Haven of Lakeside

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation and staff interview, the facility failed to ensure that the electrical panel and electrical circuit breaker for the fire alarm system had visual markings to distinguish it from other breakers . Â This deficient practice could affect all of the 101 residents and staff.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, which would cause harm to the patients and/or staff in the affected areas.Â

Violation cited

Violation cited

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Violation cited

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Violation cited

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure two residents (#24 and #15) were not subjected to abuse by residents (#6 and #34). Findings include: Regarding resident #24 and #6 -Resident #24 was admitted to the facility on February 20, 2021 with diagnoses of hemiplegia, unspecified affecting the right dominant side, major depressive disorder, anxiety, and schizoaffective disorder. A care plan dated July 12, 2021 revealed the resident had the potential to demonstrate physical and verbal behaviors (hitting and swearing, threatening) related to poor cognition and understanding of situations. Interventions included that when the resident becomes agitated, intervene before agitation escalates; guide away from the source of distress; engage calmly in conversation; and if the resident was aggressive, staff were to walk away, and approach later. The care plan dated January 28, 2022 revealed that the resident had a psychosocial well-being problem actually related to anxiety, ineffective coping, lack of acceptance to current condition, traumatic brain injury, schizophrenia, verbal and physical aggression; and that, the resident was involved in an altercation with a peer. Interventions included assistance/encouragement/support to identify problems that cannot be controlled, and assistance/supervision/support to identify precipitating factor(s) stressors. The minimum data set (MDS) assessment dated June 20, 2024 did not include a brief interview for mental status (BIMS) score because the resident was not able to complete the interview. A progress note dated July 3, 2024 revealed the resident was watching television along with another resident. Per the documentation, staff asked another resident a question, but the other resident did not hear and "what, what?" It also included that resident #24 then quickly self-propelled himself over to the other resident and grabbed his hand; and that, the other resident tried to pull his hand away and then cocked his arm, but staff was able to intervene before the other resident was able to punch resident #24. A progress note dated July 6, 2024 revealed that resident #24 was getting angry at other residents and self-propelled himself numerous times in his wheelchair and was giving the other residents angry looks. Review of the clinical record revealed no documentation of the resident to resident altercation with resident #15 that occurred on September 10, 2024. Review of the weekly skin check and wound assessment dated September 10, 2024 revealed that resident #24 had a slightly red left cheek and red left eye. Forty-five minutes later the red left cheek and eye were resolved. -Resident #6 was admitted to the facility on April 17, 2024 with diagnoses of unspecified mood affective disorder, depression, post-traumatic stress disorder, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The care plan dated July 16, 2

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#16). Findings include: Resident #16 was admitted to the facility on 11/20/2017 and readmitted on 10/30/2020 with diagnoses that include hypertension, chronic obstructive pulmonary disease, cardiomegaly, and dementia. Review of Quarterly Minimum Data Set assessment from 01/18/2024 revealed resident #16 Brief Interview for Mental Status (BIMS) score was unable to be assessed due to the resident being rarely or never understood. Staff assessment indicated there were short- and long-term memory problems and resident's cognitive skills were severely impaired. There was no fall history documented. Review of care plan initiated on 12/02/2019 reveal that resident #16 did have a goal related to her risk for falls with interventions that were updated after her 03/23/2024 fall which included being on the Falling Leaf program. A review of progress notes dated 03/23/2024 at approximately 10:30pm stated that a Certified Nursing Assistant (CNA) found the resident on the floor after an unwitnessed fall. The resident #16 had a laceration to her forehead, blood was spreading on the floor, and the resident was complaining of her hand hurting and said it was broken. The note further stated that the resident appeared confused and asked staff repeatedly where she fell from. Emergency Medical Services (EMS) were called and she was transported to the hospital. On 03/24/2024, the facility called the hospital who reported her left pinky finger was broken and her laceration had been stitched up and she would be able to return in the morning. Her x-rays and head CT were negative for any injury. The interdisciplinary team (IDT) reviewed the fall and injury on 03/26/2024 at 11:32am and placed the resident on the Falling Leaf Program for her safety. Active orders after the resident's fall on 03/23/2024 included a fall mat on floor next to the bed for prevention of injury dated 3/29/2024 and wound care for her forehead laceration dated 03/25/2024. Facility self reports for March and April 2024 were requested. None were reported for Resident #16 in that timeframe. During an interview with the Executive Director, Staff #131, on 06/06/2024 at 4:25pm he stated if a resident had a unwitnessed fall with a major injury and cannot say how it happened, that is not necessarily reportable to the Department of Health Services. He stated the interdisciplinary team will discuss it and determine if it it is reportable or not. For example, if a patient is sent to the hospital, they may have to wait on imaging from the hospital to determine if there was an injury or not. The IDT will always include the Vice President of Clinical Operations, Staff #136 as well. He stated they moved quickly and all of this was able to be accomplished within the 2 hours reporting timeframe. The team will

