 3 stated that resident 4 did not get out of bed for toileting and they changed her incontinence brief in bed. CNA 3 stated that resident 4 had always required 2 staff for incontinence care. On 12/11/25 at 2:50 PM, an interview was conducted with the DON and the Corporate Quality Assurance Nurse (CQAN). The DON stated that resident 4 required a Hoyer lift for transfers and was totally dependent on staff for all ADLs. The DON confirmed that the 7/2/25 MDS assessment documented that resident 4 was dependent and an extensive 2 person assistance for toileting. The DON stated that the aides involved in the fall on 9/4/25 during incontinence care were not specified on the incident report and she was not aware of who those individuals were. The DON was informed that the intervention on the care plan after the fall was to have 2 staff present during incontinence care. The CQAN stated that the incident report documented 2 aides were present but she was not sure why the intervention would be to have 2 aides if that was already done. The DON stated that the incident report documented 2 aides were present but did not recall if she followed up on the report and she did not recall why she implemented 2 staff for an intervention. The CQAN stated that resident 4 rolled off the bed and there should have been one staff present on either side of the bed to prevent the fall. On 12/11/25 at 3:37 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 confirmed that she was the nurse that documented resident 4's incident report for the fall on 9/3/25. RN 4 stated that CNA 4 and CNA 5 were present during resident 4's fall. RN 4 stated that CNA 5 had exited the resident room to obtain more supplies and when she walked back into the room she witnessed resident 4 falling. On 12/11/25 at 3:47 PM, an interview was conducted with CNA 5. CNA 5 stated that she was providing resident 4 with incontinence care on the night of the fall. CNA 5 stated that she exited the room to obtain a chuck pad and the other aide, CNA 4, started to roll resident 4 by herself. CNA 5 stated that when she re-entered the room resident 4's leg was over the side of the bed. CNA 5 stated that she tried to grab resident 4's leg and push her back onto the bed but it was too much weight and she assisted her to the floor. CNA 5 stated that resident 4 was dead weight and she assisted her to the ground by herself. CNA 5 stated that CNA 4 was trying to help but she was on the other side of the bed, holding resident 4's arm. CNA 5 stated that at the time of the incident resident 4 was a one person extensive assist for toileting and she had been assisting her as a one person assist since she worked with her. CNA 5 stated that she had a second aide with her because she was training CNA 4. CNA 5 stated that after the incident they changed resident 4 to a two person assist for toileting and all ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sampled residents, that the facility did not ensure that when a resident was transferred that the transfer was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider, and a copy of the notice of transfer was sent to the Office of the State Long-Term Care Ombudsman. Specifically, the resident's medical records did not have documentation of what information was provided to the receiving health care provider when they were transferred to the emergency room (ER) and no documentation could be found to indicate that the Ombudsman was notified of the transfer. Resident identifier: 8.Findings included: Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cutaneous abscess of chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia.On 12/8/25 through 12/11/25 resident 8's medical records were reviewed.Resident 8's progress notes documented the following: a. On 8/20/25 at 5:29 PM, the Nurse's Note documented, Resident's blood pressure increased 30 minutes post fall to 171/115, Pulse 101. Reports she is having chest pain. 911 called and non-emergent transfer to hospital requested. Family and medical provider and nursing administration notified. b. On 8/21/25 at 10:25 AM, the Nurse's Note documented, ER diagnosed resident with UTI [urinary tract infection] and started PO [by mouth] cephalexin.On 8/20/25, the hospital discharge summary documented that the resident was seen for a urinary tract infection, fall, and confusion. No documentation could be found in resident 8's medical records of a transfer/discharge assessment or what information was sent to the receiving provider. Additionally, no documentation could be found of the notice provided to the Ombudsman for the transfer on 8/20/25. It should be noted that the ER Transfer Assessment form contained a section for what transfer documentation was sent to the receiving provider, but the assessment was not completed for the 8/20/25 transfer. On 12/11/25 at 1:59 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that when a resident was transferred or discharged they filled out a form for a Nursing Home Resident Discharge Notice. The RA stated that they started this process a couple of months ago and prior to that she was doing a monthly notification to the Ombudsman. The RA reviewed her documentation and confirmed that the Ombudsman was not notified of resident 8's transfer to the hospital on 8/20/25. On 12/11/25 2:11 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that when they transferred a resident to the hospital they documented a progress note of the resident's condition, who was notified, the time of the transfer, and what assessment and interventions were provided. RN 2 stated that the Med Techs gathered the information that was sent to the receiving provider and it should include a face sheet, medication orders, and resident history. RN 2 stated that she would then document the discharge note and do a transfer/discharge assessment. RN 2 reviewed resident 8's medical records and confirmed that the transfer/discharge assessment was not completed for the 8/20/25 transfer to the ER. On 12/11/25 at 2:19 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when they transfer a resident to the ER, nursing staff should do an ER transfer assessment, send a face sheet, a medication list, the resident care plan, and a copy of the Physician Order for Life Sustaining Treatment (POLST). The DON stated that they have a checklist that tells the nurse what to send with the resident. The DON stated that the RA does the notification to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use were implemented. Specifically, for 1 out of 21 sampled residents, a resident was prescribed and completed an antibiotic for a suspected urinary tract infection (UTI) even after the urine culture determined no bacterial growth. Resident identifier: 22.
Findings included:
Resident 22 was admitted to the facility on [DATE] with diagnoses which included sepsis, urinary tract infection, acute kidney failure, dementia, delirium, chronic kidney disease, heart failure, atrial fibrillation, and obstructive and reflux uropathy.
On 12/18/23, resident 22's medical record was reviewed.
Resident 22's progress notes revealed the following:
a. On 8/12/23 at 12:14 AM, the nurse note documented, Resident's blood pressure was low at 88/50, CNA [Certified Nurse Assistant] told nurse at shift change and his medical POA [Power of Attorney] was walking by. We let her know and she said she would contact [provider name omitted. [Provider] called later in the day. He would like to have us continue to make sure we are hydrating him because he doesn't want to change his meds [medications] yet. [Provider] would like us to do a UA [urinalysis] and culture. Resident was really good to drink plenty of water while taking his pills, but after having his catheter tube clamped there was no urine after checking it. I will continue to try to get a sample and send it to [local hospital] asap [as soon as possible].
b. On 8/13/23 at 11:17 AM, the nurse note documented, UA with no cx [culture] results obtained. [Provider] has been notified. voice mail message left with overview of abnormal results. no new orders at this time.
c. On 8/13/23 at 1:52 PM, the nurse note documented that resident 22 was seen by the provider and new orders were obtained. New order was for Bactrim double strength (DS), give one tablet by mouth two times a day for seven days. The note also documented that the urine specimen that was collected and sent on 8/12/23, was currently in incubation and results should be available tomorrow.
d. On 8/14/23 at 11:28 AM, the nurse note documented, urine cx final results obtained. no growth after 36 hours. [Provider] notified. message left. no new orders at this time.
Resident 22's Medication Administration Record for August 2023 documented that the antibiotic Bactrim DS was administered two times a day from 8/13/23 through 8/20/23, for a total of 14 doses received.
On 8/12/23, a UA was obtained for resident 22. The abnormal results were the urine appearance was slightly cloudy, 3+ blood, 4+ protein, trace amounts of leukocyte esterase, red blood cells were too numerous to count, and white blood cells were 20-30.
On 8/14/23, the urine culture report was received by the facility and documented that no growth after 36 hours.
On 12/18/23 at 10:14 AM, an interview was conducted with the facility Infection Preventionist (IP). The IP stated that resident 22 was treated for a suspected UTI with Bactrim. The IP stated that the urine culture showed no bacterial growth after 36 hours. The IP stated that it looked like they could not get a hold of the provider and they left a message with the culture results. The IP stated that we didn't take it upon ourselves to discontinue it. The IP stated that they should have continued to follow up with the provider until they got in contact with him and received an order to either discontinue or continue the antibiotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 out of 21 sampled residents, the Registered Nurse (RN) was observed to leave a residents medications at the bedside in a medication cup and the resident had not been evaluated to determine if they were safe to self administer medications. Resident identifier: 19.
Findings included:
Resident 19 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus, epilepsy, encephalopathy, alcohol abuse with unspecified alcohol induced disorder, and ataxia.
On 12/18/23 at 8:58 AM, an observation was conducted of RN 1 preparing medications for resident 19. The medication cup that RN 1 prepared included pregabalin 50 milligrams (mg), Keppra 500 mg, metformin 1000 mg, aspirin 81 mg, Creon 24,000-76,000 units, omeprazole delayed release 20 mg, potassium 20 milliequivalent, and torsemide 20 mg two tablets. In addition, RN 1 prepared a Lantus injector pen 3 units, Lantus injector pen 51 units, and an insulin aspart injector pen 8 units. RN 1 was observed to administer the Lantus and insulin aspart to resident 19. RN 1 was observed to leave the medication cup with the pills in resident 19's room so resident 19 could self administer the medications.
Resident 19's medical record was reviewed on 12/18/23.
A quarterly Minimum Data Set assessment dated [DATE], documented that resident 19 had a Brief Interview for Mental Status (BIMS) score of 12. A BIMS score of 8 to 12 would suggest moderate cognitive impairment.
No documentation could be located indicating that resident 19 had been evaluated to safely self administer medications.
The Home Medication policy within the admission agreement documented During your stay at [facility name removed], all medication must be prescribed by your physician and administered by [facility name removed] nursing staff. Please note the Residents Rights state: You have the right to self-administer medications, upon resident's request, and if the resident's Interdisciplinary Team has determined it is clinically appropriate and safe for the resident to do so. Resident must provide secure method for storage of medication and demonstrate ability to operate chosen storage method, complying with all safety measures for storage and documentation of self-administered medications.
On 12/18/23 at 10:35 AM, an interview was conducted with RN 2. RN 2 stated that resident room [ROOM NUMBER] and resident room [ROOM NUMBER] self administered medications. RN 2 stated the facility had a form that the resident, physician, and nurse would sign. RN 2 stated the resident would have to tell the nurse what the medications were, what the medications were used for, and what time the medications were to be administered. RN 2 stated the resident would need to be assessed to determine if they could take the medications safely by themselves. RN 2 stated that resident 19 should not be self administering his medications. RN 2 stated staff tried a few months ago to see if resident 19 could self administer his medications and resident 19 was not able to do it.
On 12/18/23 at 10:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the resident in room [ROOM NUMBER] had been approved to self administer medications. The DON stated the prior company had a form that they would fill out and quiz the resident on what their medications were. The DON was unsure if resident 19 was approved to self administer medications. The DON stated that resident 19 was pretty independent.
On 12/18/23 at 11:09 AM, an interview was conducted with the Corporate Nurse (CN). The CN stated there was no self administration form for resident 19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that all residents remained free from abuse, neglect, and misappropriation of property. Specifically, for 1 out of 21 sampled residents, a dependent resident was left unattended in the shower for hours while the Certified Nurse Assistant (CNA) left their scheduled shift early. Resident identifier: 16.
Findings included:
Resident 16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, early onset cerebellar ataxia, muscle spasms, insomnia, depression, dysphagia, and dorsalgia.
On 12/11/23 through 12/18/23, resident 16's medical record was reviewed.
On 8/6/23, the annual Minimum Data Set assessment documented that resident 16 had a Brief Interview for Mental Status score of 15, which would indicate that resident 16 was cognitively intact. The assessment documented that resident 16 was a one-person extensive physical assist for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The assessment documented that resident 16 required a one-person physical assist with part of the bathing activity. The assessment documented that resident 16 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet, and any surface to surface transfers. The assessment documented that resident 16 utilized a wheelchair as a mobility device.
Review of resident 16's progress notes documented the following:
a. On 8/1/23 at 8:49 PM, the nurse note documented that resident 16's family member had reported that his condition was getting worse and that she worried about him not being able to get help when he choked. Hourly checks were initiated to better ensure safety.
b. On 8/9/23 at 11:47 AM, the nurse note documented that the Registered Nurse (RN) notified staff via group chat of resident 16's hourly checks. The note also documented that all CNAs had been notified.
c. On 8/9/23 at 2:13 AM, the nurse note documented, CNA's discovered patient following an unwitnessed fall at approximately 0115 [1:15 AM]. Patient's vitals were within normal range. Patient denies any pain or having hit head or experienced any injury and explained he had lowered himself onto the floor. DON [Director of Nursing] notified and neurological flow sheet started. Initial vitals and neurological checks were within normal range. Patient has refused subsequent neurological checks, but additional attempts will continue to be made as scheduled.
d. On 8/9/23 at 10:26 AM, the nurse noted documented, DON f/u [followed up] with res [resident] from the incident. Res states that he is doing fine and denies any injury or pain. Skin looks intact no bruising noted at this time. Res is alert and oriented to baseline. Res family was notified of the incident. DON will re-instructed staff on the care plan and routine safety checks. As well as the importance of walking rounds to ensure res is safe at shift change. NP [Nurse Practitioner] notified of res incident. Will CTM [Continue to Monitor].
e. On 8/9/23 at 12:17 PM, the nurse noted documented, Res to have shower pendant during shower. Res and staff educated on the purpose of shower call button.
f. On 8/9/23 at 4:58 PM, the nurse noted documented, Nurse's Note Incorrect Documentation - Note Text: DON interviewed staff that worked 8/8/23 and early in the am 8/9/23 to investigate res incident. Per CNA report she told one CNA that res was still in the shower when she was leaving per other CNA shower aid [CNA] didn't not [sic] report that res was in shower. Both CNA were instructed not to leave res in shower alone. Staff re-instructed on the importance of routine safety checks and walking rounds during shift change. [Facility name omitted] Management met with res family. Family is happy with CNA's staying with res during the shower. Will CTM. It should be noted that this progress note was crossed out.
Review of resident 16's care plans documented the following:
a. A care plan for Activities of Daily Living self-care performance deficit related to cerebellar ataxia was initiated on 2/8/2020. Interventions identified in the care plan included: assist resident in using toilet grab bars for ease of toileting and to prevent leaning over the toilet unsafely; resident used a wheelchair for locomotion; the resident required extensive assistance by 1 for bathing/showering; the resident required extensive assistance by 1 staff to turn and reposition in bed; the resident required extensive assistance by 1 staff to dress; the resident required set up assistance by 1 staff to eat; the resident required limited assistance by 1 staff with personal hygiene and oral care; the resident required extensive assistance by 1 staff for toileting; the resident was usually able to transfer with extensive 1 person assist; and encourage the resident to participate to the fullest extent possible with each interaction.
b. A care plan for at risk for falls due to weakness, muscle spasms, discoordination related to ataxia, and side effects of mediations was initiated on 9/16/2021. Interventions identified in the care plan included: anticipate and meet the resident's needs; encourage to wait for assistance; ensure the call light was within reach and encourage the resident to use it for assistance as needed; prompt response to all requests for assistance; bolstered mattress for safety; clean up spills immediately; continually educate the resident regarding safety issues; encourage the resident to rise slowly and be sure of their steadiness prior to walking; encourage the resident to wait for assistance; encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; ensure adequate lighting in room; check night lights and call lights at bedside, bathrooms and shower rooms, ensure call light is within reach; ensure proper body positioning; follow facility fall protocol; instruct resident to change positions slowly and ensure proper footing during transfer from wheelchair; keep room free of clutter and ensure objects the resident may need are within reach; monitor medications for side effects that could contribute to a fall; and shower pendant for use during a shower.
On 12/11/23 at 8:58 AM, an observation was made of resident 16 sleeping in bed. The bed was in a low position an a wheelchair was located at the end of the bed on the left side. A fall mattress was observed on its side on the right side of the bed, resting against the window.
On 12/11/23 at 9:39 AM, an interview was attempted with resident 16. Resident 16 was asked how he was doing and he replied good. Resident 16 did not answer any other questions asked of him.
Review of the facility initial investigation, form 358, documented an allegation of neglect by CNA 1 and CNA 2. On 8/9/23 at 1:00 AM, the report documented that CNA 3 and Licensed Practical Nurse (LPN) 1 became aware of the incident and administration was notified at 1:45 AM. The report documented that CNA 3 found resident 16 on the floor in the bathroom unattended. The report documented that the incident occurred on 8/8/23 at 10:00 PM. The report documented that resident 16 was frustrated by the situation.
The facility follow-up investigation, form 359, documented that CNA reported that they found resident on the floor in bathroom, Reported it to the nurse who assessed the resident and notified DON, and began to establish a timeline of events. The summary of the interviews documented that it was determined that there was a miscommunication amongst staff that tasks had been completed when they had not finished their entire task, and safety checks were also miscommunicated prior to shift change. The report conclusion documented that the allegation was verified and staff and resident were able to confirm the incident. The report documented that the plan of care showed that they had a safety check that was not completed and a resident task for a shower had been started and was marked complete.
On 8/10/23 at 1:10 PM, an emailed statement by CNA 2 documented, On the night of August the 8th 2023 when I came into work we decided that I would move from hall one onto the flout (sic) aid (sic). I was the one who initially told one of the CNA's that if all their work was done then I would be okay if they left early. Later that night the CNA eventually did leave early. At report I asked if all her meal ticket's [NAME] (sic) and showers were done her response was yes. Walking rounds were not done and neither were the rounds done properly. Later that evening we found one of the residents on the floor where they had been for hours.
CNA 1's personnel file was reviewed and did not contain a copy of the CNA's certification. The state nursing assistant registry was reviewed to verify the CNA's certification and it showed that the CNA's certification was issued on 8/16/23, which would be eight days after the incident with resident 16 had occurred.
On 8/9/23, CNA 1 had a Disciplinary Action Form completed by the DON. The form documented a first and second written warning for an incident that occurred on 8/8/23. The summary of the warning documented that the written warning was being issued due to the violation of rules policy, carelessness, and failure to follow instruction. On 8/8/2023, you did not complete safety rounds on residents for shift change, left a resident during a task (shower), left facility before scheduled end time without permission, and did not work on assigned floor. The warning further stated, Going forward you are expected to complete walking rounds with coworkers and stay on the floor you have been assigned to, stay for entirety of shift, and complete all tasks for all scheduled shifts.
Review of CNA 1's time card documented the following:
a. On 8/8/23, CNA 1 clocked into work at 2:00 PM and clocked out at 9:45 PM.
b. On 8/9/23, CNA 1 clocked into work at 12:00 PM and clocked out at 10:00 PM.
c. On 8/10/23, CNA 1 clocked into work at 2:00 PM and clocked out at 10:00 PM.
It should be noted that no other days were documented as worked past the shift on 8/10/23.
On 8/10/23 at 11:01 AM, an emailed statement by CNA 1 documented, I usually wait until [resident 16's] grandpa leaves before I shower him. That night his grandpa left a little later than usual and that's completely fine. We always get him on the toilet before the shower and he tells us that he'll call when he's ready to get in the shower. He called at about 9:20 [PM]. I helped assist him into the shower and started to wash his hair and handed him the shower head because he completes the rest of it on his own. I laid out his clothes and went to grab a few towels for the floor. He's usually in the shower for about 15 minutes so I assumed I had time. When I walked out to the nurses station the Noc [night] CNAs were telling me that I could leave early because every other task for the night was completed and they would have 3 CNAs that night. I responded with '[resident 16] is still in the shower though'. And they said that was alright. They asked for report which we usually do walking rounds but that night they just asked for it at the nurses station. When giving report about [resident 16] I had told them that I washed his hair and that he would be ready to get out in about 15 minutes or so. Then I proceeded to change one more person before I left and I should've stayed and completed [resident 16's] shower. But I left when he depended on my care and I am so sorry for the insecurity that [resident 16] was left with that night. I apologize to his family for the worry they must feel. I do think that Noc shift should've been checking in (sic) him every hour because we are required to but this is no bodies [sic] fault to blame except for mine.
On 8/10/23 at 3:06 PM, an emailed statement by CNA 3 documented, From what I was informed by [CNA 9] and [CNA 2], who were working the 1800-0600 [6:00 PM to 6:00 AM] shift with me, was that [CNA 1], who worked 1400-2200 [2:00 PM to 10:00 PM], gave them a report that the showers she did were done and that everyone was in bed that needed to be in bed and her vitals and meal tickets were finished. So we did assume everything was done on that hall. I was on hall 3 and 4 and I don't remember being there for report but I know they allowed her to go home early. If walking report was done like it is supposed to at every shift change then [resident 16] would have been found or if QH [every hour] checks was done as well. I was on hall 3 and 4 for the night and [CNA 9] was on Hall 1 and 2, CNA 2 was going to float around the halls and help where needed. I was scheduled for halls 1 and 2 and [CNA 9] 3 and 4 but since I was scheduled 1800-2200 for halls 3 and 4 we thought it would be easier to stay on the halls we worked for the previous shift. I started on my first rounds just before midnight toileting and checking on my residents. [CNA 9] and [CNA 2] toileted the people on hall 1 and 2 from what they told me around the same time. I found [resident 16] at about 0115 when I was going to answer a call light on that hall. His bedroom door was open and lights were on and his bathroom door was closed but cracked where I could see his wheelchair empty. I opened the door and found [resident 16] laying on the floor in his shower in the corner in front of the shower chair his wheel chair was over by the sink with a towel and clothes in it. His pendent was not on him I noticed, CNA 2 or [RN 1] the nurse found it in the bathroom later when we put him in bed. After I found him I stuck my head out his door and saw CNA 2 and had him get the nurses and a vitals cart. We assisted [resident 16] off the floor after the Nurses assessed him and helped him get dressed and in bed the we did vitals. We then put his pendent on him and his call button hooked to his bed where he would be able to reach it. I did ask him what happened when he was in bed and he said 'I was left in the shower'. We checked on him QH after that when we should have done that in the first place in previous times [resident 16] likes to stay up and play on his tablet for a while before going to bed so we were expecting him to push his call light when we should be checking on him anyway. We did try to do the neuro [neurological] checks on him but he started refusing them throughout the night after the first couple times of checking his vitals.
On 12/12/23 at 10:44 AM, an interview was conducted with CNA 5. CNA 5 stated resident 16 was an extensive 1 to 2 person assist for transfers, an extensive 1 person assist for toileting, and a 1 person extensive to total assist for bathing. CNA 5 stated that she had never assisted resident 16 with bathing because he preferred his showers at night. CNA 5 stated that resident 16 was monitored every 30 minute for suicidal ideation and was on suicide watch. CNA 5 stated that resident 16 had reported that he had a plan and they were to check on him to see if he was okay. CNA 5 stated that resident 16 had eaten a bar of soap and was moved from safety checks every hour to safety checks every 30 minutes. CNA 5 stated that this change occurred about a month to a month and a half ago. CNA 5 stated that resident 16 had a history of falls and interventions to prevent falls were a 2 person assist for transfers, not to leave him alone when he was on the toilet, ensure his call light was on his bed, and ensure his pendent was around his neck. CNA 5 stated that if the resident held onto the button on the pendent it signaled the staff that he was calling. CNA 5 stated that resident 16 had a separate pendent that was for showers only. CNA 5 stated that she had heard about an incident where he was left unattended in the shower. CNA 5 stated that the CNA gave report to another CNA that resident 16 was in the shower and needed assistance to finish the shower, and that CNA did not check on him.
On 12/12/23 at 11:35 AM, an interview with the DON was conducted. The DON stated that she was informed that night at about 1:00 AM, that resident 16 was found on the shower floor. The DON stated that she thinks the water was still running at the time he was found. The DON stated that they assisted him up and assessed him for signs of an injury. The DON stated that she informed the night nurse that she would look into it and notify the family of the incident. The DON stated that at the time they were not sure who left or how he was left in the shower. The DON stated that the nurse was busy doing an admit and was not aware resident 16 was still in the shower. The DON stated that the following morning she called all the CNAs and had them come in to provide written statements. Everyone felt horrible. The DON stated that CNA 1 had reported that another CNA told her she could leave early and she told him resident 16 was still in the shower. The other CNA [CNA 2] said he asked if CNA 1's tasks were done prior to them leaving and was informed that they were. The DON stated that afterwards she told the CNAs that no one could leave and they had to finish their shift. The DON stated they cracked down on walking rounds and updated the resident task sheets. The DON stated that resident 16 was already on safety checks at that time. The DON stated that resident 16's mother had requested hourly safety checks to ensure that he was doing okay because he was choking on his own saliva. The DON stated that CNA 1 was scheduled to work 2:00 PM to 10:00 PM and CNA 2 was scheduled to work 6:00 PM to 6:00 AM on 8/8/23. The DON stated that CNA 2 took over for CNA 1 and told her she could leave early. The DON stated that CNA 1 left her shift at 9:45 PM. The DON stated that resident 16 required a one person extensive assist for transfers, and was a one person assist for showers. The DON stated that resident 16 could perform some of his own bathing. The DON stated that staff should not leave resident 16 unattended in the shower. The DON stated that CNA 1 had reported that she left the room to obtain more towels. The DON stated she informed CNA 1 to call other CNAs to bring more towels. The DON stated that they discussed other options to call for assistance such as pulling the call light or using the walkie talkie. The DON stated that it was CNA 3 who discovered resident 16 in the shower at 1:15 AM, when she was going to answer another call light down the hall. The DON stated that resident 16 was left unattended in the shower for approximately 2.5 hours. The DON stated that resident 16 was found laying in the corner of the shower near the shower chair and that he probably fell from the shower chair to the floor. The DON stated that the walking rounds and hourly safety checks were not done. The DON stated that no explanation was given for why it was not done by the staff and they all agreed that it should have been completed. The DON stated that they revised the task sheet for safety checks and obtained a dedicated pendent for the shower. The DON stated that the pendent's were water resistant, but the CNAs were not aware of this. The DON stated this was the reason the pendent was removed during the shower. The DON stated that CNA 1 was terminated the next day, and that was her last shift because she was essentially quitting. The DON stated that CNA 2 was written up for not checking on resident 16 and all the CNAs were provided verbal warnings. The DON stated that she informed resident 16's mother of the incident the following morning. The DON stated that the mother was pretty taken aback, and she came to the facility and stayed with resident 16. The DON stated that the mother was emotionally upset and crying. The DON stated that she spoke with resident 16 and he reported that he was not hurt. The DON stated that she informed resident 16 that they were going to look into the incident. The DON stated that she recalled resident 16 just nodding in acknowledgement of them looking into it.
On 12/12/23 at 1:20 PM, a follow-up interview was conducted with the DON. The DON stated she was informed at approximately 1:00 AM, by LPN 1 that the CNAs found resident 16 on the shower floor and they were not sure how long he had been there. The DON stated that resident 16 did not normally shower at 1:00 AM, so she assumed he was left there. The DON stated that at some point she found out that the shower was still going. The DON stated that she reported to the Administrator after she was informed, and told him that resident 16 was found on the shower floor.
On 12/12/23 at 12:20 PM, an interview was conducted with the Administrator (ADM). The ADM stated for allegations of abuse or neglect that they should be reporting it to the State Survey Agency (SSA) within three hours. The ADM stated that he was first notified of resident 16's fall in the shower at 1:00 AM. The ADM stated that he did not know all the circumstances of the incident at that time, and the gravity of it did not get relayed to him until the next morning.
On 12/12/23 at 12:26 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that she interviewed resident 16 after the incident in the shower. The RA stated that resident 16 was really upset. I'd be too. The RA stated that the CNA helped resident 16 into the shower, left to get more towels, and never came back. The RA stated that resident 16 blamed the change in administration, and stated that all the good people had left. The RA stated that resident 16 expressed frustration and was upset that he was left on the ground for so long. The RA stated that resident 16 demanded an apology from the CNA. The RA stated that resident 16 was not his happy self and was so mad. The RA stated that resident 16 was frustrated that he did not have his pendent on in the shower. The RA stated that resident 16's mom was upset that she was not notified immediately and that she was told that it was because resident 16 had not sustained any injuries. The RA stated that the mother had said that there may have not been any physical injuries, but mentally was another story.
On 12/12/23 at 2:27 PM, a telephone interview was conducted with resident 16's mother. Resident 16's mother stated that she was his legal guardian and Power of Attorney (POA). The POA stated that the ADM called the next morning at 10:00 AM, and informed her that there was an incident. The POA stated that she was informed that resident 16 had been left in the shower for an extended period of time and that they were going to gather more information. The POA stated that 10 minutes later the DON called her. The POA stated that she was told that at 1:00 AM, resident 16 had still had not pushed his button for help to bed, and that was when staff found him. The POA stated that resident 16 was found in the shower sitting with his back in the corner. The POA stated that resident 16 had told her that he was able to turn the water off. The POA stated that the DON had informed her that she wanted to get more information, but at that point she had not talked to the CNA yet. The POA stated that she asked why the CNA was allowed to go home. The POA stated that the DON had said that the nurse was sending CNAs home because they were not busy. The POA stated that the DON told her resident 16 was in the shower for almost four hours. The POA stated that the DON had told her that legally she did not have to call her because there was no injury sustained to resident 16 during the incident. The POA stated that resident 16 was frustrated and mad, and he just wanted to forget about it and move on. The POA stated that she explained to resident 16 that he needed to answer the questions honestly so that they could ensure that it never happened again. The POA stated that she asked resident 16 if he was hurt anywhere or if he was cold and he replied no. He wanted it to go away. The POA stated that two days after the incident the girl came in to shower him again. The POA stated that it was the same CNA from the shower incident, CNA 1. The POA stated that when she came in she asked her Can we talk for a minute?. The POA stated at that time she just wanted to make sure that whoever was showering resident 16 knew what the process was. The POA stated that she asked the CNA to talk her through the shower process. The POA stated that was when CNA 1 replied, I'm not going to leave the bathroom and I'm going to make sure there are towels in there. The POA stated that she showed the CNA that there were extra towels in the bathroom and CNA 1 replied that she had no idea they were towels. The POA stated at that point she asked the CNA to tell her their name and that was when she discovered it was the same CNA that had left resident 16 unattended. The POA stated that CNA 1 started crying and told them how sorry she was. I told her we had been waiting to hear that. I told her mistakes happen, but you make sure it doesn't happen again. The POA stated that CNA 1 had reported that she told two other people that resident 16 needed help, but no one went back in and checked on him. The POA stated that CNA 2 was no longer at the facility and he had left for personnel reasons, and the other girl was still there. The POA stated that CNA 8 had told her that she heard CNA 1 tell CNA 2 and CNA 9 that resident 16 needed help. The POA stated that her main concerns were how administration handled it. The POA stated that resident 16 was so mad he would not respond to staff when they checked his vital signs. The POA stated that she did not get the opportunity to help resident 16 because she was not informed until the next day.
On 12/12/23 at 3:17 PM, a follow-up interview was conducted with the ADM. The ADM stated that he filled out form 358 and 359 for the facility investigation and interviewed staff. The ADM stated that he notified resident 16's mother between 8:45 AM and 9:15 AM, the following morning and she had not had notification prior to that. The ADM stated that he informed the mother that resident 16 had a fall, was found alone in the shower, and had been there for some time. The ADM stated that he informed her that the DON would follow up with her. The ADM stated that during the investigation they did not suspend CNA 1. The ADM stated that when a staff member was under investigation they should be suspending them pending the investigation results. The ADM stated that the purpose was to keep the individual safe, and not have any repeat occurrences. The ADM stated that CNA 1 quit before the investigation was completed. The ADM stated that CNA 1 was denying some of the allegations and until they could get more conclusive evidence they did not terminate her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 89 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with other specified complication, osteomyelitis right ankle and foot, encounter for orthopedic aftercare following surgical amputation, acquired absence of right great toe, type 2 diabetes mellitus with diabetic polyneuropathy, and essential hypertension.
Resident 89's medical record was reviewed on 12/12/23.
