Every finding on record at Agave Grove Post Acute

Based on staff and resident interviews, review of records, and review of facility policy and procedure, the facility failed to report an allegation of abuse within the required timeframe to the state agency for one (#5) out of three sampled residents. The Universe was 118. The deficient practice could lead to ongoing abuse leading to harm of a resident.-Findings include:Resident #5 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, anxiety, depression, insomnia, and hypertension. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.A care plan initiated on April 28, 2026, revealed that Resident #5 had a behavior problem related to false and accusatory statements towards staff. The interventions included assist to develop more appropriate methods of coping, interacting and encourage to express feelings appropriately.A nursing progress note dated June 21, 2026, at 1:39 p.m., revealed that Resident #5 exhibited an altered level of conscious (LOC) and altered mental status. The note revealed that the resident appeared drowsy, slurring her words and was belligerent towards staff. The nursing progress note also revealed that the resident knocked the bedside table over, water spilled and she accused staff of throwing water at her. The note indicated that Resident #5 was having accusatory delusions, refusing care and called the police. The note included that the police reported that Resident #5 was exhibiting with behavior issues and they took her to the hospital for altered mental status and behavior issues. However, there was no evidence in the clinical record that the resident's complaint reported on June 21,2026 had been reported following the facility policy, to include the state agency. On June 24, 2026 at 10:00 a.m. the facility 5 day investigation reports for May 2026 - June 2026 were requested. However, the facility reported there were no facility self reports during May 2026 and June 2026. The facility provided no evidence that the incident that occurred on June 21, 2026 was reported to the state agency. An interview was conducted on June 24, 2026, at 1:56 p.m., with a licensed Practical Nurse (LPN, staff #47) who stated that there are different types of abuse, including physical, verbal, financial. The LPN stated that facility process, when there is an altercation between a resident and a staff member, is that the resident gets separated and assessed from head to toe. The LPN stated that the incident is then reported to the state agency (Arizona Department of Health Services, AZDHS), APS (Adult Protective Services), the Police Department immediately or within 24 hours (hrs.) and an investigation will start if it deemed abuse. The LPN stated that Resident #5 had behaviors towards staff including slurring, yelling, screaming and refusing care. The LPN stated that the incident happened on Sunday, June 21, 2026, when Staff #47 went inside the room of Resident #5, and the resident started knocking over things on the bed side table including the water pitcher, then started screaming, yelling and making false allegation that the LPN threw water on her. The LPN stated that Resident #5 then called Emergency Medical Services (EMS) and notified EMS staff that LPN (staff #47) threw water on her. The LPN further stated that EMS staff notified her that Resident #5 made an allegation of throwing water on her. The EMS staff also stated that the cognition status of Resident #5 was unstable and that they took her to the hospital. The LPN stated that there were no other staff or resident present in the room during the incident. The LPN then stated that she then notified the charge nurse of the incident and the nurse notified the Director of Nursing (DON, staff #150). The LPN further stated that risk for staff and resident altercation, not investigated, would include that abuse would continue to happen and would not stop.An interview was conducted on June 24, 2026, at 2:33 p.m., with the Director of Nursing (DON, staff #150) who stated that abuse means infliction of harm towards resident, and there are all kinds of abuse including physical, verbal, mental, emotional, and financial. The DON stated that the facility process on suspected abuse would be to separate the resident, making sure resident is safe, notify State Agency within 2 hrs., suspend staff pending investigation, and then submitting the investigative report to State Agency within 5 business day. The DON stated that on June 21, 2026, Resident #5 was observed by LPN (staff #47) throwing water and other items from bedside table and accusing the LPN of throwing water on her face and chest and then calling EMS. The LPN then notified the registered nurse (RN, staff #124) of the incident, who then notified the DON. The DON stated that she would consider the incident as an allegation of abuse and should have reported the incident to the State Survey Agency with 2 hrs., as per the facility policy. The DON then stated that risk, if abuse was not reported to the State Agency and investigated then abuse would cause further harm to residents.An interview was conducted on June 24, 2026, at 3:04 p.m., with the Resident #5 who stated that the incident occurred either last Saturday or Sunday, and stated that LPN (staff #47) was screaming her name and told her to wake up but Resident #5 refused to wake up. The Resident #5 then stated that the LPN came back to her room again and forced medication into her mouth with liquid, and was screaming and throwing water on her face and chest. Resident #5 stated that she then called EMS and notified EMS and the Certified Nursing assistant (CNA, staff #64) regarding the incident.An attempt was made to call CNA (staff #64) on June 24, 2026, at 3:22 p.m. but there was no response. Review of the facility policy titled, Reporting Alleged Violations of Abuse, Exploitation or Mistreatment, the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury and not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. The policy further revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the Facility, the State Survey Agency, Adult Protective Services.

