Every finding on record at Advanced Healthcare of Mesa

Based on record review, staff interviews, review of facility documents and policy, the facility failed to provide written notice to the resident or resident representative that specifies duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility for one resident (#48). The deficient practice could result in residents not being able to exercise their right to return to the facility of choice. Number of residents sampled: 12Number of residents cited: 1 Findings include: Resident #48 was admitted to the facility on [DATE] with a diagnosis that included sepsis, anemia and hypertension.A review of Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0, cognitively intact.A review of care plan dated July 24, 2025 revealed resident has an alteration in respiratory function.A review of progress notes dated August 6, 2025 revealed resident was noted to be short of breath, febrile with a temperature of 101.4, has low blood pressure of 102 over 60, and a heart rate of 102 beats per minute. The staff notified the nurse practitioner and the staff received orders to start resident on intravenous push (IVP) Lasix 40 mg (milligram) every day for three days and to hold/not administer oral Lasix for four days due to resident have a large right pleural effusion. Resident was administered one gram of acetaminophen (APAP) for fever. The IVP Lasix was administered by the director of nursing (DON). Resident's laboratory blood work was pending. Resident's urine and stool samples were collected and were sent to lab for testing. The provider was updated about the Resident's condition and additional orders, CBC (complete blood count) and CMP (comprehensive metabolic panel) daily for three days, were received from the provider. The progress notes also revealed that resident and resident's family requested to be transferred to the hospital.Review of progress note dated August 6, 2025 at 8:43 PM revealed the date and time resident left facility: August 6, 2025 at 18:03 PM; Bed hold policy was given: Emergent transfer; and Family/Responsible party notified of transfer: Yes.Review of MDS discharge-Return Anticipated assessment revealed Resident #48 was discharged on August 6, 2025 to a short-term general hospital. An interview was conducted on September 4, 2025 at 9:28 AM with a Licensed Practical Nurse (LPN)/Staff #82. Staff #82 stated that when he transfers a resident out to a hospital, it could be due to an emergency such as chest pain, oxygen saturation dropping and not able to maintain even after titrating oxygen to keep the resident's oxygen saturation above 90 percent using a rebreather mask, and a resident looking diaphoretic. Before transferring a resident, Staff #82 notifies the provider and receives an order to call 911. Regarding a resident who was sent out to the hospital but end up not admitted to the hospital, the resident have within 24 hours and returns back to the facility. The hospital calls the facility that the resident is coming back and the facility arrange a transportation to pick resident up from the hospital. However, Staff #82 stated that if the resident is in the hospital for over 24 hours, the resident is offered a bed hold. The admission and or case manager calls the resident or resident's family regarding bed hold.An interview was conducted on September 4, 2025 at 10:00 AM in the case management office with case manager Registered Nurse (RN)/ Staff #106. Staff #106 stated that she does discharge planning, she assists with placement, help with home health resources, care giving, and transportation. Staff #106 stated that when a resident is discharged to a hospital, she does not do anything with residents that goes to the hospital, she does not do bed hold, and it is the nurse or business office that takes care of bed hold. And, their DON sent reports of discharges to the ombudsman. An interview was conducted on September 4, 2025 at 10:06 AM with Patient Account Coordinator/Staff #74. Staff #74 stated that she checks and verifies insurance and get authorization, checks resident's documentation for every resident in the facility so she and the case manager can plan a safe discharge for the resident. Staff #74 stated that she takes care of bed hold. She stated that if their resident is admitted in the hospital, she takes care of bed hold so the resident will not lose their room. She will offer the resident a bed hold either in person before going out to the hospital or she will speak or reach out to the resident's family member or Power of Attorney (POA). She stated that the cost is $600.00 per day and she will have the form ready for resident or family to sign. She sated that the Bed Hold acknowledgement form is provided each time a resident is send out. But if a resident is going home, going to an assisted living (AL), the bed hold is not offered because it is not needed. Furthermore, Staff #74 stated that if a resident was not able to consent, she would look in the resident's chart to see who the resident's POA or emergency contact. If the bed hold is not signed or was declined verbally, the resident might still be able to come back if a bed is available and that will be handled by admission and not her.On September 4, 2025 at 12:05 PM, a request was made for a bed hold document for Resident #48 and at 1:13 PM Regional Director of Clinical Resource/Staff #300 returned the form, CMS form 807, and wrote Document unavailable to provide.An interview was conducted on September 4, 2025 at 1:41 PM with DON/Staff #76. The DON stated that the process regarding bed hold, Staff #74 from the finance and the administrator handles bed hold and admission to make sure they can fill the bed. Furthermore, the DON stated that if a bed hold was not communicated to the resident, the risk is resident will not have a placed to be at and will be sent some place else.An interview was conducted on September 5, 2025 at 10:44 AM with the administrator/Staff #51 in her office. The administrator stated that their bed hold policy process is if a resident was sent out, there is a follow up with resident's family member so the resident will have the chance to hold the bed if that is what they like, and the process of bed hold starts after the resident is sent out. The administrator stated that her corporate is starting to create a packet to be given to nurses so if there is a resident who is send out, the nurses will know what to do, to always make sure that there is a bed hold when a resident is sent out, and that there is always a communication to resident and family regarding bed hold. The administrator stated that regarding Resident #48, her previous DON charted that a bed hold was given but she is not seeing the document while looking at Resident #48's electronic record. The administrator stated that during the day, the bed hold is handled by Staff #74. Despite the administrator stating that her previous DON charted that a bed hold was given, review of the progress note dated August 6, 2025 at 8:43 PM revealed a documentation Bed hold policy was given: Emergent transfer, and the documentation did not indicate whether a bed hold was given or not. Review of facility's admission packet, Section 14 Bed Holds, revealed If the Patient leaves the Facility for a temporary stay in an acute care hospital, the Patient and/or Legal Representative may request that the Facility hold a bed until the Patient returns. Determinations regarding bed hold requests will be made at the Facility's sole discretion.Review of facility's policy titled, Bed Hold, updated on April 22, 2024 revealed prior to discharge, or as soon as possible thereafter if discharge is emergent, a facility representative will provide the patient, a family member, or legal representative a written notice of the specific duration of the bed-hold and the charges included, if any.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure that written abuse policy and procedures were followed and adhered to regulations regarding the alleged abuse of one resident (Resident #20). This deficient practice could result in allegations of abuse not being appropriately handled.Findings include:Resident #20 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of the pelvis, one rib, sacrum, and vertebra, bacterial infections of unspecified site, chronic kidney disease, depression, and insomnia.An initial pool interview was conducted with Resident #20 on September 2, 2025, at 10:15 AM. During the interview, the resident stated that some of the staff are strange. The resident said that when he was first admitted to the facility, an aide was rough with him while providing care, and that she held [his] cheeks in her hands and kissed [his] forehead. Resident #20 said he didn't want to be touched or kissed in that manner and felt uncomfortable with the gesture. The resident stated that he informed the aide's boss about the incident and that the aide was then told not to be in the same room as the resident.Following the interview with Resident #20, on September 2, 2025, at 10:33 AM, an alleged abuse incident was reported to the facility Administrator (Staff #51). The Administrator stated she had not received a report of suspected abuse regarding Resident #20 before this report.On September 2, 2025, at 3:31 PM, the State Agency (SA) database of facility self-reports was reviewed online. No reports from the facility were observed.On September 3, 2025, at 11:57 AM, the SA database of facility self-reports was reviewed online. No reports from the facility were observed.An interview was conducted with the DON (Staff #76) on September 3, 2025, at 1:29 PM. The DON stated that when she receives an allegation of abuse, she first goes to see the resident who made the claim. Following a discussion with the resident, she reports the alleged abuse to the facility Administrator, the ombudsman, and the transitional nurse, Staff #122. The DON stated that she would also report the incident to Adult Protective Services (APS) if she noted bruising, a black eye, or fingerprints on the resident. She then indicated these types of abuse claims should also be reported to the State Agency (SA).The DON then said that she had received a verbal report of alleged abuse for Resident #20 from the facility Administrator on September 2, 2025. She interviewed Resident #20, who told the DON that he was fearful of explaining what had occurred, but that he did not like his current aide and wanted to talk to the DON later in the day. The DON explained that she went to speak to Resident #20 later in the day, but he was asleep. The DON stated that she had not completed an official investigation at that time, as she was waiting for instructions from the facility Administrator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 8:25 AM. The Administrator explained that when a resident makes an allegation of abuse regarding a staff member, she expects her staff to report the allegation to her and the DON immediately. She stated she would then put the alleged perpetrator on leave, complete an investigation, and then report to the SA, APS, the ombudsman, and the police if needed. The Administrator stated she always files a report if it involves alleged abuse, whether it was witnessed or reported.The Administrator stated she had not reported the alleged abuse incident regarding Resident #20, which she was made aware of on September 2, 2025, at 10:33 AM. She indicated that the reason she did not report the alleged abuse to the SA was that the incident occurred in July 2025 and that they were not informed of it at that time. She also indicated that following the DON interview of the resident on September 2, 2025, the Administrator struggled to say it was abuse. The Administrator continued to explain that Resident #20 had issues with female aides of color and that it appeared he didn't like that particular aide. After further discussion of the incident with Resident #20, the Administrator then decided to report the incident to the SA on September 4, 2025.On September 4, 2025, at 10:19 AM, the DON stated that she discussed the incident with Resident #20 and that he indicated the aide involved was Certified Nurse Assistant (CNA/Staff #79). The DON called the CNA, who acknowledged that an incident had been reported by Resident #20 and stated that the Registered Nurse (RN/Staff #49) working that shift was made aware of the situation.An interview was conducted with RN (Staff #49) on September 4, 2025, at 10:53 AM. The RN stated that Resident #20 had reported to him that the CNA (Staff #79) was inappropriate with him, referring to the CNA kissing him on his forehead. The RN instructed the CNA not to enter the resident's room. The RN stated he did not report the alleged incident to anybody at that time because the CNA had denied that the