On 8/9/23 at 5:31 AM, a Nurse's Note documented Note Text: Resident had un-witnessed fall at 0415 [4:15 AM]. Resident was assisting themselves into the bathroom when fall occurred. Resident pressed call light for assistance. CNA arrived to residents room seeing resident on floor. CNA called for assistance. LPN arrived to residents room and assessed residents vitals. Vitals were within normal parameters. Resident had small skin tear on left elbow. Resident had an area of concern on left ring finger knuckle joint. Resident had swelling bump on left anterior scalp. Resident stated having no pain at that time. LPN and CNA assisted resident to the toilet. LPN called MD [Medical Director]. MD requested that resident be sent out to ER [Emergency Room] via non emergent transport. Resident consented to be sent out to ER, at this time resident stated having mild pain in left ring finger. DON [Director of Nursing] was notified. Family was called and voicemail was left. Resident left facility via EMS [Emergency Medical Services] non emergent transport at 0500 [5:00 AM].
Form 358, Facility Reported Incidents, was reviewed. It was documented on the form that the Administrator was notified of the incident on 8/9/23 at 6:00 AM. The Ombudsman and APS were notified on 8/11/23.
The SSA Intake Information report documented the SSA was notified of the incident on 8/11/23 at 5:12 PM.
It should be noted that the notification to other agencies was two days after the incident had occurred.
Form 359, Follow-up Investigation Report, was reviewed. The final investigation report was submitted to the SSA on 8/18/23, 7 working days after the incident had occurred.
On 12/12/23 at 3:29 PM, an interview was conducted with the ADM. The ADM stated he had reported late to the SSA because resident 89 had fallen and the response time of the nursing staff was under two and a half minutes. The ADM stated that the DON had inquired as to why he had not reported. The ADM stated resident 89's fall was not neglect or abuse but the DON informed him that he should report.
4. Resident 90 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diabetes mellitus type 2, chronic diastolic heart failure, chronic kidney disease stage 3, macular degeneration, presence of cardiac pacemaker, and anxiety disorder.
Resident 90's medical record was reviewed on 12/11/23.
On 4/10/23 at 4:02 AM, a Nursing Progress Note documented Note Text: Two small bruises are noted above [name removed] right inner knee tonight when CNA's are assisting [name removed] with a brief change. The bruises are side by side, dark purple in color and appx [approximately] 1x1 [inches] in diameter each. [Name removed] is asked by this nurse with noc [night] CNA's present if she knows what happened to cause the bruising. She states 'no' she does not know. [Name removed] is asked if any staff may have assisted her in a rough manner, etc that may have caused the bruising, [name removed states 'no' and states again that she is not surewhere [sic] the bruising came from/what caused it. Will enter order for monitoring of the right inner/above knee bruising.
Form 358, Facility Reported Incidents, was reviewed. It was documented on the form that the staff became aware of the incident on 4/10/23 at 3:30 AM. The Administrator was notified of the incident on 4/10/23 at 9:30 AM. It should be noted that the Administrator was notified six hours after the staff became aware of the incident. The Ombudsman and APS were notified on 4/10/23 at 10:40 AM. The SSA was notified on 4/10/23 at 10:50 AM.
It should be noted that the notification to other agencies was approximately seven hours and 20 minutes after the incident had occurred.
On 12/12/23 at 11:23 AM, an interview was conducted with the ADM. The ADM stated that he specifically remembered getting in trouble for the investigation of resident 90 and the timely submission. The ADM stated that he was the Administrator in training at the time of the incident and was brought in as a training moment. The ADM stated he would usually submit the reports to the Ombudsman, APS, and the SSA at the same time. The ADM stated it was possible the submission to the SSA was at 10:40 AM on 4/10/23.
On 12/12/23 at 11:44 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated if abuse was suspected or an injury of unknown origin the staff were to notify the ADM immediately and they would also notify the DON. RN 3 stated they had a risk management for the injury of unknown origin. RN 3 stated they would interview the resident immediately and document what was said. RN 3 stated if the resident accused someone specific that person was not going in that room the rest of the day.
On 12/12/23 at 12:20 PM, a follow up interview was conducted with the ADM. The ADM stated the reporting requirements if the facility suspected resident abuse, neglect, or injury of unknown origin was two hours. The ADM further stated he had done some education with the staff. The ADM stated that he would report to the SSA first thing and as he was hitting send he would report to APS and the Ombudsman also.
Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). In addition, the facility did not ensure that all investigations were reported to the SSA within 5 working days of the incident. Specifically, for 4 out of 21 sampled residents, notification to the SSA and APS was not within 2 hours after allegations of abuse, neglect, and injuries of unknown origin were identified and an investigation was reported to the SSA 7 working days of the incident. Resident identifiers: 16, 23, 89, and 90.
Findings included:
1. Resident 16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, early onset cerebellar ataxia, muscle spasms, insomnia, depression, dysphagia, and dorsalgia.
On 12/11/23 through 12/18/23, resident 16's medical record was reviewed.
Review of the facility initial investigation, form 358, documented an allegation of neglect by Certified Nurse Assistant (CNA) 1 and CNA 2. On 8/9/23 at 1:00 AM, the report documented that CNA 3 and Licensed Practical Nurse (LPN) 1 became aware of the incident and administration was notified at 1:45 AM. The report documented that CNA 3 found resident 16 on the floor in the bathroom unattended. The report documented that the incident occurred on 8/8/23 at 10:00 PM. The report documented that the SSA was notified on 8/9/23 at 5:06 PM, and APS was notified on 8/9/23 at 5:30 PM.
On 12/12/23 at 12:20 PM, an interview was conducted with the Administrator (ADM). The ADM stated that for any injury of unknown origin it should be reported to the SSA within 2 hours. The ADM stated for allegations of abuse or neglect that they should be reporting to the SSA within 3 hours. The ADM stated that he was first notified of resident 16's fall in the shower at 1:00 AM. The ADM stated that he did not know all the circumstances of the incident at that time, and the gravity of it did not get relayed to him until the next morning.
[Cross-refer F600]
2. Resident 23 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hereditary ataxia, repeated falls, severe protein-calorie malnutrition, and adult failure to thrive.
Review of the facility initial investigation, form 358, documented an allegation of physical abuse. No name of the alleged perpetrator was documented on the form. On 3/13/23 at 6:00 PM, the report documented that staff became aware of the incident. On 3/14/23 at 6:30 AM, the ADM was notified of the allegation. Resident 23 alleged that the nurse held her arm down during a blood draw that resulted in a bruise. The initial report documented a bruise on the right forearm of 3.5 centimeters (cm) x 1.5 cm and was a dark brown color. The report documented that resident 23 was refusing cares and stated that one of her biggest fears was needles and that she did not want to get the blood drawn. The report documented that resident 23 stated that the nurse and the laboratory lady came and held her arm down in order to get the blood draw. The report documented that APS was not informed of the incident, and the SSA was notified on 3/14/23 at 8:30 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment that they prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Specifically, for 1 out of 21 sampled residents, an allegation of neglect was made and the alleged perpetrator was not suspended pending the investigation and was allowed access to the resident/victim. Resident identifier: 16.
Findings included:
Resident 16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, early onset cerebellar ataxia, muscle spasms, insomnia, depression, dysphagia, and dorsalgia.
On 12/11/23 through 12/18/23, resident 16's medical record was reviewed.
Review of the facility initial investigation, form 358, documented an allegation of neglect by Certified Nurse Assistant (CNA) 1 and CNA 2. On 8/9/23 at 1:00 AM, the report documented that CNA 3 and Licensed Practical Nurse (LPN) 1 became aware of the incident and administration was notified at 1:45 AM. The report documented that CNA 3 found resident 16 on the floor in the bathroom unattended. The report documented that the incident occurred on 8/8/23 at 10:00 PM. The report documented that the resident was frustrated by the situation.
The facility follow-up investigation, form 359, documented that CNA reported that they found resident on the floor in bathroom, Reported it to the nurse who assessed the resident and notified DON [Director of Nursing], and began to establish a timeline of events. The summary of the interviews documented that it was determined that there was a miscommunication amongst staff that tasks had been completed when they had not finished their entire task, and safety check were also miscommunicated prior to shift change. The report conclusion documented that the allegation was verified, and staff and resident were able to confirm the incident. The report documented that the plan of care showed that they had a safety check that was not completed and a resident task for a shower had been started and was marked complete.
On 8/10/23 at 11:01 AM, an emailed statement by CNA 1 documented, I usually wait until [resident 16's] grandpa leaves before I shower him. That night his grandpa left a little later than usual and that's completely fine. We always get him on the toilet before the shower and he tells us that he'll call when he's ready to get in the shower. He called at about 9:20 [PM]. I helped assist him into the shower and started to wash his hair and handed him the shower head because he completes the rest of it on his own. I laid out his clothes and went to grab a few towels for the floor. He's usually in the shower for about 15 minutes so I assumed I had time. When I walked out to the nurses station the Noc [night] CNAs were telling me that I could leave early because every other task for the night was completed and they would have 3 CNAs that night. I responded with '[resident 16] is still in the shower though'. And they said that was alright. They asked for report which we usually do walking rounds but that night they just asked for it at the nurses station. When giving report about [resident 16] I had told them that I washed his hair and that he would be ready to get out in about 15 minutes or so. Then I proceeded to change one more person before I left and I should've stayed and completed [resident 16's] shower. But I left when he depended on my care and I am so sorry for the insecurity that [resident 16] was left with that night. I apologize to his family for the worry they must feel. I do think that Noc shift should've been checking in (sic) him every hour because we are required to but this is nobodies [sic] fault to blame except for mine.
On 8/10/23 at 1:10 PM, an emailed statement by CNA 2 documented, On the night of August the 8th 2023 when I came into work we decided that I would move from hall one onto the flout (sic) aid (sic). I was the one who initially told one of the CNA's that if all their work was done then I would be okay if they left early. Later that night the CNA eventually did leave early. At report I asked if all her meal ticket's [NAME] (sic) and showers were done her response was yes. Walking rounds were not done and neither were the rounds done properly. Later that evening we found one of the residents on the floor where they had been for hours.
Review of CNA 1's time card documented the following:
a. On 8/8/23, CNA 1 clocked into work at 2:00 PM and clocked out at 9:45 PM.
b. On 8/9/23, CNA 1 clocked into work at 12:00 PM and clocked out at 10:00 PM.
c. On 8/10/23, CNA 1 clocked into work at 2:00 PM and clocked out at 10:00 PM.
On 12/12/23 at 2:27 PM, a telephone interview was conducted with resident 16's mother. Resident 16's mother stated that she was his legal guardian and Power of Attorney (POA). The POA stated that the Administrator (ADM) called the next morning at 10:00 AM, and informed her that there was an incident. The POA stated that she was informed that resident 16 had been left in the shower for an extended period of time and that they were going to gather more information. The POA stated that 10 minutes later the DON called her. The POA stated that she was told that at 1:00 AM, resident 16 had still had not pushed his button for help to bed, and that was when staff found him. The POA stated that resident 16 was found in the shower sitting with his back in the corner. The POA stated that the DON told her resident 16 was in the shower for almost 4 hours. The POA stated that two days after the incident the girl came in to shower him again. The POA stated that it was the same CNA from the shower incident, CNA 1. The POA stated that when she came in she asked her Can we talk for a minute?. The POA stated at that time she just wanted to make sure that whoever was showering resident 16 knew what the process was. The POA stated that she asked the CNA to talk her through the shower process. The POA stated that was when CNA 1 replied, I'm not going to leave the bathroom and I'm going to make sure there are towels in there. The POA stated that she showed the CNA that there were extra towels in the bathroom and CNA 1 replied that she had no idea they were towels. The POA stated at that point she asked the CNA to tell her their name and that was when she discovered it was the same CNA that had left resident 16 unattended. The POA stated that CNA 1 started crying and told them how sorry she was. I told her we had been waiting to hear that. I told her mistakes happen, but you make sure it doesn't happen again. The POA stated that CNA 1 had reported that she told two other people that resident 16 needed help, but no one went back in and checked on him.
On 12/12/23 at 3:17 PM, an interview was conducted with the ADM. The ADM stated that he filled out form 358 and 359 for the facility investigation and interviewed staff. The ADM stated that during the investigation they did not suspend CNA 1. The ADM stated that when a staff member was under investigation they should be suspending them pending the investigation results. The ADM stated that the purpose was to keep the individual safe, and not have any repeat occurrences. The ADM stated that CNA 1 quit before the investigation was completed. The ADM stated that CNA 1 was denying some of the allegations and until they could get more conclusive evidence they did not terminate her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each receives adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 21 sampled residents, facility staff attempted to transfer a resident from her bed to her wheelchair using a Hoyer lift without properly securing the Hoyer straps. Resident identifier: 17
Findings included:
Resident 17 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, autonomic dysreflexia, neuromuscular dysfunction of bladder, atherosclerosis of aorta, morbid (severe) obesity due to excess calories, major depressive disorder, contracture of muscle, and dependence on wheelchair.
On 10/3/23, the State Survey Agency received a facility reported incident that documented that resident 17 had fallen during a staff assisted transfer from her bed to her wheelchair using a Hoyer lift. Forms 358 and 359 were reviewed. The incident occurred on 10/2/23 at 5:20 PM. The alleged incident was verified to have actually occurred per form 359. Resident 17 received a 1.57 centimeter (cm) abrasion on her left elbow from the incident and was sent to the emergency room for an x-ray. No bone fractures were found.
Resident 17's medical record was reviewed from 12/11/23 through 12/18/23.
A quarterly Minimum Data Set assessment dated [DATE], documented that resident 17's had a Brief Interview for Mental Status (BIMS) Score of 15. A BIMS score of 13 to 15 would suggest intact cognition.
A care plan Focus initiated on 5/10/23 and revised on 5/24/23, documented The resident is risk for falls r/t [related to] dependence on staff for all ADLs [Activities of Daily Living] and dependence on hoyer lift for transfers. The care plan Goal documented The resident will not sustain serious injury through the review date. Interventions included:
a. Initiated on 5/10/23, Anticipate and meet the resident's needs. Encourage to wait for assistance.
b. Initiated on 5/24/23, Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
c. Initiated on 5/24/23, Be sure bed was in low position and locked in place.
d. Initiated on 5/24/23, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.
e. Initiated on 5/24/23, Follow facility fall protocol.
A care plan Focus initiated on 5/10/23 and revised on 5/24/23, documented The resident has an ADL self-care performance deficit r/t hx [history] of MVA [myocardial vascular accident] with neurological trauma, autonomic dysreflexia, muscle contractures, class 3 obesity, depression, pulmonary htn [hypertension] and neurogenic bladder. The care plan Goal documented The resident will maintain current level of function in eating and driving her electric wheelchair through the review date. The Interventions included, but were not limited to:
a. Initiated on 5/24/23, BED MOBILITY: The resident is usually able to: perform ADL with total dependence on 1-2 staff and use of hoyer lift for safe transfers.
b. Initiated on 5/24/23, TRANSFER: The resident is usually able to: perform ADL with total dependence on 1-2 staff and use of hoyer lift for safe transfers.
The ADL Self Performance for Transfers was reviewed for dates between 11/14/23 and 12/12/23. For 42 out of 51 occurrences, resident 17 was totally dependent on staff for transfers. For 3 out of 51 occurrences, resident 17 required extensive assistance from staff for transfers. For 6 out of 51 occurrences, there was no data or there was no transfer.
The ADL Transfer Support Provided was reviewed for dates between 11/14/23 and 12/12/23. For 37 out of 51 occurrences, resident 17 was a two-person physical assist for transfers. For 7 out of 51 occurrences, resident 17 was a one-person physical assist for transfers. For 7 out of 51 occurrences, there was no data or there was no transfer.
On 10/2/23 at 8:38 PM, a nursing progress note documented, At approximately 1720 [5:20 PM], CNA's [sic] put Hoyer sling under resident, attached clips to Hoyer and lifted resident. Sling loops became unattached from Hoyer clips. Resident fell to floor, approximately 18 inches. CNAs reported left elbow hit the floor first. Vital signs obtained. There is a 1.5 cm abrasion on left elbow; elbow swollen. Resident's head hit floor. Provider, family, and administration notified. Neuro [neurological] checks initiated. Resident sent to hospital via EMS [Emergency Medical Services] for x-rays. Resident returned to facility at approximatley [sic] 1940 [7:40 PM]. No fractures.
On 10/2/23 at 10:57 PM, a nursing progress note documented, Resident returned from hospital at approximately 1940. Order to apply ice to left elbow. Neuros and vitals continued.
On 12/11/23 at 12:35 PM, Resident 17 was observed laying in her bed in her room and an interview was conducted with resident 17. Resident 17 stated that on 10/2/23, two CNAs were transferring her from her bed to her wheelchair. Resident 17 stated that one of the straps on the Hoyer lift had not been properly secured. Resident 17 stated that she fell onto the floor and injured her left arm. Resident 17 stated that her left arm was bruised.
On 12/13/23 at 11:03 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 17 required a Hoyer lift to transfer.
On 12/13/23 at 1:03 PM, an interview was conducted with CNA 5. CNA 5 had been present at the time of the incident. CNA 5 stated that resident 17's Hoyer sling had four straps. CNA 5 stated that in the incident with resident 17, one of the Hoyer sling straps was likely not secured to the hook on the Hoyer lift. CNA 5 stated that during the incident, the leg strap on resident 17's Hoyer sling came off and resident 17 slipped through the Hoyer sling and her torso fell sideways out of the opening. CNA 5 stated that it was very unlikely for a Hoyer sling to become unhooked unless the sling was loaded over its weight limit or if the sling was not criss crossed underneath the resident.
On 12/13/23 at 2:29 PM, an interview was conducted with CNA 6. CNA 6 had been present at the time of the incident. CNA 6 stated that she had put resident 17's Hoyer sling straps on the Hoyer lift. CNA 6 stated that when she and CNA 5 initially lifted resident 17 off of her bed, nothing had happened. CNA 6 stated that as she and CNA 5 moved the Hoyer lift from underneath resident 17's bed two of the Hoyer straps on the end of Hoyer lift fell off. CNA 6 stated that resident 17's hip hit the floor first, then her elbow. CNA 6 stated that resident 17's head also hit the floor, but not hard enough to cause an injury.
On 12/13/23 at 2:57 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 was the nurse that CNA 5 and CNA 6 reported to after resident 17's fall. RN 3 stated that both CNAs were too shocked to remember what had happened. RN 3 stated that when she went into resident 17's room, the Hoyer lift was between the sliding bathroom door and the wall, quite far from resident 17's bed. RN 3 stated that two of the very back sling hooks were not on the Hoyer lift. RN 3 stated that upon assessment of resident 17 she found resident 17's elbow to be bruised and found that resident 17 had hit her head. RN 3 stated that resident 17 was sent out to the hospital for evaluation. RN 3 stated that it would not be possible for the sling to come off of the Hoyer lift if that sling had been secured properly. RN 3 stated the Hoyer sling straps have to be all the way on the Hoyer lift hooks or else the straps would fall off.
On 12/18/23 at 10:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that during the incident with resident 17, resident 17 had fallen, had a hard time feeling her left elbow, and was sent out to the emergency room. The DON stated that the facility required all nursing staff to complete a mandatory Hoyer lift training and that physical therapy and occupational therapy had assessed resident 17's Hoyer sling after the incident. The DON stated that an audit was completed on the Hoyer lift itself and the facility had been completing twice weekly Hoyer lift audits since the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 21 sampled residents, a residents medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 4.
Findings included:
Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder.
Resident 4's medical record was reviewed on 12/11/23.
On 11/30/23 at 10:19 PM, an Orders - Administration Note documented Note Text: Latuda Oral Tablet 20 MG [milligrams] Give 1 tablet by mouth at bedtime related to SCHIZOPHRENIA, UNSPECIFIED . Medication was not delivered with pharmacy order. New pharmacy will be [sic] sent [sic] medication for delivery tomorrow.
On 12/1/23 at 2:39 AM, a Nurse's Note documented Note Text: Resident made odd statements regarding invisible friends and had episode of forgetfulness of who nurse was and about medications to which resident is normally aware. NP [Nurse Practitioner] was notified and informed nurse of resident recently having discontinued Latuda r/t [related to] schizophrenia. NP had made order for resident to restart medication, however, medication was not delivered by [name of pharmacy removed] pharmacy. Due to pharmacy company change on 12/1 [23], order was sent to [name of pharmacy removed] pharmacy via fax. Will pass to oncoming shift to follow up about receiving Latuda medication for resident and continue to monitor hallucinations and behaviors per NP order.
On 12/1/23 at 6:59 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available from pharmacy. stat [urgent] safe has 200mg only capsule. Will call pharmacy NP notified.
On 12/1/23 at 11:43 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not here from pharmacy.
On 12/1/23 at 11:22 PM, an Orders - Administration Note documented Note Text: Latuda Oral Tablet 20 MG Give 1 tablet by mouth at bedtime related to SCHIZOPHRENIA, UNSPECIFIED . Medication was not delivered by pharmacy. Pharmacy was called, pharmacy stated medication could possibly be delivered between 1-2am. Pharmacist also stated that medication had not been 'cleared' but he would add it to the schedule to be delivered 'for sure' tomorrow.
On 12/1/23 at 11:48 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Medication was not delivered by pharmacy. Nurse called pharmacy; pharmacist stated that they did not receive order for that medication. Nurse asked if order was sent over tonight, if it will be delivered by tomorrow, pharmacist replied yes. Will send order via fax to be delivered tomorrow.
On 12/2/23 at 11:09 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available, pharmacy notified.
On 12/2/23 at 1:13 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available, pharmacy notified.
On 12/2/23 at 2:20 PM, a Nurse's Note documented Note Text: NP ordered depakote BID [twice daily] to manage symptoms related to schizophrenia until Latuda can become therapeutic. First dose of depakote was given now. Pharmacy was called earlier today and Latuda will be delivered tonight.
On 12/2/23 at 7:19 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Pharmacy deliver has not gotten here yet.
On 12/5/23 at 8:56 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Dosage hold ordered by [name removed]. Medication was only provided with 3-day supply from pharmacy, which ran out during the day. Will refax and/or call pharmacy to follow up on medication and request replenished supply.
On 12/6/23 at 6:36 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Not available from pharm [pharmacy] or stat safe. NP aware.
On 12/6/23 at 11:33 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available from pharmacy. Not in stat safe. Pharmmacy [sic] states it will be here tonight.
On 12/7/23 at 12:31 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Medication arrived late from pharmacy, and resident requested for it to be brought in during 12am or 3am blood sugar check once it arrived.
On 12/12/23 at 1:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated if he needed to refill a resident medication he would print off a script from the resident Medication Administration Record and fax the script to the pharmacy. LPN 2 stated a lot of times if the pharmacy was not sending the medication he would call the pharmacy and clarify that the refill was received. LPN 2 stated in the past the facility did have problems with the pharmacy not delivering but the facility was also in the process of switching pharmacies. LPN 2 stated the new pharmacy had been much better. LPN 2 stated if he faxed a refill in the morning it should be to the facility by late tonight. LPN 2 stated the pharmacy started their deliveries in Salt Lake City. LPN 2 stated the facility had an emergency medication system that was stocked with medications. LPN 2 stated that resident 4's Celebrex was 100 mg and there were only 200 mg capsules in the emergency medication system.
On 12/12/23 at 1:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility was integrated with the former pharmacy and with the new pharmacy the facility was not integrated yet so the staff were faxing medication refills. The DON stated the pharmacy delivered daily. The DON stated the pharmacy would deliver STAT medications but the pharmacy was located in Springville so it was a little harder to get the medications to the facility quickly. The DON stated the pharmacy transition was a little bit hard and the new pharmacy thought they were going to be integrated. The DON stated the facility changed pharmacies on 12/1/23.
The PHARMACY AGREEMENT dated 10/1/23, documented . ARTICLE 1 RESPONSIBILITIES OF THE PHARMACY 1.1 General. During the Term (as defined below) of the Agreement, the Pharmacy shall: (a) provide the Pharmacy Products to the Facility and its residents in a prompt and timely manner in accordance with all applicable local, state and federal laws and regulations (collectively, 'Applicable Law'); . 1.2 Delivery Schedule. The Pharmacy shall deliver the Pharmacy Products to the Facility daily or as otherwise mutually agreed by the parties in writing. See Exhibit A. Exhibit A Delivery The Pharmacy shall deliver at no charge to the Facility (i) up to four times per day at approximately 10am, 2pm, 5pm and 8pm on non-holiday weekdays and (ii) up to two (2) times per day on weekends and holidays at approximately 2pm and 8pm. The Facility shall place their order at least two hours prior to the applicable departure time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address the irregularity. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Specifically, for 2 out of 21 sampled residents, pharmacy recommendations including the physician's documentation was not included in the resident's medical record. Resident identifier: 1 and 4.
Findings included:
1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder.
Resident 4's medical record was reviewed on 12/11/23.
The August, September, October, and November 2023 Consulting Reports documented a Yes as Recommended Changes. The identified irregularities were unable to be located within resident 4's medical record.
2. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, neuromuscular dysfunction of the bladder, epilepsy, Crohn's disease, anxiety disorder, major depressive disorder, and osteoarthritis.
On 12/11/23 through 12/18/23, resident 1's medical record was reviewed.
Review of resident 1's medical record revealed no documentation of the monthly drug regimen review conducted by the pharmacist for November 2023 through January 2023 through. Review of the facility pharmacy binder revealed no documentation of the monthly drug regimen review for July 2023 through November 2023.
On 12/11/23 at 3:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they just switched to a new pharmacy last week. The DON stated that the monthly drug regimen reviews were emailed for awhile and she would check the email for the pharmacy reviews from July 2023 through November 2023.
On 12/12/23 at 8:18 AM, the DON stated that she had all the pharmacy reviews and recommendations from June 2023 through November 2023 on her computer, but she was not able to print them so she had the pharmacy fax them over to her again.
Review of the monthly pharmacy drug regimen reviews revealed that on 11/16/23 the pharmacist had identified that resident 1 had two orders for Diclofenac gel and recommended to consider discontinuing one of the orders and combine the areas of treatment. The provider agreed to the recommendation and signed the form, but did not date it. It should be noted that the recommendation was not contained within resident 1's medical record.
On 12/12/23 at 1:42 PM, an interview was conducted with the DON. The DON stated the pharmacy would review the residents offsite monthly and fax the reviews to the DON. The DON stated she would put the recommendations in the doctors box for review. The DON stated once the doctor completed the recommendations the DON would fax the reviews back to the pharmacy. The DON stated that they would now be uploading the recommendations into the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 21 sampled residents, the provider was not notified per the physician's order when a resident's blood glucose (BG) and systolic blood pressure (SBP) were outside of the physician's ordered parameters. In addition, a resident's long acting insulin was held when it should have been administered per the sliding scale physician's order. Resident identifier: 4.
Findings included:
Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder.
Resident 4's medical record was reviewed on 12/11/23.
1. On 9/6/23, a physician's order documented Insulin Lispro Subcutaneous Solution Pen-injector 200
UNIT/ML [milliliter] (Insulin Lispro) Inject as per sliding scale: if 0 - 300 = 0 [sic] 0 units; 301 - 400 = 3; 401 - 600 = 4 [sic] 4 units, recheck BG after 2 hors [sic] and notify provider if > [greater than] 350., subcutaneously one time a day for DM [diabetes mellitus].
The December 2023 Medication Administration Record (MAR) documented on 12/5/23 at 8:00 PM, resident 4's BG was documented as 309. Insulin Lispro was not administered due to 4=Vitals Outside of Parameters for Administration. Resident 4 should have received 3 units of insulin Lispro.
2. On 10/14/23, a physician's order documented hydrALAZINE HCl [hydrochloride] Oral Tablet 10 MG [milligrams] (Hydralazine HCl) Give 1 tablet by mouth as needed for hypertension Notify provider for SBP is greater than 160.
The December 2023 MAR documented on 12/1/23 at 6:57 AM, the hydralazine was administered and the SBP was documented as 168. The provider was not notified as ordered.
3. On 10/24/23, a physician's order documented Blood Pressure to be taken TID [three times daily] d/t [due to] elevated blood pressure and Hypertension. Notify provider for systolic greater than 160. three times a day for Hypertension Report SBP >160.
A review of the December 2023 MAR documented the following SBP greater than 160 and the provider was not notified as ordered.
a. On 12/1/23 at 7:00 AM, 168.
b. On 12/1/23 at 2:00 PM, 161.
c. On 12/6/23 at 9:00 PM, 166.
d. On 12/9/23 at 7:00 AM, 164.
e. On 12/10/23 at 7:00 AM, 169.
On 12/12/23 at 1:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated if he needed to notify the provider he would send a text message to the provider and document in a progress note. LPN 2 stated that way other staff would see what was done for the resident and he would give report. LPN 2 stated that resident 4 would frequently refuse her insulin at night.
On 12/12/23 at 1:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if the staff were to contact the provider they should be documenting in a progress note. The DON stated the staff would usually call the provider and not text.

Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. In addition, the facility did not ensure that all drugs and biologicals were stored under proper temperature controls. Specifically, opened insulin injector pens were not labeled with open dates and the insulin injector pens were in the medication cart available for resident use. In addition, the medication refrigerator was found to have low temperatures not compatible with medication storage.
Findings included:
On 12/18/23 at 8:41 AM, an observation was conducted of Registered Nurse (RN) 1 preparing resident medications. RN 1 prepared an insulin Aspart injection pen. The insulin Aspart injection pen was observed and was open for administration and was not labeled with an open date. RN 1 was immediately interviewed. RN 1 stated that the insulin injection pens were to be dated with the open date. RN 1 stated he thought the insulin Aspart injection pen was opened a week ago. The Director of Nursing (DON) was present and instructed RN 1 to dispose of the insulin injection pen and get a new one.
On 12/18/23 at 8:45 AM, an observation was conducted with RN 1 of the medication fridge in the medication storage room. The temperature of the medication fridge was observed at 30 degrees Fahrenheit (F). RN 1 was immediately interviewed. RN 1 stated the medication fridge had been registering low temperatures and some adjustments had been made according to the fridge temperature form.
On 12/18/23 at 10:19 AM, an observation was conducted of Licensed Practical Nurse (LPN) 1's medication cart. The medication cart contained an insulin glargine injection pen that was not labeled with an open date. LPN 1 was immediately interviewed. LPN 1 stated that she would discard the injection pen and would get a new one. LPN 1 stated she would date the insulin injection pens with the open date.
On 12/18/23 at 10:21 AM, an observation was made of the medication fridge in the medication storage room. The temperature of the medication fridge was observed at 34 degrees F. The medication fridge contained 3 vials of tuberculin purified protein derivative, 3 bulbs of cefepime, 1 bulb of ceftriaxone, 1 vial of influenza vaccine, 4 insulin aspart injection pens, 3 insulin lispro injection pens, 1 insulin lispro vial, 5 insulin lantus injection pens, and 2 insulin levemir injection pens.
The December 2023 Fridge Temperature Log was reviewed and documented All fridges in the facility need to have a temperature log on the door of the fridge. It is a state and community requirement to have temperature logs documented once daily. Please keep one log for each fridge and return to the DON at the end of the month. It will be the PM nurse's responsibility to document the temperature nightly, but both AM and PM nurses are responsible for checking the log for documentation daily. Please do not mix resident food with staff food. Food and beverages need to ben [sic] dated and discarded after 3 days according to food content. Normal Temperatures: Fridge: 38-41 F Freezers: Below 0 F Report to maintenance if temperature is not with in normal range. The following temperatures were documented for the medication fridge.
a. On 12/1/23, 34 F.
b. On 12/2/23, 34 F.
c. On 12/3/23, 32 F.
d. On 12/4/23, 32 F.
e. On 12/5/23, 34 F.
f. On 12/6/23, 38 F.
g. On 12/7/23, 34 F.
h. On 12/8/23, 35 F.
i. On 12/9/23, 36 F.
j. On 12/10/23, 28 F.
k. On 12/11/23, 16 F.
l. On 12/12/23, 32 F.
m. On 12/13/23, 32 F.
n. On 12/14/23, 32 F.
o. On 12/15/23, 34 F.
p. On 12/16/23, 34 F.
q. On 12/17/23, 30 F.
