Provo Rehabilitation and Nursing

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide respiratory care and tracheostomy care to residents who required these services. Specifically, for 3 out of 9 sampled residents, staff did not follow physician orders for changing tracheostomies; staff were not obtaining needed consultations with outside providers; staff were not accurately documenting the resident condition prior to the tracheostomy change; staff did not initiate a hospital transfer for a resident with concerns about the integrity of the tracheostomy. Additionally, staff interviews revealed knowledge of faulty equipment with a resident experiencing a broken flange which caused a dislodged tracheostomy, and subsequently going into cardiac arrest and dying. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the resident was free from neglect. Specifically, for 2 out of 9 sampled residents, the facility did not provide the resident with access to an outside provider appointment for the treatment and care of their tracheostomy tube and verbal orders for the tracheostomy change were not followed. In addition, a comatose resident in a vegetative state experienced a broken flange which caused a dislodged tracheostomy, and the resident subsequently went into cardiac arrest and died. This resulted in a finding of harm for 2 residents. Resident identifiers: 1 and 9.

Inspectors wroteBased on interview and record review the facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events resulted in serious bodily injury to the administrator, State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 9 sampled residents, the SSA and APS were not notified when a resident's tracheostomy flange broke, resulting in a dislodged tracheostomy tube. The resident subsequently went into cardiac arrest and died. This will be cited at a harm level. Resident identifier: 9.

Inspectors wroteBased on interview and record review, the facility in response to an allegation of abuse, neglect, or mistreatment did not have evidence that the alleged violation was thoroughly investigated. Specifically, for 1 out of 9 sampled residents, an investigation into the cause of a broken tracheostomy flange in a comatose resident that was dependent on a ventilator was not investigated. This will be cited at a harm level. Resident identifier: 9.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the services provided by the facility met professional standards of practice. Specifically, for 1 out of 9 sampled residents, the facility Respiratory Therapist Director did not ensure that a Verbal Order (VO) was entered into the resident's medical record which resulted in the respiratory staff providing a treatment that deviated from the prescribed order. This will be cited at a harm level. Resident identifier: 1.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the resident was provided access to an outside provider when the qualified professional person was not employed by the facility, and the facility assumed responsibility for obtaining those services in a timely manner. Specifically, for 1 out 9 sampled residents, the facility did not obtain an appointment with an Ear, Nose, and Throat (ENT) provider for the evaluation of a resident's tracheostomy and tracheal stenosis as ordered. This resulted in a finding of harm for resident 1. Resident identifier:1.

Inspectors wroteBased on interview and record review, it was determined that the facility did not demonstrate identification, reporting, investigation, analysis and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective action. Specifically, the facility did not identify or investigate in their Quality Assurance Performance Improvement (QAPI) three respiratory-related resident deaths. This will be cited at a harm level. Resident identifiers: 1, 5, and 9.

Inspectors wroteBased on interview and record review, it was determined that the facility did not maintain all mechanical, electrical, and patient care equipment in a safe and operating condition. Specifically, a ventilator did not alarm when a resident's tracheostomy tube's flange broke and dislodged and the resident went into cardiac arrest and died. This will be cited at a harm level. Resident identifier: 9. Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed that on [DATE] at 9:00 PM, respiratory staff entered resident 9's room and found the tracheostomy flange broken, the tracheostomy tube was dislodged, and approximately 1.5 inches out of position, shifted to the right and not midline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Specifically, for 7 out of 69 sampled residents, residents were having consensual relationships per their families consent and the residents were not assessed and did not have the capacity to consent and residents were being sexually abused by other residents. Resident identifiers: 50, 70, 208, 209, 310, 311, and 409.

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, steam table was soiled, hood vents were dusty, the wall behind the dish machine was soiled, tile missing grout, and a fan had dust build up.