incident occurred. The RN reported he had received training from the facility regarding reporting alleged abuse and that he had a lack of judgment by not reporting the incident.On September 4, 2025, at 10:58 AM, an interview was conducted with a CNA (Staff #84) regarding facility abuse policy and procedures. The CNA stated she did not know if she had received training regarding abuse and neglect. She left to ask her supervisor a question. She returned to the interview and stated she had received abuse and neglect training. The CNA stated that if an incident of alleged abuse were reported to her by a resident, she would report it to her supervisor. The CNA was unable to give the name of the facility's abuse coordinator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 1:16 PM. The Administrator acknowledged that RN (Staff #49) did not report the incident he was made aware of with Resident #20 in July 2025. The administrator did not state what the risk of the nurse not reporting was, but reiterated that this particular case did not seem to fall into the abuse category. The Administrator then acknowledged the finding of deficient practice and stated she would report all alleged abuse in the future, as well as perform in-service training to the facility staff.An interview was conducted with the RN (Staff #49) on September 5, 2025, at 10:24 AM. The RN stated that the resident had made an allegation of abuse in July 2025, but the RN did not report it at that time.A policy titled Abuse Policy and Procedure, Version E1107 was reviewed. The policy revealed that all patients have the right to be free from any form of verbal, sexual, physical. abuse. The policy stated that all personnel are required to immediately report incidents of suspected mistreatment or abuse to the facility administration. The policy further stated that an incident of patient abuse must be reported to a supervisor regardless of the time lapse since the incident occurred. The policy also instructed that should the investigation reveal 'reasonable cause to believe' that abuse. had occurred, the administrator and/or director of nursing would then report findings immediately to the required SA.Appendix PP of the State Operations Manual (SOM), issued August 8, 2024, was reviewed. Code 42 CFR 483.12(b)(5) instructs that all alleged violations involving abuse are to be reported immediately, but not later than 2 hours after the allegation is made.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure that an allegation of abuse for one resident (Resident #20) was reported to the State Agency (SA) in a timely manner. This deficient practice could result in allegations of abuse not being reported and investigated.Findings include:Resident #20 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of the pelvis, one rib, sacrum, and vertebra, bacterial infections of unspecified site, chronic kidney disease, depression, and insomnia.A Minimum Data Set (MDS) dated [DATE], indicated that Resident #20 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment.An initial pool interview was conducted with Resident #20 on September 2, 2025, at 10:15 AM. During the interview, the resident stated that some of the staff are strange. When asked to explain the statement, the resident said that when he was first admitted to the facility, an aide was rough with him while providing care, and that she held [his] cheeks in her hands and kissed [his] forehead. Resident #20 said he didn't want to be touched or kissed in that manner and felt uncomfortable with the gesture. The resident stated that he informed the aide's boss about the incident and that the aide was then told not to be in the same room as the resident. Resident #20 stated he currently felt safe in the facility, but was fearful of the staff finding out that he reported the incident.Following the interview with Resident #20, on September 2, 2025, at 10:33 AM, the surveyor reported the alleged abuse incident to the facility Administrator (Staff #51). The Administrator indicated that the aide that Resident #20 was referring to was most likely Staff #79. The Administrator stated she had not received a report of alleged abuse regarding Resident #20 before this report. The Administrator left her office to discuss with the staff.On September 2, 2025, at 11:08 AM, the Director of Nursing (DON/Staff #76) informed the surveyor that Resident #20 had been placed on 2-hour checks and that she ensured that the psychiatric nurse practitioner was following the resident's care. The DON stated that Resident #20 had not mentioned being mistreated by staff before the current date.On September 2, 2025, at 3:31 PM, the SA database of facility self-reports was reviewed online. No reports from the facility were observed.On September 3, 2025, at 11:57 AM, the SA database of facility self-reports was reviewed online. No reports from the facility were observed.An interview was conducted with the DON (Staff #76) on September 3, 2025, at 1:29 PM. The DON stated that when she receives an allegation of abuse, she first goes to see the resident who made the claim. Following a discussion with the resident, she reports the alleged abuse to the facility Administrator, the ombudsman, and the transitional nurse, Staff #122. The DON stated that she would also report the incident to Adult Protective Services (APS) if she noted bruising, a black eye, or fingerprints on the resident. She then indicated these types of abuse claims should also be reported to the State Agency (SA).The DON then said that she had received a verbal report of alleged abuse for Resident #20 from the facility Administrator on September 2, 2025. She interviewed Resident #20, who told the DON that he was fearful of explaining what had occurred, but that he did not like his current aide and wanted to talk to the DON later in the day. The DON explained that she went to speak to Resident #20 later in the day, but he was asleep. The DON stated that she had not completed an official investigation at that time, as she was waiting for instructions from the facility Administrator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 8:25 AM. The Administrator explained that when a resident makes an allegation of abuse regarding a staff member, she expects her staff to report the allegation to her and the DON immediately. She stated she would then put the alleged perpetrator on leave, complete an investigation, and then report to the SA, APS, the ombudsman, and the police if needed. The Administrator stated she always files a report if it involves alleged abuse, whether it was witnessed or reported.When the facility Administrator was asked if she had reported the alleged abuse incident regarding Resident #20, which she was made aware of on September 2, 2025, at 10:33 AM, she stated she had not. The Administrator indicated that the reason she did not report the alleged abuse to the SA was that the incident occurred in July 2025 and that they were not informed of it at that time. She also indicated that following the DON interview of the resident on September 2, 2025, the Administrator struggled to say it was abuse. The Administrator continued to explain that Resident #20 had issues with female aides of color and that it appeared he didn't like that particular aide. After further discussion of the incident with Resident #20, the Administrator then decided to report the incident to the SA on September 4, 2025.Attempts were made to contact the alleged perpetrator (Staff #79) on September 3, 2025, at 1:46 PM, September 4, 2025, at 9:59 AM, September 4, 2025, at 12:37 PM, and September 4, 2025, at 2:16 PM. All attempts were unsuccessful.On September 4, 2025, at 10:19 AM, the DON stated that she discussed the incident with Resident #20 and that he indicated the aide involved was Certified Nurse Assistant (CNA/Staff #79). The DON called the CNA, who acknowledged that an incident had been reported by Resident #20 and stated that the Registered Nurse (RN/Staff #49) working that shift was made aware of the situation.An interview was conducted with RN (Staff #49) on September 4, 2025, at 10:53 AM. The RN stated that Resident #20 had reported to him that the CNA (Staff #79) was inappropriate with him, referring to the CNA kissing him on his forehead. The RN instructed the CNA not to enter the resident's room. The RN stated he did not report the alleged incident to anybody at that time because the CNA had denied that the incident occurred. The RN reported he had received training from the facility regarding reporting alleged abuse and that he had a lack of judgment by not reporting the incident.On September 4, 2025, at 10:58 AM, an interview was conducted with a CNA (Staff #84) regarding facility abuse policy and procedures. The CNA stated she did not know if she had received training regarding abuse and neglect. She left to ask her supervisor a question. She returned to the interview and stated she had received abuse and neglect training. When asked what she would do if a resident reported an incident to her, the CNA stated that she would report it to her supervisor. The CNA was unable to give the name of the facility's abuse coordinator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 1:16 PM. The Administrator acknowledged that RN (Staff #49) did not report the incident he was made aware of with Resident #20 in July 2025. When asked what the risk of the nurse not reporting was, the Administrator did not comment, but reiterated that this particular case did not seem to fall into the abuse category. The Administrator then acknowledged the finding of deficient practice and stated she would report all alleged abuse in the future, as well as perform in-service training to the facility staff.An interview was conducted with the RN (Staff #49) on September 5, 2025, at 10:24 AM. The RN again stated that Resident #20 did make the report of alleged abuse in July 2025, but the RN did not report it at that time.A policy titled Abuse Policy and Procedure, Version E1107 was reviewed. The policy revealed that all patients have the right to be free from any form of verbal, sexual, physical. abuse. The policy stated that all personnel are required to immediately report incidents of suspected mistreatment or abuse to the facility administration. The policy also noted that abuse should be reported by the Administrator and/or the Director of Nursing immediately to the required state agency.Appendix PP of the State Operations Manual (SOM), issued August 8, 2024, was reviewed. Code 42 CFR 483.12(b)(5) instructs that all alleged violations involving abuse are to be reported immediately, but not later than 2 hours after the allegation is made.

Based on clinical record review, staff interview, the Resident Assessment Instrument (RAI) manual, and facility failed to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31. The deficient practice could result in delayed identification of potential risks and care needs of the residents. Findings include: Resident #31 was admitted into the facility on [DATE] with a diagnosis of surgical wound infections, peritoneal abscess, elevated white blood cell count, chronic obstructive pulmonary disease, and epigastric pain. MDS revealed that the resident had been discharged to a short-term general hospital. Progress notes for resident #31 revealed that residents had been discharged home with Home Health services with discharge summary, and medication review on July 19, 2024. Resident #31 was discharged on [DATE]; however, MDS and progress notes there was a discrepancy between progress notes, and MDS. An interview was conducted on October 17, 2024 at 1:19PM with RN/MDS Coordinator (Registered Nurse & Minimum Data Set) (Staff #9) review with progress notes and states that resident #31 was discharged to home health and that the resident never went to the hospital. RN MDS (Staff # 9) had reviewed resident MDS and stated that on the MDS it is revealed that resident has been discharged to a short term hospital. RN MDS Coordinator ( staff # 9) stated that the MDS was inaccurate and that this is not part of the facility expectation. An interview was conducted on October 17 at 1:56 PM with DON ( Director of Nursing) staff # 48 stated that this resident came in here for rehab , and when resident # 31 was discharged and they went home. In the MDS it gives you 4 option to pick from in regard to the resident discharge in this case RN MDS coordinator (staff # 9) had selected option 1 instead of opinion 4. The facility expectation would be that they are supposed to follow the Medicare Guide that applies to all staff. Review of the facility Policy titled, Patient Assessment revealed, that any individual who completes any part of the assessment on RAI will sign and certify the accuracy of that part of the assessment they have completed.

Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified in writing regarding the reason for transfer and a copy was sent to the ombudsman. Findings include: Resident #86 was admitted to the facility on [DATE] with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her. A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status. -Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment. During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital. An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the nurse/charge nurse informs the resident and family verbally regarding the reason for transport to the hospital. She also stated that the ombudsman is notified of the transfer at the end of the month, but the reason for discharge is not included. An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the (DON/staff #81). , Interview with 1. Administrator and 2. DON, Staff #81 stated that the facility did not give the residents a written reason for being transferred to the hospital, so the ombudsman did not receive a copy. She stated that the facility has never been provided the resident with a reason for transfer in writing and is currently looking at how to develop a process. Staff #90 stated that when she was at a conference, she heard other facilities talking about notifying the ombudsman about the reason for the transfer, but didn't know what they were talking about. The facility's policy Admission, Transfer, Discharge Rights (F-Tag) states that before a facility transfers or discharges a patient, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Subject to the resident's agreement, the facility must send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman.

Based on clinical review, staff interviews and the facility policy and procedures, the facility failed to ensure one resident (#86) was permitted to return to the facility after a hospitalization . Findings include: Resident #86 was admitted to the facility on [DATE] with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. Review of a Covid-19 test dated November 14, 2023 revealed a positive result. A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her. A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status. Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member. An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident was transferred to the hospital because she tested positive for Covid, was symptomatic, and the physician wanted her transferred to the hospital. She stated that the facility did not keep residents who tested positive for Covid and would transfer them to the hospital or another facility. She stated that if the resident would have passed the quarantine period, she would have been able to come back to the facility. Then she reviewed the progress notes and stated that the daughter was told on November 14, 2021, that the resident could not return to the facility, which is the same day that the resident was transferred to the hospital. She acknowledged that on November 14, 2023, she did not know how long the hospital was going to keep the resident or if the resident was being admitted , but knew that the resident was in the incubation period, so was not admitted back to the facility. She stated that the facility was able to isolate residents with Covid-19 by room, but did not have staff to care for the residents. She wouldn't have hired registry staff to provide one to one care for residents with Covid-19 because it is not practical for financial reasons, but doesn't have any documentation of trying to find additional staff or telling AZDHS that this was not feasible. An interview was conducted on November 8, 2023 at 9:04 AM with a Registered Nurse/Critical Nurse Manager (RN/staff #25), who stated that she was responsible for discharge planning and any family concerns. She stated that if a resident was Covid-19 positive in 2021 and symptomatic, the resident was transferred to the hospital if ordered by the physician. During the interview, she reviewed facility documentation and stated that she didn't have any notes regarding the resident's discharge. She stated that it was her understanding that the facility did not have a Covid unit and she followed facility protocol, which was to transfer the Covid-19 positive residents to the hospital or another facility. During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid-19 positive. An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the Director of Nursing (DON/staff #81). Both staff stated that they developed a plan for Covid positive residents, but didn't implement the plan. Staff #90 stated that they were a Covid-19 free facility and wanted to remain that way. The facility's Covid-19 Emergency Plan, Location of Confirmed Patients with SARS-CoV-2 states to identify space in the facility that could be dedicated to care for residents with confirmed Covid-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with Covid-19. Determine the location of the Covid-19 care unit and create a staffing plan before residents or HCP with Covid-19 are identified in the facility.

Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified were made aware of the bed-hold policy upon transfer to the hospital. Findings include: Resident #86 was admitted to the facility on [DATE] with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her. A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status. Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member. -Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment. A progress note dated September 10, 2023 revealed that the resident was transported to the hospital as per physician's orders for possible sepsis at approximately 6:40 a.m. The vital signs were taken prior to transport and were as follows: 112/57 blood pressure, 121 heart rate, 72% oxygen on 1 liter., 102.7 temperature, and 22 respiratory rate. There was an attempt to contact the resident's daughter, but there was no answer. The nurse sent the face sheet and orders to transport. Review of the clinical record did not reveal a bed-hold policy. During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital. An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident is given a bed-hold policy when he/she is transported to the hospital if it is feasible. If the situation is emergent, the bed hold policy is discussed with a family member, who would decide if he/she wanted to pay the rate required. She stated that she was not sure if the conversation regarding the bed hold policy with the family member is documented in a progress note. She also, stated that if the bed-hold form was used, she would expect that it was signed and dated by the resident or family member. During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid positive. The facility's policy Admission, Transfer, Discharge Rights (F-Tag) states that before a patient is transferred to a hospital or goes on therapeutic leave, the facility will provide written information to the patient, a family member or resident representative specifying the duration of the bed-hold policy during which the patient is permitted to return and resume temporary residence in the facility.

Based on observation, clinical record, staff interviews and the facility policy and procedures, the facility failed to use appropriate hand hygiene practices and PPE when providing wound care for one resident (#18). The deficient practice could result in infection. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture of left femur, and abnormalities of gait and mobility. A care plan dated October 9, 2023 for an actual impaired skin integrity related to admitted with surgical incision left hip. admitted with deep tissue injury on (DTI) on right buttock and left heel. The resident admitted with a stage II pressure ulcer to sacrum. -October 11, 2023 DTI right buttock is resolved. -October 11, 2023, stage II sacrum is now an unstageable pressure ulcer on her sacrum. -October 20, 2023, sacrum ulcer is resolved. -November 6, 2023, left heel is now stage III. Interventions include to treat left heel per order. Wound order dated November 3, 2023 revealed skin prep, okay open to air daily, float heels in bed, offload wound, reposition per facility protocol, offloading mattress. November 6, 2023 wound note revealed a facility acquired left heel non-blanchable redness -October 9, 2023: 3 cm length x 3 cm width -November 6, 2023: 0.8 length cm x 0.5 cm width On November 7, 2023 at 10:31 a.m. observed a Registered Nurse/Clinical Nurse Manager (RN/staff #1) clean a pressure ulcer on left heel. Staff #1 was observed: -sanitzing hands -donning gown and gloves -placing a paper towel below resident's left foot (foot was elevated by a pillow and did not touch the paper towel -removed the resident's sock and bandage/gauze -bandage/gauze was placed on the paper towel -cleansed the left heel with clean gauze and then placed gauze on the paper towel -doffed dirty gloves and placed them on the paper towel -reached under her gown and pulled out another pair of gloves from her pocket and did not sanitize hands prior to donning the gloves -Collagen pad was applied and covered -doffed gloves and washed hands An interview was conducted on November 8, 2023 at 11:10 AM with (RN/staff #1), who stated that she doesn't necessarily need to sanitize her hands after doffing soiled gloves and before donning the new gloves because she has already cleaned her hands prior to beginning wound care. She acknowledged that she didn't sanitize her hands after doffing the soiled gloves and donning a new pair of gloves when she cleaned the resident's wound on November 7, 2023. She also, stated that it would not be appropriate to take new gloves from her pocket beneath her gown because the gown could be contaminated and she acknowledged that she pulled her gloves from underneath her gown when providing wound care on November 7, 2023. An interview was conducted on November 8, 2023 at 11:22 AM with the Director of Nursing (DON/staff #81), who stated that when wound care is provide, the nurse should doff her gloves after removing the bandage, sanitize hands, and don new gloves. She stated that the hands should be sanitized because the old gloves may be contaminated. She also stated that the inside of the gown has the potential to be contaminated because it is touching the staff's clothing, so reaching underneath the gown to get gloves from the pocket creates the potential for contamination. The facility's policy Isolation Procedures and Universal Precautions states that hand washing is considered the single most important procedure for preventing infections. Hand washing is necessary before and after removal of gloves and barriers.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure that a physician's order had been obtained to treat and monitor a skin injury for one resident (#86). The deficient practice may result in additional resident skin injuries being treated without a physician's order for treatment. Findings include: Resident #86 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated September 19. 2022 included that resident #86 had fallen in her bathroom that resulted in a large skin tear on her right upper extremity. The note included that the skin tear required Steri-strips, and a non-adherent gauze and small island dressing. Review of the clinical record for resident #86 revealed that there were no physician's orders for treatment or monitoring of the large skin tear on the resident's right upper extremity. A care plan dated September 20, 2022 included that resident #86 was at risk for falls related to weakness, and had a fall with a skin tear on September 19, 2022. The care plan included a goal to minimize the risk of falls throughout the resident's stay. The care plan did not include any additional interventions regarding wound care for a skin tear on the right upper extremity, or interventions for monitoring of the wound. Observations conducted on September 27, 2022 at 10:10 AM, during the Recertification survey, resident #86 was observed sitting upright in chair and had a 4x4 island dressing near her right elbow. The dressing was observed to be clean, dry and intact. During an interview conducted on September 27, 2022 at 10:14 AM with resident #86, she stated that she sustained a small skin tear on her elbow when she fell at the facility, and stated that she had no recollection of the incident. Resident #86 stated that the bandage on her right arm/elbow has not been changed or looked at since the fall happened. During an interview conducted on September 29, 2022 at 11:01 AM. with an LPN (Licensed Practical Nurse/Staff #29), he stated that he was aware that resident #86 had fallen and that the resident had a skin tear. Staff #29 stated that he has never changed the dressing on the resident's wound because that was the wound nurse's job. An observation of wound care for resident #86 was conducted on September 29, 2022 at 11:40 AM with an LPN (Staff #25). During observation of the wound care provided by staff 25, the wound dressing was noted to be well secured and was not soiled, and the resident's skin under the dressing was clean. There was no foul odor Steri-strips were not present on the wound, which appeared to be healed. During an interview conducted on September 29, 2022 at 11:44 AM with Staff #25, she stated that she had not previously changed the wound dressing on the resident's (#86) arm/elbow because she was not aware of the wound. Staff #25 included that there should have been an order to change the dressing and monitor for infection, and that it was apparently overlooked. During an interview conducted on September 29, 2022 at 12:36 PM with the Director of Nursing (DON/Staff #47), she stated that the wound should have been monitored and should have a had a physician's order for treatment. The DON stated that the nurse should have reported the resident's (#86) skin tear to the wound nurse, and that if she had known of the resident's fall and the skin tear, as the director of nursing, she would have followed up on the wound. A facility Policy titled, Care of Skin Tears and Abrasions (revised 28 Sept. 2022) stated the facility shall obtain and verify that there is a physician's order to treat the wound.