Based on concerns identified during the survey, review of the facility assessment, staff interviews, Quality Assurance (QA) documentation, and policy review, the Quality Assessment and Assurance (QAA) committee failed to ensure the director of nursing (DON) attended the QAA meeting. Findings include: During the survey which was conducted on June 3, 2024 through June 6, 2024, concerns were identified regarding the attendance of the director of nursing during QAA meeting. Review of the facility document titled, "QAPI Attendance Record" revealed that on January 25, 2024 the executive director, medical director, DON, Infection Preventionist (IP), and others revealed a signature for each attendee except the pharmacy consultant. But for the months of February through May 2024, the document revealed the DON's "QAPI Attendance Record" signature was left blank. Furthermore, a review of the facility document titled, "Facility Assessment" revealed a list of "Persons involved in completing assessment". The list of persons included the executive director /Staff #131, DON/Staff #43, governing body rep/Staff #136 and "Date(s) of assessment or update" was "Updated 05/20/2024". However, review of facility record revealed Staff #43 is a licensed practical nurse (LPN) and assistant director of nursing (ADON). Additional facility record revealed that Staff #134 was the DON from August 2, 2022 through March 8, 2024, Staff #136 filled in as DON from March 9, 2024 through April 21, 2024, and Staff #135 was the DON from April 22, 2024 through May 20, 2024. An interview was conducted with the human resources (HR) manager/Staff #83, on June 5, 20204 at 1:40 PM. Staff #83 stated that the facility had a DON from July 2022 through March 2024. Staff #134 left the facility on March 8, 2024. He added that on April 28, 2024, Staff #135 resumed the DON role and then resigned from the position on May 20, 2024. Then the ADON took over full time as acting DON on May 20, 2024. He stated that the ADON is still the acting DON up to present. He stated that his understanding of the State law allows an LPN to act as acting DON up to 8 months. An interview was conducted with the executive director/Staff #131 on June 6, 2024 at 5:28 PM regarding Quality Assurance and Process Improvement (QAPI). Present with the interview were Staff #132/Vice President Clinical Operation and Staff #133/Compliance Director/Acting DON. Staff #131 stated that they meet once a month with the medical director, executive director, IP, and multiple others are invited and also at least quarterly with the medical director, consultant pharmacist, and executive director. Staff #131 stated that the executive director, IP, DON, medical director are required to attend the QAA meeting. During the interview, the facility was not able to provide documentation that the DON was present onsite during the QAA meetings for the months of February through May 2024. Review of the Quality Assurance and Performance Improvement (QAPI)

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#31) was able to make choices about their care. The deficient practice could result in residents being denied the right to make their own choices. Findings include: Resident #31 was admitted to the facility on 10/03/2022 with diagnoses that included spondylolisthesis, anxiety disorder, chronic obstructive pulmonary disease, and osteoarthritis. The Quarterly Minimum Data Set assessment from 02/29/2024, the Brief Interview for Mental Status (BIMS) score was 10 which suggested moderate cognitive impairment. There was no evaluation of bathing ability due to the bathing activity not being performed in the lookback period. Care plan initiated on 10/13/2022 had a goal for a performance deficit for activities of daily living (ADL) related to her diagnoses. It documented that she is bedfast most of the time and interventions included encouraging resident to participate to the fullest extent possible with each interaction, use the call light to call for assistance, and completing skin inspection during routine cares and per bath schedule. According to the facility shower schedule, Resident #31 is on the schedule to receive showers on the night shift on Mondays and Thursdays. The night shift is from 6:00pm to 6:00am. A review of shower sheets from April, May, and June 2024 show the resident refused a shower or bed bath 4 times on 4/15/24, 5/6/24, 5/27/24, and 6/3/24. Of those, three refusal forms are signed by resident with her handwritten note saying staff came at 8pm instead of 3pm, as a reason for why she refused. There are no showers documented for the three month period. Of approximately 18 scheduled bathing opportunities for Resident #31 from 04/01/2024 to 06/03/2024, 14 showers were not documented as being attempted. A progress note dated 5/18/2024 at 5:26pm stated that the resident#31 had not been showering because she needed assistance in shower. In an interview with resident #31 on 06/04/24 at 10:23am, she reported staff always gave her nighttime showers which she did not want because then her long hair would still be wet when she went to bed. She said she told them this, but they would instead mark her down as a refusal and she would miss her shower for that day. She said the most recent time this has happened was "last night" which was 06/03/2024. Certified Nursing Assistant (CNA) Staff #78 was interviewed on 06/05/2024 at 1:34pm. While she did not recall Resident #31 specifically, she stated that if a resident refuses a shower or bed bath, staff will ask if they want it at a different time and try to accommodate the resident. During an interview at 01:15pm on 06/06/2024 with Licensed Vocational Nurse (LVN), Staff #112, she reported that the facility does AM and PM baths according to the schedule, where each resident has designated weekdays and a shift they have showers or bed baths. She stated residents are able to re