On 12/18/23 at 10:28 AM, an observation was conducted of RN 2's medication cart. The medication cart contained 2 insulin glargine injection pens that were not labeled with an open date.
On 12/18/23 at 10:39 AM, an interview was conducted with the DON. The DON stated that the medication fridge temperature should be 38 to 41 degrees F. The DON stated that she would have to look at the medication recommendations for storage. The DON stated the nursing staff should be dating insulin when they were opened. The DON stated that insulin was good for 28 days after it was opened.
On 12/18/23 at 10:43 AM, an interview was conducted with the Corporate Nurse (CN). The CN stated that the tuberculin purified protein derivative, influenza vaccine, and insulin should be stored at 35 to 46 degrees F.
On 12/18/23 at 11:09 AM, an additional interview was conducted with the CN. The CN stated that she had contacted the pharmacy and the intravenous antibiotics should be stored between 35 to 46 degrees F. The CN stated the pharmacy instructed that as long as the medications were not frozen the facility did not need to reorder. The CN stated that the pharmacy instructed that the influenza vaccine came to them on ice and should be fine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, for 1 out of 21 sampled residents, the facility did not obtain a specimen for a lab that was ordered by the provider. Resident identifier: 1.
Findings included:
Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, neuromuscular dysfunction of the bladder, epilepsy, Crohn's disease, anxiety disorder, major depressive disorder, and osteoarthritis.
On 12/11/23 through 12/18/23, resident 1's medical record was reviewed.
Resident 1's laboratory orders revealed the following:
a. On 2/3/23, a Complete Blood Count (CBC), lipid panel, and Keppra serum concentration level was ordered.
b. On 2/24/23, a Levetiracetam (Keppra) serum level was ordered.
Resident 1's laboratory results revealed no documentation of the above mentioned lab orders.
On 2/23/23 at 11:01 AM, the progress note documented that it was noted that the Levetiracetam serum lab that was ordered was not obtained. The provider was notified and the order was rescheduled to be drawn on 2/24/23.
On 12/12/23 at 8:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she did not have the lab results for the Keppra ordered but found a progress note that stated that it was completed on 3/7/23. The DON stated that she called the lab and they could not find the laboratory results for the Keppra order either. The DON stated that the Keppra ordered on 2/3/23, was not obtained. The DON stated that the Keppra was also not obtained on 2/24/23, and was rescheduled and completed on 3/7/23. The DON stated that the lab process was that as soon as the nurse obtained the results they should note it that day and notify the provider the next morning unless it was a critical value that should be reported immediately.
On 12/12/23 at 8:50 AM, the DON emailed results for a CBC and Lipid panel that was obtained for resident 1 on 2/4/21, and not the order for the CBC, lipid panel, and Keppra level that was ordered on 2/3/23.

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, there were numerous undated and unlabelled items in both the walk-in refrigerator and freezer, items stored on the floor in both the walk-in refrigerator and freezer, and there was a significant layer of dust on vents located above food preparation and plating areas.
Findings included:
1. On 12/11/23 at 8:25 AM, an initial kitchen walkthrough was conducted.
In the walk-in fridge, there were boxes of cheese, liquid eggs, tomatoes, strawberries, zucchini, bell peppers, and honeydew stored on the floor.
On a sheet pan rack in the walk-in fridge, there were several sheet pans with undated bowls of salad, undated fruit cups, undated cake slices, undated pasta cups, and undated bags of carrots.
On the third shelf up from the floor, there was a Ziploc bag of cubed chicken with no date or label.
In the walk-in freezer, there was a box of nutritional shakes, frozen rolls, and frozen vegetables stored on the floor. There was an unlabelled undated Ziploc bag filled with ground beef.
Two ceiling vents above food preparation tables and plating tables in the kitchen were covered in dust.
On 12/11/23 at 8:37 AM, an interview was conducted with the Dietary Aide (DA). The DA stated that food items in the walk-in fridge and freezer were thrown away after seven days. The DA stated that the walk-in fridge and freezer were checked daily. The DA stated that if produce was undated, kitchen staff would check to make sure that the produce looks good before using it.
2. On 12/12/23 at 1:12 PM, a follow up kitchen walkthrough was conducted.
The two ceiling vents above food preparation tables in the kitchen were still covered in dust.
In the walk-in fridge, there was still an undated and unlabelled Ziploc bag of cubed chicken. There was an open undated bag of shredded cheese. There were two bags of open undated bagels on the top shelf.
In the walk-in freezer, there were two boxes of nutritional shakes stored on the floor. There was an open bag of frozen tater tots with no date. There was an unlabelled undated Ziploc bag filled with ground beef.
On 12/12/23 at 1:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the walk-in fridge and freezer should be checked daily for expired items. The DM stated that if there was no date on a food item in the fridge, it should be thrown out. The DM stated that leftovers were thrown out the next morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not 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, including Coronavirus Disease 2019 (COVID-19). Specifically, for 2 out of 21 sampled residents, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, Transmission Based Precautions (TBP) and quarantine was discontinued for a COVID-19 positive resident after only six days of isolation, and staff face masks were observed worn down below the nose and mouth. Resident identifiers: 17 and 133.
Findings included:
1. On 12/11/23 at 8:49 AM, an observation was made of Registered Nurse (RN) 4 at the nurse's medication cart near room [ROOM NUMBER]. RN 4 had their facemask down below their nose. RN 4 was observed to assist resident 1 in the hallway with their surgical facemask pulled down below their nose.
2. Resident 17 was admitted to the facility on [DATE] with diagnoses which included autonomic dysreflexia, rosacea, neuromuscular dysfunction of the bladder, uterovaginal prolapse, atherosclerosis of the aorta, hyperlipidemia, morbid obesity, and major depressive disorder.
On 12/8/23, the facility COVID-19 resident tracking sheet documented that resident 17 tested positive for COVID-19. The tracking form documented the date of symptom onset as 12/6/23.
On 12/8/23 at 11:00 AM, resident 17's antigen testing form documented that resident 17 had symptoms of diarrhea and a temperature of 99.0 Fahrenheit. The COVID-19 antigen test results were positive.
On 12/11/23 at 8:51 AM, an observation was made of Certified Nurse Assistant (CNA) 4 exiting resident 17's room. Resident 17's room had a droplet/contact precaution sign posted on the door. CNA 4 was observed to doff a N95 mask and placed it on top of the PPE cart outside the room. CNA 4 then donned a surgical mask and performed hand hygiene. CNA 4 stated that resident 17 was on TBP for COVID-19. CNA 4 was observed to walk away from the room leaving the used N95 mask on top of the clean PPE cart. CNA 4 was observed exiting the room without eye protection donned.
3. Resident 133 was admitted to the facility on [DATE] with diagnoses which included fracture of left femur and left ulna, urinary tract infection, congestive heart disease, atrial fibrillation, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, and presence of cardiac pacemaker.
On 12/5/23, the facility COVID-19 resident tracking sheet documented that resident 133 tested positive for COVID-19. The tracking form documented the date of symptom onset as 12/5/23.
On 12/11/23 at 8:55 AM, resident 133's room was observed with a droplet/contact sign posted on the door and a PPE cart located outside of the room. The door to the room was observed closed.
On 12/11/23 at 9:31 AM, resident 133's room was observed with the droplet/contact sign and PPE cart removed. CNA 4 was observed entering the room with only a surgical mask donned. An immediate interview was conducted with CNA 4. CNA 4 stated that the resident was no longer on TBP for COVID-19. The facility Infection Preventionist (IP) stated that resident 133 was on day six of quarantine for COVID-19 and they could be removed from isolation because resident 133 did not have any acute symptoms that required medications such as a fever. The IP stated that this was the guidance that she had received from the local health department representative. The IP stated that they did not conduct a COVID-19 test after the initial test or for the use in discontinuation of quarantine. The IP stated that the guidance provided by their health department representative was that the testing was an option but not required as the resident would most likely continue to test positive. Resident 133 was heard from the hallway with a deep, wet, productive cough. The IP stated that they did not need to continue quarantine for a lingering cough. Resident 133 was observed wheeling herself to the doorway of the room and exiting into the hallway directly outside of her room. The IP was observed to leave to obtain an oxygen tank for resident 133's wheelchair. When the IP returned with the oxygen tank she also instructed resident 133 to donn a surgical mask.
On 12/13/23 at 9:31 AM, an observation was made of resident 133 ambulating down the main hallway with the therapy staff. Resident 133 was observed with their surgical mask down below her chin. Resident 133 was heard stating that she was short of breath and needed to sit down.
Review of the facility COVID-19 Policy and Procedures documented under Duration of TBP for Resident with SARS-CoV-2 infection that Residents with mild to moderate illness who are not moderately to severely immunocompromised:
*At least 10 days have passed since symptoms first appeared and
*At least 24 hours have passed without use of fever-reducing medications and
*Symptoms have improved
*A test-based strategy may be used to discontinue TBP prior to 10 days.
The policy documented under the Test-Based Strategy that for residents who were symptomatic TBP could be discontinued if they had the resolution of fever without the use of fever-reducing medications; and symptoms had improved; and results were negative from at least two consecutive respiratory specimens collected 48 hours apart using an antigen or Nucleic Acid Amplification Test (NAAT). The policy was adopted on March 19, 2020 and was last revised on August 4, 2023.
Review of the Centers for Disease Control and Prevention guidance for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Duration of Transmission-Based Precautions for Patients with SARS-CoV-2 Infection it documented, Patients with mild to moderate illness who are not moderately to severely immunocompromised:
At least 10 days have passed since symptoms first appeared and
At least 24 hours have passed since last fever without the use of fever-reducing medications and
Symptoms (e.g., cough, shortness of breath) have improved, and
The criteria for the test-based strategy are:
Patients who are symptomatic:
Resolution of fever without the use of fever-reducing medications and
Symptoms (e.g., cough, shortness of breath) have improved, and
Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
On 12/18/23 at 10:40 AM, a follow-up interview was conducted with the IP. The IP stated that staff should be doffing their PPE upon exit of a TBP room for COVID-19. The IP stated that disposal bins were located inside the resident room next to the door. The IP stated that staff would doff the gown and gloves inside the room before exiting and should remove the N95 mask after exiting the room. The IP stated that the N95 mask should be disposed of in the nearest garbage can. The IP stated that staff should wash their hands and donn a surgical mask. The IP stated that staff should not leave the used N95 mask on top of the PPE cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that in response to allegation of abuse the facility did not ensure that all alleged violations involving abuse were immediately, but no later than 2 hours after the allegation was made, if the event that caused the allegation involved abuse. This involved reporting to other officials in accordance with State law. Specifically, the facility did not report when a resident was involuntarily secluded. In addition, the facility did not report within 2 hours to the State Survey Agency when same resident was physically and verbally abused by a family member. Other officials were not contacted regarding both incidents. Resident identifier: 6.
Findings include:
Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
Resident 6's electronic medical record review was completed on 3/2/22.
1. Seclusion:
On 2/22/22 at 1:13 PM, resident 6 revealed that she was put into room [ROOM NUMBER] overnight from 2/21/22 to 2/22/22.
The facility census revealed that resident 6 had been residing in room [ROOM NUMBER] since admission.
On 7/31/21, resident 6 had a Preadmission Screening Resident Review (PASRR) Level II completed and revealed that resident 6 was vulnerable to exploitation. Resident 6 displayed increasing cognitive impairment with impaired short-term memory and periods of confusion and disorientation .
A nursing note dated 2/21/22 at 9:28 PM, revealed that on 2/21/22, resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed.
On 2/21/22 at 9:30 PM, an incident report was created because while staff were transferring resident 6 from room [ROOM NUMBER] to room [ROOM NUMBER], her foot was run over by the wheelchair. This incident was created as an injury and revealed that while resident 6 was being moved to room [ROOM NUMBER] (not her room), CNA 4 ran over resident 6's foot. Resident 6 had new pain at the time of the incident and complained of pain at 11:00 PM.
A nursing note dated 2/21/22 at 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time.
On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over. Immediately following incident resident refused to allow this nurse to assess for injury, she allowed later at 2300 (11:00 PM) when she complained of pain in her left foot, no apparent signs of injury were noted; no redness, no bruising, no swelling.
On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that resident 6 had fits and staff took her back to her room and helped her calm. CNA 8 stated that resident 6 did not always like to go to her room, but that's where we take her. CNA 8 stated that resident 6 was placed in her room for an average of 10 minutes. CNA 8 stated that she was told resident 6 was taken to another room so that other residents could sleep, and that resident 6 was only taken, until she calmed down.
On 2/23/22 at 4:13 PM, an interview was conducted with RN 3. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER].
On 2/24/22 at 6:11 AM, CNA 3 was interviewed. CNA 3 stated that he was working the evening of 2/21/22 when resident 6 had a melt down. CNA 3 stated that resident 6 wanted to watch a different program, but was told that the other residents wanted to listen to something else. CNA 3 stated that resident 6 began screaming and a nurse, Licensed Nurse (LN) 4 told resident 6 in a stern voice to quiet down and to stop behaving like that. CNA 3 stated that resident 6 yelled, I hate you and LN 4 and resident 6 began to argue. Resident 6 also yelled I hate you as CNA 4 was pushing her in her wheelchair to her room. CNA 3 stated that resident 6 was stomping her feet. CNA 3 stated that resident 6 yelled from about 5:30 PM until 3:30 AM. CNA 3 stated that sometimes resident 6's door was closed and sometimes open. CNA 3 stated that resident 6 was moved to room [ROOM NUMBER] between 10:30 PM and 11:00 PM, because other residents were complaining. room [ROOM NUMBER] was located in a hall where there were no other residents in the immediate area. CNA 3 stated that CNA 7 reported that resident 6 screamed until 3:30 AM. CNA 3 stated that resident 6's voice was raspy because she spent 10 hours screaming. CNA 3 stated that there was no training for staff on what to do for resident 6 when her behaviors escalated. CNA 3 stated that he did not feel that the nursing home was a good fit for resident 6. CNA 3 stated that resident 6 needed more attention than we can give. CNA 3 further stated that with resident 6 her emotions came before her thoughts and her brain processed things differently.
On 2/24/22 at 7:02 AM, CNA 4 was interviewed. CNA 4 stated that he worked the night shift, including on 2/21/22. CNA 4 stated that after he took resident 6 to be weighed, other residents were at the round table and had changed the television from resident 6's preferred station. CNA 4 stated that resident 6 began yelling abnormally loud compared to her usual frustration. CNA 4 stated that other residents asked staff to take resident 6 to her room. CNA 4 stated that resident 6 was yelling out of rage. CNA 4 stated that he took resident 4 to her room at approximately 6:15 to 6:30 PM, and resident 6 was upset and used profanity about the other residents. CNA 4 stated that resident 6 was stomping her feet and yelling. CNA 4 stated that resident 6 stated that no one appreciated her and she was mad at CNA 4 for taking her to her room. CNA 4 stated that he asked CNA 7 to assist resident 6 because resident 6 was mad at him. CNA 4 stated that resident 6 was moved from her room, room [ROOM NUMBER], to room [ROOM NUMBER] to get her away from some of the other residents that were complaining. CNA 4 stated that resident 6 was grinding her feet into the floor. CNA 4 stated that resident 6 shoved her heels into the floor and pushed herself back in the chair. CNA 4 stated that he asked resident 6 to put her feet up, but she was being more aggressive than usual, and when she put her foot down, her shoe came off and her foot was run over by the wheelchair. CNA 4 stated that when the wheelchair ran over resident 6's foot, she yelled and said, My foot! CNA 4 stated that resident 6 yelled until after 2:00 AM, but he was not assigned to her after taking her to room [ROOM NUMBER]. CNA 4 stated that resident 6 remained in room [ROOM NUMBER] until after he left the facility at approximately 6:30 AM. CNA 4 stated that room [ROOM NUMBER] was the furthest spot away from other residents.
On 2/24/22 at 8:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the incident was discussed the following morning and the information was turned over to the Administrator. The DON stated that she did not believe that this was an incident of abuse with resident 6's foot being injured in the room transfer.
On 2/24/22 at 11:44 AM, the Administrator (ADM) was interviewed. The ADM stated staff had been trained about abuse on January 19, 2022 and reported any abuse to her because she was the abuse coordinator. The ADM stated that if there was an allegation of abuse, she would report to the Ombudsman, corporation and to Adult Protective Services (APS). The ADM stated that she reviewed the incident from the night of 2/21/22 on 2/23/22, and had not been contacted by staff regarding the incident. The ADM stated that resident 6 screamed, yelled, and kicked her legs when she gets upset, which can be scary. The ADM stated that staff decided to separate her from the rest of the group. The ADM stated that staff took resident 6 to another room and asked her to be quiet. The ADM stated that the incident lasted until the morning of 2/22/22 and that resident 6's foot was injured during the episode. The ADM stated that staff had not reported to her because the physician looked at resident 6's foot and there was no apparent injury. The ADM stated that she did not know resident 6 stayed in room [ROOM NUMBER] overnight. The Administrator stated she would not have done an investigation because she did not feel it was involuntary seclusion. The Administrator stated she did not report to the State Survey Agency, APS, or any other agency because she did not see it as involuntary seclusion. The Administrator stated she would have liked to be informed of incidents like this when it happens.
[Cross refer F600]
2. Physical and Verbal Abuse:
The facility abuse investigations were reviewed on 2/23/22. There was one abuse investigation regarding resident 6 and a family member. The previous facility Administrator reported an abuse allegation on 11/28/21 at 9:55 AM to the State Survey Agency.
According to the Initial Entity Report form On 11/27/21 at 12:22 PM, Staff was alerted to the TV area where it was reported that [resident 6's family member] had reached out, slapped and pinched [resident 6]. It was also reported that he had stated 'the (sic) she shouldn't eat because she was to fat.' Staff immediately separated the two residents to prevent any further altercation. [Resident 6's family member] is [resident 6's] father. It should be noted that the incident was reported to the State Survey Agency approximately 22.5 hours after the incident occurred.
There were no other documentation regarding APS or local law enforcement being contacted.
On 2/24/22 at 11:44 AM, an interview was conducted with the facility ADM. The ADM stated that she was the abuse coordinator. The ADM stated when she received an allegation of abuse she began an abuse investigation. The ADM stated that she would provide a written report to the State Survey Agency, report to the ombudsman, corporate and APS. The ADM stated that she would report to local law enforcement if there was actual harm or a sexual thing. The ADM stated that she had not reviewed any of the previous abuse investigations that were conducted by the previous ADM.
[Cross refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included but were not limited to atherosclerosis of aorta, hypertension, insomnia, low vision of the right eye, and mild cognitive impairment.
On 2/22/22 at 10:09 AM, an interview was conducted with resident 4. Resident 4 stated that she had some problems with another resident in the facility, resident 6. Resident 4 stated that there was a group of residents in the facility that would go on van rides together and play UNO together and resident 6 gets upset and throws a tantrum. Resident 4 stated that she understood resident 6 had problems but they all have problems and she was not responsible for resident 6's issues. Resident 4 stated that when resident 6 throws a tantrum it disrupted her activity. Resident 4 stated that resident 6 would then leave the activity. Resident 4 then stated that resident 6 had Downs Syndrome. Resident 4 stated that she told resident 6 , I don't like this shit, use your words to communicate with people, you can't yell and scream and expect things to go your way. Resident 4 stated that she let the staff know when resident 6 was acting this way. Resident 4 stated that out of respect for resident 6 she talked with her. Resident 4 stated that when she talked to resident 6 she responded good and replied that she understood. Resident 4 stated that she told resident 6 that no she did not understand or else she would not act like this. Resident 4 stated that to her this was being respectful, talking to her quietly. Resident 4 stated I'm not my brother's keeper.
On 2/23/22 at 3:47 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 4 appeared cognitively intact most of the time. RN 1 stated that resident 4 had the kind of dementia that she talked behind peoples backs, stirred things up, lashed out, had confrontations, and had poor impulse control. RN 1 stated that resident 4 had issues with other residents and she would talk about other people. RN 1 stated for example, resident 4 did not like resident 14 so when she had a headache she would say she had a [resident 14's name]. RN 1 stated that resident 4 could do tasks and follow directions, but did not get along with some people. RN 1 stated that resident 6 had Downs Syndrome, was child like, and yelled and screamed. RN 1 stated that resident 4 would respond to resident 6's behaviors and say things like this is why people don't like you because you scream a lot. RN 1 stated that when resident 6 was in the middle of doing this it was not helpful. RN 1 stated that resident 4 thought that resident 6 needed more discipline and that was what she was doing.
On 2/24/22 at 6:11 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that he had not witnessed any resident to resident altercations between resident 4 and resident 6, but that resident 4 had reported them to CNA 3. CNA 3 stated that resident 4 had reported that she told resident 6 that she needed to knock off her attitude and be quiet. CNA 3 stated that resident 4 had reported that it was hard when resident 6's emotions came up at dinner, and it happened more often. CNA 3 stated that when this happened they tried to separate the residents. CNA 3 stated that when the other residents responded to resident 6's behaviors resident 6 took it as a personal attack and said that everyone hated her. CNA 3 stated that this made it worse for resident 6.
On 2/24/22 at 7:33 AM, an interview was conducted with RN 2. RN 2 stated that resident 4 was outspoken and sometimes what she said came across as abrasive. RN 2 stated that at times resident 6 would take offense to what resident 4 said. RN 2 stated that resident 4 was blunt and she could see that resident 6 would take offense. RN 2 stated that resident 4 had told resident 6 to stop crying or whining and it would upset resident 6. RN 2 stated that usually if resident 6 was emotionally distraught it would escalate the situation instead. RN 2 stated that when this would happen they would separate the two of them and give them time to de-escalate. RN 2 stated that they tried to get them away from each other so they can start fresh. RN 2 stated that this would happen 1-2 times a week, and it occurred on a regular basis.
On 2/24/22 at 11:11 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 4 would tell resident 6 that she was whining and mean. CNA 5 stated that resident 6 would respond back with you are mean and you are never nice to me. CNA 5 stated that staff would respond to these interactions with separation and breaks from each other. CNA 5 stated that we asked them to go to their room if they could not be nice. CNA 5 stated that there were no other interventions for when resident 4 and resident 6 had verbal altercations.
On 2/24/22 at 11:44 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated she was the abuse coordinator. The ADM stated that the process was that if anyone sees any signs of abuse (verbal or mental) or signs of distress they were to call the nurse on the floor and then call her and she would starts an investigation. The ADM stated that she would obtain written statements from the aides on the floor, call the state to report it, and continue to get interviews. The ADM stated she would involve the other administrative staff, complete a written report and submit it to the state agency, and report to the police depending on the situation. The ADM stated that she had a flow sheet that went over the steps. The ADM stated that she was not aware of any resident to resident altercations between resident 4 and resident 6. The ADM stated that there have been problems in activities from time to time where resident 6 would throw things down. The ADM stated that behavioral interventions were to find individual time and they did the best to separate the residents when this occurred. The ADM stated that resident 4 would make comments towards resident 6 and that they were not going to be able to change resident 4's behavior. The ADM stated that they just tried to make sure that resident 6 was separated from the group so that she would not be able to hear what resident 4 was saying.
[Cross refer to F600]
Based on interview and record review it was determined that the facility did not ensure that the abuse policies and procedures were implemented to prevent abuse for 3 of 25 sample residents. Specifically, one resident experienced physical, verbal, financial, and emotional abuse and was involuntarily secluded. Resident identifiers: 4, 6, and 14.
Findings include:
1. Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that there were two residents who said mean to her, naming resident 4 and resident 14. Resident 6 stated that the other residents told her to shut up and go to her room when they were at activities. Resident 6 stated that she had fought with her family member (FM 2) who was a resident in another area of the facility, who can visit resident 6 as desired. Resident 6 stated that she was kept in another room overnight, away from her own room. Resident 6 stated that FM 2 had asked her for money.
On 2/23/22 at 2:10 PM, resident 6's family member (FM) 1 stated that resident 6 had fought with FM 2 for years. FM 1 stated that FM 2 had pinched and hit resident 6 while in the facility in November, 2021. FM 1 stated that the administration team was aware that when FM 2 was having anger issues, FM 2 could not be around resident 6. FM 1 stated that FM 2 had a history of pounding on the table and throwing things, as well as demeaning resident 6. FM 1 stated that when they were told that FM 2 had slapped resident 6, FM 1 told staff to keep resident 6 safe through whatever means necessary. FM 1 stated that there may have been other forms of abuse from FM 2 to resident 6. FM 1 stated that FM 2 requested money from resident 6 and should not need resident 6's money because FM 2 had money in his possession. FM 1 stated that they were not told about resident 6's involuntary seclusion and did not consent. FM 1 stated that they were aware of conflicts between resident 6 and other residents.
Incident reports revealed that resident 6 was pinched and slapped by FM 2 in November, 2021. Staff continued to allow FM 2 access to resident 6.
Nursing notes revealed that resident 6 had disagreements with other residents that were not identified as abusive. Staff interviews revealed that resident 6 was emotionally upset and comments were abusive.
Resident 6 was taken away from other residents and her room on 2/21/22 and was taken to room [ROOM NUMBER] by staff.
Resident 6's family member (FM 2) had taken money from resident 6. Staff had witnessed resident 6's family member (FM 2) ask resident 6 for money but had not identified that the money belonged to resident 6.
On 2/24/22, the staff at the facility provided copies of the following policies: Policy on the Prevention of Resident Abuse, Neglect, and Misappropriation of Resident Property, Policy on Preventing Resident to Resident Abuse, Policy on Investigating Allegations of Resident Abuse, Actual Abuse and Neglect of a Resident, Policy on Investigating Misappropriation of Resident Property, Policy on Investigation Injuries of Unknown Origin, Policy on Investigating a Suspected Rape of a Resident, Policy on Protecting Residents during an Investigation of Abuse and Neglect, and Mission Health Services; Abuse Prohibition Education and Information Sheet on 7 Components.
The Policy on the Prevention of Resident Abuse, Neglect, and Misappropriation of Resident Property revealed that Each resident living in this Community has the right to be free from abuse, neglect . The Community will enforce polices and procedures that protect each resident from abuse, neglect and misappropriation of property by employees, other residents . family members and legal guardians, friends, or other individuals 'Abuse and Allegations of Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment that result in physical harm, pain, or mental anguish. This definition includes residents who are comatose or are unable to respond due to physical or cognitive deficits to what an individual would normally consider to be physical harm, pain, or mental anguish. 'Verbal abuse' is defined as the use of oral, written, or gestured language that wilfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend or disability 'Physical abuse' includes hitting, slapping, pinching and kicking 'Mental abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff talking . in any manner that would demean or humiliate a resident (s) 'Involuntary seclusion' means separation of the resident from other residents or from their bedroom or confinement in their bedroom against the resident's will or the will of the resident's legal representative. Emergency separation of the resident monitored by employee for a limited time to reduce agitation or to protect other persons is not considered involuntary seclusion All reported incidents of resident abuse and allegations of abuse, neglect and misappropriation of property will be promptly investigated. Measures will be taken to protect residents during an investigation
Procedure .6. d. How to recognize signs and symptoms in a resident that could lead to aggressive behavior and how to defuse these situations before physical or verbal abuse occurs.
e. Methods to assist a resident to control aggressive and disruptive behaviors.
f. How to promptly report any incidents that could be perceived to be abuse, neglect or exploitation of a resident to the nurse responsible for the resident, the employee's supervisor, or any supervisor
9. All employees are responsible for reporting promptly any incident that has the potential to be considered an allegation of abuse, or actual abuse, neglect or exploitation of a resident.
From Policy on Preventing Resident to Resident Abuse: Procedure:
1. Residents with a history of physical and/or verbal abuse of other persons will be evaluated prior to admission to ensure that this Community has the services the resident needs to achieve their highest practicable level of functioning and to protect other residents from harm
6. If the resident continues to exhibit behaviors that could harm residents, the interdisciplinary team will meet with the resident, the resident's legal representative and or designated family member to discuss the ability or inability of the Community to meet the resident's needs and the possible and potential need for a move to another residence that can better meet the needs of the resident.
Policy on Investigating Allegations of Resident Abuse, Actual Abuse and Neglect of a Resident .Procedure:
1. In the event that an incident that meets or has the potential to meet one of the definitions stated in the policy on abuse or neglect of a resident, the incident is reported to the Administrator and or designee. An investigation of the incident will be commenced promptly. This included incidents in which a resident is injured or had the potential for injury and the cause of the incident is unknown
5. The resident, the resident's legal representative and or designated family member will be informed of the investigation.
6. Information will be compiled of all witnesses and other persons who have knowledge of the event.
7. The following individuals will be interviewed:
a. The person making the report.
b. Individuals alleged to have been involved in the incident.
c. The resident, if able and willing to be interviewed.
d. Staff members on duty during the time of the alleged incident.
e. Other staff that may have information about the incident.
f. Staff that may have had contact with the resident before or after the period of the alleged incident.
g. Resident's roommate, family members and visitors.
h. Other residents who received care and services from the individual or individuals alleged to have committed abuse or neglect
12. If there is enough evidence to suspect that an individual may have abused or neglected a resident, that individual will be suspended and or denied access until the outcome of the investigation is known
14. In the event the abuse or neglect was perpetrated by a member of the public, this information will be provided to appropriate state agencies.
Policy on Protecting Residents during an Investigation of Abuse and Neglect: Procedure:
1. Any employee or employees implicated in an incident where they have committed abuse or neglect of a resident will be placed on administrative leave pending the outcome of an investigation.
2. If the incident involved a resident's family member or visitor:
a. The resident will be asked if they wish to continue to receive visits from that individual.
b. The resident's designated family member will be notified.
c. If the resident has a power of attorney for health care decisions that individual must be approached for a decision.
d. If the resident's response is that they want to continue seeing the individual; the visits will be supervised until the investigation is completed.
e. The local Ombudsman may be asked to be involved.
f. If the resident states that they do not want to see the individual, the individual will be notified by the Administrator/designee of the resident's right to deny visitation.
g. Staff will be notified of the denial of visitation or the need for supervised visits.
h. Incidents of abuse or neglect or suspected abuse or neglect involving a resident's family member or visitor will be reported to appropriate state agency responsible for adult protective services, including local law enforcement if needed.
3. Staff will be available to the resident for reassurance and support following an incident of abuse and neglect.
4. The resident's legal representative and/or designated family member will be notified when there is an incident that is being investigated as potential or actual abuse, neglect or misappropriation of a resident's property.
From the policy entitled Mission Health Services: Abuse Prohibition Education and Information Sheet on 7 Components:
. 3. Prevention means providing residents, families, and staff information on how to and to who they may report concerns, incidents, grievances without fear of retribution. Be able to identify potential and or actual abuse, correct and intervene in situations in which abuse, neglect or misappropriation of resident property is more likely to occur.
4. Identification means being able to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, and determine the direction of the investigation.
5. Investigation means to investigate different types of incidents, and identify staff members responsible for the initial reporting, investigation, of allegations, and reporting the results to proper authorities.