Based on clinical record review, observations, staff interviews, policies and procedure, the facility failed to ensure medication was administered as ordered by the physician for one (#281) of 11 sampled residents. The census was 36. The deficient practice could result in residents not receiving the medications as prescribed by the physician and developing complications and adverse effects. Findings include: Resident # 281 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing progress note dated June 25, 2021 included the resident was alert and oriented x1, required 3 person assistance with slide transfer from gurney to bed, required 2 person assist with bed mobility, was incontinent and had an indwelling catheter on. A physician order dated June 25, 2021 included the following instructions for [MEDICATION(S)] sliding scale before meals and at bedtime: -BS (blood sugar) of 0-150 mg/dl (milligrams per deciliter), give 0 units -BS 151-200 mg/dl, give 2 units -BS 201-250 mg/dl, give 4 units -BS 251-300 mg/dl, give 6 units -BS 301-350 mg/dl, give 8 units -BS 351-400 mg/dl, give 10 units -BS >400 mg/dl, call the physician. The order also included to notify the physician if BS <60 mg/dl or >400 mg/dl as needed. The NP (nurse practitioner) progress note dated June 27, 2021 included the resident was alert to self, had an assessment of DM and was on SSI (sliding scale insulin). A review of Medication Administration Record (MAR) revealed that on June 27, 2021 on the 8:00 p.m. to 10:00 p.m. shift, it was documented the resident had a blood glucose of 215 mg/dl and was administered with 2 units of insulin instead of 4 units that was ordered. There was no evidence found in the clinical record of a reason why 2 units were administered (instead of the 4 units as ordered) on June 27, 2021; or that, the physician was notified. The clinical record also revealed no evidence the resident refused medications or care on June 27, 2021. The care plan dated June 28, 2021 included the resident had an identified endocrine disorder as evidenced by a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included medication, treatment and diet as ordered. An interview was conducted on June 28, 2021 at 2:31 p.m. with a registered nurse (RN/staff #60) who stated that medications with ordered parameters are documented on the MAR. She stated that when giving medications to residents prescribed with insulin, she would review the order in the electronic medical record (EMR) and would follow the parameters per the sliding scale and as written in the physician's orders. She stated it is the facility expectation to follow the physician's orders as written. The RN further stated that if parameters are not followed staff are to document the reason in a progress note and call the physician. In another interview with the RN (staff #60) conducted on June 29, 2021 at 10:06 a.m., staff #60 stated resident #281 was diabetic and had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview, a review of the clinical record was conducted by staff #60 who stated the resident's BS on June 27, 2021 was documented as 215 mg/dl; and, was administered 2 units of insulin which was not according to the insulin sliding scale parameter ordered by the physician. Staff #60 further stated the resident should have been given 4 units of insulin (instead of 2 units). Staff #60 also said that if the ordered amount of insulin was not given to a resident, the nurse should have documented the reason in a progress note and should have called the physician as well. However, staff #60 said the clinical record revealed no documentation that explained why the resident did not received the ordered amount of insulin and that the physician was notified. Staff #60 stated the facility policy for medication administration is to give insulin following the sliding scale as ordered by the physician. Staff #60 also stated that the administration of 2 units of insulin to resident #281 on June 27, 2021 was not following the facility's policy or expectations. During an interview with the Director of Nursing (staff #48) conducted on June 29, 2021 at 10:26 a.m., the DON stated that she conducts an occasional audit of blood glucose/insulin administration if a concern is brought to her attention. She stated the physician reviews the blood sugars (high and low BS readings) and medication orders of a resident. She stated that physician orders are followed as written for medication administration, including insulin sliding scale parameters. During the interview, a review of the clinical record was conducted by the DON who stated the physician's order for a blood glucose of 215 mg/dl was to give 4 units of insulin to the resident. However, the DON stated the physician's order was not followed as written because the resident was given 2 units of insulin. The DON stated this could result in the resident having a high blood sugar. Review of the facility policy titled, Insulin Administration, revealed a standard of practice that included the nurse will ensure, prior to administering each dose of insulin, that both the correct type and dose of insulin, and number of units ordered, are checked against the physician orders, the insulin vial, and syringe before the patient receives the medication. The standard of care included that the patient who has been prescribed insulin can expect that the medication be administered in the correct form and dosage, at the correct time, with the correct injection techniques with concurrent observation of benefit and potential side effects or drug interactions. It is their policy that patients who are prescribed insulin receive the medication by injection only after the nurse prepares the insulin and verifies: correct patient, medication, dose, route and time. The procedure included that the nurse prior to preparing to administer a coverage of regular dose of insulin, checks the physician order to verify order and to be sure to understand the value of the lines on the syringe, and be accurate in drawing up the desired number of insulin units. The policy on Medication Administration revealed that medications are provided to patients by licensed nursing staff, are administered in accordance with a physician's written orders to the appropriately identified patient and are administered only if properly identified. The policy also included that medication errors are promptly reported to the charge nurse and attending physician.

Based on observations, clinical record review, staff interviews, policy and procedures, the facility failed to ensure fall interventions were implemented as ordered by the physician for one sampled resident (#281). The census was 36. The deficient practice could result in increase resident's risks of fall and injury. Findings include: Resident #281 was admitted to the facility on [DATE], with diagnoses of critical illness [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, severe [CONDITION(S)], mild protein calorie malnutrition, type II diabetes and [CONDITION(S)]. The nursing progress note dated June 25, 2021, included the resident was admitted from the hospital s/p GLF (status post ground level fall). According to the documentation, the resident was alert and oriented x1, required 3 person slide transfer from gurney to bed, required 2 person assist with bed mobility, was incontinent and had an indwelling catheter. An undated admission information for CNAs (certified nurse assistants) documented yes for fall mats. The fall risk assessment dated [DATE] revealed a score of 15, indicating the resident was at moderate risk for falls. Interventions included use of fall mats and an OT/PT (occupational therapy/physical therapy) consult. Review of a physician's order dated June 25, 2021, included an order to place fall mats to each side while patient is in bed and to verify placement every shift. The NP (nurse practitioner) progress note dated June 27, 2021 included the resident was alert to self, and had bilateral upper and lower extremity weakness. Review of the fall care plan dated June 28, 2021 revealed the resident was identified at risk for falls related to impaired safety awareness, impaired mobility secondary to a diagnoses of stroke. The goal was for the risk of falls and/or injury related to falls will be minimized throughout the resident's stay. Interventions included fall mats per order. Further review of the clinical record revealed the order for the fall mats was transcribed onto the June 2021 TAR (treatment administration record) with a start date of June 25, 2021. The TAR revealed that the fall mats were marked as documented in place on both day and night shift from June 26 through 28, 2021. However, multiple random observations conducted on June 28, 2021 at different times of the day revealed the resident was laying on her back in the bed with no fall mats on the floor on either side of the resident's bed. On some occasions, the head of the resident's bed was elevated. Random observations were conducted on June 29, 2021 at 8:00 a.m. and 8:55 a.m. On both occasions, the resident was in bed and there were no fall mats on the floor on each side of the bed. An interview was conducted on June 29, 2021 at 9:00 a.m. with a registered nurse (RN/staff #42), who stated that if a resident is found to be a fall risk on admission, they will put interventions in place depending on the resident's risk. A review of the clinical record was conducted with staff #42 who stated resident #281's fall risk score was 15; and, the interventions for this score would be to use a fall mat and physical/occupational therapy. During the interview, an observation of resident #281 in the room was conducted with staff 42 who stated the resident did not have the fall mats in place. An interview was conducted on June 29, 2021 at 9:15 a.m. with a CNA (staff #110) who stated she repositions resident #281 every 2 hours, provide catheter care, place pillows under the resident's heels and assists with feeding. Staff #110 further stated that staff are not using fall mats for resident #281 at this time. On June 29, 2021 at 9:20 a.m., the CNA (staff #110) was carrying 2 fall mats down the hall and stated that they are now putting fall mats in resident #281's room because the resident was a fall risk. Staff #110 further stated resident #281 did not have or used fall mats until now. An interview was conducted on June 29, 2021 at 10:19 a.m. with another RN (staff #60), who stated that resident #281 did not have the fall mats in place as ordered. However, staff #60 stated she had documented that the fall mats were in place. Staff #60 stated she must have been busy and did not check the room prior to completing her documentation. Staff #60 further stated the resident not having the fall mats in place was an oversight on her part. The RN also stated the fall mats should be in place next to the bed when the resident is in bed unless staff are doing treatments. Staff #60 also stated the risk of the fall mats not being in place could have resulted in an injury if the resident had fallen from the bed. An interview with the Director of Nursing (DON/staff #48) was conducted on June 29, 2021 at 10:26 a.m. The DON stated that fall interventions implemented are dependent on the resident's score on the fall risk assessment. During the interview, a clinical record review was conducted with the DON who stated there was a physician's order for the use of fall mats for resident #281. The DON further stated the fall mats were not in place as ordered until after the survey team brought this to attention. She stated the risk could have been a fall with injury; and that, not having a fall mat for a resident identified as at risk for fall is not following facility expectations. A review of the facility policy titled, Fall Prevention, revealed that it is their policy to ensure optimal safety while promoting patient independence and maximizing psychosocial well-being. Safety interventions will be implemented and monitored with appropriate documentation as indicated. Discontinuation of safety interventions will require IDT (interdisciplinary team) review and appropriate documentation of rationale and supporting data. Upon admission, each patient will be evaluated for risk of falls utilizing the Fall Risk Assessment and based upon the calculated score, the Fall risk Protocol and Care Plan will be completed and the appropriate interventions initiated. The admitting nurse/nurse manager will be responsible for insuring that the interventions are initiated and communicated to appropriate staff for follow through. A review of the Fall Risk Protocol and Care Plan included that a fall risk protocol and care plan is to be completed with the Fall Risk Assessment initiating interventions based upon the resident's history of falls and/or total score value. It also included that interventions are guidelines and may not be appropriate for each patient; if an intervention is not initiated, an explanation should be provided. Interventions indicated in lower risk categories should also be provided for higher risk patients. The goal of the protocol was for the patient will remain free from serious injury related to falls with appropriate interventions in place while maintaining patient's independence and rights including the right to refuse interventions with appropriate informed decision making. According to the protocol scores of 0-11 is low risk with no interventions indicated; scores of 12-20 is moderate risk with interventions that included fall mats and therapy consult; and, scores of 21-34 indicated high risk with interventions such as fall mats, therapy consult and bed in lowest position. Residents with history of repetitive falls regardless of the score will have the following interventions: fall mats, therapy consult, bed in lowest position and frequent checks.