Based on concerns identified during the survey, review of the facility assessment, staff interviews, Quality Assurance (QA) documentation, and policy review, the Quality Assessment and Assurance (QAA) committee failed to ensure the director of nursing (DON) attended the QAA meeting. The deficient practice can result in quality care concerns not being identified and corrected. Findings include: During the survey which was conducted on June 3, 2024 through June 6, 2024, concerns were identified regarding the attendance of the director of nursing during QAA meeting. Review of the facility document titled, "QAPI Attendance Record" revealed that on January 25, 2024 the executive director, medical director, DON, Infection Preventionist (IP), and others revealed a signature for each attendee except the pharmacy consultant. But for the months of February through May 2024, the document revealed the DON's "QAPI Attendance Record" signature was left blank. Furthermore, a review of the facility document titled, "Facility Assessment" revealed a list of "Persons involved in completing assessment". The list of persons included the executive director /Staff #131, DON/Staff #43, governing body rep/Staff #136 and "Date(s) of assessment or update" was "Updated 05/20/2024". However, review of facility record revealed Staff #43 is a licensed practical nurse (LPN) and assistant director of nursing (ADON). Additional facility record revealed that Staff #134 was the DON from August 2, 2022 through March 8, 2024, Staff #136 filled in as DON from March 9, 2024 through April 21, 2024, and Staff #135 was the DON from April 22, 2024 through May 20, 2024. An interview was conducted with the human resources (HR) manager/Staff #83, on June 5, 20204 at 1:40 PM. Staff #83 stated that the facility had a DON from July 2022 through March 2024. Staff #134 left the facility on March 8, 2024. He added that on April 28, 2024, Staff #135 resumed the DON role and then resigned from the position on May 20, 2024. Then the ADON took over full time as acting DON on May 20, 2024. He stated that the ADON is still the acting DON up to present. He stated that his understanding of the State law allows an LPN to act as acting DON up to 8 months. An interview was conducted with the executive director/Staff #131 on June 6, 2024 at 5:28 PM regarding Quality Assurance and Process Improvement (QAPI). Present with the interview were Staff #132/Vice President Clinical Operation and Staff #133/Compliance Director/Acting DON. Staff #131 stated that they meet once a month with the medical director, executive director, IP, and multiple others are invited and also at least quarterly with the medical director, consultant pharmacist, and executive director. Staff #131 stated that the executive director, IP, DON, medical director are required to attend the QAA meeting. During the interview, the facility was not able to provide documentation that the DON was present onsite during the QAA meetings for the months of