Based on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that medication was not left unattended in the one Resident's (#10) room. The sample size was 3. The deficient practice potential for overdose, and other residents accessing medication not prescribed for them.Findings include:Resident #10 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses that included Polyneuropathy, Dorsalgia, and Hypertension. A discharge Minimum Data Set (MDS) assessment dated [DATE], revealed no BIMS (brief interview of mental status) score but documented that Resident #10's cognitive skills for daily decision-making were independent. A care plan dated April 09, 2026, revealed a focus area noting that Resident #10 had a potential for pressure ulcer development related to immobility, obesity, and incontinence. The goal is that the resident will have intact skin and be free from blisters, redness, and discoloration. Intervention included notifying the nurse immediately of any new areas of skin breakdown.The care plan further revealed no evidence for a goal, focus, and intervention area for self-administration of medication. An order summary dated April 10, 2026, revealed an order dated March 24, 2026, for Nystatin External Power 100000 UNIT, Gram (GM). A Medication Administration Record (MAR) from April 2026 indicates that on April 9, 2026, at 18:00, Nystatin external powder was applied topically under the resident's breast and to the groin. The record further shows that on April 10, 2026, at 06:00, Nystatin external powder was applied topically to the breast.An observation was conducted on April 10, 2026, at 10:54 AM, in Resident # 10's room, where a Nystatin External Power was observed on the Television (TV)counter. Documentation noting resident BIMS scores for the 3rd floor where resident resided was provided by the facility and noted 12 residents with BIMS scores under 8. The documentation also revealed that 8 residents were non-ambulatory. An attempted interview was conducted on April 10, 2026, at 10:54 AM with Resident #10, the resident was sleepy at the time. An interview was conducted on April 10, 2026, at 10:59 AM in Resident #10's room with LPN (licensed practical nurse/ staff #30), who stated that someone had probably left the Nystatin External Powder in the room, and it was applied to the breast and abdominal folds of the resident. Staff #30 then stated that the order for the topical powder was placed on March 24, 2026, with an expiration date of November 20, 2027. Staff #30 also stated that there is no risk or impact if the Nystatin powder is left in the room, as most residents on that floor are alert and oriented. However, she then stated that the Nystatin powder should be stored in the treatment cart.An interview was conducted on April 10, 2026, at 12:25 PM, with LPN (staff #70), who stated that Resident #10 had chronic Moisture-Associated Skin damage and had a mild fungal wound with slight redness under the right breast. She stated that on March 5, 2026, Calazinc powder was ordered, then changed to Calazinc ointment on March 10, 2026, and then changed to Miconazole treatment on March 17, 2026, to reduce redness under the right breast. She also stated that the Nystatin powder was ordered on March 24, 2026, which she identified as a medicated treatment. Staff # 70 then said that medication is something that is prescribed by a physician. She also stated that each floor has a treatment cart and that Nystatin powder should be stored in the treatment cart because it is a medicated antifungal agent. She confirmed that Nystatin was ordered on March 24, 2026, and remains an active order. She further stated that there is no order indicating that the resident may self-administer the medication. She further stated that if the Nystatin powder is left in a resident's room, she is unsure of any specific risk or impact regarding adverse reactionAn interview was conducted on April 10, 2026, at 1:45 PM with the DON (Director of Nursing /Staff #100), who stated that a medication is something that is prescribed by the provider. She then stated that during medication pass, staff would verify the right resident by checking identifiers such as the door tag, Medication Administration Record (MAR), and confirming the order, route, and frequency prior to administration. Staff #100 further stated that this process also applies to treatment carts. DON then stated that the treatment cart is accessible to floor nurses and contains items such as antibiotic creams, dressings, and cleansers. Staff #100 then stated that her expectation is that when a resident wants to self-administer medication, staff will assess whether a resident is cognitively intact, obtain a physician's order authorizing self-administration, and document when a resident self-administers medication. She further stated that there is no current resident who can self-administer medication. She then stated that a nurse informed her that Nystatin Power was found on Resident #10's television stand, but it was not within the resident's reach. She then confirmed that there was an order in place on March 24, 2026, for the Nystatin powder, and it would be placed in the treatment cart. She further stated that Resident #10 is alert and oriented, and her door is typically kept closed. She then stated that the risk of leaving treatments in the room unattended in the resident room can pose a potential risk to those who are not alert and oriented. However, she then stated that there is not much of a risk imposed for residents who are alert and oriented. She then stated that not all residents who reside on the same floor as Resident #10 are alert and oriented.A policy revised in July 2024 titled Medication Access and Storage, E kit access revealed that all drugs and biologicals should be stored in a locked compartment under proper temperature controls. A policy revised in December 2024 titled Self Administration of Medications revealed that If a resident is a candidate for self-administration of medication, this will be indicated in the chart, and the resident will be evaluated for cognition, communication, visual, and physical ability to be able to self-administer medication.