6. Protection means protecting the resident from harm during the investigation.
7. Reporting means reporting all allegations to the appropriate agencies and take necessary corrective actions, analyze the occurrences to determine changes needed if any, to prevent recurrence
An incident report created on 11/27/21 at 11:45 AM, revealed that resident 6's family member (FM 2) was visiting resident 6 when FM 2 made [resident 6] upset and staff heard her yell 'stop pinching me!' She began to clean up her coloring supplies he reached over and slapped her face. She started to cry and staff separated them. [FM 2] was assisted back to the lighthouse .
On 11/28/21 at 4:01 PM, a nursing note revealed that resident 6's Power of Attorney (POA) was contacted about FM 2 slapping resident 6 in the face the previous day. The POA requested that staff keep resident 6 safe.
In a follow-up letter to the State Agency on 12/1/21, the previous Administrator (ADM 2) revealed that resident 6's FM 2 had also told resident 6 that she shouldn't eat because she was too fat.
Resident 6 had a Minimum Data Set (MDS) quarterly evaluation completed on 12/17/22. Resident 6 had a PHQ-9 evaluation for depression. Resident 6 scored 19/27, which indicated moderately severe depression.
A physician's note dated 2/4/22 revealed that resident 6's behaviors are up-and-down but seems to be relatively stable with changing of medication . here for long term care .
On 2/23/22 at 3:57 PM, FM 2 was observed leaving resident 6's room. Staff were not observed to be present when resident 6 and FM 2 were alone together in resident 6's room.
On 2/23/22 at 3:42 PM, Certified Nurse Assistant (CNA) 5 was interviewed. CNA 5 stated that she was familiar with resident 6 and her family member (FM 2). CNA 5 stated that FM 2 got into little tiffs when they were together. CNA 5 stated that staff had to monitor FM 2 and that she witnessed FM 2 hit resident 6. CNA 5 stated that resident 6 was upset and crying when she stomped off to her room. CNA 5 stated that resident 6 took a while to calm. CNA 5 stated that staff separated resident 6 from FM 2 for five days after he slapped resident 6 to ensure her safety. CNA 5 stated that she did not know what interventions prevented FM 2 from slapping resident 6 currently. CNA 5 stated that she had talked to a family member of resident 6 (FM 3) who told CNA 5 that FM 2 had hurt resident 6 a lot when resident 6 was growing up. CNA 5 stated that FM 3 had told CNA 5 that FM 2 had pinched her and was visibly upset. CNA 5 stated that resident 6 had told CNA 5 that FM 2 had hit her. CNA 5 stated that she saw FM 2 pinch resident 6 on the shoulder/back. CNA 5 stated that FM 2 liked to pick a fight with resident 6. CNA 5 stated that she was aware that FM 2 visited resident 6 in her room, but was not aware of any fighting that occurred in her room. CNA 5 stated that there were no special instructions to monitor the two, but if FM 2 was to hit resident 6, CNA 5 would tell the nurse. CNA 5 stated that resident 6 and resident 14 argue all the time. CNA 5 stated that the residents said mean things to each other. CNA 5 stated that resident 14 liked to pick a fight with resident 6 and most games ended with the two swearing at each other. CNA 5 stated that the problems were often with resident 14, sometimes resident 4 would tell resident 6 that resident 6 was whiney, mean and that resident 6 was cheating. CNA 5 stated that when she heard that the residents were planning to play a card game, she knew how it was going to go.
On 2/23/22 at 4:13 PM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that the relationship between resident 6 and FM 2 was unstable. RN 3 stated that at times, they got along, but at other times, FM 2 tried to take control of resident 6, and FM 2 really aggravated resident 6 when they were together. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that there were a few residents that provoked resident 6. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that CNA 4, CNA 3 and CNA 7 attempted to calm resident 6, but resident 6 yelled at them, and attempted to kick them. Staff offered to let resident 6 watch TV in her room, but resident 6 wanted to watch television at the round table. RN 3 stated that at 9:30 PM, resident 6 was asked to quiet to allow other residents to sleep. RN 3 stated that resident 6 refused to quiet, so RN 3 called the physician to obtain a prescription for medication to help resident 6 sleep. The physician told RN 3 he would call her back. RN 3 stated that other residents were concerned and asked if resident 6 was okay, due to her screaming and crying. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that she took resident 6's oxygen concentrator, a blanket, and water to room [ROOM NUMBER]. RN 3 stated that resident 6 definitely did not want to go, but RN 3 stated that she felt it was better for everyone else for her to move. RN 3 stated that six residents expressed concern or complaints about resident 6's yelling. RN 3 stated that resident 6 was yelling loudly in the hallway when she was being taken to room [ROOM NUMBER]. In room [ROOM NUMBER], RN 3 placed the oxygen cannula on resident 6. RN 3 stated the physician called back at approximately 10:00 PM, and ordered an extra dose of Hydroxyzine for resident 6 for anxiety. RN 3 stated that it was approximately 11:00 PM when resident 6 agreed to take the Hydroxyzine medication, and allowed staff to toilet her. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER]. RN 3 stated that resident 6 was able to move her foot and did not appear to have any bruising. RN 3 stated that resident 6 sat in the recliner in room [ROOM NUMBER] and the nurse examined her right foot as well. RN 3 stated that resident 6 complained of pain, so RN 3 provided as needed (PRN) ibuprofen and staff retrieved some ice for her foot. RN 3 stated that resident 6 was in room [ROOM NUMBER] when she left the facility at 12:00 AM on 2/22/22. RN 3 stated that when she arrived back at the facility on 2/22/22 at 8:00 AM, the previous shift nurse reported that resident 6 complained of right foot pain. RN 3 stated that she saw resident 6 walking with the restorative aide around lunch and was able to walk without a limp. RN 3 stated that resident 6 stated that her foot hurt, but did not request PRN pain medication. RN 3 stated that resident 6 was more agitated.
On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that resident 6 had family difficulties and that resident 6 and FM 2 had to be monitored when they were together. CNA 8 stated that she had separated resident 6 and FM 2 sometime last week because FM 2 was upsetting resident 6. CNA 8 stated that FM 2 told resident 6 that she needed to stop talking. CNA 8 stated that resident 6 had fits and staff took her back to her room and helped her calm. CNA 8 stated that resident 6 did not always like to go to her room, but that's where we take her. CNA 8 stated that resident 6 was placed in her room for an average of 10 minutes. CNA 8 stated that she was told resident 6 was taken to another room so that other residents could sleep, and that resident 6 was only taken, until she calmed down. CNA 8 stated that resident 6 had problems with other residents and with family members.
On 2/24/22 at 7:48 AM, CNA 6 was interviewed. CNA 6 stated that resident 6's family member (FM 2) told resident 6 to calm down often when he visited. CNA 6 stated that after FM 2 hit resident 6, FM 2 was not allowed to come over and visit for three to four days but both resident 6 and FM 2 were upset after the separation. CNA 6 that resident 6 had little disputes with some of the other residents at the facility. CNA 6 stated that one resident in particular that resident 6 had a problem with was resident 14. CNA 6 stated that resident 14 told resident 6 how to behave and resident 6 became upset with resident 14 frequently. CNA 6 stated that staff removed resident 6 from activities if resident 6 became upset and tried to calm her down by leaving her in her room for up to 15 minutes. CNA 6 stated that about half the time, resident 6 would become more upset. CNA 6 stated that resident 6 and resident 14 butted heads and that resident 4 picked on resident 6 for a while.
On 2/24/22 at 9:48 AM, RN 2 was interviewed. RN 2 stated that after she saw FM 2 pinch resident 6, there were no marks on resident 6's arm. RN 2 stated that after FM 2 pinched resident 6, resident 6 started to pick up her art supplies when FM 2 struck resident 6 on the side of her face. RN 2 stated that she saw FM 2 hit resident 6 from half way down the hall. RN 2 stated the slap did not appear terribly forceful and did not see resident 6's face turn red. RN 2 stated that resident 6 began crying, cleaned up her things faster, and went to her room. RN 2 stated that she took FM 2 back to his area in the building and then attempted to comfort resident 6. RN 2 stated that staff attempted to get FM 2 and resident 6 back together later that evening to see if they were OK with each other. RN 2 stated that they were cordial to each other later that evening. RN 2 stated that FM 2 told resident 6 to quit being a baby when she was upset, and she does not take that well. RN 2 stated that resident 6 would probably think that was verbal abuse because of where she is cognitively. RN 2 stated that she also thought it was verbal abuse. RN 2 stated that as long as FM 2 and resident 6 were being amicable they could remain together, but staff would check on them every 30 minutes. RN 2 stated that she had heard of concerns from the family about FM 2 being abusive to resident 6, but that there was nothing in the documentation. RN 2 stated that residents enjoyed going to the Cove, a room used for activities. RN 2 stated that residents watched television in the Cove room as well. RN 2 stated that resident 6 sometimes became frustrated, and letting resident 6 express herself helped, along with getting away from large groups. RN 2 stated that resident 6 calmed when she was in her room. RN 2 stated that although resident 6 did not like a lot of stimulation when she was upset, we try not to isolate her. RN 2 stated that she had heard that FM 2 had asked resident 6 for money when they went on van rides together in the community. RN 2 stated that for resident 6, two of the residents set her off and that staff had to watch the interactions bet[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 25 sample residents, that the facility did not ensure that all residents were free from involuntary seclusion. Involuntary seclusion was defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative. Specifically, a resident was taken away from a group of residents to her room, and then placed in an unfamiliar room overnight against her will and without the knowledge of the resident's Power of Attorney. The deficient practice identified was found to have occurred at a harm level. Resident identifier: 6.
Findings included:
Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that her voice was hoarse because she was screaming overnight. Resident 6 stated that she was yelling at the other residents and staff and she was told she was going to be taken to another room to yell all you want. Resident 6 stated that staff left her there all night long. Resident 6 stated that her foot was bent back when she was being pushed by [Certified Nurse Aide 4] to room [ROOM NUMBER]. Resident 6 stated that she told Certified Nurse Aide (CNA) 4 No, No, No, stop. Resident 6 stated I put my foot back and he kept pushing me and pushing me. Resident 6 stated that he was too strong for her to resist and ran over her left foot. Resident 6 stated that room [ROOM NUMBER] was scary.
On 2/22/22 at 1:33 PM, a follow-up interview was conducted with resident 6. Resident 6 stated that her foot still hurt a little bit. Resident 6 stated that she was placed into room [ROOM NUMBER] in her wheelchair and had ice for her foot. Resident 6 stated that two CNAs were not nice to her. One of the CNAs was CNA 4, who resident 6 referred to as mean, and always will be and the other CNA was described as tall with long dark hair and skinny. Resident 6 later recalled the other CNA's name and identified them as CNA 7.
On 2/24/22 at 10:00 AM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] was located in the southwest corner of the facility. There were no other residents residing in that corner of the facility. The Cove activity room was also observed and had doors on the East and [NAME] sides that could be closed.
On 3/2/22, resident 6's electronic medical record review was completed.
On 10/22/21, resident 6 was assessed during a Minimum Data Set (MDS) evaluation of having a Brief Interview for Mental Status (BIMS) score of 9/15, or mildly impaired.
A nursing note dated 2/21/22 at 9:28 PM, revealed that on 2/21/22, resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room . Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed. At 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time.
On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over. Immediately following incident resident refused to allow this nurse to assess for injury, she allowed later at 2300 (11:00 PM) when she complained of pain in her left foot, no apparent signs of injury were noted; no redness, no bruising, no swelling.
On 2/21/22 at 10:08 PM, a nursing note for an additional 50 mg (milligrams) of Hydroxyzine was ordered to help resident 6 relax.
On 2/21/22 at 10:58 PM, a nursing note revealed that resident 6 agreed to take two Hydroxyzine at 10:15 PM and go to the toilet and put on pajamas. Resident 6 complained that her foot hurt, but no discoloration was noted and resident 6 was able to move her foot and wiggle her toes. The resident was able to bear weight on her left foot when needed for transfers. CNA 4 reported that resident 6 put her right foot down under the wheelchair wheel when she was being assisted to room [ROOM NUMBER] earlier this evening . Resident 6 showed no signs of trauma and was provided ibuprofen to treat pains and her legs were elevated in the recliner and ice pack on left foot. She seems more calm at this time, yelling has stopped for now .
On 2/22/22 at 4:05 AM, a nursing note revealed that resident 6 had been asleep for about 3 hours. Prior to that she yelled out off and on [for] about 30 minutes intervals in between until she drifted off .
On 2/22/22 at 5:26 AM, a nursing note revealed that resident 6 was awake and having a hard time talking and her throat hurts as well as her right ankle. Medicated with Tramadol 5 mg. Discussed she strained her voice with all her yelling last night try to let her voice rest and it will get better
On 2/22/22 at 12:01 PM, a nursing note revealed that the doctor examined resident 6 and was given details about the previous night. The doctor ordered a urinalysis to rule out a urinary tract infection. The physician examined resident 6's feet and discerned no bruising. The physician ordered monitoring of resident 6's feet for pain and swelling. No bruising or swelling is noted. [Resident 6] is also able to bare (sp) weight to both feet at this time. [Resident 6] complains of pain in her left foot this morning during AM shift, she is given prn [as needed] medications to treat. [Resident 6's doctor] gives new orders to monitor only, of her bilateral feet for increased pain or swelling at this time; further interventions will be added if needed.
On 2/22/22 at 1:32 PM, a nursing note revealed resident 6 was ambulating and complained of pain in her left leg but was able to walk behind her wheelchair.
On 2/24/22 at 12:06 PM, a nursing note revealed that resident 6's Power of Attorney (POA) was contacted.
Resident 6 had a care plan focus The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] decreased mobility and cognitive deficit, initiated on 11/1/21.
On 2/23/22 at 9:17 AM, RN 2 was interviewed. RN 2 stated that resident 6 had a medication change that may have been part of the issue why resident 6 was out of control. RN 2 stated that staff had offered resident 6 activities and redirection when she was frustrated, and letting resident 6 express herself helped. RN 2 stated that taking resident 6 to her room helped because resident 6 became agitated in larger groups. RN 2 stated that resident 6 liked Western shows and would watch them at the round table in the common area or in her room. RN 2 stated that she did not make resident 6 watch television in her room because she did not want to isolate resident 6. RN 2 stated that resident 6 would accompany RN 2 to the Cove while RN 2 was charting because talking to staff helped calm resident 6. RN 2 stated that if resident 6 was left alone, resident 6 would perseverate about her frustrations.
On 2/23/22 at 2:16 PM, a family member (FM) 1 of resident 6 was contacted. FM 1 stated that they visited resident 6 the previous week and resident 6 reported being happy at the facility. FM 1 stated that resident 6 was changed to a new medication that caused her to shake. FM 1 stated that they had not been contacted about the incident with resident 6 on Monday night and that the facility did not communicate well with the family. FM 1 stated that resident 6 needed someone to talk calmly and logically to her to help calm her down.
On 2/23/22 at 3:17 PM, the Resident Advocate (RA) was interviewed. The RA stated that the facility did not have a social worker, but had contracted with a consultant. The RA stated that the social worker had not been in the facility since the COVID-19 outbreak began in March, 2020. The RA stated that the social worker had not had contact with resident 6.
On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that when resident 6 had fits, staff took her back to her room which usually helped her calm down. CNA 8 stated that she would get resident 6 ice water, a snack, have her take a few deep breaths and get her away from whatever had triggered her. CNA 8 stated that resident 6 did not always like going to her room, but that was where she was taken. CNA 8 stated that it was usually about 10 minutes before resident 6 calmed. CNA 8 stated that she had report on Tuesday 2/22/22 that resident 6 was taken to room [ROOM NUMBER]. CNA 8 stated that she would not have left resident 6 alone because CNA 8 did not always know what resident 6 might do. CNA 8 stated that she would talk to resident 6 to help her calm, set up her television and make her comfortable. CNA 8 stated that she was told resident 6 started screaming, kicking, and yelling when staff attempted to calm her down, and was yelling for hours. CNA 8 stated that staff moved resident 6 to a room away from the other residents to help them sleep.
On 2/23/22 at 4:13 PM, an interview was conducted with RN 3. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that there were a few residents that provoked resident 6. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that CNA 4, CNA 3 and CNA 7 attempted to calm resident 6, but resident 6 yelled at them, and attempted to kick them. Staff offered to let resident 6 watch TV in her room, but resident 6 wanted to watch television at the round table. RN 3 stated that at 9:30 PM, resident 6 was asked to quiet to allow other residents to sleep. RN 3 stated that resident 6 refused to quiet, so RN 3 called the physician to obtain a prescription for medication to help resident 6 sleep. The physician told RN 3 he would call her back. RN 3 stated that other residents were concerned and asked if resident 6 was okay, due to her screaming and crying. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that she took resident 6's oxygen concentrator, a blanket, and water to room [ROOM NUMBER]. RN 3 stated that resident 6 definitely did not want to go, but RN 3 stated that she felt it was better for everyone else for her to move. RN 3 stated that six residents expressed concern or complaints about resident 6's yelling. RN 3 stated that resident 6 was yelling loudly in the hallway when she was being taken to room [ROOM NUMBER]. In room [ROOM NUMBER], RN 3 placed the oxygen cannula on resident 6. RN 3 stated the physician called back at approximately 10:00 PM, and ordered an extra dose of Hydroxyzine for resident 6 for anxiety. RN 3 stated that it was approximately 11:00 PM when resident 6 agreed to take the Hydroxyzine medication, and allowed staff to toilet her. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER]. RN 3 stated that resident 6 was able to move her foot and did not appear to have any bruising. RN 3 stated that resident 6 sat in the recliner in room [ROOM NUMBER] and the nurse examined her right foot as well. RN 3 stated that resident 6 complained of pain, so RN 3 provided as needed (PRN) ibuprofen and staff retrieved some ice for her foot. RN 3 stated that resident 6 was in room [ROOM NUMBER] when she left the facility at 12:00 AM on 2/22/22. RN 3 stated that when she arrived back at the facility on 2/22/22 at 8:00 AM, the previous shift nurse reported that resident 6 complained of right foot pain. RN 3 stated that she saw resident 6 walking with the restorative aide around lunch and was able to walk without a limp. RN 3 stated that resident 6 stated that her foot hurt, but did not request PRN pain medication. RN 3 stated that resident 6 was more agitated.
On 2/24/22 at 6:11 AM, CNA 3 was interviewed. CNA 3 stated that he was working the evening of 2/21/22 when resident 6 had a melt down. CNA 3 stated that resident 6 wanted to watch a different program, but was told that the other residents wanted to listen to something else. CNA 3 stated that resident 6 began screaming and a nurse, Licensed Nurse (LN) 4 told resident 6 in a stern voice to quiet down and to stop behaving like that. CNA 3 stated that resident 6 yelled, I hate you and LN 4 and resident 6 began to argue. Resident 6 also yelled I hate you as CNA 4 was pushing her in her wheelchair to her room. CNA 3 stated that resident 6 was stomping her feet. CNA 3 stated that resident 6 yelled from about 5:30 PM until 3:30 AM. CNA 3 stated that sometimes resident 6's door was closed and sometimes open. CNA 3 stated that resident 6 was moved to room [ROOM NUMBER] between 10:30 PM and 11:00 PM, because other residents were complaining. room [ROOM NUMBER] was located in a hall where there were no other residents in the immediate area. CNA 3 stated that CNA 7 reported that resident 6 screamed until 3:30 AM. CNA 3 stated that resident 6's voice was raspy because she spent 10 hours screaming. CNA 3 stated that there was no training for staff on what to do for resident 6 when her behaviors escalated. CNA 3 stated that he did not feel that the nursing home was a good fit for resident 6. CNA 3 stated that resident 6 needed more attention than we can give. CNA 3 further stated that with resident 6 her emotions came before her thoughts and her brain processed things differently.
On 2/24/22 at 7:02 AM, CNA 4 was interviewed. CNA 4 stated that he worked the night shift, including on 2/21/22. CNA 4 stated that after he took resident 6 to be weighed, other residents were at the round table and had changed the television from resident 6's preferred station. CNA 4 stated that resident 6 began yelling abnormally loud compared to her usual frustration. CNA 4 stated that other residents asked staff to take resident 6 to her room. CNA 4 stated that resident 6 was yelling out of rage. CNA 4 stated that he took resident 4 to her room at approximately 6:15 to 6:30 PM, and resident 6 was upset and used profanity about the other residents. CNA 4 stated that resident 6 was stomping her feet and yelling. CNA 4 stated that resident 6 stated that no one appreciated her and she was mad at CNA 4 for taking her to her room. CNA 4 stated that he asked CNA 7 to assist resident 6 because resident 6 was mad at him. CNA 4 stated that resident 6 was moved from her room, room [ROOM NUMBER], to room [ROOM NUMBER] to get her away from some of the other residents that were complaining. CNA 4 stated that resident 6 was grinding her feet into the floor. CNA 4 stated that resident 6 shoved her heels into the floor and pushed herself back in the chair. CNA 4 stated that he asked resident 6 to put her feet up, but she was being more aggressive than usual, and when she put her foot down, her shoe came off and her foot was run over by the wheelchair. CNA 4 stated that when the wheelchair ran over resident 6's foot, she yelled and said, My foot! CNA 4 stated that resident 6 yelled until after 2:00 AM, but he was not assigned to her after taking her to room [ROOM NUMBER]. CNA 4 stated that resident 6 remained in room [ROOM NUMBER] until after he left the facility at approximately 6:30 AM. CNA 4 stated that room [ROOM NUMBER] was the furthest spot away from other residents.
On 2/24/22 at 8:38 AM, the DON was interviewed. The DON stated that resident 6 had episodes once in a while when she did not understand what was happening, because resident 6 had an intellectual disability. The DON stated that resident 6 was usually redirected within 10 minutes. The DON stated that on 2/18/22, resident 6 was upset over an UNO card game. The DON stated that on Saturday resident 6 was upset about a card game and Sunday resident 6 continued to be upset about music, but went to her room willingly and calmed there. The DON stated that resident 6 appeared to escalate over the weekend, with the episode on Sunday lasting about 30 minutes. The DON stated that on Monday, 2/21/22, the DON received a call at approximately 5:30 PM, and RN 3 told her that resident 6 was upset. The DON stated that she instructed RN 3 to give resident 6 her night time medications and have resident 6 perform her night time routine to help her calm down. The DON stated that RN 3 called the DON at approximately 9:30 PM and stated that resident 6 was still yelling and crying. The DON stated that LN 4 had reported that other residents were concerned about resident 6. The DON stated that she told RN 3 to put resident 6 in a quiet environment and call the physician. The DON stated that RN 3 suggested to move resident 6 to the rooms on the other side of the facility that were a little more quiet. The DON stated that she agreed that it was a good idea. The DON stated that she called LN 4 at approximately 3:30 AM on 2/22/22 and LN 4 stated that resident 6 had fallen asleep. The DON stated that as far as she knew, LN 4 had checked on resident 6 every 15 minutes, but there was no documentation created. The DON stated that resident 6 told her that her voice was hoarse.
On 2/24/22 at 10:33 AM, the Resident Advocate (RA) was interviewed. The RA stated that she checked on resident 6 daily to see how her day was going. The RA stated that on 2/22/22, resident 6 stated that she had a tough weekend. The RA stated that resident 6 told her that she had been upset and was yelling, and the RA noticed that resident 6's voice was hoarse. The RA stated that resident 6 reported being taken to another room and that resident 6 was not happy about it and wanted her things moved back into her room. The RA stated that resident 6's oxygen concentrator and mugs were in room [ROOM NUMBER]. The RA stated that resident 6 told her that resident 6 wanted to be in her own room. The RA stated that a medication review was completed for resident 6 and staff determined that they needed to be firm and direct with resident 6, but also to be kind. The RA stated that resident 6 had not seen the Licensed Clinical Social Worker (LCSW) that was contracted for behavioral services because he had not been in the facility since the COVID-19 pandemic began, approximately 2 years ago.
On 2/24/22 at 11:44 AM, the Administrator (ADM) was interviewed. The ADM stated staff had been trained about abuse on January 19, 2022 and reported any abuse to her because she was the abuse coordinator. The ADM stated that if there was an allegation of abuse, she would report to the Ombudsman, corporation and to Adult Protective Services (APS). The ADM stated that she reviewed the incident from the night of 2/21/22 on 2/23/22, and had not been contacted by staff regarding the incident. The ADM stated that resident 6 screamed, yelled, and kicked her legs when she gets upset, which can be scary. The ADM stated that staff decided to separate her from the rest of the group. The ADM stated that staff took resident 6 to another room and asked her to be quiet. The ADM stated that residents called their family members and said something bad was going on and it sounded like someone was dying. The ADM stated that the incident lasted until the morning of 2/22/22 and that resident 6's foot was injured during the episode. The ADM stated that staff had not reported to her because the physician looked at resident 6's foot and there was no apparent injury. The ADM stated that she did not know resident 6 stayed in room [ROOM NUMBER] overnight. The ADM stated that there should have been documentation by the nurse and CNAs about 15 minute checks.
On 2/24/22 at 1:29 PM, the Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that RN 3 worked until midnight and assisted resident 6 into her pajamas. CRN 1 stated that CNA 7 conducted checks on resident 6 every 15 minutes, but they did not have any paperwork to demonstrate that this had been completed. CRN 1 stated that the staff did not start the 15 minute check paperwork. CRN 1 stated that there was a 15 minute check form that was indicated for a situation like this, to document incidents like this. CRN 1 stated that CNA 7 reported that resident 6 was comfortable, had intervals of screaming followed by periods of calm, and eventually fell asleep. CRN 1 stated that they did not have a focused timeline of resident 6's behaviors and interventions.
On 2/24/22 at 5:16 PM, CNA 7 was interviewed. CNA 7 stated that when resident 6 returned to the round table the other residents had changed the television channel. CNA 7 stated that this was what had initially upset resident 6. CNA 7 stated that one of the other residents started to yell back at resident 6 so CNA 4 and LN 4 went over to intervene. CNA 7 stated that resident 6 had a care plan intervention to take her to her room to calm down, so that was why they initially took her back when she became upset. CNA 7 stated that she went into resident 6's room a few times to check on her and one time she noticed that she was about to fall from the her wheelchair because she was yelling and screaming. CNA 7 stated that CNA 3 and RN 3 went in and talked to resident 6 to try and calm her down. CNA 7 stated that after resident 6 had been crying for approximately 2 hours CNA 4 took her to room [ROOM NUMBER]. CNA 7 stated that as he was wheeling her she was yelling obscenities'. CNA 7 stated that she assisted resident 6 out of her wheelchair into the recliner, and RN 3 assisted with resident 6's toileting. CNA 7 stated that resident 6 did not want CNA 4 to come into the room, she was mad at him. CNA 7 stated that she spent the remainder of the evening in the Cove and set her timer to check on resident 6 every 15 minutes. CNA 7 stated that resident 6 screamed most of the time and somewhere around 4 AM resident 6 fell asleep. CNA 7 stated that she left the facility at 5:15 AM on 2/22/22. CNA 7 stated that resident 6 complained of pain in the left foot. CNA 7 stated that she did not personally see how it was injured. CNA 7 stated that resident 6 told her that her foot got hurt and was run over by her wheelchair. CNA 7 stated that resident 6 did not want to place weight on the injured foot. CNA 7 stated that resident 6 did not walk on the foot, but she did bear weight on it when she was transferred from the wheelchair to the recliner. CNA 7 stated that resident 6 complained of pain in the foot and RN 3 got her ice for it. CNA 7 stated that every time she offered resident 6 the ice pack she declined it. CNA 7 stated that resident 6 was upset that they had moved her. CNA 7 stated that they moved her because she was being loud. CNA 7 stated that to her knowledge resident 6 had not been to that room before. CNA 7 stated that they chose that room because there were not any residents nearby. CNA 7 stated that after resident 6 was moved to room [ROOM NUMBER] the door to the room remained open, but when she was in her own room the door was closed. CNA 7 stated that they took resident 6's oxygen tank, tubing, briefs, blanket, and pajamas to room [ROOM NUMBER]. CNA 7 stated that resident 6's nighttime routine was coloring and watching television. CNA 7 stated that resident 6's TV was on in room [ROOM NUMBER] and they had provided resident 6 a mug of water as well. CNA 7 stated that the move to room [ROOM NUMBER] was explained to resident 6 more than once by RN 3. CNA 7 stated that she did not know if resident 6 thought she was in trouble and that was why she was being moved.
On 3/1/22 at 8:17 AM, CRN 1, CRN 2, and the ADM were interviewed. The ADM stated that resident 6 did not have and Specialized Rehabilitative Services. CRN 2 stated that staff were aware of her behaviors and interventions were to have resident 6 take a deep breath and get it back together. CRN 2 stated that they had to balance how to protect the other resident's emotional state, they were complaining about the yelling that continued for hours. CRN 2 stated that the staff transferred resident 6 to room [ROOM NUMBER], assisted her into a recliner and checked on her every 15 minutes. CRN 2 stated that she was not sure if the physician was contacted about the move to the other room. CRN 2 stated that they were looking to see if a Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) would be a better option for resident 6.
On 3/1/22 at 9:39 AM, a follow-up interview was conducted with CRN 1 and CRN 2. CRN 2 stated that the physician was notified of the situation per the nursing note. CRN 2 stated that the staff attempted other interventions prior to the room change such as offers of food and beverages, watching TV in the Cove, and attempts at switching the staff members. CRN 2 stated that resident 6 was also able to self propel herself in the wheelchair. CRN 2 was not able to state if resident 6's foot injury would have impeded her ability to independently mobilize herself in the wheelchair. CRN 2 stated that staff did not determine nor document if resident 6 perceived the move to room [ROOM NUMBER] as punitive or a form of punishment, that's a good question. CRN 2 stated that they reviewed resident 6's behavioral care plan and interventions of a quiet place were updated today. CRN 2 stated that staff have been provided training on dementia and training was about redirection and managing behaviors but it was not specific to intellectual disabilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that there were two residents who said mean things to her, naming resident 4 and resident 14. Resident 6 stated that the other residents told her to shut up and go to her room when they were at activities. Resident 6 stated that she had fought with her family member (FM 2) who was a resident in another area of the facility, who could visit resident 6 as desired. Resident 6 stated that she was kept in another room overnight, away from her own room. Resident 6 stated that FM 2 had asked her for money.
On 2/23/22 at 2:10 PM, resident 6's family member (FM) 1 stated that resident 6 had fought with FM 2 for years. FM 1 stated that FM 2 had pinched and hit resident 6 while in the facility in November, 2021. FM 1 stated that the administration team was aware that when FM 2 was having anger issues, FM 2 could not be around resident 6. FM 1 stated that FM 2 had a history of pounding on the table and throwing things, as well as demeaning resident 6. FM 1 stated that when they were told that FM 2 had slapped resident 6, FM 1 told staff to keep resident 6 safe through whatever means necessary. FM 1 stated that there may have been other forms of abuse from FM 2 to resident 6. FM 1 stated that FM 2 requested money from resident 6 and should not need resident 6's money because FM 2 had money in his possession. FM 1 stated that they were not told about resident 6's involuntary seclusion and did not consent. FM 1 stated that they were aware of conflicts between resident 6 and other residents.
On 3/2/22, resident 6's electronic medical record review was completed.
On 6/9/21 at 1:35 PM, a skilled progress note for resident 6 revealed that resident 6 has been rather anxious today and staff have made additional efforts to calm her worries and understand what has caused her anxiety. [Resident 6] has stated that her anxiety began with the admission of her [family member 2] into the facility, although it is unclear as to why she is anxious as she states that her and her [FM 2] are pals and that she loves him . Efforts are continually made to address her anxiety
On 10/22/21, resident 6 was assessed during a Minimum Data Set (MDS) evaluation of having a Brief Interview for Mental Status (BIMS) score of 9/15, or mildly impaired.