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#31) was able to make choices about their care. Findings include: Resident #31 was admitted to the facility on 10/03/2022 with diagnoses that included spondylolisthesis, anxiety disorder, chronic obstructive pulmonary disease, and osteoarthritis. The Quarterly Minimum Data Set assessment from 02/29/2024, the Brief Interview for Mental Status (BIMS) score was 10 which suggested moderate cognitive impairment. There was no evaluation of bathing ability due to the bathing activity not being performed in the lookback period. A care plan initiated on 10/13/2022 had a goal for a performance deficit for activities of daily living (ADL) related to her diagnoses. It documented that she is bedfast most of the time and interventions included encouraging resident to participate to the fullest extent possible with each interaction, use the call light to call for assistance, and completing skin inspection during routine cares and per bath schedule. According to the facility shower schedule, Resident #31 is on the schedule to receive showers on the night shift on Mondays and Thursdays. The night shift is from 6:00pm to 6:00am. A review of shower sheets from April, May, and June 2024 show the resident refused a shower or bed bath 4 times on 4/15/24, 5/6/24, 5/27/24, and 6/3/24. Of those, three refusal forms are signed by resident with her handwritten note saying staff came at 8pm instead of 3pm, as a reason for why she refused. There are no showers documented for the three month period. Of approximately 18 scheduled bathing opportunities for Resident #31 from 04/01/2024 to 06/03/2024, 14 showers were not documented as being attempted. A progress note dated 5/18/2024 at 5:26pm stated that the resident#31 had not been showering because she needed assistance in shower. In an interview with resident #31 on 06/04/24 at 10:23am, she reported staff always gave her nighttime showers which she did not want because then her long hair would still be wet when she went to bed. She said she told them this, but they would instead mark her down as a refusal and she would miss her shower for that day. She said the most recent time this has happened was "last night" which was 06/03/2024. Certified Nursing Assistant (CNA) Staff #78 was interviewed on 06/05/2024 at 1:34pm. While she did not recall Resident #31 specifically, she stated that if a resident refuses a shower or bed bath, staff will ask if they want it at a different time and try to accommodate the resident. During an interview at 01:15pm on 06/06/2024 with Licensed Vocational Nurse (LVN), Staff #112, she reported that the facility does AM and PM baths according to the schedule, where each resident has designated weekdays and a shift they have showers or bed baths. She stated residents are able to request a different day and time, but if they move to days, then a resident from days will have to

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#27) received necessary services to maintain personal hygiene. Findings include: Resident #27 admitted to the facility on 02/04/2023 with diagnoses that included myotonic muscular dystrophy, acute respiratory failure with hypoxia, and major depressive disorder. Care plan initiated on 02/04/2023 had a goal for a performance deficit for activities of daily living (ADL) related to her diagnoses. Interventions included encouraging resident to participate to the fullest extent possible with each interaction, use the call light to call for assistance, and assistance with bathing/showering per bath schedule preference and as necessary. Review of quarterly Minimum Data Set (MDS) assessment from 04/04/2024 revealed resident #27 the Brief Interview for Mental Status (BIMS) score was 13 which indicated no cognitive impairment. For performance of activities of daily living, the MDS documented she was dependent for personal hygiene and mobility. According to the facility shower schedule, Resident #27 is on the schedule to receive showers on the night shift on Wednesdays and Saturdays. The night shift is from 6:00pm to 6:00am. A review of paper shower sheets from April, May, and June 2024 show the resident refused a shower or bed bath 3 times on 06/01/2024, 05/19/2024, and 05/01/2024. The electronic chart shows 3 refusals were documented on 05/09/2024, 05/23/2024, and 06/01/2024. Certified Nursing Assistant (CNA) documentation in the electronic health records shows no showers in the last 30 days. Paper documentation shows no showers for April, May, or June 2024. Of approximately 18 scheduled bathing opportunities for Resident #27 from 04/01/2024 to 06/03/2024, 12 showers were not documented as being attempted. A review of progress notes shows that on 5/18/2024 at 8:10pm, nursing documented the resident needs to be showered and have oral care on regular basis. It showed linens, gown, and socks were all changed. In an interview with Resident #27 on 06/04/24 at 12:57pm, she stated that she believed it had been a month since she last received any shower or bed bath. Observations showed her hair to be stringy in appearance and clumped together. Certified Nursing Assistant (CNA) Staff #78 was interviewed on 06/05/2024 at 1:34pm. She stated when completing personal hygiene they will ask the resident if they are able to do it themselves and also determine if it will be a one or two person job to assist. If a resident refuses a shower, staff will ask if they want it at a different time. If they do not want a shower after they will have to sign a shower sheet showing their refusal. Staff will try to encourage residents to try it in an hour or a later time. Staff #78 stated that Resident #27 prefers bed baths to showers. In an interview on 06/05/2024 at 4:15p, the Assistant Director of Nursing (ADON), Staff #43 stated that her expectation is fo

Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#304) was free from abuse by another resident (#20). Findings include: Resident #20 was admitted on February 20, 2021 with diagnoses that included cerebrovascular accident (CVA), epilepsy, traumatic brain injury (TBI), major depressive disorder, and schizoaffective disorder. Review of the care plan initiated on January 28, 2022 and revised on April 4, 2022 revealed that resident #20 have a psychosocial well-being problem related to anxiety, ineffective coping, lack of acceptance to current condition, TBI, schizophrenia, verbal and physical aggression. It also stated that he had been involved in altercation with peer. The interventions initiated on January 29, 2022 included need of assistance/encouragement/support to identify problems that cannot be controlled, and identify precipitating factor(s)/stressors. Another care plan initiated on July 12, 2021 revealed resident #20 have a potential to demonstrate physical and verbal behaviors (hitting and swearing, threatening) related to poor cognition and understanding of situations. The interventions initiated on July 12, 2021 included cognitive assessment, evaluate effectiveness and side effects of psychoactive medications, psychiatric/psychogeriatric consult as indicated, and when become agitated, intervene before agitation escalates, and guide away from source of distress. A nursing progress note dated August 2, 2022 revealed that resident #20 had stated he hit another resident on the cheek and there were no witness. The documentation further revealed that the nurse had a talk with the resident about the other resident being very old, frail and not strong. A physician progress note dated August 4, 2022 at 20:00 stated that resident #20 may have had a possible altercation, but it was unwitnessed and resident #20 admitted to hitting another resident on the cheek. A quarterly Minimum Data Set (MDS) assessment dated August 18, 2022 included the resident #20 was admitted from an acute hospital and his Brief Interview for Mental status (BIMS) score was not assessed. The resident mood was not assessed, there were no indicators of psychosis behavior, he did not exhibited behaviors of physical, verbal, or other behavioral symptoms directed toward others. In addition, his quarterly MDS included that he had received antipsychotic, antianxiety, and antidepressant medication. -Resident #304 was admitted on August 1, 2022 with diagnoses that included Alzheimer's disease, major depressive disorder, and bilateral hearing loss. Resident #304 admission MDS assessment BIMS score was not assessed. It was identified that his hearing was highly impaired and he makes himself understood and sometimes understand others. In regards to physical and verbal behavioral symptoms directed toward others, behavior of this type occurred. In addition, the MDS revealed the resident had

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#16). Findings include: Resident #16 was admitted to the facility on 11/20/2017 and readmitted on 10/30/2020 with diagnoses that include hypertension, chronic obstructive pulmonary disease, cardiomegaly, and dementia. Review of Quarterly Minimum Data Set assessment from 01/18/2024 revealed resident #16 Brief Interview for Mental Status (BIMS) score was unable to be assessed due to the resident being rarely or never understood. Staff assessment indicated there were short- and long-term memory problems and resident's cognitive skills were severely impaired. There was no fall history documented. Review of care plan initiated on 12/02/2019 reveal that resident #16 did have a goal related to her risk for falls with interventions that were updated after her 03/23/2024 fall which included being on the Falling Leaf program. A review of progress notes dated 03/23/2024 at approximately 10:30pm stated that a Certified Nursing Assistant (CNA) found the resident on the floor after an unwitnessed fall. The resident #16 had a laceration to her forehead, blood was spreading on the floor, and the resident was complaining of her hand hurting and said it was broken. The note further stated that the resident appeared confused and asked staff repeatedly where she fell from. Emergency Medical Services (EMS) were called and she was transported to the hospital. On 03/24/2024, the facility called the hospital who reported her left pinky finger was broken and her laceration had been stitched up and she would be able to return in the morning. Her x-rays and head CT were negative for any injury. The interdisciplinary team (IDT) reviewed the fall and injury on 03/26/2024 at 11:32am and placed the resident on the Falling Leaf Program for her safety. Active orders after the resident's fall on 03/23/2024 included a fall mat on floor next to the bed for prevention of injury dated 3/29/2024 and wound care for her forehead laceration dated 03/25/2024. Facility self reports for March and April 2024 were requested. None were reported for Resident #16 in that timeframe. During an interview with the Executive Director, Staff #131, on 06/06/2024 at 4:25pm he stated if a resident had a unwitnessed fall with a major injury and cannot say how it happened, that is not necessarily reportable to the Department of Health Services. He stated the interdisciplinary team will discuss it and determine if it it is reportable or not. For example, if a patient is sent to the hospital, they may have to wait on imaging from the hospital to determine if there was an injury or not. The IDT will always include the Vice President of Clinical Operations, Staff #136 as well. He stated they moved quickly and all of this was able to be accomplished within the 2 hours reporting timeframe. The team will