Based on observations, staff interviews, and policy and procedure, the facility failed to ensure that refuse/garbage was disposed of properly. The deficient practice could result in an unsanitary condition and pest harborage and infestation. Findings include: During an initial kitchen observation conducted on June 28, 2021 at 8:39 a.m. with the Dietary Manager (staff #46), the area behind a trash dumpster was observed to have two unopened plastic trash bags lying on the ground. In another observation conducted with the Dietary Manager (staff #46) on June 29, 2021 at 9:22 a.m., there were 2 opened plastic trash bags on the ground behind the dumpster. There were paper products overflowing and falling out of the two bags. An interview with the dietary director (staff #46) was conducted on June 29, 2021 immediately following the observation. Staff #46 stated that the fallen leaves around and behind the dumpster were cleaned up yesterday. However, he was not sure how the garbage bags behind the dumpster were missed and not removed by staff. The dietary director stated opened garbage bags on the ground did not follow facility policy and was an infection control issue. An interview was conducted on June 29, 2021 at 12:13 p.m. with the Director of Nursing (DON/staff #48) who stated the city picks up the garbage from the dumpster on a daily basis. The DON also stated trash should be inside and not outside the dumpster. The DON stated the trash on the ground behind the dumpster did not meet the facility's expectation and the risk of opened trash could result in pest infestation. Review of the facility policy titled, Waste Disposal, included that it is their policy that garbage will be disposed of and as needed throughout the day and at the end of each day. Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered when not in use. Containers will be emptied as often as necessary throughout the day and at the end of each day. Trash bags shall be sealed prior to removing them from the facility. Trash will be deposited into a sealed container outside the premises. The policy further included that the dumpster will be inspected for debris and lid closed when trash is disposed of by food service. Maintenance and other staff are also responsible for ensuring the dumpster lid is closed and area is free of accumulated debris, foul odors and waste fat. Maintenance will be notified if any issues arise.

Based on observation, interview, and record review the facility failed to implement and maintain an infection control program designed to prevent the development and transmission of communicable diseases and infections when they: 1. Failed to complete steps during the doffing (removal) process designed to prevent spread of pathogens from contaminated Personal Protective Equipment (PPE) to staff. Four of four facility staff observed to potentially contaminate themselves during the removal of their PPE while exiting rooms under transmission based precautions for COVID-19. 2. Rehab staff were observed to have drinks on their mobile desks in the hallways directly outside of rooms under transmission based precautions for COVID -19. These failures placed all residents and staff at risk for exposure and infection of the highly transmissible [DIAGNOSES REDACTED] CoV-2 virus which causes COVID-19. Findings: 1. PPE Observed housekeeping staff 1 (HKS1) cleaning room [ROOM NUMBER] on 7/6/2020 at 11:25 AM. Signage posted on the door read the room was under Droplet Precautions and PPE was stored in a cabinet just outside the room. HKS1 wore PPE while in the room, a yellow gown, a mask, a face shield, and gloves. Upon completion of cleaning, HKS1 proceeded to doff the PPE at the doorway. She untied the waist ties of the gown, then reached a gloved hand under the gown neck and lifted it over her head. Observed gloved hand touch her shirt, neck, hair and face. She then placed the gown in a linen bin. HKS1 then removed 2 pairs of gloves, discarded them, and proceeded to clean her hands with an alcohol based hand rub. She then stepped outside the room and re-gloved, cleaned the face-shield and discarded her mask and gloves, and performed hand hygiene. HKS1 interviewed immediately following the doffing process at 11:30 AM. When asked if she had tried to untie the neck ties of the gown, HKS1 stated No I just pull it over head. When asked how she keep the contaminated glove from spreading infectious material to her shirt, neck, hair and face, she stated I try not to touch. Observed Registered Nurse (RN) 2 provide resident care on 7/7/20 at 11:38 AM. RN2 donned (put on) PPE and entered Resident A's room. RN2 wore a gown, a face shield, a mask, and gloves. Upon completion of a capillary blood glucose reading, RN2 came to the doorway and asked another staff to get her additional supplies to recheck the blood sugar reading. While standing in the doorway RN2 stated my mask just broke. She then removed her gloves and grasped the ear loops of the mask, touching the side of her face, and removed the mask. She did not perform hand hygiene after removing gloves, before touching the sides of her face while removing the mask. Once additional supplies and PPE were handed to RN2, she donned a new mask and completed the resident care tasks. RN2 doffed her PPE at 11:48 AM, removed gloves, then mask, then gown, placed gown in a bin, and then performed hand hygiene. RN2 stepped out of the room and proceeded to remove and clean the face shield and the glucometer with disinfectant, and then performed hand hygiene. RN2 did not perform hand hygiene after removing her gloves and before touching her head to remove the mask. During an interview with RN2 on 7/6/2020 at 11:50 AM, she described the transmission based precautions used were to prevent the spread of potential COVID-19, and PPE needed was a new mask, goggles or face shield, a gown and gloves. She described that the gowns were reused after washing, the face shield was also reused after disinfection. The resident should also wear a mask while staff are in the room, if possible. She clarified that if the resident had confirmed COVID-19 or it was suspected, then staff would wear an N95 respirator and use a disposable gown. She confirmed that she had recently had training on the donning and doffing of PPE. She stated that hand washing was done after all PPE was removed. When asked if she had missed a step between doffing her gloves, and touching her mask straps she rubbed her hands together in a hand washing motion and stated oh yeah, they are dirty. Observed RN2 in Resident B's room, in full PPE on 7/6/2020 at 12:05 PM. Sign outside of Resident B's door read Droplet Precautions. RN2 doffed her PPE in the following sequence: removed gloves, removed outer mask (worn over the source mask), removed gown, readjusted source mask on her face, and then performed hand hygiene. She then removed face shield and stepped outside of the room and disinfected the face shield. RN5 did not perform hand hygiene following the removal of gloves and prior to touching her head, or after removal of a contaminated gown and readjusting her source mask. When asked about the lack of hand hygiene she stated okay. Observed Nursing Assistant (NA) 4 don PPE to bring a lunch tray to Resident C on 7/6/2020 at 12:11 PM. Sign outside of Resident C's door read Droplet Precautions. After setting up Resident C's lunch tray, NA4 proceeded to doff her PPE. NA4 removed gloves, removed goggles, removed mask, touched neck while untied gown ties, removed gown and then washed hands. She stepped out of the room and donned her source mask. NA4 then donned gloves and disinfected the used goggles. NA4 did not perform hand hygiene following the removal of gloves, and touched her neck after touching contaminated goggles and mask, potentially spreading microorganisms. During an interview immediately following the observation, NA4 described the steps of doffing. She stated they were, 'gloves off first, then mask. Remove gown, put it in the bin, remove goggles, clean them and hang them up.' When asked if she was trained to wash hands at any points in the doffing process, she said at the end. When asked to clarify if she was trained to wash her hands after removing gloves, or at any other times during the removal of PPE, she again confirmed it was only at the end. Observed NA5 set up a lunch tray for Resident A on 7/6/2020 at 12:25 PM. NA5 was wearing a gown, mask, gloves, and eye glasses. Resident 5 requested a salad. NA 5 doffed her PPE in the following sequence, removed gown and placed it in a bin, untied face mask ties and removed, then removed gloves and performed hand hygiene. Upon exit, NA5 doned her source mask hanging outside the doorway. NA5 did not wear a face shield or goggles while in the room, and did not perform hand hygiene after removing a contaminated gown and touched her head with contaminated gloves. NA5 walked down the hallway toward the kitchen area. NA5 returned at 12:29 PM with a salad and donned PPE, entered room and assisted the resident. Observed NA5 doff PPE before exiting the room at 12:35 PM. NA 5 untied gown and removed it, placing in a bin; removed gloves, removed face mask and then washed hands. She exited the room, and donned her source mask, then removed face shield and disinfected it. NA 5 did not perform hand hygiene after removing gloves and before touching her head to remove the mask. During an interview on 7/6/2020 at 12:30 PM, NA5 described the steps for doffing as I usually take the gown off first, then the gloves. Then mask off, wash hands and come out here. Surveyor asked if the facility had educated her on when to wash hands during the doffing process, she stated she was taught to hand wash after all PPE is removed. When asked about not wearing a face shield while in Resident A's room, she stated yeah, I realized it on my way out. Interviewed the Clinical Nurse Manager (CNM) and the Director of Nursing (DON) on 7/6/2020 at 1:00 PM who together fulfill the Infection Preventionist's responsibilities. Together they confirmed the facility used the CDC Guidelines as their standard for policy, procedure, and plan development related to infection control. The CNM stated that she provided the staff in-services, and the DON described other duties she managed such as monitoring and tracking. The DON explained that all residents in the facility were under droplet transmission based precautions to prevent the potential spread of COVID-19 due to the wide-spread community transmission in Maripcopa County, previous out breaks in the facility, and the short stay nature of the residents served. This was a decision made in conjunction with the Medical Director. Surveyor asked what the expected steps for doffing PPE were. The CNM stated the sequence of steps was to remove gloves, remove gown, remove mask, remove face shield, and after all PPE removed, wash hands. The DON clarified that hand hygiene was expected after removing gloves, and signage posted indicated hand hygiene was to be done after touching any contaminated PPE. Reviewed facility's COVID-19 Emergency Plan dated 1/31/2019. Under the heading of Admissions point 5 read Asymptomatic patients . should be placed on a quarantine isolation (or other transmission-based precautions if directed by the . medical director) for 14 days even with negative test(s). Under the heading Transmission-Based Precautions it read to Follow standard, contact, and droplet precautions. Facility record dated 6/13/2018, titled Infection Control Standard Precautions Policy and Procedure reviewed on 7/7/2020. Under the heading of Procedure, point 2. Hand Washing read, wash hands after touching . contaminated items . Wash hands immediately after gloves are worn. Under point 3. Gloves it read, Remove gloves promptly after use, before touching non-contaminated items . and wash hands immediately to avoid transfer of microorganisms to other patients and environments. 2. Drinks in care area During PPE observations on 7/7/2020 at 11:45 AM, a potable desk was observed in the hallway outside of an unexampled resident's room. On the desk were papers, a clipboard, theraband (a resistance bands used for physical therapy exercises), and a cup with a straw covered by a glove. Therapy Assistant TA7 was in the resident's room working with the resident, wearing a gown, face shield, mask, and eye protection. During a phone interview on 7/8/2020 at 08:40 AM, the Rehab Manager was asked about drinks left on potable desks in the hallways outside of rooms. The Rehab Manager stated that that staff were spending time away from their usual work areas and were trying to stay hydrated. When asked if this was an acceptable practice she stated No, it not. She then added, We will address this. The Administrator who was also on the call, confirmed they were making a change, as that was not a good practice.