1. Resident 6 reported verbal and physical abuse in November, 2021.
An incident report created on 11/27/21 at 11:45 AM, revealed that resident 6's family member (FM 2) was visiting resident 6 when FM 2 made [resident 6] upset and staff heard her yell 'stop pinching me!' She began to clean up her coloring supplies he reached over and slapped her face. She started to cry and staff separated them. [FM 2] was assisted back to the lighthouse .
On 11/28/21 at 4:01 PM, a nursing note revealed that resident 6's Power of Attorney (POA) was contacted about FM 2 slapping resident 6 in the face the previous day. The POA requested that staff keep resident 6 safe.
In a follow-up letter to the State Agency on 12/1/21, the previous Administrator (ADM 2) revealed that resident 6's FM 2 had also told resident 6 that she shouldn't eat because she was too fat.
Resident 6 had a Minimum Data Set (MDS) quarterly evaluation completed on 12/17/22. Resident 6 had a PHQ-9 evaluation for depression. Resident 6 scored 19/27, which indicated moderately severe depression.
A physician's note dated 2/4/22 revealed that resident 6's behaviors are up-and-down but seems to be relatively stable with changing of medication . here for long term care .
On 2/23/22 at 3:57 PM, FM 2 was observed leaving resident 6's room. Staff were not observed to be present when resident 6 and FM 2 were alone together in resident 6's room.
On 2/23/22 at 3:42 PM, CNA 5 was interviewed. CNA 5 stated that she was familiar with resident 6 and her family member (FM 2). CNA 5 stated that FM 2 got into little tiffs when they were together. CNA 5 stated that staff had to monitor FM 2 and that she witnessed FM 2 hit resident 6. CNA 5 stated that resident 6 was upset and crying when she stomped off to her room. CNA 5 stated that resident 6 took a while to calm. CNA 5 stated that staff separated resident 6 from FM 2 for five days after he slapped resident 6 to ensure her safety. CNA 5 stated that she did not know what interventions prevented FM 2 from slapping resident 6 currently. CNA 5 stated that she had talked to a family member of resident 6 (FM 3) who told CNA 5 that FM 2 had hurt resident 6 a lot when resident 6 was growing up. CNA 5 stated that FM 3 had told CNA 5 that FM 2 had pinched her and was visibly upset. CNA 5 stated that resident 6 had told CNA 5 that FM 2 had hit her. CNA 5 stated that she saw FM 2 pinch resident 6 on the shoulder/back. CNA 5 stated that FM 2 liked to pick a fight with resident 6. CNA 5 stated that she was aware that FM 2 visited resident 6 in her room, but was not aware of any fighting that occurred in her room. CNA 5 stated that there were no special instructions to monitor the two, but if FM 2 was to hit resident 6, CNA 5 would tell the nurse.
On 2/23/22 at 4:13 PM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that the relationship between resident 6 and FM 2 was unstable. RN 3 stated that at times, they got along, but at other times, FM 2 tried to take control of resident 6, and FM 2 really aggravated resident 6 when they were together.
On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that resident 6 had family difficulties and that resident 6 and FM 2 had to be monitored when they were together. CNA 8 stated that she had separated resident 6 and FM 2 sometime last week because FM 2 was upsetting resident 6. CNA 8 stated that FM 2 told resident 6 that she needed to stop talking.
On 2/24/22 at 7:48 AM, CNA 6 was interviewed. CNA 6 stated that resident 6's family member (FM 2) told resident 6 to calm down often when he visited. CNA 6 stated that after FM 2 hit resident 6, FM 2 was not allowed to come over and visit for three to four days but both resident 6 and FM 2 were upset after the separation.
On 2/24/22 at 8:15 AM, an interview was conducted with the Activities Director (AD). The AD stated that FM 2 cajoled resident 6 about her eating, her actions, her mood and her language.
On 2/24/22 at 8:32 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 6 and FM 2 ate most of their meals together. The DON stated that FM 2 told resident 6 what to eat, and that they got agitated with each other. The DON stated I don't think it's out of the ordinary. The DON stated that she knew of one time that FM 2 pinched resident 6's arm, but they were separated at that time. The DON stated that she knew resident 6 had a Power of Attorney (POA), but did not know if the POA had been notified.
On 2/24/22 at 9:48 AM, RN 2 was interviewed. RN 2 stated that after she saw FM 2 pinch resident 6, there were no marks on resident 6's arm. RN 2 stated that after FM 2 pinched resident 6, resident 6 started to pick up her art supplies when FM 2 struck resident 6 on the side of her face. RN 2 stated that she saw FM 2 hit resident 6 from half way down the hall. RN 2 stated the slap did not appear terribly forceful and did not see resident 6's face turn red. RN 2 stated that resident 6 began crying, cleaned up her things faster, and went to her room. RN 2 stated that she took FM 2 back to his area in the building and then attempted to comfort resident 6. RN 2 stated that staff attempted to get FM 2 and resident 6 back together later that evening to see if they were OK with each other. RN 2 stated that they were cordial to each other later that evening. RN 2 stated that FM 2 told resident 6 to quit being a baby when she was upset, and she does not take that well. RN 2 stated that resident 6 would probably think that was verbal abuse because of where she is cognitively. RN 2 stated that she also thought it was verbal abuse. RN 2 stated that as long as FM 2 and resident 6 were being amicable they could remain together, but staff would check on them every 30 minutes. RN 2 stated that she had heard of concerns from the family about FM 2 being abusive to resident 6, but that there was nothing in the documentation.
On 2/24/22 at 10:50, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 had expressed frustration about FM 2. The RA stated that she was aware that FM 2 made comments about resident 6's eating and that resident 6 was sassy back. The RA stated that she knew FM 2 asked resident 6 for money, but thought that FM 2 had plenty of money and had resident 6 put it in her purse for him. The RA stated that she had heard about FM 2 telling resident 6 she was too fat and that he said things that were not appropriate, even if it's your kid. The RA stated that FM 2 appeared to not be concerned with resident 6's well being. The RA stated that she had watched resident 6 and FM 2 interact, and it's kind of shocking. The RA stated that a lot of the other residents were frustrated with resident 6 because of her behaviors. The RA stated that some of the other residents had pulled resident 6 aside and chided her for her behaviors. The RA stated that this was mainly resident 14.
On 2/24/22 at 11:44 AM, ADM 1 was interviewed. ADM 1 stated that she had never witnessed resident 6 and FM 2 fighting, but she had received reports that they have had disagreements. ADM 1 stated that both residents had a right to see each other, and staff needed to be vigilant to watch resident 6 for signs of distress so they could intervene before things got out of hand. ADM 1 stated that she recently read the incident report from November and she would not want resident 6 and FM 2 unsupervised in a room together. ADM 1 stated that she did not know there was a history of abuse.
2. On 2/22/22 at 1:13 PM, resident 6 revealed that she was put into room [ROOM NUMBER] overnight from 2/21/22 to 2/22/22.
The facility census revealed that resident 6 had been residing in room [ROOM NUMBER] since admission.
On 7/31/21, resident 6 had a Preadmission Screening Resident Review (PASRR) Level II completed and revealed that resident 6 was vulnerable to exploitation. Resident 6 displayed increasing cognitive impairment with impaired short-term memory and periods of confusion and disorientation .
d. A nursing note dated 2/21/22 at 9:28 PM, revealed that on 2/21/22, resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed.
On 2/21/22 at 9:30 PM, an incident report was created because while staff were transferring resident 6 from room [ROOM NUMBER] to room [ROOM NUMBER], her foot was run over by the wheelchair. This incident was created as an injury and revealed that while resident 6 was being moved to room [ROOM NUMBER] (not her room), CNA 4 ran over resident 6's foot. Resident 6 had new pain at the time of the incident and complained of pain at 11:00 PM.
A nursing note dated 2/21/22 at 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time.
On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over. Immediately following incident resident refused to allow this nurse to assess for injury, she allowed later at 2300 (11:00 PM) when she complained of pain in her left foot, no apparent signs of injury were noted; no redness, no bruising, no swelling.
On 2/21/22 at 10:08 PM, a physician's order for an additional 50 mg (milligrams) of Hydroxyzine was ordered to help resident 6 relax.
Additional nursing notes revealed the following:
a. On 2/21/22 at 10:58 PM, resident 6 agreed to take two Hydroxyzine at 10:15 PM and go to the toilet and put on pajamas. Resident 6 complained that her foot hurt, but no discoloration was noted and resident 6 was able to move her foot and wiggle her toes. The resident was able to bear weight on her left foot when needed for transfers. CNA 4 reported that resident 6 put her right foot down under the wheelchair wheel when she was being assisted to room [ROOM NUMBER] earlier this evening . Resident 6 showed no signs of trauma and was provided ibuprofen to treat pains and her legs were elevated in the recliner and ice pack on left foot. She seems more calm at this time, yelling has stopped for now .
b. On 2/22/22 at 4:05 AM, resident 6 had been asleep for about 3 hours. Prior to that she yelled out off and on [for] about 30 minutes intervals in between until she drifted off .
c. On 2/22/22 at 5:26 AM, resident 6 was awake and having a hard time talking and her throat hurts as well as her right ankle. Medicated with Tramadol 5 mg. Discussed she strained her voice with all her yelling last night try to let her voice rest and it will get better
d. On 2/22/22 at 12:01 PM, the doctor examined resident 6 and was given details about the previous night. The doctor ordered a urinalysis to rule out a urinary tract infection. The physician examined resident 6's feet and discerned no bruising. The physician ordered monitoring of resident 6's feet for pain and swelling. No bruising or swelling is noted. [Resident 6] is also able to bare (sp) weight to both feet at this time. [Resident 6] complains of pain in her left foot this morning during AM shift, she is given prn [as needed] medications to treat. [Resident 6's doctor] gives new orders to monitor only, of her bilateral feet for increased pain or swelling at this time; further interventions will be added if needed.
e. On 2/22/22 at 1:32 PM, resident 6 was ambulating and complained of pain in her left leg but was able to walk behind her wheelchair.
f. On 2/24/22 at 12:06 PM, resident 6's Power of Attorney (POA) was contacted.
On 2/23/22 at 9:12 AM, CNA 12 was interviewed. CNA 12 stated that resident 6 had been moved to room [ROOM NUMBER], which was in an area of the building that had not been used since the facility experienced the COVID-19 outbreak. CNA 12 stated that staff walked through the area when going to get drinks for residents on the [NAME] side of the building, but did not have any direct need to be in the area where room [ROOM NUMBER] was located.
On 2/23/22 at 9:17 AM, RN 2 was interviewed. RN 2 stated that residents enjoyed going to the Cove, a room used for activities. RN 2 stated that residents watched television in the Cove room as well. RN 2 stated that resident 6 sometimes became frustrated, and letting resident 6 express herself helped, along with getting away from large groups. RN 2 stated that resident 6 calmed when she was in her room. RN 2 stated that although resident 6 did not like a lot of stimulation when she was upset, we try not to isolate her.
On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that resident 6 had fits and staff took her back to her room and helped her calm. CNA 8 stated that resident 6 did not always like to go to her room, but that's where we take her. CNA 8 stated that resident 6 was placed in her room for an average of 10 minutes. CNA 8 stated that she was told resident 6 was taken to another room so that other residents could sleep, and that resident 6 was only taken, until she calmed down. CNA 8 stated that resident 6 had problems with other residents and with family members.
On 2/23/22 at 4:13 PM, an interview was conducted with RN 3. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that there were a few residents that provoked resident 6. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that CNA 4, CNA 3 and CNA 7 attempted to calm resident 6, but resident 6 yelled at them, and attempted to kick them. Staff offered to let resident 6 watch TV in her room, but resident 6 wanted to watch television at the round table. RN 3 stated that at 9:30 PM, resident 6 was asked to quiet to allow other residents to sleep. RN 3 stated that resident 6 refused to quiet, so RN 3 called the physician to obtain a prescription for medication to help resident 6 sleep. The physician told RN 3 he would call her back. RN 3 stated that other residents were concerned and asked if resident 6 was okay, due to her screaming and crying. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that she took resident 6's oxygen concentrator, a blanket, and water to room [ROOM NUMBER]. RN 3 stated that resident 6 definitely did not want to go, but RN 3 stated that she felt it was better for everyone else for her to move. RN 3 stated that six residents expressed concern or complaints about resident 6's yelling. RN 3 stated that resident 6 was yelling loudly in the hallway when she was being taken to room [ROOM NUMBER]. In room [ROOM NUMBER], RN 3 placed the oxygen cannula on resident 6. RN 3 stated the physician called back at approximately 10:00 PM, and ordered an extra dose of Hydroxyzine for resident 6 for anxiety. RN 3 stated that it was approximately 11:00 PM when resident 6 agreed to take the Hydroxyzine medication, and allowed staff to toilet her. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER]. RN 3 stated that resident 6 was able to move her foot and did not appear to have any bruising. RN 3 stated that resident 6 sat in the recliner in room [ROOM NUMBER] and the nurse examined her right foot as well. RN 3 stated that resident 6 complained of pain, so RN 3 provided as needed (PRN) ibuprofen and staff retrieved some ice for her foot. RN 3 stated that resident 6 was in room [ROOM NUMBER] when she left the facility at 12:00 AM on 2/22/22. RN 3 stated that when she arrived back at the facility on 2/22/22 at 8:00 AM, the previous shift nurse reported that resident 6 complained of right foot pain. RN 3 stated that she saw resident 6 walking with the restorative aide around lunch and was able to walk without a limp. RN 3 stated that resident 6 stated that her foot hurt, but did not request PRN pain medication. RN 3 stated that resident 6 was more agitated.
On 2/24/22 at 6:11 AM, CNA 3 was interviewed. CNA 3 stated that he was working the evening of 2/21/22 when resident 6 had a melt down. CNA 3 stated that resident 6 wanted to watch a different program, but was told that the other residents wanted to listen to something else. CNA 3 stated that resident 6 began screaming and a nurse, Licensed Nurse (LN) 4 told resident 6 in a stern voice to quiet down and to stop behaving like that. CNA 3 stated that resident 6 yelled, I hate you and LN 4 and resident 6 began to argue. Resident 6 also yelled I hate you as CNA 4 was pushing her in her wheelchair to her room. CNA 3 stated that resident 6 was stomping her feet. CNA 3 stated that resident 6 yelled from about 5:30 PM until 3:30 AM. CNA 3 stated that sometimes resident 6's door was closed and sometimes open. CNA 3 stated that resident 6 was moved to room [ROOM NUMBER] between 10:30 PM and 11:00 PM, because other residents were complaining. room [ROOM NUMBER] was located in a hall where there were no other residents in the immediate area. CNA 3 stated that CNA 7 reported that resident 6 screamed until 3:30 AM. CNA 3 stated that resident 6's voice was raspy because she spent 10 hours screaming. CNA 3 stated that there was no training for staff on what to do for resident 6 when her behaviors escalated. CNA 3 stated that he did not feel that the nursing home was a good fit for resident 6. CNA 3 stated that resident 6 needed more attention than we can give. CNA 3 further stated that with resident 6 her emotions came before her thoughts and her brain processed things differently.
On 2/24/22 at 7:02 AM, CNA 4 was interviewed. CNA 4 stated that he worked the night shift, including on 2/21/22. CNA 4 stated that after he took resident 6 to be weighed, other residents were at the round table and had changed the television from resident 6's preferred station. CNA 4 stated that resident 6 began yelling abnormally loud compared to her usual frustration. CNA 4 stated that other residents asked staff to take resident 6 to her room. CNA 4 stated that resident 6 was yelling out of rage. CNA 4 stated that he took resident 4 to her room at approximately 6:15 to 6:30 PM, and resident 6 was upset and used profanity about the other residents. CNA 4 stated that resident 6 was stomping her feet and yelling. CNA 4 stated that resident 6 stated that no one appreciated her and she was mad at CNA 4 for taking her to her room. CNA 4 stated that he asked CNA 7 to assist resident 6 because resident 6 was mad at him. CNA 4 stated that resident 6 was moved from her room, room [ROOM NUMBER], to room [ROOM NUMBER] to get her away from some of the other residents that were complaining. CNA 4 stated that resident 6 was grinding her feet into the floor. CNA 4 stated that resident 6 shoved her heels into the floor and pushed herself back in the chair. CNA 4 stated that he asked resident 6 to put her feet up, but she was being more aggressive than usual, and when she put her foot down, her shoe came off and her foot was run over by the wheelchair. CNA 4 stated that when the wheelchair ran over resident 6's foot, she yelled and said, My foot! CNA 4 stated that resident 6 yelled until after 2:00 AM, but he was not assigned to her after taking her to room [ROOM NUMBER]. CNA 4 stated that resident 6 remained in room [ROOM NUMBER] until after he left the facility at approximately 6:30 AM. CNA 4 stated that room [ROOM NUMBER] was the furthest spot away from other residents.
On 2/24/22 at 8:38 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 6 had episodes once in a while when she did not understand what was happening, because resident 6 had an intellectual disability. The DON stated that resident 6 was usually redirected within 10 minutes. The DON stated that on 2/18/22, resident 6 was upset over an UNO card game. The DON stated that on Saturday resident 6 was upset about a card game and Sunday resident 6 continued to be upset about music, but went to her room willingly and calmed there. The DON stated that resident 6 appeared to escalate over the weekend, with the episode on Sunday lasting about 30 minutes. The DON stated that on Monday, 2/21/22, the DON received a call at approximately 5:30 PM, and RN 3 told her that resident 6 was upset. The DON stated that she instructed RN 3 to give resident 6 her night time medications and have resident 6 perform her night time routine to help her calm down. The DON stated that RN 3 called the DON at approximately 9:30 PM and stated that resident 6 was still yelling and crying. The DON stated that LN 4 had reported that other residents were concerned about resident 6. The DON stated that she told RN 3 to put resident 6 in a quiet environment and call the physician. The DON stated that RN 3 suggested to move resident 6 to the rooms on the other side of the facility that were a little more quiet. The DON stated that she agreed that it was a good idea. The DON stated that she called LN 4 at approximately 3:30 AM on 2/22/22 and LN 4 stated that resident 6 had fallen asleep. The DON stated that as far as she knew, LN 4 had checked on resident 6 every 15 minutes, but there was no documentation created. The DON stated that resident 6 told her that her voice was hoarse.
On 2/24/22 at 10:33 AM, the Resident Advocate (RA) was interviewed. The RA stated that she checked on resident 6 daily to see how her day was going. The RA stated that on 2/22/22, resident 6 stated that she had a tough weekend. The RA stated that resident 6 told her that she had been upset and was yelling, and the RA noticed that resident 6's voice was hoarse. The RA stated that resident 6 reported being taken to another room and that resident 6 was not happy about it and wanted her things moved back into her room. The RA stated that resident 6's oxygen concentrator and mugs were in room [ROOM NUMBER]. The RA stated that resident 6 told her that resident 6 wanted to be in her own room. The RA stated that a medication review was completed for resident 6 and staff determined that they needed to be firm and direct with resident 6, but also to be kind. The RA stated that resident 6 had not seen the Licensed Clinical Social Worker (LCSW) that was contracted for behavioral services because he had not been in the facility since the COVID-19 pandemic began, approximately 2 years ago.
On 2/24/22 at 11:44 AM, the Administrator (ADM) was interviewed. The ADM stated staff had been trained about abuse on January 19, 2022 and reported any abuse to her because she was the abuse coordinator. The ADM stated that if there was an allegation of abuse, she would report to the Ombudsman, corporation and to Adult Protective Services (APS). The ADM stated that she reviewed the incident from the night of 2/21/22 on 2/23/22, and had not been contacted by staff regarding the incident. The ADM stated that resident 6 screamed, yelled, and kicked her legs when she gets upset, which can be scary. The ADM stated that staff decided to separate her from the rest of the group. The ADM stated that staff took resident 6 to another room and asked her to be quiet. The ADM stated that residents called their family members and said something bad was going on and it sounded like someone was dying. The ADM stated that the incident lasted until the morning of 2/22/22 and that resident 6's foot was injured during the episode. The ADM stated that staff had not reported to her because the physician looked at resident 6's foot and there was no apparent injury. The ADM stated that she did not know resident 6 stayed in room [ROOM NUMBER] overnight. The ADM stated that there should have been documentation by the nurse and CNAs about 15 minute checks.
On 2/24/22 at 1:29 PM, the Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that RN 3 worked until midnight and assisted resident 6 into her pajamas. CRN 1 stated that CNA 7 conducted checks on resident 6 every 15 minutes, but they did not have any paperwork to demonstrate that this had been completed. CRN 1 stated that the staff did not start the 15 minute check paperwork. CRN 1 stated that there was a 15 minute check form that was indicated for a situation like this, to document incidents like this. CRN 1 stated that CNA 7 reported that resident 6 was comfortable, had intervals of screaming followed by periods of calm, and eventually fell asleep. CRN 1 stated that they did not have a focused timeline of resident 6's behaviors and interventions.
On 2/24/22 at 5:16 PM, CNA 7 was interviewed. CNA 7 stated that when resident 6 returned to the round table the other residents had changed the television channel. CNA 7 stated that this was what had initially upset resident 6. CNA 7 stated that one of the other residents started to yell back at resident 6 so CNA 4 and LN 4 went over to intervene. CNA 7 stated that resident 6 had a care plan intervention to take her to her room to calm down, so that was why they initially took her back when she became upset. CNA 7 stated that she went into resident 6's room a few times to check on her and one time she noticed that she was about to fall from the her wheelchair because she was yelling and screaming. CNA 7 stated that CNA 3 and RN 3 went in and talked to resident 6 to try and calm her down. CNA 7 stated that after resident 6 had been crying for approximately 2 hours CNA 4 took her to room [ROOM NUMBER]. CNA 7 stated that as he was wheeling her she was yelling obscenities'. CNA 7 stated that she assisted resident 6 out of her wheelchair into the recliner, and RN 3 assisted with resident 6's toileting. CNA 7 stated that resident 6 did not want CNA 4 to come into the room, she was mad at him. CNA 7 stated that she spent the remainder of the evening in the Cove and set her timer to check on resident 6 every 15 minutes. CNA 7 stated that resident 6 screamed most of the time and somewhere around 4 AM resident 6 fell asleep. CNA 7 stated that she left the facility at 5:15 AM on 2/22/22. CNA 7 stated that resident 6 complained of pain in the left foot. CNA 7 stated that she did not personally see how it was injured. CNA 7 stated that resident 6 told her that her foot got hurt and was run over by her wheelchair. CNA 7 stated t[TRUNCATED]

Based on interview and record review it was determined that the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision. Specifically, facility grievance records could not be located prior to November 2021.
Findings included:
On 2/23/22 the facility grievance binder was reviewed. The Grievance Log documented complaints from 11/9/2021 to 2/10/2022. The log provided the date of the incident, name of person filing the report, name of person investigating, the dates the parties were informed of the findings and the disposition of the complaint. Additional documentation included a Grievance Tracking Report that documented the issue/concern, how the concern was corrected, the date the concern was corrected, and the responsible person.
On 2/23/22 at 1:34 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. The grievance log from May 2021 to November 2021 was also requested. CRN 1 stated that the previous Administrator had all the grievance forms in his office and when he left the facility they could not locate the grievance forms prior to November 9, 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that the resident had the right to personal privacy and confidentiality of their personal and medical records. Specifically, a licensed nurse was observed to provide a visitor with a resident's personal health information without determining who the visitor was first and if they had access to that information. Resident identifier: 127.
Findings included:
Resident 127 was admitted to the facility on [DATE] with diagnoses which consisted of congestive heart failure, acute kidney failure, type 2 diabetes mellitus, dementia, and hyperlipidemia.
On 2/23/22 at 4:02 PM, an observation was made of a visitor attempting to enter resident 127's room. Resident 127's room had a sign posted on the door that stated isolation precautions, COVID isolation. Droplet precautions were check marked as indicated and the following instructions were listed: Patient to have private room; Surgical mask to be worn by all hospital personnel entering the room; Hospital personnel wear gloves when entering the room; and Perform hand hygiene before leaving the room. Registered Nurse (RN) 1 was heard to instruct the visitor to donn a gown and gloves prior to entering the room. RN 1 then told the visitor that it was for quarantine due to resident 127 not having a COVID-19 vaccine.
On 2/23/22 at 4:08 PM, an interview was conducted with RN 1. RN 1 stated that she did not know who the visitor was that had entered resident 127's room.
Resident 127's medical records were reviewed.
Resident 127's immunization history was reviewed and no documentation could be found for any COVID-19 immunizations.
On 2/24/22 at 10:35 AM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated if he did not know who a person was that was in the facility he would ask if they needed help and if he could take them to a certain room or person to visit. CNA 6 stated that he would identify who the individual was before he provided them with any resident information. CNA 6 stated that it would not be appropriate to provide a visitor information about the resident's vaccination status. CNA 6 stated that they would inform anyone entering a Transmission Based Precaution (TBP) what Personal Protective Equipment (PPE) they needed to wear. CNA 6 further stated that he would also provide instructions on how to donn it, take it off before leaving the room, perform hand hygiene when leaving the room, and to wipe off the goggles when leaving the room. CNA 6 stated that they did not tell any visitors that this was because that individual was not vaccinated for COVID-19.
On 2/24/22 at 3:01 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should educate visitors on the PPE required for TBP rooms and to follow the signs posted on the door. The DON stated that the nursing staff should be compliant with the Health Insurance Portability and Accountability Act (HIPAA). The DON stated that the nurse should not provide information on vaccination status without knowing who the visitor was first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not immediately consult with the resident's physician when there was a change in the resident's physical, mental, or psychosocial status or when a decision to transfer the resident from the facility was made. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain and the physician was not notified. Resident identifier: 22.
Findings included:
Resident 22 was admitted to the facility on [DATE] with diagnoses which included Friedreich ataxia, mood disorder, cardiomyopathy, gastro-esophageal reflux disease, and muscle weakness.
On 2/22/22 at 10:57 AM, an interview was conducted with resident 22. Resident 22 stated that she requested to go to the hospital for back pain and that she thought the rods in her back had been dislocated. Resident 22 stated that she had her family member take her to the ER. Resident 22 stated that it was determined in the ER that the rod placement was correct, and everything was okay.
Resident 22's medical records were reviewed.
On 12/30/21 at 1:52 PM, resident 22's progress notes documented that resident 22 was complaining of lower back pain, and that resident 22's family member took her to get an x-ray of the lower back. The progress note did not document that the physician was notified of the complaints of back pain, the request for an x-ray, or the transfer to the ER.
On 2/24/22 at 10:30 AM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated he was not certain if resident 22 had gone to the hospital for any reason, but that her family transported her to appointments.
On 2/24/22 at 2:18 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 22 went to the ER for complaints of back pain, and it was documented in the nurse's notes. RN 2 reviewed resident 22's progress notes and referred to the note on 12/30/21 at 1:52 PM. RN 2 stated that the ER visit was non-emergent, but usually when a resident went to the hospital it was doctor driven. RN 2 stated that she did not see in the progress note that the physician was notified of the transfer and that would be where it should be documented.
On 2/24/22 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for a resident transferred to the hospital ER was that they called 911 or a non-emergent transport, depending on the situation. The DON stated that the physician should be notified, and it should be documented in the nurse's progress note. The DON stated that the licensed nurse should document what happened, who they called, and the physician notification. The DON stated that if resident 22 was complaining of back pain and was requesting to go to the hospital the provider should have been made aware of this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not promote and facilitate the resident's self-determination through support of the resident's choice. Specifically, the resident requested that their breakfast meal tray be left at the bedside with the lid left on and the kitchen staff told the resident no, that it would be returned to the kitchen if not eaten within an hour. Resident identifier: 125.
Findings included:
Resident 125 was admitted to the facility on [DATE] with diagnoses which included encounter for orthopedic aftercare, depression, hypertension, asthma, gastro-esophageal reflux disease, irritable bowel syndrome, and obstructive sleep apnea.
On 2/22/22 at 12:52 PM, an interview was conducted with resident 125. Resident 125 stated that the day before yesterday when the dietary staff delivered the breakfast tray she asked him to leave the tray with the lid on so she could get up in a minute and he said no. Resident 125 stated that the dietary staff told her that he would have to take the tray back to the kitchen if resident 125 was not going to eat it. Resident 125 stated that the dietary staff told her that the tray could only be left in the room for one hour. Resident 125 stated it had not been an hour and she just needed some time to wake up. Resident 125 stated that the dietary staff was antagonistic, threatening, and confrontational. Resident 125 stated that she had to holler to get someone else to come and get him out of the room. Resident 125 stated that licensed nurse (LN) 1 came into the room and asked the dietary staff to leave. Resident 125 stated that the dietary staff had stated that it was a facility policy not to leave food in the room for more than an hour, but again stated that it had not even been an hour.
Review of resident 125's progress notes documented that the resident was alert and oriented times four (person, place, time, and situation). On 2/20/21 at 11:15 AM, the progress note documented, Resident has been very emotional and yelled at one of the kitchen staff today, see progress note. No other documentation could be found regarding this incident.
On 2/24/22 at 10:01 AM, an interview was conducted with dietary staff (DS) 1. DS 1 stated that he was aware of the incident between resident 125 and DS 2. DS 1 stated that on the day of the incident resident 125 had on her breakfast tray a waffle, an egg, and bacon and sausage. DS 1 stated that resident 125 wanted to sleep for a couple extra hours and they could not leave the tray out for that length of time. DS 1 stated that DS 2 had told resident 125 that he would bring the tray back later when she was awake, but she did not want that. DS 1 stated that DS 2 attempted to take the tray and explained that germs would start to grow. DS 1 stated that resident 125 was not having it, she grabbed the tray, and she yelled for help. DS 1 stated that Certified Nurse Assistant (CNA) 6 went into resident 125's room to help and explain. DS 1 stated that resident 125 was not happy for the remainder of the day. DS 1 stated that resident 125 was provided a meal tray approximately an hour later.
On 2/24/22 at 10:21 AM, an interview was conducted with CNA 6. CNA 6 stated that on the day of the incident between resident 125 and DS 2, resident 125 told DS 2 that she was going back to sleep. CNA 6 stated that DS 2 told resident 125 that he would need to take the tray back to the kitchen then. CNA 6 stated that resident 125 had said she was going to sleep for a couple of hours, and DS 2 tried to get a definitive time frame and she said a couple of hours. CNA 6 stated that DS 2 told resident 125 that he could not leave the meal tray because after an hour they had to take it. CNA 6 stated that they explained that after an hour the food was in the temperature danger zone and bacteria could grow and it would become too dangerous to eat. CNA 6 stated that he was not certain what was on the tray to eat, but probably bacon, a pancake or waffle, and some fruit as that was what resident 125 had each morning. CNA 6 stated that resident 125 became upset. CNA 6 stated that resident 125 kept yelling at DS 2 to get out. CNA 6 stated that the nurse then walked into the room and tried to explain the situation to resident 125. CNA 6 stated that they ended up leaving the tray for one hour and then after one hour they removed the tray. CNA 6 stated that resident 125 actually sat up and ate the food before they returned to pick up the tray. CNA 6 stated that they eventually determined to leave the meal tray for that one hour timeframe and then returned for it later. CNA 6 stated that she had reported that she was going to sleep for a few hours. CNA 6 stated that he offered to take it to the kitchen to keep it warm for her, and gave her alternatives. CNA 6 stated that resident 125 was just mad that the tray was not being left for her. CNA 6 stated that resident 125 had a routine and this was off of her routine and it made her upset. CNA 6 stated that they figured out what resident 125's routine was now, but at the time she was new and had only been at the facility for 5 days.