Based on observations, staff interviews, policy review, and observation of current practice, the facility failed to ensure that resident drinks were transported from the kitchen to the residents' rooms in accordance with professional standards. The sample size was 22. The deficient practice could result in contamination of the resident's drinks. Findings include: An observation was conducted on May 7, 2025 at 12:00 P.M., with a Certified Nursing Assistant (CNA/Staff #39) who was carrying a drink tray with 5 uncovered drinks down the hall, approximately 50 steps. Continued observation on May 7, 2025 at 12:05 P.M. revealed another CNA (Staff #30) carrying a tray with an uncovered drink into room [ROOM NUMBER]; approximately 50 steps. An interview was conducted on May 7, 2025 at 12:11 P.M. with a Licensed Practical Nurse (LPN/Staff #169), who stated that food is delivered first and then drinks are delivered after, and the process is the same for residents eating in their room. The LPN stated drinks should be covered when delivered to the residents' room. She further stated that she had not observed whether the drinks were covered or not when they were being delivered. However, the LPN stated that she had to issue some reminders to staff in the past to cover drinks. The LPN further stated that the expectation is all drinks are covered until they reach the patient. The LPN also stated that the risk of transferring uncovered drinks from the kitchen to the residents' rooms could result in contamination of the drinks. An interview was conducted on May 7, 2025 at 12:18 P.M. with a CNA (Staff #39), who stated that drink glasses should have been covered prior to delivery, but they weren't. The CNA also stated that in the morning, the drinks they receive from the kitchen are usually covered, but not during lunch time. Staff #39 also revealed that the risk of transferring uncovered liquids could result in contamination. An interview was conducted on May 7, 2025 at 12:20 P.M. with a CNA (Staff #30), who stated that when drinks are transported to resident rooms, they should be covered. The CNA said that the drinks were not covered when they were delivered, and the risk could result in contamination. An interview was conducted on May 9, 2025 at 09:05 A.M. with the Director of Nursing (DON/Staff #41), who stated that stated that the expectation is for drinks to be covered in the kitchen. The DON also stated covering drinks when transporting them decreases chances of infection and spills. A facility policy entitled, Food Safety and Sanitation, dated 2017, revealed that all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. During a lunch observation on May 7, 2025 at 11:15 AM on the 3rd floor of the facility, Certified Nursing Assistant (CNA/staff # 99) was observed to remove a plastic wrap covering from a pitcher of juice. The CNA was then observed to pour juice into approximately 8 plastic cups. The CNA was not observed to cover the cups with any type of covering. The CNA (staff #99), along with another CNA (staff #52), were then observed to put the uncovered cups of juice on residents' meal trays and walk down the hall to deliver the trays to the residents in their rooms. The cups of juice remained uncovered as they walked down the hallways.

Based on clinical record review, interviews, facility documents, and policy review, the facility failed to ensure 2 residents (#458 and #16) were free from abuse. The deficient practice resulted in residents being abused. Findings include: Related to resident #458- Resident #458 was admitted to the facility on [DATE] with diagnoses that included epilepsy, dementia, psychosis, and anxiety disorder. A review of the quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #458 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated she had moderate cognitive impairment. The same MDS also noted resident #458 displayed verbal behaviors directed towards others during the assessment period. A review of a care plan, revised on January 22, 2024 indicated Resident #458 had cognitive/communication deficits due to the progression of her dementia diagnosis. The goal was for Resident #458 to remember who she was and to be able to recognize her name. Interventions included asking her closed ended questions and allow additional time for responses to be formulated, anticipate her needs, assist her with making safe choices, and to watch for signs that she is becoming upset or uncomfortable and redirect as needed. A review of progress notes, dated June 3, 2024, indicated Resident #458 was increasingly accusing others of stealing items from her room. The notes also revealed Resident #458 was calling other residents names and was unable to be redirected. A second progress note, dated June 4, 2024, indicated that activities staff had informed the Registered Nurse (RN/Staff #168) that Resident #458 was accusing other residents of stealing her things and calling them names. The note reveals that Staff #168 had asked Resident #458 questions regarding if she had seen anyone take items from her room. However, it also noted that Resident #458 denied seeing people in her room but continued to yell and scream at other residents in the dining room. A third progress note, dated June 5, 2024, at 8:15 AM, indicated that the nurse (Staff #168) was overheard telling Resident #458, loudly, stop, shut up, you cannot disrespect others like that. The note also indicated that Staff #168 was suspended pending investigation and the police department was notified. An interview was conducted on May 9, 2025 with the MDS coordinator, Staff #25, at 11:11 AM. Staff #25 shared that she had overheard Staff #168 yelling and telling a resident to shut up and that she had no right to talk to people like she was. Staff #25 indicated that she separated Staff #168 from Resident #458 and told Staff #168 that she couldn't talk to residents like that. Staff #25 then reported the situation to her supervisor. Staff #25 also indicated that Certified Nursing Assistant (CNA/Staff #147) and CNA #72 had heard the commotion when it happened. A telephonic interview was attempted with Staff #147 on May 9, 2025 at 11:03 AM but was unsuccessful. An interview was conducted with Staff #72 on May 9, 2025 at 11:20 AM. Staff #72 recalled Staff #168 raising her voice at Resident #458. Staff #72 explained that she was in her office when she heard the yelling and she had left her office to investigate along with Staff #25. Staff #72 indicated that Staff #168 said something like shut up, you don't say that, and she, along with Staff #25, had separated Staff #168 and Resident #458. Staff #72 recalled