Inspectors wroteBased 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 two hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 69 sampled residents, notification to the SSA and APS was not done when residents with cognitive impairments and without the capacity to consent were found in a resident room and one of the residents was disrobed from the waist down. Resident identifiers: 70 and 208.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, for 2 out of 69 sampled residents, a resident with cognitive impairment eloped from the facility memory care unit. In addition, a resident with cognitive impairment was moved out of the memory care unit and eloped from the facility. Resident identifiers: 50 and 70.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences. Specifically, for 1 out of 69 sampled residents, a resident that required oxygen (O2) therapy did not have physician's orders indicating the type of oxygen delivery system, when to administer the oxygen, and the equipment settings for the prescribed flow rates. Resident identifier: 103.

Inspectors wroteBased on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 69 sampled residents, a resident that complained about mouth pain for approximately ten months was not provided interventions timely. Resident identifier: 64.

Inspectors wroteBased on interview and record review, the facility did not provide routine and emergency drugs to its residents. Specifically, for 1 out of 69 residents, a resident that was experiencing pain, agitation, and depression did not have their medications available for administration. Resident identifier: 64.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was 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 69 sampled residents, a resident administered his own blood pressure medication, diabetes medication, and blood thinner that his family member brought from home. There was no documentation from the nurse regarding the incident, dosage of the medications, and why medications were listed as administered by the nurse. Resident identifier: 160.

Inspectors wroteBased on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, experienced falls with injuries, and obtained wounds. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244.

Inspectors wroteBased on interview, record review, and observation, the facility failed to be administered in a manner that enables 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, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349.

Inspectors wroteBased on interview, record review, and observation, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. Specifically, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349.

Inspectors wroteBased on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244.

Inspectors wroteBased on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not maintain an infection prevention and control program that was designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff and outside providers not wearing personal protective equipment (PPE) correctly, the appropriate PPE not being worn in contact and droplet isolation rooms, observations of cross contamination during medication pass and wound care, soiled staff telecommunication equipment being used without being cleaned, and equipment not being cleaned in between resident use. Resident identifiers:

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure that the residents' medical records were secure and confidential. Specifically, observations were made of a computer screen and paperwork left unattended and displaying residents' personal information.

Inspectors wroteBased on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the wall behind the head of the bed in rooms 504, 505, 506 and 510 were in disrepair. The base of the intravenous (IV) poles and the front of the night stands in rooms 500, 501, 504, 505, 506, 508, and 510 were covered with layers of dried enteral feeding solution and the night stands had many areas of missing paint on the top, sides and front. Additionally, the wheelchairs throughout the facility were dirty and not cleaned regularly. Resident identifiers: 24, 27, 50, 68, 81, 82, 85, 298, and 349.

Inspectors wrote2. On 1/25/23 at 7:30 AM, an observation was made of LPN 7. LPN 7 left a medication administration card which held Pantoprazole on top of the medication cart and went down the 200 hallway into a resident room. Other residents were observed in the hallway near the medication cart. On 1/25/23 at 7:38 AM, an interview was conducted with LPN 7. LPN 7 stated she always leaves medications on top of the medication cart when she needs to have them reordered by pharmacy, they are discontinued or she had a question about them. LPN 7 stated she would then take the medication cards with her to the nursing desk to put them in the proper place. On 1/30/23 at 3:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses should not leave medications on top of the medication cart; all medications should be locked up when the nurse is not directly by the cart. [...]

Inspectors wroteBased on observation and interview, the facility did not treat 2 of 54 sample residents with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a resident was dressed in a hospital gown because no clean clothes were available, and a request for pain medication went unanswered for a period of time. Resident identifiers: 22 and 47.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure the resident's right to formulate an advanced directive. Specifically, for 1 out of 54 sampled residents, the resident's electronic medical record did not document a code status, the staff stated the resident was a full code and the Physician Orders for Life-Sustaining Treatment (POLST) form documented the resident's wishes as Do not attempt or continue any resuscitation (DNR). Resident identifier: 298.