On 2/24/22 at 2:46 PM, an interview was conducted with the Director of Nursing (DON) and the Corporate Resource Nurse (CRN) 1. The DON stated that the process was for dietary staff to take meal trays out of the resident room and return it to the kitchen if not eaten right away. The DON stated that the tray could be brought back into the resident at a later time when they were ready to eat. The DON stated that if the resident requested it to be left at the bedside the dietary staff should respect that request. The DON stated that the dietary staff could go back later to check and see if they still would like it or if it needed to be returned to the kitchen. The DON stated that it should never become a power struggle and upsetting to the resident. The DON stated that she had heard that the dietary aide had been confrontational to resident 125. The DON confirmed that it was reasonable to leave the meal tray for the approved amount of time and then return for the tray after that time had passed. The DON stated that if the policy was to not leave it longer than one hour, then at least leave it for one hour. It should be noted that a copy of the facility policy on timeframes for meal trays at the bedside was requested. No documentation or policy was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 or 25 sampled residents, that the facility did not ensure that the interdisciplinary team (IDT) had determined that the resident's right to self administer medications was clinically appropriate. Specifically, two residents were not evaluated to determine if they were safe to self administer medications. Resident identifiers: 4 and 125.
Findings included:
1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included atherosclerosis of aorta, hypertension, insomnia, low vision right eye, and mild cognitive impairment.
On 2/22/22 at 10:21 AM, an interview was conducted with resident 4. An observation was made of 4 medications at the bedside located in a medication cup. Resident 4 stated that they were her morning pills and she had not taken them yet. Resident 4 stated she had her own routine. Resident 4 was observed to swallow one pill and then set the remaining pills down. Resident 4 stated that she loved the medical director and he had her down to 5 pills a day.
Resident 4's medical records were reviewed. No documentation could be found for an assessment for a self administration of medication.
Review of resident 4's Quarterly Minimum Data Set Assessment on 2/9/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, which would indicate cognitively intact.
On 2/23/22 at 3:28 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. CRN 1 stated that resident 4 did not have a self administration assessment and does not self administer her medications. CRN 1 stated that they had not done an assessment of resident 4 to determine if she was safe to self administer medication. CRN 1 was informed that medication was found at resident 4's bedside.
On 2/23/22 at 3:47 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 4 appeared cognitively intact most of the time. RN 1 stated that resident 4 had the kind of dementia that she talked behind peoples backs, stirred things up, lashed out, had confrontations, and had poor impulse control. RN 1 stated that she did not recall leaving resident 4's pills in her room yesterday morning. RN 1 stated that resident 4 would not be safe dispensing her medication, but she would probably be okay with the task of taking the medication. RN 1 stated that she would want to check back and make sure resident 4 was okay though. RN 1 indicated with a shake of the head, no, that they do not leave medication at the bedside. RN 1 stated that sometimes it was hard when talking to resident 4 to determine there was dementia, but with the right situation you could see it.
2. Resident 125 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare, depression, hypertension, asthma, irritable bowel syndrome, gastro-esophageal reflux disease, and obstructive sleep apnea.
On 2/23/22 at 9:55 AM, an observation was made of RN 1 during the morning medication administration. RN 1 was observed to dispense resident 125's Aspirin 81 milligram (mg) tablet; Calcium Citrate 200 mg tablet; Vitamin D3 25 microgram (mcg) tablet; Colace 100 mg capsule; Diltiazem 180 mg capsule; Duloxetine 30 mg capsule; Esomeprozole 40 mg capsule; Multivitamin 1 tablet; Equate daily fiber 2 capsules; Simethicone 80 mg tablet; and Valsartan-Hydrochlorothiazide 160/12.5 mg tablet. RN 1 was observed to deliver the medication to resident 125 at the bedside and the medication cup was left on resident 125's bedside table for the resident to take independently.
On 2/23/22 at 10:04 AM, an interview was conducted with RN 1. RN 1 stated that resident 125 was care planned to have the pills at the bedside. RN 1 stated that resident 125 stated she did not like the staff watching her swallow her pills. RN 1 stated that the Director of Nursing (DON) informed her that resident 125 was care planned to take her pill independently. RN 1 stated that the criteria was that resident 125 was up and sitting at the bed side with her food in front of her before the medication could be left with with resident 125.
Resident 125's medical records were reviewed. No documentation could be found for an assessment for a self administration of medication.
Review of resident 125's care plan revealed a focus area that stated, The resident prefers to take her medications one at a time with one bite of food. She has been assessed and deemed appropriate to have meds (medications) at bedside with meals. The care plan was initiated on 2/20/22. Interventions identified were; allow resident adequate time to take medications the way she preferred in accordance with her medication regimen; answer all resident questions in regards to medications; educate resident on safety measures to follow with specific medication routine; and nurse to bring medications into room promptly when resident had her meal tray brought in.
On 2/23/22 at 3:28 PM, an interview was conducted with CRN 1. CRN 1 stated that resident 125 did not have an assessment to self administer medications but was care planned to have her medication with breakfast. CRN 1 stated that resident 125 chose to have the medication with meals one at a time. CRN 1 stated that resident 125 did not want to store the medication in her room and some of the medication was different than what she had at home. CRN 1 stated that the care plan should reflect that she could have them at her bedside and take them by herself. CRN 1 stated that resident 125 did not have an assessment showing that resident 125 was able to safely self administer her medications independently. CRN 1 stated that the facility assessment had a portion that asked if the resident could recognize the medication label and dispense the medication. CRN 1 stated that the licensed nurse was dispensing the medication for resident 125. CRN 1 stated that resident 125 was alert and oriented and knew every single pill that she was taking. CRN 1 stated that they did not have any documentation to show that they had assessed resident 125's cognitive ability, ability to recognize the medication, and that she was safe to take the medication independently.
On 2/23/22 at 4:30 PM, a follow-up interview was conducted with CRN 1. CRN 1 stated that the process in the past would be to complete the self administration assessment. CRN 1 stated that resident 125 did not want the pill bottles by the bedside. CRN 1 stated that the plan was for the licensed nurse to dispense the medication and resident 125 could take the medication alone with her meals. CRN 1 stated that the actual assessment went through if the resident could locate the container, could read the label, could prepare the medication, and could they dispose of the medication. CRN 1 stated that she contacted her company's resource and they have identified a different self administration assessment template that would be more appropriate for resident 125. The new assessment will address resident 125's ability to recognize the medication, the color, the size, the shape or the label of the medication, and what they are used for. CRN 1 stated that the timeframe for re-evaluation of the assessment was quarterly with the Minimum Data Set assessment and anytime there was change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 25 sampled residents, that the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 34 medication opportunities, on [DATE], revealed 5 medication errors which resulted in a 14.71% medication error rate. Specifically, two residents received Levothyroxine with meals, a full dose of Miralax was not administered, Fiber capsules were administered without verification of dosage, and a Symbicort inhaler was administered without verification of the medication expiration. Resident identifiers: 9, 12, and 125.
Findings included:
1. Resident 12 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, atherosclerosis of aorta, benign prostatic hyperplasia, chronic obstructive pulmonary disease, emphysema, anxiety disorder, gastro-esophageal reflux disease, hypothyroidism, polyneuropathy, sleep apnea, and dementia.
On [DATE] at 8:36 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to administer resident 12 Levothyroxine 50 micrograms (mcg) tablet. Resident 12 was observed eating his breakfast meal.
On [DATE] at 9:00 AM, RN 1 was observed to obtain resident 12's Symbicort inhaler from the medication cart. The inhaler was stored in a plastic bag and did not have an expiration date listed on the plastic bag or the written on the inhaler. RN 1 stated that without the original medication box she did not have an expiration date for the medication. RN 1 stated that the medication was provided by resident 12's family and was brought from home. RN 1 stated that she was going to give the medication to resident 12 and then order a new refill for resident 12. RN 1 provided resident 12 with the Symbicort inhaler. Resident 12 was observed to administer 2 puffs of the medication to himself with standby assist by RN 1. Resident 12 was observed to pause, hold his breath, and wait between inhalations. Resident 1 declined to rinse his mouth with water after the medication administration.
Resident 12's Medication Administration Record (MAR) for February 2020 was reviewed and revealed the following:
a. Levothyroxine tablet 50 mcg, give one tablet by mouth in the morning for thyroid. The medication had an administration hour listed at 6:00 AM.
b. Symbicort Aerosol 160-4.5 mcg per actuation, give 2 puffs inhale orally two times a day for breathing. The medication had an administration hour listed at 6:00 AM and 6:00 PM.
On [DATE] at 10:04 AM, a follow-up interview was conducted with RN 1. RN 1 stated that she did not know if the Symbicort was an expired medication, and without the original package she had no way of knowing. RN 1 stated that she did not know if resident 12 received an effect dose of the medication. RN 1 stated that her concern was not having any medication would cause resident 12 distress, so she went ahead and gave him the medication she had on hand. RN 1 stated the medication would arrive from the pharmacy by 10 PM tonight. RN 1 stated that was that the soonest they could get the medication, but sometimes with antibiotics they could get them sooner. RN 1 stated that the facility had a stat safe for emergency medication but she did not think it had inhalers. RN 1 stated that when they get medication sent from the hospital they sometimes reorder them, but because inhalers were expensive they always kept the medication that was sent with the resident.
2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, hyperlipidemia, macular degeneration insomnia, hypothyroidism, chronic kidney disease, morbid obesity, atrial fibrillation, type 2 diabetes mellitus, and sleep apnea.
On [DATE] at 8:57 AM, an observation was made of RN 1 administering resident 9's Levothyroxine 100 mcg tablet and Polyethylene Glycol 3350 Powder (Miralax), 17 grams was mixed with 240 milliliters of apple juice. Resident 9 was observed eating her breakfast meal at the time of the medication administration. Resident 9 was observed to drink the apple juice mixed with the Miralax. RN 1 was observed to take the cup from resident 9 and discarded it into the garbage without resident 9 finishing the contents within the cup, leaving approximately 3/4 to 1 inch of liquid in the bottom of the cup.
Resident 9's MAR for February 2020 was reviewed and revealed the following:
a. Synthroid tablet (Levothyroxine Sodium), give 100 mcg by mouth in the morning for Hypothyroidism. The medication had an administration hour listed at 6:00 AM.
b. Polyethylene Glycol 3350 Powder, give 17 gram by mouth in the morning for constipation. The medication had an administration hour listed at 6:00 AM.
On [DATE] at 8:59 AM, an interview was conducted with RN 1. RN 1 stated that she did not give the last little bit of liquid [Miralax] because it was too grainy. RN 1 confirmed that the grainy consistency was due to the medication accumulation at the bottom of the cup. RN 1 stated that if she had hot water the medication would have dissolved. RN 1 stated that it was her understanding that she had up to 10% of the medication to discard and it would still be okay.
3. Resident 125 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare, depression, hypertension, asthma, gastro-esophageal reflux disease, irritable bowel syndrome, obstructive sleep apnea, and morbid obesity.
On [DATE] at 9:55 AM, an observation was made of RN 1 administering Equate daily Fiber, 2 capsules to resident 125.
Resident 125's MAR for February 2020 was reviewed and revealed FiberCon Tablet 625 milligrams (mg) (Calcium Polycarbophil), give 2 tablet by mouth two times a day for fiber. The medication had an administration hour listed at 6:00 AM and 6:00 PM.
On [DATE] at 10:04 AM, a follow-up interview was conducted with RN 1. RN 1 stated that the Synthroid use to be given 30 minutes before breakfast, but new literature stated that it did not need to be given that way anymore. RN 1 stated that now the Synthroid was given in the morning but not before breakfast. RN 1 was asked what literature she was referencing, and RN 1 clarified that this was the guidance that was provided to her when she started orienting at the facility. RN 1 stated that prior to working at this facility she understood that Synthroid needed to be given on an empty stomach to be absorbed. RN 1 stated that if the Synthroid medication did not have specific parameters for administration then she did not put it in to be administered before breakfast. RN 1 stated that if the resident stated that they took the Synthroid before all the other pills then she would call the physician and get an order to give it at a scheduled time. RN 1 stated that to her knowledge the Synthroid did not have to be given on an empty stomach, but it use to be. RN 1 stated that changed when she came to the facility and had to put her own orders in. RN 1 reviewed resident 125's order for FiberCon Tablet 625 mg and stated that the order read to give 2 tablets for a total dose of 1250 mg. RN 1 reviewed the Equate Daily Fiber bottle that was administered to resident 125 and stated that it did not have normal mg listed on the label. RN 1 calculated that she gave the resident 1600 mg of the Equate Daily Fiber based on the label that read 5 capsules was a serving of 2 grams per serving.
On [DATE] at 3:32 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. CRN 1 stated that the facility utilized flex medication administration times. CRN 1 asked for the time that the Synthroid medications were given and the time that the MAR had the order scheduled for administration. CRN 1 stated that the expectation was for the licensed nurse to notify the physician if the medication on hand was not the same as the physician order.
Review of the Medication Administration Times provided in the entrance conference documentation listed the medication flex times from 4:00 AM to 6:00 AM, then 6:00 AM to 10:00 AM, then 10:00 AM to 2:00 PM then 2:00 PM to 6:00 PM, and then 6:00 PM to 10:00 PM.
Review of the Nursing 2022 Drug Handbook guidance stated to give Synthroid medication at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. Wolters Kluwer. (2022). Nursing 2022 Drug Handbook. Philadelphia, PA. 42nd Edition, p. 878.

Based on observation, interview and record review it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, the dish machine wash temperature was not meeting the manufacture requirements and there were soiled areas in the kitchen.
Findings include:
1. On 2/22/22 at 9:09 AM, an initial kitchen tour of the kitchen was conducted. The following was observed:
a. There was whipped topping with no open date in the walk in refrigerator.
b. There was debris on the floor in the walk in freezer.
c. The inside of the microwave was soiled.
e. The shelf above the steam table was soiled under the shelf which was above the prepared foods.
f. There was food splatter on the wall behind the oven, fryer, griddle and stove.
2. On 2/22/22 at 9:15 AM, an observation was made of the facility dish machine. The wash temperature was 110 degrees Fahrenheit and the rinse temperature was 200 degrees Fahrenheit. The dishes were observed to be removed from the dish machine and placed in the clean dish area.
A poster next to the dish machine revealed the dish machine was a high temperature machine. The temperatures for the wash cycle was to be above 150 degrees Fahrenheit and the rinse temperature was to be above 180 degrees Fahrenheit.
3. On 2/22/22 at 9:30 AM, an observation was made of the sanitizer bucket. Dietary Staff (DS) 1 stated he had changed the sanitizer 15 minutes previous. The Dietary Manager (DM) was observed to obtain the temperature of the sanitizer solution which was 87 degrees Fahrenheit. The DM stated the water needed to be colder. DS 1 was observed to place a sanitizer strip into the sanitizer water. The strip did not change color which revealed there was not enough sanitizer. DS 1 stated the strip did not change color so it meant Neutral, nothing. DS 1 was not observed to change the sanitizer solution.
4. On 2/24/22 at 10:26 AM, a follow up observation was made of the dish machine. The following temperatures were obtained: [Note: All temperatures were in degrees Fahrenheit.]
a. The wash cycle was 130 and the rinse cycle was 200.
b. The wash cycle was 130 and the rinse cycle was 200.
The DM was observed to remove the dishes from the dish machine and replace them with clean dishes. The DM stated she had not recorded dish machine temperatures since she started 3 weeks previous. The DM stated she had January 2022 temperatures. The DM provided the temperatures. The Dishwasher Temperature Chart revealed the following:
a. On 1/3/22, there were no temperatures for breakfast, lunch, or dinner.
b. On 1/4/22, there were no temperatures for breakfast and lunch.
c. On 1/5/22, there were no temperatures for breakfast, lunch, and dinner.
d. On 1/6/22 through 1/10/22, there were no temperatures for breakfast and lunch.
e. On 1/11/22, there were no temperatures for breakfast, lunch, and dinner.
f. On 1/12/22 through 1/14/22, there were no temperatures for breakfast and lunch.
g. On 1/16/22, there were no temperatures for dinner.
h. On 1/17/22 through 1/20/22 there were no temperatures for breakfast and lunch.
i. On 1/24/22 through 1/25/22, there were no temperatures for breakfast and lunch.
j. On 1/27/22, there were no temperatures for lunch and dinner.
k. On 1/28/22, there were no temperatures for breakfast, lunch, and dinner.
l. On 1/29/22 through 1/31/22, there were no temperatures for breakfast and lunch.
The February Dishwasher Temperature Chart was provided by [NAME] 1. [NAME] 1 stated the temperatures were on the meal carts. The February chart revealed the following regarding the dish machine temperatures:
a. On 2/1/22, there was no temperatures for lunch.
b. On 2/2/22 through 2/4/22 there were no temperatures for breakfast and lunch.
c. On 2/7/22 through 2/8/22, there were no temperatures for breakfast and lunch.
d. On 2/9/22, there were no temperatures for lunch and dinner.
e. On 2/10/22 through 2/15/22 there were no temperatures for breakfast and lunch.
f. On 2/16/22, there was no temperatures for dinner.
g. On 2/17/22, there were no temperatures for breakfast and lunch.
h. On 2/18/22 and 2/19/22 there were no temperatures for lunch.
i. On 2/22/22, there was no temperatures for breakfast.
The DM stated if the dish machine was not at the temperature, she notified the Maintenance Director and the dish machine company. The DM stated the dish machine company was in the building the previous week and looked at all the equipment.
5. On 2/24/22 at 10:45 AM, [NAME] 1 stated that she did not change the sanitizer. [NAME] 1 stated that DS 1 changed the sanitizer. DS 1 stated he did not change the sanitizer solution. [NAME] 1 as observed to check the sanitizer solution. The sanitizer strip did not change color. [NAME] 1 stated that it was 0 and there was no sanitizer. [NAME] 1 was observed to change the sanitizer and used a brown rag. [NAME] 1 stated the had brown rags were clean. [NAME] 1 stated that it was 300 Part Per Million (PPM) of Quaternary ammonium (quats).
6. On 2/24/22 at 2:30 PM, an observation was made of the refrigerator in the cove. There was a chocolate shake with no date.
7. On 2/24/22 at 2:53 PM, a follow-up kitchen tour was conducted. The following was observed:
a. The microwave was soiled on the inside
b. There was food splatter behind the oven, fryer, stove, and griddle.
c. The large mixer had food splatter on the back cover of the mixer.
d. The shelf above tray line was soiled under the shelf.
DS 3 stated that the mixer had not been used for about a month but it needed to be cleaned. DS 3 stated that the shelf above the tray line food and not been cleaned underneath.
Cook 1 stated to clean behind the oven, fryer, stove and griddle every thing had to be moved out which was very hard to do. [NAME] 1 stated the wall was cleaned twice a year when the vents were closed. [NAME] 1 stated the the dish machine needed to have a wash temperature above 155 and rinse above 180 degrees Fahrenheit.
The DM stated the Microwave was cleaned every couple of days because it got messy from the supper shakes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not provide, for 1 of 25 sample residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided assessed specialized rehabilitation. Resident identifier 6.
Findings include:
Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
Resident 6's electronic medical record review was completed on 3/2/22.
Resident 6's Preadmission Screening Resident Review (PASRR) Level II, created on 7/31/21 revealed that resident 6 had a diability that limited her in learning, self-direction, and capacity for independent living. The functional assessment revealed that reident 6 showed an inability to learn new skills without aggressive and consistent training. The summary of Specialized Rehabilitative Services (SRS) for Intellectual diaability stated that resident 6 would benefit from an SRS program that works on maintaining as much independence as possible. [Resident 6] will tend to passively allow others to do things for her that she is still capable of doing independently. She would also benefit from recreational opportunities that are geared to her developmental and intellectual level. Additonal recommendations were that resident 6 meets IDRC criteria with an intellectual disability, likely mild, and a seizure disorder .
Physician orders revealed that resident 6 had active orders for the following:
a. 5/17/21: Speech therapy to evaluate and treat as necessary
b. 5/17/21: Occupational therapy to evaluate and treat as necessary
A care plan for falls reevaled that resident 6 had an intervention of PT consult for strength and mobility in initiated on 11/1/21 and revised on 1/24/22.
Fall reports revealed that resident 6 had a fall on 6/2/21, 10/20/21, 12/7/21, and 1/27/22.
A Minimum Data Set, dated [DATE] revealed that resident 6 required staff assistance to stabilize when moving from a seated to a standing position, when moving off and onto the toilet, and when transferring from one surface to another. Resident 6 was unsteady when walking and turning around but was able to stabalize with a walker or wheelchair. Resident 6 required one person assistance with bed mobility, walking, dressing, toileting and for personal hygiene. At the time of the assessment, resident 6 was unable to walk 10 feet, was unable to take a step up or down from a curb, or pick up an object from the floor. The MDS stated that resident 6 last had therapy in October, 2021.
An MDS was completed on 12/17/21 that revealed that resident 6 had a mood interview, a Patient Health Qustionnaire-9 (PHQ-9). Resident 6 scored 19/27, indicating moderately severe depression.
Nursing notes revealed that resident 6 worked with therapy from admit from 5/15/21 until 7/30/21. There were no additional nursing notes about therapy.
A care plan for ADL (activities of daily living) self-care performance deficit r/t (related to) encephalopathy was created on 5/16/21. Resident 6 was to be prvoided nursing rehab/restorative assistance for walking and active range of motion.
On 2/24/22 at 10:15 AM, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 would benefit from behavior therapy. The RA stated that resident 6 did not receive behavioral therapy due to the COVID-19 pandemic, which interfered with the contracted behavioral therapist entering the facility and providing services.

Based on observation, record review and interview the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, one resident was abused and involuntarily secluded with the permission of management, which was cited at an Immediate Jeopardy, scope and severity of H. Resident identifiers: 4,6, 14, 125, and 127.
Findings included:
1. Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility failed to ensure that a symptomatic staff members, who subsequently tested positive for COVID-19, were screened accurately and notification and evaluation was completed per the facility protocol, that negative antigen tests were completed, and that symptomatic staff members were provided appropriate Personal Protective Equipment (PPE). The failure resulted in 6 residents exposure and 2 testing positive with a facility outbreak. In addition, staff and visiting essential personnel who have continued to test negative for COVID-19 were also at an elevated risk. Additionally, staff did not wear required PPE for a newly admitted unvaccinated resident. In addition, a nurse was observed to handle residents medications with bare hands. Resident identifiers: 125 and 127.
[Cross refer F880]
2. Based on observation, interview and record review it was determined, for 3 of 25 sample residents, that the facility did not ensure residents were free from abuse. This included but was not limited to involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. In addition, the facility must not use verbal, mental, sexual, or physical abuse corporal punishment or involuntary seclusion. Specifically, a resident with intellectual disabilities was verbally abused, physically abused, psychologically abused and involuntarily secluded by residents, a family member and staff members. In addition, staff members were unable to identify and report abuse. The resident was not provided interventions to prevent further abuse by a family member, verbal abuse from other residents, and was involuntarily secluded when behaviors escalated. The facility's failure to protect resident 6 from abuse was determined to constitute Immediate Jeopardy. Resident identifiers: 4, 6, and 14.
[Cross refer F600]

Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, F600, abuse was cited at an Immediate Jeopard, scope and severity of H. Resident identifiers: 6, 125, and 127.
Findings include:
1. Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility failed to ensure that a symptomatic staff members, who subsequently tested positive for COVID-19, were screened accurately and notification and evaluation was completed per the facility protocol, that negative antigen tests were completed, and that symptomatic staff members were provided appropriate Personal Protective Equipment (PPE). The failure resulted in 6 residents exposure and 2 testing positive with a facility outbreak. In addition, staff and visiting essential personnel who have continued to test negative for COVID-19 were also at an elevated risk. Additionally, staff did not wear required PPE for a newly admitted unvaccinated resident. In addition, a nurse was observed to handle residents medications with bare hands. Resident identifiers: 125 and 127.
2. Based on observation, interview and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure residents were free from abuse. This included but was not limited to involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. In addition, the facility must not use verbal, mental, sexual, or physical abuse corporal punishment or involuntary seclusion. Specifically, a resident with intellectual disabilities was verbally abused, physically abused, psychologically abused and involuntarily secluded by residents, a family member and staff members. In addition, staff members were unable to identify and report abuse. The resident was not provided interventions to prevent further abuse by a family member, verbal abuse from other residents, and was involuntarily secluded when behaviors escalated. The facility's failure to protect resident 6 from abuse was determined to constitute Immediate Jeopardy. Resident identifier: 6.
On 3/2/22 at 5:05 PM, an interview was conducted with the Administrator. The Administrator stated that hand washing and linens were addressed in a QA meeting. The Administrator stated a re-inservice was conducted for staff regarding on testing stuff and glucometer cleaning. The Administrator stated that abuse was not discussed in QA because management performed room rounds daily for the first part of February. The Administrator stated that during room rounds, residents were asked about abuse and being treated roughly. The Administrator stated there were no reports of abuse so it was not addressed in QA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Screening of staff and visitors prior to entering the facility:
On 2/24/22 at 4:41 PM, a interview was conducted with the facility Administrator (ADM). The ADM stated that the Administrator in Training (AIT) was filling in as the Business Office Manager (BOM) and then they hired another staff for the BOM position. The ADM stated that the AIT stayed on for a week afterwards, but she was not getting paid the week of January 18th, 2022, but she was at the facility. The ADM stated that the AIT was signing in for screening and she would come and go as needed. The ADM stated that she did not track the AIT's hours at the facility.
On 2/24/22 at 5:12 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 stated that the AIT did just come and go because she was an AIT. CRN 2 stated that the AIT should still be screening when she came into the facility.
Review of the COVID-19 Screening of Staff for January 2022 revealed the following:
a. On 1/3/22, the Resident Advocate (RA) marked yes to signs and symptoms (s/sx.) of COVID-19. No documentation was found that the RA was tested for COVID-19 on 1/3/22.
b. On 1/4/22, the RA marked yes to s/sx. of COVID-19. The RA tested negative for COVID-19 on 1/4/22 according to the state reporting spreadsheet.
c. On 1/6/22, the AIT marked yes to s/sx. of COVID-19. The signature was confirmed by telephone text message with the AIT. The AIT tested negative for COVID-19 on 1/5/22 and 1/7/22.
d. On 1/8/22, Certified Nurse Assistant (CNA) 9 and CNA 10 marked yes to s/sx. of COVID-19. No documentation was found that CNA 9 and CNA 10 were tested for COVID-19 on 1/8/22.
e. On 1/9/22, Registered Nurse (RN) 1 and CNA 9 marked yes to s/sx. of COVID-19. No documentation was found that RN 1 and CNA 9 were tested for COVID-19 on 1/9/22.
f. On 1/9/22, CNA 4 marked yes to contact with persons with COVID-19. No documentation was found that CNA 4 was tested for COVID-19 on 1/9/22.
g. On 1/10/22, CNA 4 and CNA 11 marked yes to contact with persons with COVID-19. No documentation was found that CNA 4 and CNA 11 were tested for COVID-19 on 1/10/22.
h. On 1/12/22, CNA 5 did not mark a temperature reading. CNA 5 tested negative for COVID-19 on 1/12/22.
i. On 1/13/22, Licensed Nurse (LN) 2 marked yes to s/sx. of COVID-19. LN 2 tested negative for COVID-19 on 1/13/22.
j. On 1/13/22, CNA 4 marked yes to contact with persons with COVID-19. CNA 4 tested negative for COVID-19 on 1/13/22.
k. On 1/14/22, RN 1 marked yes to s/sx. of COVID-19. RN 1 was tested negative for COVID-19 on 1/14/22.
l. On 1/14/22, CNA 13 and Staff Member (SM) 1 marked yes to contact with persons with COVID-19. No documentation was found that CNA 13 or SM 1 were tested for COVID-19 on 1/14/22.
m. On 1/15/22, LN 2 marked yes to s/sx. of COVID-19. No documentation was found that LN 2 was tested for COVID-19 on 1/15/22.
n. On 1/15/22, SM 2, Dietary Staff (DS) 3, the Director of Nursing (DON), SM 1, CNA 9, CNA 16, CNA 17, LN 3, CNA 5, SM 3 marked contact with persons with COVID-19. No documentation was found that any of the above mentioned individuals were tested for COVID-19 on 1/15/22.
o. On 1/16/22, CNA 1, CNA 9, LN 2, and SM 2 marked yes to s/sx. of COVID-19 and contact with persons with COVID-19. No documentation was found that CNA 1, CNA 9, LN 2, or SM 2 were tested for COVID-19 on 1/16/22.
p. On 1/17/22, SM 2 marked yes to s/sx. of COVID-19. No documentation was found that SM 2 was tested for COVID-19 on 1/17/22.
q. On 1/18/22, the Maintenance Director marked yes to s/sx. of COVID-19. The Maintenance Director tested negative for COVID-19 on 1/18/22.
r. On 1/19/22, CNA 4, CNA 15, CNA 16, and the Activities Director (AD) marked yes to contact with persons with COVID-19. No documentation was found that CNA 4, CNA 15, CNA 16, or the AD were tested for COVID-19 on 1/19/22.
s. On 1/19/22, the Maintenance Director marked yes to s/sx. of COVID-19. The Maintenance Director tested negative for COVID-19 on 1/19/22.
t. On 1/20/22, the Maintenance Director marked yes to s/sx. of COVID-19. The Maintenance Director tested positive for COVID-19.
u. On 1/20/22, CNA 4 marked yes to contact with persons with COVID-19. No documentation was found that CNA 4 was tested for COVID-19 on 1/20/22.
v. On 1/21/22, the AD and SM 4 marked yes to contact with persons with COVID-19. SM 4 tested negative for COVID-19 on 1/21/22. No documentation was found that the AD was tested for COVID-19 on 1/21/22.
w. On 1/22/22, CNA 11 and [NAME] 2 marked yes to s/sx. of COVID-19. No documentation was found that CNA 11 or [NAME] 2 were tested for COVID-19 on 1/22/22.
x. On 1/26/22, CNA 12 marked yes to contact with persons with COVID-19. No documentation was found that CNA 12 was tested for COVID-19 on 1/26/22.
y. On 1/27/22, CNA 8 and CNA 13 marked yes to s/sx. of COVID-19 and contact with persons with COVID-19. CNA 8 tested negative for COVID-19 on 1/27/22. No documentation was found that CNA 13 were tested for COVID-19 on 1/27/22.
z. On 1/28/22, CNA 8 marked yes to s/sx. of COVID-19 and contact with persons with COVID-19. CNA 8 tested negative for COVID-19 on 1/28/22.
aa. On 1/28/22, SM 5 marked yes to contact with persons with COVID-19. No documentation was found that SM 5 was tested for COVID-19 on 1/28/22.
bb. On 1/29/22, CNA 12, LN 3, and SM 6 marked yes to contact with persons with COVID-19. No documentation was found that CNA 12, LN 3 or SM 6 were tested for COVID-19 ON 1/29/22.
cc. On 1/30/22, CNA 12 marked yes to s/sx. of COVID-19 and contact with persons with COVID-19. No documentation was found that CNA 12 was tested for COVID-19 ON 1/30/22.
dd. On 1/30/22, SM 7 marked yes to s/sx. of COVID-19. No documentation was found that SM 7 was tested for COVID-19 on 1/30/22.
ee. On 1/30/22, CNA 5 did not documented a temperature reading. No documentation was found that CNA 5 was tested for COVID-19 on 1/30/22.