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#27) received necessary services to maintain personal hygiene. The deficient practice may cause a decline or decrease in a resident's quality of life. Findings include: Resident #27 admitted to the facility on 02/04/2023 with diagnoses that included myotonic muscular dystrophy, acute respiratory failure with hypoxia, and major depressive disorder. Care plan initiated on 02/04/2023 had a goal for a performance deficit for activities of daily living (ADL) related to her diagnoses. Interventions included encouraging resident to participate to the fullest extent possible with each interaction, use the call light to call for assistance, and assistance with bathing/showering per bath schedule preference and as necessary. Review of quarterly Minimum Data Set (MDS) assessment from 04/04/2024 revealed resident #27 the Brief Interview for Mental Status (BIMS) score was 13 which indicated no cognitive impairment. For performance of activities of daily living, the MDS documented she was dependent for personal hygiene and mobility. According to the facility shower schedule, Resident #27 is on the schedule to receive showers on the night shift on Wednesdays and Saturdays. The night shift is from 6:00pm to 6:00am. A review of paper shower sheets from April, May, and June 2024 show the resident refused a shower or bed bath 3 times on 06/01/2024, 05/19/2024, and 05/01/2024. The electronic chart shows 3 refusals were documented on 05/09/2024, 05/23/2024, and 06/01/2024. Certified Nursing Assistant (CNA) documentation in the electronic health records shows no showers in the last 30 days. Paper documentation shows no showers for April, May, or June 2024. Of approximately 18 scheduled bathing opportunities for Resident #27 from 04/01/2024 to 06/03/2024, 12 showers were not documented as being attempted. A review of progress notes shows that on 5/18/2024 at 8:10pm, nursing documented the resident needs to be showered and have oral care on regular basis. It showed linens, gown, and socks were all changed. In an interview with Resident #27 on 06/04/24 at 12:57pm, she stated that she believed it had been a month since she last received any shower or bed bath. Observations showed her hair to be stringy in appearance and clumped together. Certified Nursing Assistant (CNA) Staff #78 was interviewed on 06/05/2024 at 1:34pm. She stated when completing personal hygiene they will ask the resident if they are able to do it themselves and also determine if it will be a one or two person job to assist. If a resident refuses a shower, staff will ask if they want it at a different time. If they do not want a shower after they will have to sign a shower sheet showing their refusal. Staff will try to encourage residents to try it in an hour or a later time. Staff #78 stated that Resident #27 prefers bed baths to showers. In an interview on 06/05/2024 at 4:15

Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#304) was free from abuse by another resident (#20). Findings include: Resident #20 was admitted on February 20, 2021 with diagnoses that included cerebrovascular accident (CVA), epilepsy, traumatic brain injury (TBI), major depressive disorder, and schizoaffective disorder. Review of the care plan initiated on January 28, 2022 and revised on April 4, 2022 revealed that resident #20 have a psychosocial well-being problem related to anxiety, ineffective coping, lack of acceptance to current condition, TBI, schizophrenia, verbal and physical aggression. It also stated that he had been involved in altercation with peer. The interventions initiated on January 29, 2022 included need of assistance/encouragement/support to identify problems that cannot be controlled, and identify precipitating factor(s)/stressors. Another care plan initiated on July 12, 2021 revealed resident #20 have a potential to demonstrate physical and verbal behaviors (hitting and swearing, threatening) related to poor cognition and understanding of situations. The interventions initiated on July 12, 2021 included cognitive assessment, evaluate effectiveness and side effects of psychoactive medications, psychiatric/psychogeriatric consult as indicated, and when become agitated, intervene before agitation escalates, and guide away from source of distress. A nursing progress note dated August 2, 2022 revealed that resident #20 had stated he hit another resident on the cheek and there were no witness. The documentation further revealed that the nurse had a talk with the resident about the other resident being very old, frail and not strong. A physician progress note dated August 4, 2022 at 20:00 stated that resident #20 may have had a possible altercation, but it was unwitnessed and resident #20 admitted to hitting another resident on the cheek. A quarterly Minimum Data Set (MDS) assessment dated August 18, 2022 included the resident #20 was admitted from an acute hospital and his Brief Interview for Mental status (BIMS) score was not assessed. The resident mood was not assessed, there were no indicators of psychosis behavior, he did not exhibited behaviors of physical, verbal, or other behavioral symptoms directed toward others. In addition, his quarterly MDS included that he had received antipsychotic, antianxiety, and antidepressant medication. -Resident #304 was admitted on August 1, 2022 with diagnoses that included Alzheimer's disease, major depressive disorder, and bilateral hearing loss. Resident #304 admission MDS assessment BIMS score was not assessed. It was identified that his hearing was highly impaired and he makes himself understood and sometimes understand others. In regards to physical and verbal behavioral symptoms directed toward others, behavior of this type occurred. In addition, the MDS revealed the resident had