Inspectors wroteBased on observation, interview and record review, for 2 of 54 sampled residents, that the facility did not ensure that the residents were free from physical restraints imposed for purposes of convenience, and not required to treat the residents' medical symptoms. Specifically, a resident had bed rails that were not used for mobility, and a resident with a hand mitt was not assessed regularly and evaluated for the continued need of the restraint. Resident identifiers: 82 and 146.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse. Specifically, an injury of unknown origin was identified on a resident with cognitive impairment, and the resident alleged that staff hit him; however, the incident was not reported to the State Survey Agency. Resident identifier: 33.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse. Specifically, an injury of unknown origin was identified on a resident with cognitive impairment, and the resident alleged that staff hit him; however, no investigation was completed. Resident identifier: 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, for 1 out of 54 sampled residents, a resident who required oxygen did not have a care plan developed for oxygen use. Resident identifiers: 298.

Inspectors wroteBased on interview and record review, the facility did not ensure that for 1 of 54 sample residents the resident had a discharge summary that includes, but is not limited to: a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; a final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter); [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 54 sampled residents, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident did not receive catheter care in coordination with good nursing care and as outlined in the residents care plan and went to the hospital for treatment. Resident identifiers: 295.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 54 sampled residents, the facility did not ensure that a resident who was supplemented with enteral means received the appropriate treatment and care of the feeding tube such as providing needed personal, skin, oral and nasal care as well as examining and cleaning the insertion site in order to identify, lessen or resolve possible skin irritation and local infection. Specifically, multiple observations were made of a resident with a dirty nasal gastric feeding tube over multiple days. Resident identifier: 39.

Inspectors wroteBased on observation, interview, and record review it was determined, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, for 1 out of 54 sampled residents, a resident who required oxygen was not provided supplemental oxygen on admission and did not have a physicians order for oxygen and supplemental oxygen. Resident identifiers: 298.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 54 sampled residents, the facility failed to keep a resident's drug regimen free from unnecessary drugs. Specifically, a resident was prescribed an antibiotic medication for excessive duration without adequate indications for use. Resident identifier: 20.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 30 medication opportunities, on 1/25/23, revealed 2 medication errors which resulted in a 6.67% medication error rate. Specifically, one resident received an incorrect dose of Vitamin D3 and the same resident received a dose of Active Protein without the amount being specified in the order. Resident identifiers: 53.

Inspectors wroteBased on interview and record review, the facility did not provide laboratory services to meet the needs of 1 of 54 sample residents. Resident identifier: 33.

Inspectors wroteBased on interview and record review, it was determined, for 1 or 54 sampled residents, the facility failed to keep an antibiotic stewardship program that included antibiotics use protocols and a system to monitor all antibiotic use for all residents. Specifically, a resident had an order for an antibiotic (ABX) for over five years. Resident identifier: 20.

Inspectors wroteBased on observation, interview and record review it was determined, for 7 out of 51 residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) located on the bilateral heels did not have the heels floated as ordered and repositioning did not occur for an observed 3 hour time period, and a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These examples of neglect were cited at a harm level. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 17 of 51 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) was not repositioned for an observed 3 hour time period, a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation.

Inspectors wroteBased 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, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for psychosocial concerns, and staffing. There were multiple residents who were identified to have outcomes cited at a harm level. Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112.

Inspectors wroteBased on observation, record review and interview the facility Quality Assessment and Assurance (QAA) Committee did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for psychosocial concerns, and staffing. There were multiple residents who were identified to have outcomes cited at a harm level. Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112.

Inspectors wroteBased on interview, record review and observation it was determined, for 1 of 51 sample residents, that the facility did not provide care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 51 sample residents, that the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a head laceration. This incident was found to have occurred at a harm level. In addition, a resident sustained a burn after a staff member placed a wet wash cloth from the microwave on the resident. This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103.

Inspectors wroteBased on observation, interview and record the review, for 6 of 51 sample residents, it was determined that the facility did not ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112.

Inspectors wroteBased on observation, interview and record the review, for 3 of 51 sample residents, it was determined that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident experienced uncontrolled pain from a hip fracture for at least six hours prior to being sent to the hospital. This resulted in a finding of harm. In addition, the nursing staff did not provide oral or topical pain medication to residents who were complaining of pain. Resident identifiers: 17, 53 and 110.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there was a black substance on the walls in the dishmachine room, Teflon was torn and missing from pans, the trayline was soiled, the ceiling had splatter, vents were dirty on the ceiling, there were tiles missing and gashes in the dry wall.