Review of the COVID-19 Screening of Staff for February 2022 revealed the following:
a. On 2/7/22, CNA 10 marked yes to s/sx. of COVID-19. CNA 10 tested negative for COVID-19 on 2/7/22.
b. On 2/8/22, CNA 10 marked yes to s/sx. of COVID-19. No documentation was found that CNA 10 was tested for COVID-19 on 2/8/22.
c. On 2/9/22, CNA 10 marked yes to s/sx. of COVID-19. CNA 10 tested negative for COVID-19 on 2/9/22.
d. On 2/10/22, CNA 14 marked yes to s/sx. of COVID-19. No documentation was found that CNA 14 was tested for COVID-19 on 2/10/22.
e. On 2/12/22, CNA 10, and [NAME] 2 marked yes to s/sx. of COVID-19. No documentation was found that CNA 10 or [NAME] 2 were tested for COVID-19 on 2/12/22.
f. On 2/13/22, CNA 10, CNA 5 marked yes to s/sx. of COVID-19. No documentation was found that CNA 5 was tested for COVID-19 on 2/13/22.
g. On 2/14/22, CNA 5 and CNA 10, and SM 8 marked yes to s/sx. of COVID-19. No documentation was found that CNA 5, CNA 10, or SM 8 were tested for COVID-19 on 2/14/22.
h. On 2/15/22, CNA 11 and CNA 14 marked yes to s/sx. of COVID-19. No documentation was found that CNA 11 was tested for COVID-19 on 2/15/22. CNA 14 tested negative for COVID-19 on 2/15/22.
i. On 2/16/22, CNA 10, CNA 14, and CNA 11 marked yes to s/sx. of COVID-19. No documentation was found that CNA 10, CNA 14, or CNA 11 were tested for COVID-19 on 2/16/22.
j. On 2/17/22, CNA 10 and CNA 14 marked yes to s/sx. of COVID-19. No documentation was found that CNA 10 or CNA 14 were tested for COVID-19 on 2/17/22.
k. On 2/19/22, CNA 10 marked yes to s/sx. of COVID-19. No documentation was found that CNA 10 was tested for COVID-19 on 2/19/22.
l. On 2/20/22, CNA 10 and [NAME] 2 marked yes to s/sx. of COVID-19. No documentation was found that CNA 10 or [NAME] 2 were tested for COVID-19 on 2/20/22.
m. On 2/21/22, CNA 10 marked yes to s/sx. of COVID-19. No documentation was found that CNA 10 was tested for COVID-19 on 2/21/22.
n. On 2/24/22, [NAME] 2 marked yes to s/sx. of COVID-19. No documentation was found that [NAME] 2 was tested for COVID-19 on 2/24/22.
o. On 2/26/22, SM 9 marked yes to s/sx. of COVID-19. The form documented that the staff had the flu. No documentation was found that the staff was tested for COVID-19 on 2/26/22.
On 2/24/22 at 4:58 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that she had been keeping a spreadsheet to track reported COVID-19 testing. The ADON stated that if the person's name was not on the spreadsheet, a test was not reported for that staff member.
On 2/28/22 at 1:11 PM, the Administrator was re-interviewed. The ADM stated that the AIT's symptoms were a runny nose and raspy voice. The ADM stated that the AIT took a POC test and went on a van ride with six residents, and continued to work through Friday that week with symptoms (1/4 - 1/7/22). The ADM stated that the only day that week the AIT had contact with residents was on 1/6/22. The ADM stated that the AIT did not wear an N95 mask. The ADM stated that two residents on the van ride tested positive for COVID-19, with one on 1/10/22 and the second on 1/12/22. Additionally, one resident who frequently interacted with one of those residents tested positive for COVID-19 on 1/12/22. The ADM stated that screening questionnaires were often placed on the ADON's desk, and were not reviewed by any other staff.
On 2/28/22 at 9:36 AM, an interview was conducted with CNA 2. CNA 2 stated that she conducted screening in the morning upon arrival to the facility. CNA 2 stated that she performed hand hygiene with alcohol based hand rub (ABHR), signed in, conducted a temperature check, donned a surgical mask and goggles, clocked in and reported to the conference room to receive report. CNA 2 stated that if there was any COVID-19 positive residents in the building they were to wear a N95 mask and they were located on the front desk. CNA 2 stated that a nurse was sitting at the front desk to monitor the screening process for all oncoming staff. CNA 2 stated that there was always someone supervising the screening process. CNA 2 stated that if they marked yes to any questions on the screening they were supposed to COVID-19 test and if the test was negative they were permitted to work their shift. CNA 2 stated that the testing was conducted at the front desk before entering the main part of the building. CNA 2 stated that if they should develop s/sx. consistent with COVID-19 while they were working they were instructed to leave the floor and have someone test them. CNA 2 stated that they were instructed to inform the ADM, DON, and charge nurse on the floor. CNA 2 stated that the facility would test the staff anytime they requested it. CNA 2 stated that if they were symptomatic but tested negative for COVID-19 they were to wear a N95 mask while working. CNA 2 stated that she was not sure if it was policy at the facility, but even if she had a common cold she would not want to give it to a resident.
On 2/28/22 at 9:47 AM, an interview was conducted with RN 1. RN 1 stated that she entered the facility through the front door, signed in, checked her temperature, answered the screening questions, donned a mask, punched in for the shift, performed hand hygiene with ABHR, and reported to the huddle room to receive report. RN 1 stated that the night nurse sat by the front desk and monitored staff entering the building for the oncoming shift. RN 1 stated that if they marked yes to any s/sx. or fever then they were instructed to perform a COVID-19 test. RN 1 stated that they were instructed to inform the Assistant Director of Nursing (ADON) if they had any s/sx. and she would usually have you test. RN 1 stated that the nurse who was monitoring the screening would also monitor the test results. RN 1 stated that if the test was negative for COVID-19, but you still had a fever and were sick they were supposed to call the ADON. RN 1 stated that they would then get someone to come in and cover the shift for you. RN 1 stated that if you were symptomatic, but did not feel sick and tested negative for COVID-19 then you were allowed to work your shift. RN 1 stated that if you were not feeling well or were symptomatic they were supposed to upgrade their PPE and change from a surgical mask to a N95 mask.
On 2/28/22 at 9:47 AM, an interview was conducted with CNA 18. CNA 18 stated that she screened at the front desk when she came into work. CNA 18 stated if she answered yes to symptoms of COVID-19 she would notify the nurse. CNA 18 stated that after obtaining her temperature she completed a form. CNA 18 stated that she had not worked with symptoms, but if she did she would wear a different mask, eye protection and sanitize her hands often. CNA 18 stated that the nurse was usually at the front desk when she came to work.
On 2/28/22 at 9:39 AM, an interview was conducted with LN 1. LN 1 stated that she screened for COVID-19 at the front desk. LN 1 stated that she obtained her temperature and completed the log. LN 1 stated that she would contact a manager or Administration if she marked yes to any symptoms. LN 1 stated she would call work prior to coming to the facility if she had symptoms. LN 1 stated she would not come to work with symptoms. LN 1 stated that if staff were fully vaccinated with signs and symptoms of COVID-19, they did not have to perform a COVID-19 test. LN 1 stated that she screened herself at the front door.
On 2/28/22 at 10:01 AM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that he started feeling symptomatic over the previous weekend on 1/15/22 to 1/16/22, and had symptoms of a sore throat, sniffles, body aches and feeling run down. The Maintenance Director stated that when he reported to work on Monday he informed management (was unable to recall who) that he had symptoms and he tested himself. The Maintenance Director stated that he let them know that he was not feeling well. The Maintenance Director stated that he was testing himself daily and would put the test form on the ADON's desk so she was aware that he was performing the tests himself. The Maintenance Director stated that he was instructed that if he was symptomatic and was testing negative for COVID-19 he was allowed to continue to work. On 1/20/22 the Maintenance Director tested positive for COVID-19.
On 2/28/22 at 12:08 PM, an interview was conducted with the AD. The AD stated that the van ride in January was on 1/6/22 and they went to a restaurant to get the residents ice cream. The AD confirmed that the residents on the van ride were resident 14, resident 7, resident 4, resident 6, resident 18, and resident 5. The AD stated that the staff on the van ride wore a surgical mask and eye protection. The AD stated that some of the residents would wear a surgical mask but they would take the mask off to eat. The AD stated that the food obtained at the restaurant was eaten in the van and all residents were unmasked. The AD stated that the screening process was to answer the questionnaire, take their temperature, and perform hand hygiene upon arrival. The AD confirmed that the AIT accompanied her and the residents on the van ride and that she did not appear to be sick. The AD stated that if they were to mark yes to any s/sx. of COVID-19 they were supposed to let the nurse know and then test for COVID-19. The AD stated that no one monitored her when she screened in, and if they come in earlier then they just do their own screening. The AD stated that if someone was up front they would monitor the screening process, but they had not had a receptionist for two weeks.
On 2/24/22 at 5:30 PM, a telephone interview was conducted with the AIT. The AIT stated she tested positive for COVID 19 on 1/10/22 at her other job. The AIT stated that she was symptomatic the week prior. The AIT stated that she had a runny nose and raspy voice. The AIT stated that she screened at the front door by obtaining her temperatures, marking on the form if she had been at another building with COVID-19 and marking if she had s/sx. of COVID-19. The AIT stated she tested negative for COVID-19 for 6 days prior to testing positive. The AIT stated that she marked she had a runny nose and tested negative. The AIT stated that she tested the morning of the van ride, but could not remember when the van ride was.
On 2/28/22 at 12:27 PM, a follow-up telephone interview was conducted with the AIT. The AIT stated that on 1/4/22 to 1/7/22 she worked at the facility from 9:00 AM to approximately 4:00 PM. The AIT stated that she tested positive for COVID-19 on 1/10/22 and did not return to the facility until 1/18/22. The AIT stated that she was symptomatic with a runny nose and a raspy voice. The AIT stated that on 1/6/22 she wore a surgical mask during the van ride with the residents. The AIT stated that she probably was in the building longer on 1/6/22. The AIT stated that she was tested for COVID-19 on 1/6/22, but was not able to recall the name of the nurse who tested her. No documentation was found for the test results for 1/6/22. After she tested positive she quarantined at home until 1/18/22 and had a negative COVID-19 test. The AIT stated that she did not eat anything during the van ride on 1/6/22.
On 2/28/22 at 12:32 PM, an interview was conducted with the ADON. The ADON stated that she was the Infection Preventionist (IP) and wound nurse. The ADON stated that the screening process was that everyone signed in on the sheet, and anyone that marked yes to s/sx. of COVID-19 were tested with the rapid antigen test. The ADON stated that they did not do anything different for staff that marked yes to contact with persons with COVID-19. The ADON stated that everyone was in contact with persons with COVID-19 in the community so they just watch for s/sx. The ADON stated that if the antigen test result was negative they were allowed to work, but should wear an N95 mask and a face shield. The ADON stated that everyone monitored the screening process and that there was not a designated person. The ADON stated that there was not someone assigned to the front desk at all times so typically someone on shift would monitor the screening process, and it was usually the charge nurse. The ADON stated that was if the charge nurse was not busy with patient care. The ADON stated that the staff were instructed that if someone had s/sx. of COVID-19 they should be tested. The ADON stated that the test results were documented on a separate form for each test that they conducted and the staff placed them on her desk to record later. The ADON stated that the staff have been instructed to notify her if any test was positive and she was to inform the state agency within 24 hours with a list of exposures. The ADON stated that if a staff member tested positive they were instructed to leave the facility immediately. The ADON stated that if staff had s/sx. they were instructed come to the facility for testing. The ADON stated that this was done to ensure that staff were not calling off without actually being sick. The ADON stated that they had N95 masks at the front door by the PPE, and if staff were symptomatic and tested negative they were to wear a N95 mask. The ADON reviewed the screening sheets and stated that the RA tested on [DATE] but was documented on the spreadsheet on 1/4/22. The ADON stated that the AIT tested on [DATE] and was documented on the spreadsheet on 1/7/22. The ADON stated that everyone should document a temperature reading. The ADON stated that if the thermometer read Low the staff were documenting low on the screening sheet because they reasoned that they did not have a fever. The ADON stated that they had not checked the accuracy of the thermometer when it was reading low. The ADON stated that they probably should get another thermometer to check the temperature when the other one reads low for accuracy. The ADON stated that the staff all have access to unlock the front doors with their key fobs, so when the doors were locked after hours staff could still enter the facility.
On 2/28/22 at 2:12 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. CRN 1 stated that they recently transitioned to a new DON, but that the screening process had not changed. CRN 1 stated that the staff were competent enough to COVID-19 test themselves, but it should be observed by a nurse. CRN 1 stated that if someone was symptomatic they were to notify the ADON and MD and conduct a COVID-19 test. CRN 1 stated that the nurses were not testing all of the staff and that the Maintenance Director tested himself. CRN 1 stated that the staff had been provided training on how to conduct the antigen test, fill out the testing form and deliver the form to the ADON for reporting and documenting.
On 2/28/22 at 2:42 PM, a telephone interview was conducted with CNA 10. CNA 10 stated that she was symptomatic with a cough, sore throat, fatigue, and body aches and tested positive on a Thursday (2/10/22). CNA 10 stated that she started wearing a N95 mask a couple of days before she tested positive and wore it until the cough went away. CNA 10 clarified and stated that she began having s/sx. on 2/7/22 and that was when she initiated a N95 mask, and tested positive for COVID-19 on 2/10/22. CNA 10 stated that the 5 day quarantine period calculation began on 2/7/22, the day that she became symptomatic. CNA 10 stated that she quarantined for a couple of days and then was cleared to work because the 5 days started from the time that she began her symptoms and not 5 days from the time she tested positive. CNA 10 stated that her symptoms slowly came on and started with sore throat and cough and then went away. CNA 10 stated that she continued to marked s/sx. until 2/21 because she continued to have a lingering cough. CNA 10 stated that she did not stop wearing a N95 mask until the cough was completely gone. CNA 10 stated that she came in before the shift and the secretary conducted a rapid antigen test. It should be noted that no documentation was found for COVID-19 testing for 2/8/22, 2/12/22, through 2/14/22, 2/16/22, 2/17/22, 2/19/22, 2/20/22 and 2/21/22 when CNA 10 reported s/sx.
On 2/28/22 at 3:19 PM, a telephone interview was conducted with [NAME] 2. According to the screening forms [NAME] 2 marked yes to s/sx. of COVID-19 on 2/12/22, 2/20/22 and 2/24/22. [NAME] 2 stated that the screening process was to take the temperature, fill out the questionnaire, and every once in awhile take a COVID-19 test. [NAME] 2 stated that he was not sure why he took the COVID-19 tests, other than they did not want it in the facility. [NAME] 2 stated that the COVID-19 tests were conducted regularly every 1-2 weeks and since he had been at the facility he had been tested 2 times. [NAME] 2 stated that he was tested on other time when he was not feeling well. [NAME] 2 stated that at the time that he was not feeling well he felt like his head was not feeling well, some dizziness, not like a headache. [NAME] 2 stated that he had COVID-19 last year and felt off balance with it. [NAME] 2 stated that because of the previous experience he asked to be tested when he developed these s/sx. [NAME] 2 stated that on the screening questionnaire he did not mark yes to s/sx. of COVID-19 because he developed these symptoms during his shift. [NAME] 2 stated that the nurse did a nasal swab and he tested negative for COVID-19. [NAME] 2 stated that the symptoms did not cause him to leave work sick. [NAME] 2 stated that while working in the kitchen he wore a surgical mask and eye protection, and after he tested negative he continued to wear the same PPE. [NAME] 2 stated that he has marked yes to s/sx. for a cough in the past and had thought that it might be caused by an allergy to high fructose corn syrup. [NAME] 2 stated that he was not tested for COVID-19 on those dates that he marked yes to s/sx. and he did not change his surgical mask to a different mask. [NAME] 2 stated that no one had informed him that he needed to notify anyone if he marked yes to any questions for s/sx. [NAME] 2 stated that his trainer was new and had left shortly after he had started. [NAME] 2 stated that no one monitored his screening when he came into the facility, and no one monitored his screening on the days that he indicated yes to s/sx.
On 2/28/22 at 3:34 PM, a follow-up interview was conducted with the ADON. The ADON stated that the DON was tested on [DATE] and she thought it was an accidental documentation that indicated a positive result. The ADON stated that she tested because she was not vaccinated. The ADON confirmed that she did not have any tests for [NAME] 2.
On 2/28/22 at 3:52 PM, a telephone interview was conducted with the DON. The DON stated she did her test on 2/23/22 and the results were negative. The DON stated she would have done 2 tests last week. The other test was done on Monday or Tuesday, it could have been back to back. The DON stated that the end of the last outbreak was depending on the paper chart on the wall in her office. It told her the next time to test. The DON stated that after two rounds of negative tests, they tested immediately and then again another 5-7 days later. The DON stated she did not know the date that they came off of outbreak status. The DON stated that the screening process was s/sx., a temperature screening, and go to the staff member and test if it warrants a test. The DON stated that a test was required if any s/sx. were present such as a cough, sore throat, vomiting, headache, body ache, or nasal congestion. The DON stated that the nurses or administration can perform the test, but they have taught all the staff how to perform the test. The DON stated that if the test results were questionable then they retest. The DON stated that because they had been seeing a delay with a COVID positive test result, they have been having any symptomatic staff wear a N95 mask. On 2/10/22 and 2/11/22 had 2 staff members test positive, CNA 10 and CNA 5. The DON stated that they did not test CNA 5 because he had not worked with residents in the last 5 days.
On 2/28/22 at 4:46 PM, an interview was conducted with CRN 1. CRN 1 stated that they were out of outbreak status on 1/25/22 per state Healthcare-Associated Infection (HAI) team guidance even though last COVID-19 positive staff and resident were on 1/19/22 with no further resident testing.
On 3/1/22 at 8:02 AM, a follow-up interview was conducted with the ADM. The ADM stated that if staff had signs and/or symptoms consistent with COVID-19, they were to wear an N95, KN95 or higher respirator and tight fitting mask. The ADM stated that after the AIT was positive, there was no change to policy and procedures about staff working with symptoms. The ADM stated that staff had done contract tracing for the outbreak of COVID-19, and had determined that it started with the AIT. The ADM stated that after the outbreak, they were informed that as of 1/19/22, they did not need to do any more outbreak testing.
Review of the Centers for Disease Control and Prevention guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes documented Symptomatic HCP [Healthcare Personnel], regardless of vaccination status, should be restricted from work pending evaluation for SARS-CoV-2 infection. The guidance further stated that All HCP who have had a higher-risk exposure and residents who have had close contacts, regardless of vaccination status, should be tested as described in the testing section. The guidance was last updated on February 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631031505598
2. Transmission based precautions:
Resident 127 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, acute kidney failure, type 2 diabetes mellitus, dementia, and hyperlipidemia.
On 2/22/22 at 9:16 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 127 was a new admit on quarantine for 2 weeks on droplet precautions because he was not vaccinated for COVID-19. RN 1 stated that they did not usually have the door open but he was a memory care resident and for safety reasons they needed the door open. Resident 127's room had a sign posted on the door that stated isolation precautions, COVID isolation. Droplet precautions were check marked as indicated and the following instructions were listed: Patient to have private room; Surgical mask to be worn by all hospital personnel entering the room; Hospital personnel wear gloves when entering the room; and Perform hand hygiene before leaving the room. A Personal Protective Equipment (PPE) cart was located outside of resident 127's room. Inside the PPE cart was biohazard bags, gloves, and disposable gowns.
Resident 127's medical records were reviewed.
Resident 127's immunization history was reviewed and no documentation could be found for any COVID-19 immunizations.
On 2/22/22 at 10:33 AM, an observation was made of a staff member in resident 127's room seated on the resident's walker talking to the resident. The staff member had a surgical mask and eye protection on. The staff member did not have a gown, gloves or N95 mask donned. The staff member was observed to exit resident 127's room, perform hand hygiene, and approach nurse's station to speak with RN 1.
On 2/22/22 at 10:37 AM, an interview was conducted with RN 1. RN 1 stated that the staff member that she was speaking with and who had just exited resident 127's room was Medical Doctor (MD) 2.
On 2/22/22 at 4:03 PM, the Administrator provided a tour of the laundry facilities. The ADM stated that the Maintenance Director (MD) was responsible for the laundry procedures. The ADM stated that red bags were utilized for laundry that had been obtained from a resident's room on precautions. The ADM stated that the MD was given information abo[TRUNCATED]

Based on observation, interview and record review it was determined the facility did not follow policy and procedures for residents with COVID-19 vaccination exemptions. Specifically, staff with COVID-19 vaccination exemptions were not wearing personal protective equipment according to the facility's policy and procedures.
Findings include:
On 2/23/22, the Administrator provided a list of staff who were fully vaccinated for COVID-19 or had an exemption.
Registered Nurse (RN) 2 was listed to have a medical exemption. Certified Nursing Assistant (CNA) 3 had a religious exemption.
On 2/23/22, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection.
On 2/24/22 at 2:45 PM, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection.
On 2/24/22 at 5:45 AM, an observation was made of CNA 3. CNA 3 was observed to be wearing a surgical mask with eye protection.
The facility COVID-19 Vaccine Policies and Procedures with no date revealed, .The purpose of this policy and procedure is to outline the community approaches to encourage both care partners and residents to receive a COVID-19 vaccine. The policy further revealed Within 30 days from January 14, 2022, 100% of staff will have received at least one dose of COVID-19 vaccine, or having a pending request for, or have been granted qualifying exemption. Reasonable Accommodations were All staff with exemptions or who are not fully vaccinated will wear a KN95 or a NIOSH-approved N95 or equivalent or higher-level respirator at all times, unless actively eating or drinking during working hours.
On 2/24/22 at 4:59 PM, an interview was conducted with RN 2. RN 2 stated that because of her exemption she was told that she had to wear a surgical mask and goggles, and that it had to be worn at all times. RN 2 stated that she had not seen the facility policy and procedure for medical exemptions accommodations. RN 2 stated that she had to screen for signs and symptoms consistent with COVID-19 every day when she started her shift. RN 2 stated that she had to test two times per week based on county transmission rate, and she was not aware if the frequency of testing changed because she had an exemption.
On 2/24/22 at 5:12 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 confirmed that the facility COVID-19 vaccine policy stated that staff with qualifying exemptions needed to wear a KN95 or N95 mask while inside the facility. CRN 2 stated she was the individual who wrote the policy and that she had educated the staff on the requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 1 of 25 sample residents that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, a resident with intellectual and behavior issues was not evaluated by or treated by a Licensed Clinical Social Worker (LCSW). Resident identifier 6.
Findings include:
Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
Resident 6's electronic medical record review was completed on 3/2/22.
An MDS was completed on 12/17/21 that revealed that resident 6 had a mood interview, a Patient Health Qustionnaire-9 (PHQ-9). Resident 6 scored 19/27, indicating moderately severe depression.
A care plan with the focus of resident 6 exhibits/at risk for behaviors; yelling out, arguing with other residents/staff, grunting, rubbing legs and crying was initiated on 5/16/21 and revised on 1/24/22. Behaviors were identified as yelling, crying, moaning, causing disruptions with other residents . One intervention was initiated on 5/16/21 to Assist the resident to develop more appropriate methods of coping and interacting. Encourage [resident 6] to express feelings appropraitely. Goals were:
a. On 1/20/22: [Resident 6] will have fewer episodes of described behaviors to 4 days a week or less by review date.
b. On 1/20/22: [Resident 6] will respond to redirection when having described behaviors with each episode by review date.
Behavior tracking completed in the CNA Tasks for the previous 30 days, from 1/25/22 to 2/23/22, revealed that resident 6 had the following behaviors documented:
a. cursing at others, 4 episodes
b. expressing frustration/anger at others, 7 episodes
c. screaming at others, 5 episodes
d. disruptive sounds, 4 episodes
e. accusing of others, 3 episodes
f. And 1 episode of the following behaviors: grabbing others, hitting others, kicking others, and pushing others.
Interventions for behaviors were to remove from the situation, provide a calm environment, re-approach, provide 1:1 staff attention, redirect, offer food and drink, provide comfort, and toilet resident 6.
A care plan focus, initiated on 5/17/21 for resident 6 using an antidepressant had an intervention of Refer to psychologist/psychiatrist as indicated.
A care plan focus, initiated on 5/18/21, for resident 6 using anti-anxiety medications included an intervention to refer to psychologist/psychiatrist as indicated.
Nursing notes, visit notes, and scanned documents revealed that resident 6 did not meet with a social worker.
Physician progress notes revealed the following:
a. On 6/16/21 at 6:36 AM, revealed that resident 6 .has some history of behavioral disturbances . we discussed some boundary setting and non-pharmacological interventions that worked well in the past.
Nursing notes revealed the following behaviors:
a. On 6/17/21 at 11:11 PM, .noted episodes of agitation and anxiety reported on day shift. Staff reported reassurance & give her time to respond to questions upon questioning, with speech at times hard to understand
b. On 6/21/21 at 11:44 PM, .noted episodes of agitation and anxiety reported on day shift. Staff reported reassurance & give her time to respond to questions upon questioning, with speech at times hard to understand
c. On 6/25/21 at 11:53 PM, .She likes having things done for her often acting like she is unable to do for herself .
d. On 8/1/21 at 11:37 PM, Resident 6 became very distraught tonight. She was not able to find
her father. He was not in his room or at the table where he normally sits. She was frantically walking around the halls trying to find him while she was crying, where's my dad? I can't find my dad. I need my dad. He was in the dining room. After they were reunited she was able to calm down and return to her coloring until bed time.
e. On 8/4/21 at 11:38 PM, Resident 6 .has problems with anxiety and needs to be redirected at times .
f. On 8/5/21 and 8/6/21, resident 6 continued with anxiety
g. On 9/5/21 through 9/20/21, resident 6 had increased pain for which she received pain medications.
h. On 9/21/21 at 9:03 PM, resident 6 was in her room crying and yelling out due to back pain. When the nurse encouraged a deep breath, resident 6 became upset.
i. On 10/21/21 at 8:40 PM, resident 6 stated, everyone here hates me, no one cares about me. Resident was reassured that staff did not hate her.
j. On 10/24/21 at 5:27 AM, .oh God, no-one likes me .
k. On 11/27/21 at 12:38 PM, Resident's father came to visit from the lighthouse. While visiting [resident 6's father] made [resident 6] upset and staff heard her yell stop pinching me! She began to
clean up her coloring supplies he reached over and slapped her face. She started to cry and staff separated them. [Her father] was assisted back to the lighthouse
l. On 11/28/21 at 4:01 PM, resident 6's Power of Attorney (POA) 1 was contacted. POA 1 was informed that resident 6 was slapped the previous day. POA 1 stated that there was a suspected history of abuse when resident 6 and her father lived together. POA 1 stated that they wanted resident 6 to be kept safe.
m. On 12/1/21 at 11:54 AM, the nurse requested that the physician provide assistance with resident 6's sleep, as resident 6 had continued behaviors and up at all hours of the night .
n. On 12/17/21 at 11:30 PM, resident 6 had been having frequent emotional outbursts .
o. On 12/18/21 at 8:26 PM, resident 6 had emotional outbursts during this shift .
p. On 12/19/21 at 11:34 AM, resident 6 was easily frustrated and has loud emotional outbursts if she doesn't get what she wants right away .
q. On 12/21/21 at 8:31 PM, resident 6 has been non compliable with staff tonight. Resident has been using vulgar language towards staff .
Further behaviors were noted in the nursing notes:
a. On 12/22/21 at 9:45 PM, anxious episodes
b. On 12/23/21 at 7:35 PM, frequent emotional outbursts and cries frequently
c. On 12/30/21 at 4:54 AM, anxiety, stated she couldn't breathe
d. On 1/20/22 at 12:24 PM, mood outbursts
e. On 1/29/22 at 3:04 AM, resident 6 cried hysterically due to a bad dream and soiling herself
f. On 1/30/22 at 11:37 AM, resident 6 was having anxiety and a panic attack in the morning
g. On 2/2/22 at 1:29 AM, resident 6 stated she couldn't breathe
h. On 2/6/22 at 11:38 PM, resident 6 complained of being shaky
i. On 2/19/22 at 6:00 PM, resident 6 was unhappy about a card game and yelled at another resident
j. On 2/19/22 at 7:00 PM, resident 6 was yelling at another resident who screamed back at her and was mean and nasty to the aide who took her to her room. The nurse told resident 6 that the doctors orders were that when resident 6 was fighting and being mean to other residents she was to be taken to her room until she could calm down and play nice and treat others kindly. Resident 6 told the aide that she was an awful person and she hated her.
k. On 2/21/22, resident 6 had an outburst, was taken to her room where she screamed until she was taken to room [ROOM NUMBER]. Resident 6 was .given the choice to either allow staff to assist her to the toilet .or we would have to move her to another room if she continues to yell and holler keeping other residents awake .
l. On 2/22/22 resident 6 was hoarse and was having a hard time talking and her throat hurt as well as her right ankle.
On 2/24/22 at 10:15 AM, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 would benefit from behavior therapy. The RA stated that therapy services for resident 6 were missed. The RA stated that the contracted behavioral health provider had not been at the facility since the COVID-19 outbreak, approximately two years ago.
On 2/24/22 at 11:44 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the facility would want behavioral interventions for resident 6. The ADM stated that the staff try to get resident 6 everything she wants at meal times to help with behaviors then. The ADM stated that she spent a lot of individual time with resident 6.

Based on observation, interview and record review, the facility did not receive registry verification for a nurse aide prior to allowing the staff member to serve as a nurse aide.
Findings include:
On 2/22/22, an observation was made of Certified Nursing Assistant (CNA) 18. CNA 18 was observed to be working with residents as a CNA. CNA 18 was interviewed. CNA 18 stated her job title was a CNA.
On 2/24/22, the Administrator provided a list of staff hired in the last 6 months.
On 3/2/22 at 12:00 PM, CNA 18's employee file was reviewed. CNA 18 was hired on 3/12/21 for the nursing department. An Employment Authorization Form for the Direct Access Clearance System (DACS) did not reveal information regarding certification or License information.
Review of the February 2022 CNA schedule for the facility revealed that CNA 18 worked on 2/7/22, 2/8/22, 2/10/22, 2/14/22, 2/15/22, 2/21/22, 2/24/22, and 2/28/22.
A Nursing Assistant Registry form was provided by Corporate Resource Nurse (CRN) 1. The form was dated 3/2/22 at 12:37 PM.
On 3/2/22 at 12:54 PM, CRN 1 was interviewed. CRN 1 stated that the DACS and nurse aide registry were to be checked upon hire prior to the CNA working with residents. CRN 1 stated the nurse aide registry was not overlooked. CRN 1 stated she did not know why the date 3/2/22 was on the nurse aide registry form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not develop and implement a comprehensive person-centered care plan for 1 of 25 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, activities of daily living function/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, and dehydration/fluid maintenance were not developed as required. Resident identifier: 6.
Findings included:
Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
On 3/2/22, resident 6's medical record review was completed.
On 5/10/21, a Pre-admission Screening Applicant/Resident Review (PASRR) was completed for resident 6. Resident 6 had functional limitations in the areas of self-care, learning, and self-direction.
Hospital history and physical from resident 6's admission 5/9/21 revealed that resident 6 had a level of maturity being close to [AGE] years old There was a report of a stranger who picked her up and took her home.
Resident 6's care plan had a focus stating The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) decreased mobility and cognitive deficit, initiated on 11/1/21. Interventions were to Invite the resident to scheduled activities and The resident needs assistance/escort to activity functions.