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that residents, their representatives and families were notified of the COVID status of the building for two residents (#2 and #4). The deficient practice can result in residents' and families' potential uninformed exposure to COVID-19 infection. Findings include: -Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) for resident #2 dated May 6, 2020 was reviewed and included the resident had a score of 13 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. An interview was conducted with the facility administrator (staff #13) on June 18, 2020 at 8:15 am. Staff #13 stated the facility publishes a website with the facility's COVID-19 status and updates. She stated the website address is given to residents upon admission. An interview with the Director of Nursing (DON/staff #21) was conducted on June 18, 2020 at 12:15 pm. The DON stated there is no available documentation to indicate resident #2's family was made aware of the website which published the facility's COVID-19 status and updates. Another interview was conducted with the DON and facility administrator on June 18, 2020 at 12:54 pm. Staff #13 stated all of the residents are provided with the website address upon admission. The website was first published in early May. Staff #13 stated the families of the residents who were current residents at the time the website was published were sent an email with instructions on how to access the website. She stated there was no confirmation that Resident #2's family received the email. -Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS for resident #4 dated May 30, 2020 was reviewed. It included that the resident had a BIMS score of 15, indicating the resident was cognitively intact. An interview was conducted on June 18, 2020 at 11:45 a.m. with Resident #4, regarding facility notification/ Covid 19 updates. Resident #4 stated that the only information she has received from the facility is what was overheard amongst facility staff in the halls. Resident #4 stated that no one specifically from the facility has come to her and said what was going on. Resident #4 stated that she was not given any information on a website from Advanced Health Care. In an interview conducted with the DON and facility administrator on June 18, 2020 at 12:54 pm, the DON stated she has not checked with residents to see if they were able to access the website. She stated she was not aware that Resident #4 did not know about the website. The facility policy COVID-19 Emergency Plan includes that patients, their representative, and families are to be informed of confirmed COVID-19 infections and respiratory infections of three or more residents within 72 hours of each other. The policy includes that the information should be easily available to residents and their families.

Based on observations, staff interviews and policy review, the facility failed to ensure that multiple narcotic medications and controlled substances were stored via a double-lock system. The facility census was 37 residents. The deficient practice could result in failure to prevent loss or diversion. Findings include: During random observations conducted on (MONTH) 7, 2019 between 9:00 a.m. and 12:00 p.m., the doors to the Director of Nursing's (DON/staff #59) office were observed to be open and the room was unoccupied. The office was located adjacent to the nurse's station and resident rooms, and was easily accessible from the resident corridor. An interview was conducted on (MONTH) 8, 2019, at 9:10 a.m., with a LPN (Licensed Practical Nurse/staff #74). Staff #74 stated that when narcotic medications and other controlled substances are discontinued, the medications and the sign-out sheets for the medications are given to the DON for disposal. Another observation was conducted on (MONTH) 8, 2019 at 9:17 a.m., and the 2 doors to the DON's office were open, and the office was unoccupied. An interview was conducted on (MONTH) 8, 2019 at 9:20 a.m., with the DON. The DON said that the nurses bring her the narcotic medications and other controlled substances, which are then destroyed a couple of times a month. She said that she locks the medications in a drawer in her office where they are stored, until they are destroyed. The DON agreed that sometimes her office door is left open. She stated that it was difficult to lock the doors to her office since they connect to the back offices. The DON stated that she was not aware that the narcotic medications and other controlled substances stored in her office were not being stored as double-locked and that it did not meet the requirement for adequate storage. At this time, multiple medications were observed to be stored in a single-locked cabinet. Inside of the cabinet, there were over 20 medication cards inside. The medications consisted of narcotic pain medications, antianxiety medications and hypnotic medications. Review of a policy titled, Medication Storage revealed that the purpose is to ensure that medications are stored in a safe and secure manner. The policy also included All controlled drugs are stored in a separate area under double lock.

Based on observation, facility documentation, staff interviews and policy review, the facility failed to ensure that the daily nurse staffing information that was posted was accurate regarding the resident census and the number of nursing shifts. Findings include: An observation was conducted on (MONTH) 6, 2019 at 8:13 a.m., of the Daily Nurse Staffing information, which was posted on a table in the front lobby. The form contained areas to document the daily resident census and the nurse staffing information for each shift. Further review of the daily nurse staffing information dated (MONTH) 6, 2019, revealed the facility census was 37. However, according to the resident census for (MONTH) 6, 2019, the actual census was 36, as one resident had been discharged . Also on the daily nurse staffing information form were three nursing shifts listed (for RN's and LPN's) with the following times: 6 am-2:30 pm, 2 pm-10:30 pm and 10 pm-6:30 am. In addition, previous daily nurse staffing information forms were reviewed for (MONTH) 2019, and also listed the facility had three nursing shifts for RN's and LPN's, with times as noted above. An interview was conducted on (MONTH) 7, 2019 at 11:45 a.m., with the Director of Nursing (DON/staff #59). Staff #59 stated that she has worked at the facility for a little over a year and during that time, there has only been two nursing shifts (for RN's and LPN's), 6 a.m. to 6 p.m. and 6 p.m. to 6 a.m. She reviewed the nurse staffing information forms and stated that the three nursing shifts listed on the forms were incorrect and should be updated to reflect two nursing shifts. She said that she and the Administrator were responsible for making changes to the daily nurse staffing form. An interview was conducted on (MONTH) 7, 2019 at 1:28 p.m. with the Administrator (staff #44), who stated that she and the DON are responsible for ensuring that the daily postings are correct. According to the Posted Nursing Staff policy dated (MONTH) 12, (YEAR), the facility will post the current census and the actual hours worked by nursing staff, each shift.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#79) was assessed to safely self-administer a medication and a topical [MEDICATION NAME]. Findings include: Resident #79 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of a nurses note dated (MONTH) 23, (YEAR) revealed the resident had stated that she had been putting bag balm ointment on areas while in the hospital, and had put some on this a.m. The note further included that the resident was educated on not using bag balm, as it was not intended to be used on humans. According to a Minimum Data Set assessment dated (MONTH) 1, (YEAR), the resident had a Brief Interview for Mental Status score of 15, which indicated no cognitive impairment. An observation was conducted on (MONTH) 5, (YEAR) at 10:51 a.m., of the resident in her room. At this time, a bottle of TUMS and a container of bag balm were observed on a table in the resident's room. Another observation was conducted on (MONTH) 6, (YEAR) at 11:40 a.m. and the resident was in her room. On a table in the resident's room was a bottle of TUMS and a container of bag balm. At this time, an interview was conducted with the resident who stated that she brought the TUMS from the hospital, but has not used them since she has been at the facility. She said she uses the TUMS for heartburn. The resident also stated that she uses the bag balm on her hands when they are dry. An observation was conducted on (MONTH) 7, (YEAR) at 8:35 a.m., and the TUMS and bag balm were on the table in the resident's room. An interview was conducted on (MONTH) 7, (YEAR) at 8:40 a.m. with a licensed nursing assistant (staff #36), who stated that residents are not to have meds in their room. She said that if she saw any meds in a resident's room, she would let the nurse know. An interview was conducted on (MONTH) 7, (YEAR) at 9:55 a.m., with a registered nurse (RN/staff #95). She stated that if a resident wants to self administer medications, a form has to be filled out by the nurses, and signed by the nurse and the resident. She said then you have to have an order. Staff #95 stated the meds should be kept in the resident's room in a locked box. She stated that she will write in the nurses notes if the resident said they took the medication, but does not put down the time it was taken. An observation of the resident's room was conducted on (MONTH) 7, (YEAR) at 10:34 a.m., with staff #95, and the TUMS and bag balm were still on the table. Staff #95 stated that she did not know that the resident had TUMS and bag balm in her room. She stated that she did not know if the resident had taken any of the TUMs. She further stated that there should be orders for the TUMS and bag balm. At this time, staff #95 reviewed the clinical record and stated that there was no self administration assessment form completed for this resident, and there were no orders for TUMS or bag balm. During an interview with a RN (staff #72) conducted on (MONTH) 7, (YEAR) at 11:30 a.m., staff #72 stated that if a resident wants to self administer meds, the nurse completes a self medication assessment, which has questions such as can the resident read a label, can they open the bottle, can they distinguish colors, and do they have good judgement. She said that once this form is completed, the nurse calls the physician and obtains an order to self administer the medication. She said that once they receive the order, then it is entered in the Medication Record, and the medication comes up in the computer that the resident is self administering it. She said the times also show up on the Medication Record and the nurse is suppose to ask the resident when the medication was taken and document it. Staff #72 stated that the medication is kept in the resident's room. An interview was conducted on (MONTH) 8, (YEAR) at 7:58 a.m., with the acting Director of Nursing (staff #119). She stated that for residents who want to self administer medications, they have an assessment which needs to be completed. She said the form includes areas such as; if the resident is alert and oriented and if they understand why they are taking the medication. Staff #119 stated if the resident is assessed to safely self administer medication, they obtain orders and the medication is then put into the Medication Record, with the times to be given. She said the nurse is to check with the resident to see if they took the medication and then document it on the Medication Record. Staff #119 further stated that if a resident wants to use bag balm, the assessment for self administration should be done by the nurse, then an order obtained and the bag balm should be added to the Medication Record. Review of a blank self-medication administration assessment form revealed questions such as; can the resident open a flip-cap or screw bottle; is resident psychologically capable to handle and administer own drug regimen; has a history of using poor judgement with dispensing medications; physician's orders [REDACTED]. According to the Self-Administration of Drugs policy, each resident has a right to self-administer drugs if the interdisciplinary team has assessed the resident and determined the practice is safe. Upon admission, each resident will be asked whether he/she wishes to self-administer their own drugs. The interdisciplinary team will document this in the resident's medical record. If the resident expresses a desire to self-administer drugs, the attending physician will be notified. The interdisciplinary team, including the attending physician, will assess the resident to determine if this practice is safe. The facility recognizes the significant risk that may be involved in allowing residents to self-administer drugs. Therefore, the attending physician must agree to allow the resident to self-administer drugs as his/her medical judgment is essential to determine whether or not this practice is safe. If the interdisciplinary team, including the physician determines that the resident may self-administer drugs safely, the resident will be instructed on the proper methods of administration, infection control measures, amount of each medication to be administered, the expected effects and possible side effects of each medication. Each resident who wishes to self-administer drugs will sign a statement in his/her medical record confirming this wish. An order will be written in the resident's medical record by the attending physician, permitting the resident to self-administer drugs. The medication sheet will be clearly labeled to alert the medication nurse that the resident is permitted to self-administer drugs. The medication nurse will bring the drugs to the resident within one hour of the time scheduled for administration. The medication nurse will red flag the medications left with the resident. The medication nurse will return within one hour and retrieve the medication. The nurse will confirm self-administration of the drugs left with the resident and document it in the medical record.

Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure that one resident (#25) was free of an unnecessary medication, by failing to ensure there were adequate indications for the use of an antipsychotic medication. Findings include: Resident #25 had multiple readmissions to the facility including (MONTH) 10, (YEAR), (MONTH) 8, (YEAR) and (MONTH) 16, (YEAR). [DIAGNOSES REDACTED]. Review of the nursing notes from (MONTH) 10 through (MONTH) 14, (YEAR) revealed the resident was alert and oriented, with some confusion at times. A nursing progress note dated (MONTH) 16, (YEAR) included the resident was readmitted from the hospital and had a foam wedge between his legs, due to status [REDACTED]. Review of the physician's progress notes revealed the resident was seen on (MONTH) 20, (YEAR) and on (MONTH) 21, (YEAR). The note from (MONTH) 21 revealed the resident has [MEDICAL CONDITION] and presents with good controlled tremors. The resident was also seen on (MONTH) 22 and 23, (YEAR). There was no documentation that the resident experienced any hallucinations or had a [DIAGNOSES REDACTED]. Review of a 5-day Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS also included that the resident had no hallucinations or delusions and had no [MEDICAL CONDITION]. A nursing progress note dated (MONTH) 25, (YEAR) included the nurse observed that the resident was jerking and stiffening his body in bed. Will continue to monitor. Review of a nursing progress note dated (MONTH) 26, (YEAR) at 8:10 a.m., revealed the nurse observed that the resident's arms and legs started twitching for about two seconds. A family member stated that he has been doing this. Will report findings to physician. The physician's orders dated (MONTH) 26, (YEAR) included for [MEDICATION NAME] 25 mg at hours of sleep for [MEDICAL CONDITION], as evidenced by hallucinations, with a discontinue date of (MONTH) 26, (YEAR). A consent for the [MEDICATION NAME] was signed by a family member on (MONTH) 26, (YEAR) for a [DIAGNOSES REDACTED]. A Psychopharmocological Medication Review dated (MONTH) 26, (YEAR) included that the medication being administered was [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The documentation included that the therapy was initiated in-house, that the medication was appropriate for use in geriatric patients and that behavior monitoring was in place. Review of a physician's progress note dated (MONTH) 26, (YEAR) at 1:59 p.m., revealed the resident continues with spastic and jerking all body movements and is positive for ataxia, weakness and muscular [DIAGNOSES REDACTED], and abnormal body movements with contractions. Per the note, the resident was seen by the neurologist today, who recommended starting [MEDICATION NAME] and to stop any muscle relaxers and [MEDICATION NAME]. The note included that the physician called the neurologist but talked with his assistant or NP, who said to give the resident [MEDICATION NAME] for his worsening agitation and that the Neupro could be stopped for a few days. The note further included the physician was going to stop all of his meds, except the [MEDICATION NAME] (interact also w Neupro) that was indicated by his neurologist. If tomorrow cont w this abnormal body [DIAGNOSES REDACTED] movements and mentation impairment, I will stop all of this meds and he will be sent to the ER for an evaluation. However, the physician note also included, Hold starting [MEDICATION NAME] until Patient is more conscious and less muscular [DIAGNOSES REDACTED]. Further review of the physician's progress notes dated (MONTH) 26, (YEAR), revealed there was no documentation that the resident exhibited any hallucinations or had a [DIAGNOSES REDACTED]. A nursing progress noted dated (MONTH) 26, (YEAR) at 7:02 p.m. included that the resident continues to display jerking behavior during shift and the physician was notified. New order for [MEDICATION NAME] was obtained. Jerking decreased after [MEDICATION NAME] administered, but still present. Resident visited neurologist outside of facility. Review of a care plan initiated on (MONTH) 26, (YEAR) revealed the resident was at risk for adverse consequences related to receiving antipsychotic medication for [MEDICAL CONDITION] as evidenced by hallucinations. An intervention included to monitor the resident's behavior and response to medication. A nursing progress note dated (MONTH) 27, (YEAR) at 1:59 p.m. included the resident did have twitching of his arms while the nurse was in the room. Will continue to monitor. Another physician's order dated (MONTH) 27, (YEAR) at 2:12 p.m. included for [MEDICATION NAME] 25 mg at hours of sleep for [MEDICAL CONDITION], as evidenced by hallucinations. There was no end date for this order. According to the (MONTH) (YEAR) Medication Administration Record (MAR), [MEDICATION NAME] 25 mg was first administered on (MONTH) 27, in the evening. A physician's progress note dated (MONTH) 27, (YEAR) at 8:02 p.m. included that after discontinuing two medication (Neupro and [MEDICATION NAME]) the resident was presenting with less muscular spasms or [DIAGNOSES REDACTED] body movements. The note further included to continue holding [MEDICATION NAME] also. However, there was no physician's order to hold the [MEDICATION NAME] in the resident's clinical record. A physician's noted dated (MONTH) 28, (YEAR) included the resident was improving on his mentation and had less abnormal body movements. There was no documentation that the resident exhibited any hallucinations or had a [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 28, (YEAR) included the resident was started on [MEDICATION NAME] as ordered. Further review of the (MONTH) (YEAR) MAR revealed that [MEDICATION NAME] was administered on (MONTH) 28. Review of the nursing notes for (MONTH) (YEAR) revealed there was no documentation that the resident experienced any hallucinations or psychotic episodes. Review of the (MONTH) (YEAR) Physician Order Report revealed orders for [MEDICATION NAME] 25 mg at bedtime for [MEDICAL CONDITION], as evidenced by hallucinations. The orders also included to monitor for the following: [MEDICAL CONDITION]-as evidenced by hallucinations. Indicate the number of times the behavior(s) occurred each shift. Anti-psychotic use: Observe patient closely for significant side effects. Review of the 14 day MDS assessment dated (MONTH) 2, (YEAR), revealed the resident had a BIMS score of 14, which indicated intact cognition. The MDS also assessed the resident to have no hallucinations, delusions and no [MEDICAL CONDITION]. However, the MDS included that the resident was on an antipsychotic medication. Review of the (MONTH) (YEAR) MAR revealed the resident was administered [MEDICATION NAME] 25 mg in the evening from (MONTH) 1-7. This record also indicated that the resident was being monitored for hallucinations, however, there was no documentation that the resident experienced any hallucinations. Review of the (MONTH) (YEAR) physician's progress notes revealed the resident was seen on (MONTH) 1, 2, 3, 4, 5 and 6. According to the (MONTH) 5 and 6 notes, the resident was making good improvements on muscle strengthening and improved cognition, and presented with minimum tremor, but was still walking with spastic or ataxic walking. There was no documentation in the physician's progress notes that the resident was experiencing any hallucinations or had a [DIAGNOSES REDACTED]. There was also no documentation in the nursing progress notes from (MONTH) 1-7, (YEAR) that the resident had any hallucinations or psychotic episodes. An interview was conducted on (MONTH) 8, (YEAR) at 10:08 a.m. with the resident's nurse (registered nurse/staff #95). She stated that the resident is taking [MEDICATION NAME] in the evening for [MEDICAL CONDITION], as the resident had been saying random things. An interview was conducted on (MONTH) 8, (YEAR) at 10:35 a.m., with the residents' physician, who had documented in the physician progress notes [REDACTED]. She stated that the neurologist discontinued [MEDICATION NAME], due to interacting with a neuro medication that the resident was taking for Parkinson disease, as he became more irritated and had increased spastic movements, so the neurologist recommended [MEDICATION NAME] and she ordered it. She further stated that later in the day on (MONTH) 26, she evaluated the resident and his spastic movement was worse and so was his cognitive status. She said that is why she wrote in her notes to hold the [MEDICATION NAME]. She said that due to his condition, she didn't want him to get the [MEDICATION NAME], as the [MEDICATION NAME] can make those symptoms worse. When questioned why there was no written order to hold the [MEDICATION NAME], she stated that she gave a verbal order to the nurse and did not know what had happened. The physician further stated that the resident is not currently on [MEDICATION NAME]. At this time, the electronic MAR for (MONTH) (YEAR) was reviewed with the physician. The MAR included the order to administer [MEDICATION NAME] 25 mg at bedtime. In addition, the MAR showed that the resident was receiving [MEDICATION NAME] daily. The physician then stated that she did not know that the resident was on [MEDICATION NAME]. She said that since he was doing well, she did not want to stop it. When questioned regarding the lack of documentation in her progress notes regarding the resident having hallucinations, psychotic episodes or a [DIAGNOSES REDACTED]. She said the resident came back from the hospital and had some confusion, and based on his neurologist's recommendation, she ordered the [MEDICATION NAME]. The physician was unable to recall any psychotic episodes or hallucinations, which the resident had exhibited. A follow up interview was conducted on (MONTH) 8, (YEAR) at 11:47 a.m. with the resident's physician. She stated that on the progress note from (MONTH) 27, (YEAR) where it said to hold meds except for [MEDICATION NAME], she stated that was a mistake, as she wanted the [MEDICATION NAME] held. She stated it was suppose to say hold meds except for Clonazapam, not [MEDICATION NAME] and that she just changed it in her notes. During an interview conducted on (MONTH) 8, (YEAR) at 11:34 a.m. with the acting Director of Nursing (staff #119), she stated that they try not to prescribe antipsychotic medications. She said if an antipsychotic is ordered, it should have a [DIAGNOSES REDACTED]. She said there