Inspectors wrote5. Resident 102 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to thrombosis of right vertebral, hemiplegia, and hypertension. On 5/26/21 at 9:06 AM, an interview and observation was conducted with resident 102. Resident 102 was observed to be wheeled in her wheelchair from the dining room to her room. Resident 102 was observed to be wearing a hospital gown. Resident 102 stated that she was in the dining room for breakfast and wore a gown. Resident 102 stated that she would like to wear clothing to the dining room. Resident 102 stated she was going to have a shower so the staff did not dress her to go to the dining room. Resident 102's medical record was reviewed 5/25/21 through 5/28/21. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 102 had a BIMS score of 14 which revealed resident was cognitive. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 4 of 51 sample residents, that the facility did not provide residents with the right to make choices about aspects of his or her life that were significant to the residents. Specifically, residents that had requested female staff members to care for them were not provided female staff members. In addition, residents were not allowed to get out of bed when they desired. Resident identifiers: 82, 99, 101 and 112.

Inspectors wroteBased on observation, interview and record the review, for 4 of 51 sample residents, it was determined that the facility did not ensure that residents had a safe, clean, comfortable and homelike environment. Specifically, there were strong urine and fecal odors, torn wall paper in resident rooms, soiled wheelchairs, a broken head board, and arm rests torn on wheelchairs. Resident identifiers: 51, 101, 105 and 112.

Inspectors wroteBased on interview and record review it was determined, for 4 of 51 sample residents, that the facility did not establish a grievance policy to ensure the prompt resolution of all grievances regarding resident rights. In response to a grievance, the facility did not ensure all written grievance decisions included the date the grievance that was received, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, nor a statement as to whether the grievance was confirmed or not confirmed. Specifically, a resident complained of staffing, quality of food, desiring female CNAs only and not receiving showers. Other residents complained of missing items. Resident identifiers: 37, 82, 105 and 108.

Inspectors wrote2. On 5/26/21 at 9:46 AM, an interview was conducted with resident 105. Resident 105 stated that there was a nurse who was giving me a bad time. When asked to elaborate, resident 105 stated that when RN 7 administered resident 105's heparin, she sometimes doesn't clean my arm with an alcohol wipe before she gives me a heparin shot and she injects it quickly instead of slowly so it makes me bleed all over the pillowcase, my nightgown, and my pillow. Its all soaked with blood. Resident 105 stated that she asked RN 7 why she insisted on doing it that way when resident 105 had asked her to do it differently. Resident 105 stated that RN 7 responded by saying when you go to school to be a nurse, you can tell me how to give a shot. Resident 105 stated that she felt she was being verbally and physically abused. [...]

Inspectors wroteBased on interview and record review it was determined, for 3 out of 51 sampled residents, that the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility, the State Survey Agency (SSA), and adult protective services (APS), and the results of all investigations were reported to the Administrator and the SSA within 5 working days of the incident. Specifically, allegations of abuse were not reported to the SSA or APS. Resident identifiers: 17, 101, and 105.

Inspectors wroteBased on observation, interview and record review it was determined, for 4 of 51 sample resident, that the facility did not develop and implement a comprehensive person-centered care plan. The care plan needed to include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a care plan was not developed after a resident had a suicide attempt. In addition, care plans were not implemented for resident's in regards to bowel and bladder incontinence, positioning, restorative nursing services. Resident identifiers: 37, 99, 102, and 112.