Resident #458 was accusing other residents of stealing her hair brush and her white sweater which is what started the incident. Staff #72 indicated that Staff #168 attempted to intervene but had gone about it the wrong way. An interview was conducted with the Director of Nursing (DON/Staff #41) on May 9, 2025 at 11:36 AM. Staff #41 indicated that the facility trains staff on abuse annually in addition to frequent reviews during staff meetings. Staff #41 indicated that she recalled Staff #168 and didn't recall who the resident was. However, she did remember that Staff #168 was yelling at a resident and that they had terminated the staff because they felt it was abuse. She also added that Staff #168 should have spoken to the resident in a better way regardless of the resident's dementia diagnosis. There were other ways to address the situation. When asked if the way Staff #168 spoke to the resident was within her expectations, Staff #41 replied that it was not and that her expectation was for staff to treat residents with dignity and respect because that is what they deserved. Staff #41 also shared that the risks to the residents, who are being abused, are being affected emotionally and psychologically. Residents are towards the end of their lives and it could make them question why they were here. Related to Resident #16- Resident #16 was admitted to the facility on [DATE] with diagnoses of anxiety disorder, major depressive disorder, congestive heart failure, and type 2 diabetes. A review of the annual MDS, dated [DATE] revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. A care plan, initiated on November 3, 2024, indicated that Resident #16 can be fearful at times due to bad experiences with a former caregiver. The goal was for her to feel safe and secure. Interventions included building a rapport with staff, allowing Resident to share her feelings and fears, and to make referrals to support services as needed. A review of a progress note, dated April 7, 2025 at 12:43 PM, indicated that Staff #41 spoke with Resident #16 about an incident that took place where another resident (Resident #458) had thrown a cup of warm coffee on her. It was noted that there were no injuries. An interview was conducted on May 7, 2025 at 11:19 AM with Resident #16 in her room. When asked if she was harmed by other residents in the facility, Resident #16 identified Resident #458 by her first name. She explained that Resident #458 was calling her names and accusing her of stealing her money and T.V. Resident #16 added that Resident #458 had thrown cool coffee on her. She also shared that she had no injuries from the coffee being thrown on her. Related to Resident #458- Resident #458 was admitted to the facility on [DATE] with diagnoses that included epilepsy, dementia, psychosis, and anxiety disorder. A review of the quarterly Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment. The same MDS assessment also noted resident #458 displayed hallucinations and verbal behaviors directed towards others during the assessment period. Resident #458 also rejected care at times as well. Review of physician's orders for Resident #458 revealed she was taking desvenlafaxine 50 milligrams (mg) extended release once a day, Divalproex (mood stabilizer) 250 mg three times a day, and Seroquel (antipsychotic) 300 mg twice a day. Review of Resident #458's care plan, revised on February 4, 2025 indicated that the resident had a history of making false statements and accuses other residents of going into her room and messing with her things. The goal was for Resident #458 to not make false accusations through the next review period. Interventions included not entering the day room if another resident, that she does not get along with, is in there. Review of progress notes revealed no information about the coffee throwing incident. However, in the progress notes preceding the incident date, it was noted that the provider recommended a change in Resident #485's antipsychotic medication. The recommendation was to cross taper from Seroquel to Lurasidone due to Resident #485's increased hallucinations, paranoia, and delusions. Review of a second progress note, dated April 7, 2025, a note written by Staff #41 at 12:20 PM. The note indicated that Staff #41 spoke with Resident #458 about the incident that occurred and Resident #458 had communicated that people were going into her room to steal her belongings. The note also indicated that Staff #41 and told the resident that her belongings were still in her room and were not stolen. Furthermore, the note indicated that Resident #458 was alert and oriented x2 with dementia and bipolar in addition to experiencing delusions and hallucinations. Review of the facility's 5-day (investigative) report, indicated that the altercation was witnessed by CNA/Staff #3. The report also indicated that Resident #458 asked Staff #3 to wheel her closer to Resident #16 so she could speak with her. When Resident #458 was moved closer to Resident #16, Resident #458 then threw coffee from her coffee cup at Resident #16. Staff #3 then removed Resident #458 from the area. An interview was conducted on May 7, 2025 with Staff #3 at 12:05 PM. Staff #3 confirmed that she was familiar with both Residents. Staff #3 shared that Resident #458 was drinking coffee in the common area and the coffee was not hot as she had been drinking the same cup of coffee for a while. After some time had passed, Resident #458 had seen Resident #16 and asked Staff #3 to take her towards Resident #16 to talk to her. When they had gotten closer to Resident #16, Resident #458 then threw her cup of coffee at Resident #16. Staff #3 recalled that Resident #16 did not scream when the coffee was thrown at her, she indicated that she thought Resident #16 was in shock at what had just happened. Staff #3 then wheeled Resident #458 to the Nurses' station. Staff #3 acknowledged that Resident #458 was agitated in the morning before having coffee but she was not sure why. Staff #3 also added that Resident #16 did not have any injuries from the coffee. An interview was conducted, with Staff #41, on May 9, 2025 at 1:46 PM. When asked what Resident #458's baseline for her behaviors were, Staff #41 indicated that she experiences hallucinations, delusions, has paranoia, will say that she sees bugs and people are stealing things from her. Staff #41 also added that they had recently been working with the Psychiatric Nurse Practitioner to adjust her medications to addressed her symptoms and they had also tried to have Resident #458 admitted to the Psychiatric unit at an acute care facility, however, when the Resident would be at the acute care facility, the behaviors and symptoms would stop. Staff #41 described the incident as follows: both residents were having afternoon coffee and were seated at two different tables. Resident #458 told a staff member that she wanted to talk to Resident #16. When the staff member pushed Resident #458 towards Resident #16, she threw her cup of coffee at Resident #16. Staff #41 added that they do not serve hot coffee, only lukewarm coffee for resident safety. She also added that Resident #16 did not have any injuries as a result of the coffee being thrown at her. Staff #41 indicated that when residents are abused, they are at risk of suffering from injuries, emotional dysregulation, and they might not feel safe at the facility. Review of the facility's policy, titled Freedom from Abuse, Neglect, and Exploitation, indicates that it was last revised on May 13, 2024. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include . resident to resident altercations.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one of three sampled residents (#20) had a PASARR (preadmission Screening and Resident Review) completed . The deficient practice could result in specialized services not being provided for residents who need it. Regarding Resident #20 Resident #20 was re-admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety, and heart failure. A care plan revised on May 04, 2025 revealed that the resident is being considered for a Level II PASARR, and that the paperwork has been submitted for review/determination. Further review revealed an approach dated February 10, 2023 for social services to review the PASARR as needed and during the annual review and recommendation of the level II will be followed- E.G routine psychological counseling. A Physicians order dated September 10, 2024 revealed an order for Trileptal tablet 150 mg for bipolar disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition. A review of the medical record revealed that the resident had a diagnosis of Bipolar disorder and that there was no evidence that the Level 1 PASRR had been updated/completed, despite the resident continuing to reside in the facility over 30 days. An interview was conducted on May 09, 2025 at 1:07 P.M with the Director of Social Services (SSD/#87) along with Social Worker (#68), and Director of Nursing (DON/ #41) present . Staff # 87 stated that for all residents upon admission they would review the residents PASARR and if there is no PASARR done for the resident one will be created for them. The Social Service Director stated that they would use the list of diagnoses on the PASARR to identify diagnoses relating to mental illness and intellectual disability. (SSD/#87) When a resident is at the facility for more than 30 days a PASARR level two will be completed. The Social Service Director further stated that social services will review with the interdisciplinary team (IDT) if the resident presents with behaviors like wandering out of the unit, aggression, combative, throwing items. She stated that for resident #20 based on the resident diagnosis there is no need for a PASARR to be completed. (SSD/#87) stated the clinical records will have notes about bipolar disorder behavior if the residents showed signs. She further stated that there is no need for a high level of care based on the psychology providers council. An interview was conducted with Director of Nursing (DON/ #41) who stated that the resident was diagnosed with bipolar disorder in 2021. She further stated that a PASARR was done for resident #20 on July 07, 2018, July 26, 2018, September 13, 2024, August 08, 2024, and September 10, 2024. (DON/#41) stated that the risk of not doing a PASARR is that if the resident does not have the correct diagnoses then that resident would not be medicated correctly. She also stated that in order for a resident to have a diagnosis the resident needs to present symptoms. Review of the policy titled Preadmission Screening and Resident Review (PASRR) revealed the facility to complete the level one Preadmission Screening and Resident Review (PASRR) before or at the time admission, and to request a level two PASRR in a timely fashion when indicated.

Based on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure one resident (#465) received lab services as ordered by a physician. The deficient practice could lead to delayed diagnosis or treatment or potential deterioration in the resident's condition placing the resident at risk for harm. Findings include- Resident #465 was admitted to the facility on [DATE] with diagnoses that include dementia, acute kidney failure, Encephalopathy, and cerebrovascular disease. The quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #465 was not able to complete a Brief Interview for Mental Status (BIMS) assessment. However, it was noted that staff assessed her cognitive skills for daily decision making as severely impaired. Review of the physician's orders revealed a lab order, dated March 6, 2024, for Complete Blood Count (CBC) test that also includes a differential count of white blood cells and a platelet count. This was to be done on the 1st and 3rd Monday of the month. The order was discontinued on July 30, 2024. Review of Resident #465's laboratory results revealed testing was completed on the following dates: -March 6, 2024 (1st Wednesday) -March 26, 2024 (4th Tuesday) -May 15, 2024 (3rd Wednesday) -May 22, 2024 (4th Wednesday) -July 1, 2024 (1st Monday) -July 15, 2024 (3rd Monday) Review of Resident #465's admission/discharge history revealed she was discharged from the facility on June 11, 2024 and returned on June 18, 2024. Review of Resident #465's Medication Administration Record (MAR) for the months of March, April, May, and June 2024 found the following entries: -CBC with Plt/Diff; Comprehensive Metabolic Panel (CMP) marked as being completed on Monday, March 4, 2024. -CBC with Plt/Diff; Comprehensive Metabolic Panel (CMP) marked as being completed on Monday, March 18, 2024 -CBC labs marked as being completed on Monday, April 1, 2024. -CBC labs marked as being completed on Monday, April 15, 2024. -CBC labs marked as being completed on Monday, May 20, 2024. -CBC labs marked as being completed on Monday, June 3, 2024. -CBC labs marked as being completed on Thursday, June 11, 2024. A request was made to the facility on March 9, 2025 at 8:30 AM for a copy of all lab results for Resident #465 conducted between March 1, 2024 through August 15, 2024. On March 9, 2025 at 9:20 AM, surveyor was provided a copy of lab results performed on the following dates: -May 10, 2024 (CMP) -May 15, 2024 (CBC w/diff and CMP) -May 22, 2024 (CBC w/diff and CMP) -June 20, 2024 (CBC w/diff and CMP) -July 11, 2024 Basic Metabolic Panel (BMP) -July 14, 2024 (BMP) An interview was conducted on May 9, 2025 at 10:20 AM with Licensed Practical Nurse (LPN/Staff #151). Staff #151 explained that usually labs are ordered by a provider when there is a change of condition. If for some reason labs are not done as ordered, there would be documentation on a progress notes as to why the lab was not done. Some examples are a resident refuse or if they struggle to find a vein. Staff #151 added that they will talk with the resident about the importance of doing lab work to help them treat residents. Staff #151 shared that all lab results are kept in the residents' clinical records in the Electronic Medical Record (EHR) and that the Medical Records department also kept copies of the results as well. An interview was conducted with LPN/Staff #17 on May 9, 2025 at 10:53 AM. Staff #17 was asked to review Resident #465's clinical record for lab work. She confirmed that she was not able to find evidence that Resident #465 had labs done in April of 2024. An interview was conducted with the Director of Nursing (DON/Staff #41) on May 9, 2025 at 11:45 AM. Staff #41 explained that when lab work is needed, there is an order for it and the order will show up in the MAR. Staff #41 confirmed in the EHR that Resident #465 had an order, with a start date of March 6, 2024 and end date of July 30, 2024, for labs to be done on the 1st and 3rd Monday of the month. Staff #41 added that blood is usually drawn in the early morning hours and will show up on the MAR for the Nocturnal (NOC) shift. Staff #41 was asked to confirm if there was evidence of lab work done during the month of April and the beginning of June. After reviewing facility lab work results on her computer, she confirmed that it was not done during those time frames and was unable to provide a rationale for why it was not done. When asked what were some potential risks to residents when lab services are not provided as ordered, Staff #41 shared that they could have an infection, dehydration, and it would delay treatment to them. Review of the facility's policy, titled, Physician's Orders, indicated that it was last revised on September 11, 2024. The policy explained that the physician's orders must be monitored for completion.

Based on observations, interviews, and facility documentation and policy, the facility failed to ensure one shower room was kept in clean and sanitary conditions. The deificient practice could result in the spread of disease and infection. On March 6, 2024 observed with Certified Nurse Assistants # 7 and 12, feces in the shower stall next to the shower chair and near the drain. During initial pool screeing, on March 6, 2025 at 10:27 a.m. a resdient revealed that receiving showers at the facility are hit and miss. The resident recalled wanting a shower the other night, but was tired of seeing feces on the floor, so she elected to have bed baths instead. An interview was conducted with Certified Nurse Assistants # 7 and # 12 on March 6, 2025 at 11:22 revealed that both parties were in agreement that the feces present on the floor is not a facility expectation. Both parties stated it will be cleaned up immediately and appropriately. CNA # 7 revealed being pulled away earlier and but was immediately planning to return to clean it up, which he realizes was not according to facility expectation. An interview with the Infection Preventionist (IP/Staff # ) on March 7, 2025 at approxomately 11:30 a.m., revealed that feces in the shower is an infection control issue, and is not a facility expectation. The expectation is for the shower stalls to be cleaned as per protocol to ensure a clean and sanitary environment. The facility's Cleaning Rooms and Bathrooms policy, reviewed May 21, 2024 revealed showers are cleaned and sanitized up to 2 times a day. The facility's Infection Prevention and Conrol Program, revised May 30, 2024 revealed all staff shall demonstrate competence in relevant infection control practices. Based on staff interviews and policy reviews, the facility failed to ensure that reporting guidelines were adhered to for reporting a Legionella outbreak following national standards for communicable diseases. This deficient practice could result in an outbreak not being reported to the State Agency. Findings include: A review of Maricopa County email correspondence with the facility revealed that the facility was positive for Legionella Urine Ag on December 31, 2024. Subsequent email correspondence with the Maricopa County Department of Public Health revealed that, post negative test results, the investigation was closed as completed on April 29, 2025. Review of the internal complaint tracking system revealed no evidence that the state agency had been notified of the Legionella outbreak. During an interview conducted on May 6, 2025 at 10:27 A.M. the surveyor was notified by the social worker (Staff #87) that approximately a week ago there was an outbreak of Legionella, which had been resolved. An interview was conducted on May 6 at 10:40 A.M. with the Director of Nursing (DON/Staff #41) who stated the facility recently had an outbreak of Legionella, approximately a month ago. The DON further stated that as of May 5, 2025, tests showed the water supply clear. The DON stated they were in contact with Maricopa County Health Department. She stated that one resident became ill with pneumonia with Legionella and that it had not been reported to the state agency. An additional interview was conducted on May 6, 2025 at 11:08 A.M. with the DON and the Infection Preventionist (IP/Staff #96). Both stated that the facility was not aware of a Legionella outbreak until they were notified by the County, post hospitalization of a resident. The DON stated on December 30, 2025, a resident was sent to the hospital with lowered blood pressure, altered mental status, hypoxic respiratory failure. On January 2, 2025, the IP (Staff #96) was contacted by Maricopa County to let all staff and residents know not to drink the water. The DON stated the expectation is that these types of outbreaks would be reported to the state. She also stated that the risk for not reporting could result in is the potential for all residents being affected, and the state not being aware. An interview was conducted on May 8, 2025 at 12:53 P.M. with the IP (Staff #96), who stated that families, staff, and residents were notified of the outbreak. An interview conducted on May 9, 2025 at 10:00 A.M. with the Executive Director (ED/Staff #172), who stated