will be orders to monitor for side effects on the MAR and the nurse is to put a minus sign if no symptoms and a plus sign if having symptoms, and the nurses are to chart in the nurses notes if any symptoms. She said they have a strong rule to not start antipsychotics. She said if a resident is on an antipsychotic for hallucinations, she would expect to see documentation of hallucinations in the clinical record. She further stated that behavior monitoring is done every shift and documented on the MARs. Another interview was conducted on (MONTH) 8, (YEAR) at 12:05 p.m., with staff #95. She stated that if a resident comes in on an antipsychotic, they make sure the order has a [DIAGNOSES REDACTED]. She said that if the order does not include it, the nurse should call the Dr. She said that there should be orders to monitor for behaviors such as hallucinations, and they are to document behaviors every shift on the MAR. She said if no behaviors are present then you put a minus sign on the MAR, and if the resident has behaviors then you put a plus sign and document the behavior in the nurses notes. Staff #95 stated that about two weeks ago the resident had episodes of being confused, was not making sense, and had tremors and spasms. She stated that they thought it was related to medication and some of the meds were discontinued and he got better. She further stated that the resident is receiving [MEDICATION NAME] daily as ordered. She said that she was not aware of any order to discontinue/hold the [MEDICATION NAME]. Another interview was conducted on (MONTH) 8, (YEAR) at 1:50 p.m. with staff #119. After reviewing the resident's MARs for behavior monitoring for hallucinations, she stated that the nurses are documenting a 0, instead of a minus sign or a plus sign. She stated that she had reviewed the resident's clinical record and there should have been documentation regarding the condition of the resident to show why [MEDICATION NAME] was being given. She also stated that she did not know why an order to hold the [MEDICATION NAME] was not included in the clinical record. An interview was conducted on (MONTH) 8, (YEAR) at 2:01 p.m. with a clinical nurse manager (registered nurse/staff #78). She stated that another nurse had brought her into the residents room last month (could not remember the specific date) and the resident had random jerking movements, was talking gibberish and was grabbing at things that were not there. The facility was unable to provide any clinical record documentation that the resident experienced hallucinations and/or had psychotic episodes in (MONTH) (YEAR) and from (MONTH) 1-8, (YEAR). Review of the Psychopharmacological Med Management policy and procedure revealed that each resident's drug regimen will be free from unnecessary drugs. Residents admitted to the facility on [MEDICAL CONDITION] medications will receive a comprehensive and ongoing evaluation of their current medication regimen. The evaluation will examine appropriateness of medication, dosage, duration and diagnosis, with consideration of risks and benefits in consultation with the physician. Ongoing evaluation will include side effect monitoring to be located in the MAR with the listing of possible side effects. Staff will identify possible side effects by charting a plus or minus sign on the day and shift indicated with a brief explanation of positive responses. Residents receiving [MEDICAL CONDITION] medications for the management of behavioral symptoms will have behavior monitoring in place. Residents not receiving [MEDICAL CONDITION] medications upon admission will not be prescribed psychotic medications unnecessarily. The policy included that an antipsychotic medication should be used only for certain [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. the following: inconsolable or persistent distress, a significant decline in function and/or substantial difficulty receiving needed care. In addition, the policy included that before initiating an antipsychotic medication, the target behavior must be clearly and specifically identified and monitored, in order to ensure the behavioral symptoms are not due to a medical condition or problem, or is persistent or likely to reoccur without continued treatment and not sufficiently relieved by non-pharmacological interventions, and is not due to psychological stressors.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that a medication and a topical [MEDICATION NAME] for one resident (#79) were stored in a secured manner and were inaccessible to other residents. Findings include: Resident #79 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of a nurses note dated (MONTH) 23, (YEAR) revealed the resident had stated that she had been putting bag balm ointment on areas while in the hospital, and had put some on this a.m. Resident was educated on not using bag balm, as it was not intended to be used on humans. According to a Minimum Data Set assessment dated (MONTH) 1, (YEAR), the resident had a Brief Interview for Mental Status score of 15, which indicated no cognitive impairment. An observation was conducted on (MONTH) 5, (YEAR) at 10:51 a.m. of the resident in her room. At this time, a bottle of TUMS and a container of bag balm were observed on the table in the resident's room. Another observation was conducted on (MONTH) 6, (YEAR) at 11:40 a.m. and the resident was in her room. On a table in the resident's room was a bottle of TUMS and a container of bag balm. An observation was conducted on (MONTH) 7, (YEAR) at 8:35 a.m., and the TUMS and bag balm were on the table in the resident's room. During an interview conducted on (MONTH) 7, (YEAR) at 8:40 a.m., a licensed nursing assistance (staff #36) stated that residents are not to have meds in their room, and if she saw any medications in a resident's room she would let the nurse know. An observation of the resident's room was conducted on (MONTH) 7, (YEAR) at 10:34 a.m. with a registered nurse (staff #95), and the TUMS and bag balm were still on the table. Staff #95 stated that she did not know that the resident had TUMS and bag balm in her room. An interview was conducted on (MONTH) 8, (YEAR) at 7:58 a.m., with the acting Director of Nursing (staff #119). She stated the medications should not be kept on a table in a resident's room, because you could have a confused resident wandering around. According to the Medication Storage Policy, medications and biologicals are to be stored safely and securely. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. All drugs and biologicals are stored in locked compartments.

Based on facility documentation, staff interviews, Centers for Disease Control (CDC) guidelines and policy review, the facility failed to ensure that the infection control program included the tracking of infections and that data was analyzed, in order to identify trends and patterns of infections. The facility also failed to ensure that proper handwashing technique was performed during a medication pass observation. Findings include: -Review of the infection control documentation for October and November 2015, revealed the facility had identified resident specific infections, per the Patient Infection Report forms. However, there was no documentation that the number and types of infections were tracked each month, in order to determine any trends and patterns. As a result, there was no documentation the facility evaluated the need to implement any changes with infection control practices. An interview was conducted on December 9, 2015, with the clinical RN nurse manager in charge of infection control monitoring. She stated that she has fallen behind regarding the infection control documentation for October and November 2015. She stated that she is suppose to complete a Monthly Infection Control Report each month, which includes tracking and trends of infections. She also stated that she maps the infections at the end of each month to present to the Quality Assurance Committee, however, there was no documentation of this for October and November 2015. An interview was conducted with the Administrator on December 9, 2015. She stated that the RN clinical nurse manager should be tracking the types and number of infections for trends. The facility's Infection Control Surveillance policy included, Reason: To effectively monitor infections within the facility by gathering data and assessing possible trends and to assist in minimizing the spread of infection within the facility. The policy also included that the facility will complete the Monthly Infection Control Report by the 5th working day of each month for the previous month and the report will include identified trends and abnormalities with recommendations for resolution to include specific interventions, a time frame for completion, as well as follow-up for previously identified problems/concerns and identified infectious organisms categorized by site of infection and building location or hall. -During a medication pass observation conducted on December 7, 2015 at 2:25 p.m., a RN passed medications to four different residents. Following the administration of medications to each of the residents, the RN washed her hands with soap and water, however, the RN turned off the water faucet with her bare hands, thereby recontaminating her hands. The RN then dried her hands with a paper towel. Following these observations, the RN stated she knew she was supposed to use a paper towel to turn off the faucets. During an interview conducted with the DON on December 8, 2015, the DON stated that hand washing is basic and all staff should wash their hands or use hand sanitizer if not badly soiled following any patient contact. She stated the water faucet should be turned off with a paper towel and not bare hands. Review of the facility policy titled, Hand Washing revealed that hand washing should be completed before passing medications or giving injections and during any medication pass, as dictated by professional standards. The policy did not describe the hand washing procedure or the need to use a barrier when turning off the water faucet. A review of the CDC guidelines regarding Hand Hygiene revealed the following hand washing procedure: after applying soap, rub hands and interlacing fingers and after rinsing, the hands should be dried thoroughly using a single use paper towel and then use a paper towel to turn off the faucet.