Inspectors wrote6. Resident 98 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included end stage renal disease, type 2 diabetes mellitus, congestive heart failure, left below knee amputation, morbid obesity, dorsalgia, major depressive disorder, and insomnia. On 5/26/21 at 10:46 AM, an interview was conducted with resident 98. Resident 98 stated that he frequently had to wait long times for staff to answer call lights. He stated that he had to wait for 7 days to get a shower, and that staff kept putting it off until the next day. He stated that the nursing aide staff was short of people, and he thought that having 4 aides for 100 people was not enough. Review of resident 98's shower logs for the last 30 day look back period from 4/28/21 to 5/27/21 revealed that resident 98 received a shower on 5/13/21, 5/22/21, 5/25/21, and 5/27/21. [...]

Inspectors wroteBased on interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, an agency staff member transferred a resident by themselves instead of using two staff members, resulting in the resident falling and sustaining a head laceration. Another resident sustained a burn after facility staff heated a wet wash cloth in a microwave and applied it to the resident's skin. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that for 3 of 51 sample residents, the facility's medical director acted upon the pharmacist consultant reports in a timely manner. Resident identifiers: 1, 90 and 101.

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure that 3 of 51 sample residents were free of significant medication errors. Specifically, residents' insulin was administered more than one hour after the scheduled administration time. Resident identifiers: 17, 96, and 108.

Inspectors wroteBased on observation, interview and record review it was determined, for 9 of 51 sample residents, that the facility did not provide food and drink that was palatable, attractive and at a safe and appetizing temperature. Specifically, residents complained of food quality, a sample tray was not palatable and resident council minutes revealed a complaint of food quality. Resident identifiers: 28, 33, 54, 78, 82, 94, 98, 105 and 117.

Inspectors wroteBased on observation, interview and record review it was determined, for 4 of 51 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a sanitary environment and to prevent the development and transmission of communicable diseases and infections, including SARS-CoV-2 (COVID-19). Specifically, the facility did not ensure that a symptomatic staff member, who subsequently tested positive for COVID-19, was screened accurately and excluded from work. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that residents, their representatives, and families were informed by 5:00 PM the next calendar day following the occurrence of a single confirmed infection of COVID-19. Specifically, the facility identified a COVID-19 positive infection on 5/10/21 and notification was not made to all residents and their representatives until 5/12/21.

Inspectors wroteBased on observation, interview and record the review, for 1 of 51 sample residents, it was determined that the facility did not ensure that the call light system was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area. Specifically, a resident's call light was not operating as designed, agency staff were not provided radios, and radios did not alarm when call lights were alarming. Resident identifier: 58.

Inspectors wroteBased on interview and record review it was determined, for 1 of 51 sample residents, that the facility did not determine through the interdisciplinary team that a resident was safe to self-administer medications. Specifically, a resident was not assessed for safety prior to providing the resident a pain relief gel to self administer. Resident identifier: 17.

Inspectors wroteBased on observation, interview and record the review, for 4 of 51 sample residents, it was determined that the facility did not ensure each resident had the right to receive services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Specifically, it was observed that residents call lights were out of reach of the residents. Resident identifiers: 22, 32, 101, and 167.

Inspectors wroteBased on observation, interview and record the review, for 3 of 51 sample residents, it was determined that the facility did not ensure that the resident had a right to personal privacy and confidentiality of his or her personal and medical records. Specifically, another resident's name was used in another resident's medical record. Resident identifiers: 38, 108 and 370.

Inspectors wroteBased on observation, interview and medical record review the facility did not review and revise the Care Plan for 1 out of 49 sample residents. Specifically, a resident with persistent pain had no new interventions since 11/12/19. Resident Identifier: 53.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 51 sample residents, that the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, residents did not received physician ordered RNA (Restorative Nursing Services). Resident identifiers: 99 and 102.

Inspectors wroteBased on observation, interview and record the review, for 1 of 51 sample residents, it was determined that the facility did not ensure that the resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Specifically, the facility failed to repair or provide a Continuous Positive Airway Pressure (CPAP) to the resident. Resident identifier: 28.

Inspectors wroteBased on interview and record review it was determined, for 2 of 51 sample residents, that the facility did not maintain medical records on each resident that were complete, accurate, and readily accessible. Specifically, Restorative Nursing Assistant (RNA) notes were not in the individual medical records. Resident identifiers: 99 and 102.