that a few years back they were told by the state they were reporting too much. The ED stated they were working with the County and thought that was sufficient. The ED expressed that their parent company, as well as the facility, did not know Legionella was reportable to the state. Staff #172 identified no risk by not reporting to the state as they worked closely with the County and did what needed to be done. The ED stated his expectations going forward will be to report whether they are sure or not; and to also ask the SOD (surveyor of the day) for guidance. A facility policy titled, Event Reporting of a Resident, effective date of November 8, 2019 revealed that all resident events be reported, investigated and documented adequately. A facility policy titled, Infection Prevention & Control Program, effective date of September 13, 2019, revealed that the facility failed to follow their guidelines for reporting of communicable disease and infections. -Regarding meal delivery: Findings include: During a lunch observation on May 7, 2025 at 11:15 AM on the 3rd floor of the facility, Certified Nursing Assistant (CNA/staff #99) and CNA (staff #52) were observed to deliver meal trays to all of the residents on the 3rd floor. The CNAs were not observed to sanitize their hands before meal delivery, nor in between delivering each tray. During the same observation, at 11:30 AM, CNA (staff #52) was observed to don gloves. The CNA was not observed to sanitize her hands before she donned the gloves. The CNA was then observed to pick up a piece of pizza from a resident's plate, broke the pizza into pieces with her gloved hands and handed the broken pieces of pizza to the resident. The resident was observed to put the pizza into his mouth and swallowed it. An interview was conducted with Staff #52 following the lunch observation. Staff #52 acknowledged she did not sanitize her hands before donning gloves and acknowledged that she and the other aides did not sanitize their hands in between meal delivery to residents. She stated the risk of this could be passing germs to residents. -Regarding a dressing change for Resident #63: Findings include: Resident #63 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, epilepsy, dementia, type 2 diabetes and morbid obesity. A Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating the resident had severe cognitive impairment. The same MDS also indicated that Resident #63 was at risk of developing pressure ulcers and had one stage 2 pressure ulcer (partial thickness loss of dermis; may also present as an intact or open blister). A care plan initiated on April 30, 2025, revealed that Resident #63 had a blood blister to his left 1st toe and a dried scab from a blister to his right big toe that required treatment as ordered. A progress note, titled Surgical Wound Care Consult, dated May 6, 2025, was reviewed. The note revealed that Resident #63's right 1st toe had been debrided (removal of tissue) to the level of the subcutaneous layer. Review of the order summary revealed an order dated May 6, 2025. The order prescribed to clean the resident's right toe with wound cleanser, pat it dry and apply medihoney and calcium alginate. Then, secure with kerlix (gauze wrap) until healed. The order also indicated to continue to apply iodine to the left toe. The dressing changes were ordered to be performed once daily. A dressing change was observed for Resident #63, on May 7, 2025 at 9:29 AM, with a Registered Nurse (RN/staff #60). The RN was observed to sanitize her hands with alcohol-based hand rub (ABHR) upon entering the resident's room. The RN placed a plastic bag of wound care supplies onto the bedside table. Resident's belongings were observed on the table. There was no barrier observed on the bedside table. The RN (staff #60) donned gloves, sprayed wound cleanser onto a piece of gauze and cleaned the resident's left great toe. The RN then put the used gauze onto the bedside table, without a barrier present. Then, the RN picked up the used gauze and placed a tissue under it. The RN then got another tissue and wiped her gloves. She left the toe open to air. She threw the used gauze and tissues into the garbage can. She was not observed to sanitize her hands or change her gloves. The RN (staff #60) was then observed to spray wound cleanser onto another piece of gauze. She proceeded to clean the right 1st toe with the gauze, placed the used gauze onto a tissue on the bedside table. She was not observed to sanitize or change her gloves. She then applied medihoney to a piece of calcium alginate. She was observed to wrap the right 1st toe with the calcium alginate, secured it with kerlix and tape, and wrote her initials and the date on the tape. She gathered her used supplies and threw them into the garbage can. The RN was observed to doff her gloves and through them into the garbage can. She was then observed to wash her hands with soap and water. A wet, clear liquid was observed on the resident's bedside table, where the RN had initially placed the used gauze. The RN was not observed to clean the bedside table before leaving the resident's room. The RN was not observed to wear a gown during the dressing change. Further, there was not an Enhanced Barrier Precautions (EBP) sign next to the resident's door and an EBP order was not located in the resident's record. An interview was conducted with the RN (staff #60) on May 7, 2025, following the dressing change. The RN acknowledged that she did not change her gloves during the dressing change, and only sanitized her hands upon entrance and exit of the resident's room. She further acknowledged that she did not wear a gown during the dressing change. The RN stated that she only used EBP for Foley catheters and tube feeds. Further, she stated she did not change gloves or sanitize her hands during the dressing change because the wounds were small and were only on the resident's toes. An interview was conducted with a Licensed Practical Nurse (LPN/staff #151) on May 9, 2025 at 8:38 AM. The LPN stated EBP should be used if a resident had a wound, a Foley catheter or was on isolation. The LPN explained that EBP would involve putting on a gown and gloves and washing hands before entering and exiting the resident's room. The LPN stated that Resident #63 was not currently on EBP, but should be since he had an open wound on his toe. She further stated that she had not been following EBP for Resident #63 because there was not a sign next to his door and it had not been reported to her that he was on EBP. An interview was conducted with a Certified Nurse Assistant (CNA/staff #163) on May 9, 2025 at 