Resident 6's care plan with the focus [Resident 6] exhibits/at risk for behaviors; yelling out, arguing with other residents/staff, grunting, rubbing legs and crying was initiated on 5/16/21 and was revised on 1/24/22. Goals were to have .have fewer episodes of described behaviors to 4 days a week or less by review date that was initiated on 1/20/22 and that resident 6 will respond to redirection when having described behaviors with each episode by review date. Interventions included:
a. Behavior identified: yelling, crying, moaning, causing disruptions with other residents Intervention used for redirection: invite to return to her room to calm and redirect with a chosen activity of [resident 6's] choice. Initiated 1/20/22
b. Assist the resident to develop more appropriate methods of coping and interacting. Encourage [resident 6] to express feelings appropriately. Initiated 5/16/21
c. Educate [resident 6]/family/caregivers on successful coping and interaction strategies such as. [Resident 6] needs encouragement and active support by family/caregivers when [resident 6] use these strategies. Initiated 5/16/21
d. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Initiated 1/20/22
e. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 1/20/22
A care plan focus, initiated on 5/16/21, stated [resident 6] wishes to stay long term at SNF (skilled nursing facility). Interventions included Encourage the resident to discuss feelings and concerns. Monitor for and address episodes of anxiety, fear, distress.
A care plan focus, initiated on 5/17/21 for resident 6 using an antidepressant had an intervention of Refer to psychologist/psychiatrist as indicated.
A care plan focus, initiated on 5/18/21, for resident 6 using anti-anxiety medications included an intervention to refer to psychologist/psychiatrist as indicated.
A review of nursing notes and scanned documents revealed that resident 6 did not receive psychologist/psychiatrist services.
Nursing notes revealed that resident 6 was educated about locking her wheelchair brakes (1/14/22), medications, wearing her oxygen (10/24/21), signs and symptoms of gastrointestinal (GI) bleeding (12/23/21), eating a balanced diet (12/19/21), and using a call light (10/21/21). On 11/3/21, staff were educated on encouraging resident 6 to be as independent as possible. No information was recorded about educating resident 6 about behaviors, interactions with others, and coping strategies.
No documentation was identified that staff attempted to assist resident 6 to develop more appropriate methods of coping and interacting or to express feelings appropriately.
On 2/21/22, resident 6 was isolated and screamed after being taken away from a group activity.
A nursing note dated 2/21/22 at 9:28 PM revealed that on 2/21/22 resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room . Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed. At 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time.
On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over .
On 2/22/22 at 4:05 AM, a nursing note revealed that resident 6 had been asleep for about 3 hours. Prior to that she yelled out off and on [for] about 30 minutes intervals in between until she drifted off .
On 2/22/22 at 5:26 AM, a nursing note revealed that resident 6 was awake and having a hard time talking and her throat hurts as well as her right ankle. Medicated with Tramadol 5 mg. Discussed she strained her voice with all her yelling last night try to let her voice rest and it will get better
On 2/23/22 at 9:18 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that resident 6 had been out of control, particularly when she had experienced anxiety caused by peers. RN 2 stated that when resident 6 was taken to her room, resident 6 focused more on the things that were bothering her. RN 2 stated that resident 6 did not know how to set boundaries with other residents, and therefore had frequent negative interactions.
On 2/23/22 at 11:33 AM, the Activity Director (AD) was interviewed. The AD stated that when resident 6 became upset during activities, resident 6 would storm off and return later. The AD stated that staff left resident 6 alone until she calmed and returned to the activity.
On 2/24/22 at 10:15 AM, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 would benefit from behavior therapy. The RA stated that resident 6 did not receive behavioral therapy due to the COVID-19 pandemic, which interfered with the contracted behavioral therapist entering the facility and providing services. The RA stated that a therapist had not been in the building in over two years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that the transfer was documented in the resident's medical record and included the basis for the transfer, that the services were attempted and could not be provided in the facility, that the transfer was made by the resident's physician, and that the receiving provider was provided all the necessary information to ensure a safe and effective transition of care. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain without a physician order for the transfer and no documentation could be found of a transfer assessment or documentation that was provided to the receiving provider. Resident identifier: 22.
Findings included:
Resident 22 was admitted to the facility on [DATE] with diagnoses which included Friedreich ataxia, mood disorder, cardiomyopathy, gastro-esophageal reflux disease, and muscle weakness.
On 2/22/22 at 10:57 AM, an interview was conducted with resident 22. Resident 22 stated that she requested to go to the hospital for back pain and that she thought the rods in her back had been dislocated. Resident 22 stated that she had her family member take her to the ER. Resident 22 stated that it was determined in the ER that the rod placement was correct, and was okay.
On 2/24/22, resident 22's medical records were reviewed.
On 12/30/21 at 1:52 PM, resident 22's progress notes documented that resident 22 was complaining of lower back pain, and that resident 22's family member took her to get an x-ray of the lower back. The progress note did not document that the physician was notified of the complaints of back pain, the request for an x-ray, or the transfer to the ER.
No other documentation could be found of resident 22's transfer to the ER on [DATE].
On 2/24/22 at 2:18 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 22 went to the ER for complaints of back pain, and it was documented in the nurse notes. RN 2 reviewed resident 22's progress notes and referred to the note on 12/30/21 at 1:52 PM. RN 2 stated that when a resident was transferred to the hospital they sent the resident with a facesheet that contained the resident demographics, a medication list, and a copy of the Physician Orders for Life Sustaining Treatment (POLST). RN 2 stated that according the the progress note resident 22's family member took her to the ER, and the visit was non-emergent. RN 2 stated that typically when residents go out to the hospital it was doctor driven. RN 2 stated that she did not see in the progress note that the physician was notified of the transfer and that would be where it should be documented. RN 2 stated that the physician should have be notified of the resident's condition. RN 2 stated that they did not fill out a transfer assessment or form. RN 2 stated that they could document in the nurse's note what paperwork was sent with the resident to the hospital, but it was not a typical thing to do. RN 2 stated that they did not have a checklist or an assessment of what to do when they transferred residents. RN 2 stated that usually if a resident was transferred out to the ER and came back with paperwork it would be scanned into the documents folder. RN 2 was observed to look in the Misc. folder for any documents from resident 22's ER visit on 12/30/21. RN 2 stated she was unable to locate any hospital documentation in resident 22's medical records.
On 2/24/22 at 2:33 PM, an interview was conducted with the Director of Nursing (DON) and Corporate Resource Nurse (CRN) 1. The DON stated that the process for a resident transferred to the hospital ER was that they called 911 or a non-emergent transport, depending on the situation. The DON stated that the physician should be notified, and it should be documented in the nurse's progress note. The DON stated that the licensed nurse should document what happened, who they called, and the physician notification. The DON stated that the licensed nursing staff would send a facesheet, medication list, and POLST to the receiving provider, and that this should be documented in the progress note as well. The DON stated that the licensed nurse would then call and give report to the receiving provider and document that report was given and who it was given to. The DON stated that resident 22's family member was involved in her care, but that they should have documentation of the incident. The DON stated that if resident 22 was complaining of back pain and was requesting to go to the hospital the provider should have been made aware of this.
On 2/24/22 at 4:08 PM, an interview was conducted with CRN 1. CRN 1 stated that the physician visited resident 22 on 12/29/21, the day before the transfer to the ER. CRN 1 stated that the physician increased resident 22's Baclofen to 15 milligram (mg) four times a day.
On 2/28/22, resident 22's medical record was reviewed again. Resident 22's Hospital History & Physical (H & P) from 12/30/21 was located in resident 22's medical records. The document contained a faxed date and time stamp of 2/24/22 at 4:48 PM with a cover letter that stated please find the requested documents attached.
On 12/30/21 resident 22's Hospital H & P documented that resident 22 presented to the ER with complaints of back pain and had previous rods from her pelvis to her thoracic spine. She has complained of increasing pain of her lower lumbar upper sacral area over the past several days. Patient does have frequent falls out of bed but is only from a very low height. X-rays of the lumbar spine revealed no evidence of acute fracture or acute subluxation. The impression was that the posterior spinal fusion from the sacroiliac joints superiorly, to a level in the upper spine, and was not visualized on the examination. Mild levoscoliosis was present. The radiographs were negative for any acute findings and there was no evidence of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Abuse investigation for 11/27/21.
The facility abuse investigations were reviewed on 2/23/22. There was one abuse investigation regarding resident 6 and a family member. The previous facility Administrator reported an abuse allegation on 11/28/21 at 9:55 AM to the State Survey Agency.
According to the Initial Entity Report form On 11/27/21 at 12:22 PM, Staff was alerted to the TV area where it was reported that [resident 6's family member] had reached out, slapped and pinched [resident 6]. It was also reported that he had stated 'the (sic) she shouldn't eat because she was to fat.' Staff immediately separated the two residents to prevent any further altercation. [Resident 6's family member] is [resident 6's] father.
The finial investigation dated 12/1/21 revealed the above statement in addition, There has been no further altercation between [resident 6] or [resident 6's family member] and they both have expressed that they want to see each other again. Both have agreed to try to control their emotions with each other. [Resident 6] has no signs or symptoms from this experience.
There were no other documents regarding an investigation.
On 2/24/22 at 9:48 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she witnessed the interaction between resident 6 and her family member on 11/27/21. RN 2 stated the she was halfway down the hall when resident 6's family pinched resident 6's arm and struck her on the side of the face. RN 2 stated that resident 6 was crying and gathering her things fast and started toward her room quickly. RN 2 stated that the family member and resident 6 were separated. RN 2 stated later that evening resident 6 and her family member wanted to get back together again. RN 2 stated the staff allowed them together and they were pleasant and cordial to each other. RN 2 stated the staff try to keep them in common areas. RN 2 stated that if they were being amicable, staff checked on them every 30 minutes. RN 2 stated there had been some concerns about this family member being abusive toward resident 6 but it was not charted or documented, just a concern expressed from another family member. RN 2 stated that she thought resident 6 would feel she was verbally abused by the family member because of where she was cognitively.
On 2/24/22 at 11:01 AM, an interview was conducted with CNA 5. CNA 5 stated she saw the end of the incident on 11/27/21 with resident 6 and her family member. CNA 5 stated that she heard resident 6 yelling loudly in the television area. CNA 5 stated that she witnessed resident 6's family member pinched her on the back left shoulder. CNA 5 stated she did not see the slap. CNA 5 stated that there were other staff and residents that witnessed resident 6's family member slap her. CNA 5 stated that the Administrator did not interview her regarding the incident. CNA 5 stated that resident 6 was crying and visibly upset. CNA 5 stated there were no special instructions to monitor when resident 6's family member was around. CNA 5 stated there were no interventions after the incident to prevent it from happening again.
On 2/24/22 at 11:44 AM, an interview was conducted with the facility Administrator. The Administrator stated that she was the abuse coordinator. The Administrator stated when she received an allegation of abuse she began an abuse investigation. The Administrator stated that she talked to an CNA, staff or family member that were there. The Administrator stated she was not aware of this abuse investigation and had not reviewed the previous abuse investigations. That Administrator was provided a copy of the incident report regarding the incident on 11/27/21. The Administrator stated she would have provided abuse training and what to look out for to the staff. The Administrator stated that she would have educated kitchen staff and department heads on what to look for during meals because resident 6 and her family member ate together in the dining room. The Administrator stated she would educate staff to watch resident 6 and the family member to prevent further possible abuse.
Based on observation, interview and record review it was determined, for 1 of 25 sample residents, that in response to allegations of abuse the facility did not have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse. In addition if the alleged violation was verified appropriate corrective action was not taken. Specifically, a resident that was involuntarily secluded in a room that was unfamiliar to her and an investigated was not conducted regarding potential abuse. In addition, the same resident was verbally and physically abused by a family member and a thorough investigated was not conducted to prevent possible further abuse. Resident identifier: 6.
Findings include:
Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression.
1. On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that her voice was hoarse because she was screaming overnight. Resident 6 stated that she was yelling at the other residents and staff and she was told she was going to be taken to another room to yell all you want. Resident 6 stated that staff left her there all night long. Resident 6 stated that her foot was bent back when she was being pushed by [Certified Nurse Aide 4] to room [ROOM NUMBER]. Resident 6 stated that she told Certified Nurse Aide (CNA) 4 No, No, No, stop. Resident 6 stated I put my foot back and he kept pushing me and pushing me. Resident 6 stated that he was too strong for her to resist and ran over her left foot. Resident 6 stated that room [ROOM NUMBER] was scary.
On 2/22/22 at 1:33 PM, a follow-up interview was conducted with resident 6. Resident 6 stated that her foot still hurt a little bit. Resident 6 stated that she was placed into room [ROOM NUMBER] in her wheelchair and had ice for her foot. Resident 6 stated that two CNAs were not nice to her. One of the CNAs was CNA 4, who resident 6 referred to as mean, and always will be and the other CNA was described as tall with long dark hair and skinny. Resident 6 later recalled the other CNA's name and identified them as CNA 7.
On 2/24/22 at 10:00 AM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] was located in the southwest corner of the facility. There were no other residents residing in that corner of the facility. The Cove activity room was also observed and had doors on the East and [NAME] sides that could be closed.
On 3/2/22, resident 6's electronic medical record review was completed.
On 10/22/21, resident 6 was assessed during a Minimum Data Set (MDS) evaluation of having a Brief Interview for Mental Status (BIMS) score of 9/15, or mildly impaired.
A nursing note dated 2/21/22 at 9:28 PM, revealed that on 2/21/22, resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room . Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed. At 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time.
On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over. Immediately following incident resident refused to allow this nurse to assess for injury, she allowed later at 2300 (11:00 PM) when she complained of pain in her left foot, no apparent signs of injury were noted; no redness, no bruising, no swelling.
On 2/21/22 at 10:08 PM, a nursing note for an additional 50 mg (milligrams) of Hydroxyzine was ordered to help resident 6 relax.
On 2/21/22 at 10:58 PM, a nursing note revealed that resident 6 agreed to take two Hydroxyzine at 10:15 PM and go to the toilet and put on pajamas. Resident 6 complained that her foot hurt, but no discoloration was noted and resident 6 was able to move her foot and wiggle her toes. The resident was able to bear weight on her left foot when needed for transfers. CNA 4 reported that resident 6 put her right foot down under the wheelchair wheel when she was being assisted to room [ROOM NUMBER] earlier this evening . Resident 6 showed no signs of trauma and was provided ibuprofen to treat pains and her legs were elevated in the recliner and ice pack on left foot. She seems more calm at this time, yelling has stopped for now .
On 2/22/22 at 4:05 AM, a nursing note revealed that resident 6 had been asleep for about 3 hours. Prior to that she yelled out off and on [for] about 30 minutes intervals in between until she drifted off .
On 2/22/22 at 5:26 AM, a nursing note revealed that resident 6 was awake and having a hard time talking and her throat hurts as well as her right ankle. Medicated with Tramadol 5 mg. Discussed she strained her voice with all her yelling last night try to let her voice rest and it will get better
On 2/22/22 at 12:01 PM, a nursing note revealed that the doctor examined resident 6 and was given details about the previous night. The doctor ordered a urinalysis to rule out a urinary tract infection. The physician examined resident 6's feet and discerned no bruising. The physician ordered monitoring of resident 6's feet for pain and swelling. No bruising or swelling is noted. [Resident 6] is also able to bare (sp) weight to both feet at this time. [Resident 6] complains of pain in her left foot this morning during AM shift, she is given prn [as needed] medications to treat. [Resident 6's doctor] gives new orders to monitor only, of her bilateral feet for increased pain or swelling at this time; further interventions will be added if needed.
On 2/22/22 at 1:32 PM, a nursing note revealed resident 6 was ambulating and complained of pain in her left leg but was able to walk behind her wheelchair.
On 2/24/22 at 12:06 PM, a nursing note revealed that resident 6's Power of Attorney (POA) was contacted.
Resident 6 had a care plan focus The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] decreased mobility and cognitive deficit, initiated on 11/1/21.
On 2/23/22 at 9:17 AM, RN 2 was interviewed. RN 2 stated that resident 6 had a medication change that may have been part of the issue why resident 6 was out of control. RN 2 stated that staff had offered resident 6 activities and redirection when she was frustrated, and letting resident 6 express herself helped. RN 2 stated that taking resident 6 to her room helped because resident 6 became agitated in larger groups. RN 2 stated that resident 6 liked Western shows and would watch them at the round table in the common area or in her room. RN 2 stated that she did not make resident 6 watch television in her room because she did not want to isolate resident 6. RN 2 stated that resident 6 would accompany RN 2 to the Cove while RN 2 was charting because talking to staff helped calm resident 6. RN 2 stated that if resident 6 was left alone, resident 6 would perseverate about her frustrations.
On 2/23/22 at 2:16 PM, a family member (FM) 1 of resident 6 was contacted. FM 1 stated that they visited resident 6 the previous week and resident 6 reported being happy at the facility. FM 1 stated that resident 6 was changed to a new medication that caused her to shake. FM 1 stated that they had not been contacted about the incident with resident 6 on Monday night and that the facility did not communicate well with the family. FM 1 stated that resident 6 needed someone to talk calmly and logically to her to help calm her down.
On 2/23/22 at 3:17 PM, the Resident Advocate (RA) was interviewed. The RA stated that the facility did not have a social worker, but had contracted with a consultant. The RA stated that the social worker had not been in the facility since the COVID-19 outbreak began in March, 2020. The RA stated that the social worker had not had contact with resident 6.
On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that when resident 6 had fits, staff took her back to her room which usually helped her calm down. CNA 8 stated that she would get resident 6 ice water, a snack, have her take a few deep breaths and get her away from whatever had triggered her. CNA 8 stated that resident 6 did not always like going to her room, but that was where she was taken. CNA 8 stated that it was usually about 10 minutes before resident 6 calmed. CNA 8 stated that she had report on Tuesday 2/22/22 that resident 6 was taken to room [ROOM NUMBER]. CNA 8 stated that she would not have left resident 6 alone because CNA 8 did not always know what resident 6 might do. CNA 8 stated that she would talk to resident 6 to help her calm, set up her television and make her comfortable. CNA 8 stated that she was told resident 6 started screaming, kicking, and yelling when staff attempted to calm her down, and was yelling for hours. CNA 8 stated that staff moved resident 6 to a room away from the other residents to help them sleep.
On 2/23/22 at 4:13 PM, an interview was conducted with RN 3. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that there were a few residents that provoked resident 6. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that CNA 4, CNA 3 and CNA 7 attempted to calm resident 6, but resident 6 yelled at them, and attempted to kick them. Staff offered to let resident 6 watch TV in her room, but resident 6 wanted to watch television at the round table. RN 3 stated that at 9:30 PM, resident 6 was asked to quiet to allow other residents to sleep. RN 3 stated that resident 6 refused to quiet, so RN 3 called the physician to obtain a prescription for medication to help resident 6 sleep. The physician told RN 3 he would call her back. RN 3 stated that other residents were concerned and asked if resident 6 was okay, due to her screaming and crying. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that she took resident 6's oxygen concentrator, a blanket, and water to room [ROOM NUMBER]. RN 3 stated that resident 6 definitely did not want to go, but RN 3 stated that she felt it was better for everyone else for her to move. RN 3 stated that six residents expressed concern or complaints about resident 6's yelling. RN 3 stated that resident 6 was yelling loudly in the hallway when she was being taken to room [ROOM NUMBER]. In room [ROOM NUMBER], RN 3 placed the oxygen cannula on resident 6. RN 3 stated the physician called back at approximately 10:00 PM, and ordered an extra dose of Hydroxyzine for resident 6 for anxiety. RN 3 stated that it was approximately 11:00 PM when resident 6 agreed to take the Hydroxyzine medication, and allowed staff to toilet her. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER]. RN 3 stated that resident 6 was able to move her foot and did not appear to have any bruising. RN 3 stated that resident 6 sat in the recliner in room [ROOM NUMBER] and the nurse examined her right foot as well. RN 3 stated that resident 6 complained of pain, so RN 3 provided as needed (PRN) ibuprofen and staff retrieved some ice for her foot. RN 3 stated that resident 6 was in room [ROOM NUMBER] when she left the facility at 12:00 AM on 2/22/22. RN 3 stated that when she arrived back at the facility on 2/22/22 at 8:00 AM, the previous shift nurse reported that resident 6 complained of right foot pain. RN 3 stated that she saw resident 6 walking with the restorative aide around lunch and was able to walk without a limp. RN 3 stated that resident 6 stated that her foot hurt, but did not request PRN pain medication. RN 3 stated that resident 6 was more agitated.
On 2/24/22 at 6:11 AM, CNA 3 was interviewed. CNA 3 stated that he was working the evening of 2/21/22 when resident 6 had a melt down. CNA 3 stated that resident 6 wanted to watch a different program, but was told that the other residents wanted to listen to something else. CNA 3 stated that resident 6 began screaming and a nurse, Licensed Nurse (LN) 4 told resident 6 in a stern voice to quiet down and to stop behaving like that. CNA 3 stated that resident 6 yelled, I hate you and LN 4 and resident 6 began to argue. Resident 6 also yelled I hate you as CNA 4 was pushing her in her wheelchair to her room. CNA 3 stated that resident 6 was stomping her feet. CNA 3 stated that resident 6 yelled from about 5:30 PM until 3:30 AM. CNA 3 stated that sometimes resident 6's door was closed and sometimes open. CNA 3 stated that resident 6 was moved to room [ROOM NUMBER] between 10:30 PM and 11:00 PM, because other residents were complaining. room [ROOM NUMBER] was located in a hall where there were no other residents in the immediate area. CNA 3 stated that CNA 7 reported that resident 6 screamed until 3:30 AM. CNA 3 stated that resident 6's voice was raspy because she spent 10 hours screaming. CNA 3 stated that there was no training for staff on what to do for resident 6 when her behaviors escalated. CNA 3 stated that he did not feel that the nursing home was a good fit for resident 6. CNA 3 stated that resident 6 needed more attention than we can give. CNA 3 further stated that with resident 6 her emotions came before her thoughts and her brain processed things differently.
On 2/24/22 at 7:02 AM, CNA 4 was interviewed. CNA 4 stated that he worked the night shift, including on 2/21/22. CNA 4 stated that after he took resident 6 to be weighed, other residents were at the round table and had changed the television from resident 6's preferred station. CNA 4 stated that resident 6 began yelling abnormally loud compared to her usual frustration. CNA 4 stated that other residents asked staff to take resident 6 to her room. CNA 4 stated that resident 6 was yelling out of rage. CNA 4 stated that he took resident 4 to her room at approximately 6:15 to 6:30 PM, and resident 6 was upset and used profanity about the other residents. CNA 4 stated that resident 6 was stomping her feet and yelling. CNA 4 stated that resident 6 stated that no one appreciated her and she was mad at CNA 4 for taking her to her room. CNA 4 stated that he asked CNA 7 to assist resident 6 because resident 6 was mad at him. CNA 4 stated that resident 6 was moved from her room, room [ROOM NUMBER], to room [ROOM NUMBER] to get her away from some of the other residents that were complaining. CNA 4 stated that resident 6 was grinding her feet into the floor. CNA 4 stated that resident 6 shoved her heels into the floor and pushed herself back in the chair. CNA 4 stated that he asked resident 6 to put her feet up, but she was being more aggressive than usual, and when she put her foot down, her shoe came off and her foot was run over by the wheelchair. CNA 4 stated that when the wheelchair ran over resident 6's foot, she yelled and said, My foot! CNA 4 stated that resident 6 yelled until after 2:00 AM, but he was not assigned to her after taking her to room [ROOM NUMBER]. CNA 4 stated that resident 6 remained in room [ROOM NUMBER] until after he left the facility at approximately 6:30 AM. CNA 4 stated that room [ROOM NUMBER] was the furthest spot away from other residents.
On 2/24/22 at 8:38 AM, the DON was interviewed. The DON stated that resident 6 had episodes once in a while when she did not understand what was happening, because resident 6 had an intellectual disability. The DON stated that resident 6 was usually redirected within 10 minutes. The DON stated that on 2/18/22, resident 6 was upset over an UNO card game. The DON stated that on Saturday resident 6 was upset about a card game and Sunday resident 6 continued to be upset about music, but went to her room willingly and calmed there. The DON stated that resident 6 appeared to escalate over the weekend, with the episode on Sunday lasting about 30 minutes. The DON stated that on Monday, 2/21/22, the DON received a call at approximately 5:30 PM, and RN 3 told her that resident 6 was upset. The DON stated that she instructed RN 3 to give resident 6 her night time medications and have resident 6 perform her night time routine to help her calm down. The DON stated that RN 3 called the DON at approximately 9:30 PM and stated that resident 6 was still yelling and crying. The DON stated that LN 4 had reported that other residents were concerned about resident 6. The DON stated that she told RN 3 to put resident 6 in a quiet environment and call the physician. The DON stated that RN 3 suggested to move resident 6 to the rooms on the other side of the facility that were a little more quiet. The DON stated that she agreed that it was a good idea. The DON stated that she called LN 4 at approximately 3:30 AM on 2/22/22 and LN 4 stated that resident 6 had fallen asleep. The DON stated that as far as she knew, LN 4 had checked on resident 6 every 15 minutes, but there was no documentation created. The DON stated that resident 6 told her that her voice was hoarse.
On 2/24/22 at 10:33 AM, the Resident Advocate (RA) was interviewed. The RA stated that she checked on resident 6 daily to see how her day was going. The RA stated that on 2/22/22, resident 6 stated that she had a tough weekend. The RA stated that resident 6 told her that she had been upset and was yelling, and the RA noticed that resident 6's voice was hoarse. The RA stated that resident 6 reported being taken to another room and that resident 6 was not happy about it and wanted her things moved back into her room. The RA stated that resident 6's oxygen concentrator and mugs were in room [ROOM NUMBER]. The RA stated that resident 6 told her that resident 6 wanted to be in her own room. The RA stated that a medication review was completed for resident 6 and staff determined that they needed to be firm and direct with resident 6, but also to be kind. The RA stated that resident 6 had not seen the Licensed Clinical Social Worker (LCSW) that was contracted for behavioral services because he had not been in the facility since the COVID-19 pandemic began, approximately 2 years ago.
On 2/24/22 at 11:44 AM, the Administrator (ADM) was interviewed. The ADM stated staff had been trained about abuse on January 19, 2022 and reported any abuse to her because she was the abuse coordinator. The ADM stated that if there was an allegation of abuse, she would report to the Ombudsman, corporation and to Adult Protective Services (APS). The ADM stated that she reviewed the incident from the night of 2/21/22 on 2/23/22, and had not been contacted by staff regarding the incident. The ADM stated that resident 6 screamed, yelled, and kicked her legs when she gets upset, which can be scary. The ADM stated that staff decided to separate her from the rest of the group. The ADM stated that staff took resident 6 to another room and asked her to be quiet. The ADM stated that residents called their family members and said something bad was going on and it sounded like someone was dying. The ADM stated that the incident lasted until the morning of 2/22/22 and that resident 6's foot was injured during the episode. The ADM stated that staff had not reported to her because the physician looked at resident 6's foot and there was no apparent injury. The ADM stated that she did not know resident 6 stayed in room [ROOM NUMBER] overnight. The ADM stated that there should have been documentation by the nurse and CNAs about 15 minute checks.
On 2/24/22 at 1:29 PM, the Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that RN 3 worked until midnight and assisted resident 6 into her pajamas. CRN 1 stated that CNA 7 conducted checks on resident 6 every 15 minutes, but they did not have any paperwork to demonstrate that this had been completed. CRN 1 stated that the staff did not start the 15 minute check paperwork. CRN 1 stated that there was a 15 minute check form that was indicated for a situation like this, to document incidents like this. CRN 1 stated that CNA 7 reported that resident 6 was comfortable, had intervals of screaming followed by periods of calm, and eventually fell asleep. CRN 1 stated that they did not have a focused timeline of resident 6's behaviors and interventions.
On 2/24/22 at 5:16 PM, CNA 7 was interviewed. CNA 7 stated that when resident 6 returned to the round table the other residents had changed the television channel. CNA 7 stated that this was what had initially upset resident 6. CNA 7 stated that one of the other residents started to yell back at resident 6 so CNA 4 and LN 4 went over to intervene. CNA 7 stated that resident 6 had a care plan intervention to take her to her room to calm down, so that was why they initially took her back when she became upset. CNA 7 stated that she went into resident 6's room a few times to check on her and one time she noticed that she was about to fall from the her wheelchair because she was yelling and screaming. CNA 7 stated that CNA 3 and RN 3 went in and talked to resident 6 to try and calm her down. CNA 7 stated that after resident 6 had been crying for approximately 2 hours CNA 4 took her to room [ROOM NUMBER]. CNA 7 stated that as he was wheeling her she was yelling obscenities'. CNA 7 stated that she assisted resident 6 out of her wheelchair into the recliner, and RN 3 assisted with resident 6's toileting. CNA 7 stated that resident 6 did not want CNA 4 to come into the room, she was mad at him. CNA 7 stated that she spent the remainder of the evening in the Cove and set her timer to check on resident 6 every 15 minutes. CNA 7 stated that resident 6 screamed most of the time and somewhere around 4 AM resident 6 fell asleep. CNA 7 stated that she left the facility at 5:15 AM on 2/22/22. CNA 7 stated that resident 6 complained of pain in the left foot. CNA 7 stated that she did not personally see how it was injured. CNA 7 stated that resident 6 told her that her foot got hurt and was run over by her wheelchair. CNA 7 stated that resident 6 did not want to place weight on the injured foot. CNA 7 stated that resident 6 did not walk on the foot, but she did bear weight on it when she was transferred from the wheelchair to the recliner. CNA 7 stated that resident 6 complained of pain in the foot and RN 3 got her ice for it. CNA 7 stated that every time she offered resident 6 the ice pack she declined it. CNA 7 stated that resident 6 was upset that they had moved her. CNA 7 stated that they moved her because she was being loud. CNA 7 stated that to her knowledge resident 6 had not been to that room before. CNA 7 stated that they chose that room because there were not any residents nearby. CNA 7 stated that after resident 6 was moved to room [ROOM NUMBER] the door to the room remained open, but when she was in her own room the door was closed. CNA 7 stated that they took resident 6's oxygen tank, tubing, briefs, blanket, and pajamas to room [ROOM NUMBER]. CNA 7 stated that resident 6's nighttime routine was coloring and watching television. CNA 7 stated that resident 6's TV was on in room [ROOM NUMBER] and they had provided resident 6 a mug of water as well. CNA 7 stated that the move to room [ROOM NUMBER] was explained to resident 6 more than once by RN 3. CNA 7 stated that she did not know if resident 6 thought she was in trouble and that was why she was being moved.
On 3/1/22 at 9:39 AM, a follow-up interview was conducted with CRN 1 and CRN 2. CRN 2 stated that the physician was notified of the situation per the nursing note. CRN 2 stated that the staff attempted other interventions prior to the room change such as offers of food and beverages, watching TV in the Cove, and attempts at switching the staff members. CRN 2 stated that resident 6 was also able to self propel herself in the wheelchair. CRN 2 was not able to state if resident 6's foot injury would have impeded her ability to independently mobilize herself in the wheelchair. CRN 2 stated that staff did not determine nor document if resident 6 perceived the move to room [ROOM NUMBER] as punitive or a form of punishment, that's a good question. CRN 2 stated that they reviewed resident 6's behavioral care plan and interventions of a quiet place were updated today. CRN 2 stated that staff have been provided training on dementia and training was about redirection and managing behaviors but it was not specific to intellectual disabilities.
On 3/1/22 at 8:17 AM, CRN 1, CRN 2, and the ADM were interviewed. The ADM stated that resident 6 did not have and Specialized Rehabilitative Services. CRN 2 stated that staff were aware of her behaviors and interventions were to have resident 6 take a deep breath and get it back together. CRN 2 stated that they had to balance how to protect the other resident's emotional state, they were complaining about the yelling that continued for hours. CRN 2 stated that the staff transferred resident 6 to room [ROOM NUMBER], assisted her into a recliner and checked on her every 15 minutes. CRN 2 stated that she was not sure if the physician was contacted about the move to the other room. CRN 2 stated that they were