8:44 AM. The CNA indicated that if a resident was on EBP, there was typically a cart next to the door that contains gloves, gowns and masks. The CNA indicated that she understood that EBP was for residents with open wounds and catheters. The CNA stated she was unaware that Resident 63's toe wound was now open and that she would tell somebody to get the EBP equipment in place. She was observed to report the need for EBP for Resident #63 to the staffing coordinator. An interview was then conducted with the Director of Nursing (DON/staff #41) on May 9, 2025 at 11:29 AM. The DON stated that if a resident has an open wound, they should be on EBP. She stated she did not think Resident 9 needed EBP in place due to his wound being small and barely open. Further the DON acknowledged that RN (staff #60) should have changed her gloves and sanitized her hands during the dressing change on Resident 9's toes. A policy titled, Alcohol-Based Hand Rubs & Hygiene, revised on September 20, 2023, revealed that the use of gloves does not replace hand hygiene and that if a task requires gloves, staff are to perform hand hygiene prior to donning gloves and immediately after removing gloves. The policy further indicated on a Hand Hygiene Table, that hands should be sanitized before and after handling clean or soiled dressings, as well as after handing items potentially contaminated with blood, body fluids, secretions or excretions. Additionally, during resident care, when moving from a contaminated body site to a clean body site. A policy titled, Enhanced Barrier Precautions, effective June 5, 2024, revealed an order for enhanced barrier precautions would be obtained for residents with pressure ulcers, unhealed surgical wounds, etc., even if the resident is not known to be infected or colonized with a MDRO. The policy also indicates that gowns and gloves should be immediately available near or outside the resident's room, and that the PPE was necessary when performing high-contact care activities, to include wound care: any skin opening requiring a dressing. On Table 1 of the policy, it indicates that EBP should be used when a resident has a wound, without secretions or excretions and are not known to be infected.

Based on documentation, staff interviews, and the facility policy and reviews, the facility failed to revise the care plan after one resident (#33) fell and had a change of condition. The deficient practice could result in residents not being provided the sufficient level of care needed for safety. Findings include: Review of resident #33's care plan with problem start date of August 31, 2022 revealed that the resident was a low to moderate fall risk due to muscle weakness. The care plan was last edited on February 12, 2025. Interventions included to use a sit-to-stand for transfers going forward. Resident #33's clinical record stated that she was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included unspecified fracture of left femur, Hemiplegia and hemiparesis following infarction affecting the left dominant side, and chronic kidney disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the Resident Transfer form dated January 27, 2025 revealed that resident #33 was transferred to the hospital due to a fall while being transferred from the toilet to a shower chair. Review of the meeting notes for falls dated January 29, 2025 revealed that the resident was to use stand/lift for transfers. Review of the incontinence care plan dated February 12, 2025 revealed that the resident is incontinent and needs assistance from staff with toileting. Interventions included to encourage the resident to use the restroom on routine rounds and as needed, and to use a sit-to-stand for transfers going forward. Review of the fall risk care plan date February 12, 2025 revealed that the resident has a left side deficit due to status post cerebrovascular accident (CVA) and fall on January 27. Interventions included to use a sit-to-stand for all transfers going forward. An interview was conducted on February 20, 2025 at 9:26 a.m. with MDS Coordinator (MDS/staff #4) and (MDS/staff #9) who stated that once the MDS id completed, the triggered areas are added to the care plan and if the resident has a change of condition (COC), the care plan is updated. She stated that if a fall occurs, she adds it to the care plan. She reviewed the clinical record and stated that the resident fell on [DATE], so they would have discussed it during the morning meeting on January 28, 2025. She stated that the fall was discussed, but the team didn't know what changes should occur to the resident's care plan because staff didn't have a chance to talk to the resident prior to being transferred to the hospital, so it was decided that they would retrain the staff. She stated that the resident was originally a one-person assist with transfers because she was able to stand by herself for a short period of time. She stated that the fall care plan would be updated after the resident fell because she had a fracture as a result of the fall. Staff #9 referred to the clinical record and stated that the resident was currently a two-person mechanical lift. Staff #4 stated that the purpose of the care plan is so that everyone taking care of the resident knows what to do. During a second interview conducted on February 20, 2025 at approximately 10:55 a.m. with the MDS Coordinator (MDS/staff #4), she reviewed the resident's care plan and stated that there were no new interventions added to the resident's care plan after she fell on [DATE]. An interview was conducted on February 20, 2025 at 2:43 p.m. with the Director of Nursing (DON/staff # 2), who stated that when a residents fall, the team discusses every Wednesday and when the resident fell , the team discussed the possibility of using a lift for transfers. When the resident came back from the hospital on February 6, 2025, the care plan should have been updated to include the use of a lift for transfers. She stated that the purpose of the care plan is so staff have a plan of care to follow and there is a risk to not updating the plan to include the use of a lift. The facility policy, Comprehensive Care Plans states that the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed.

Based on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to ensure residents do not sustain injuries with falls. Having mattresses that fit resident's beds properly will reduce the risk of possible slipping off the bed. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses of pneumonia, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, hypothyroidism, essential primary hypertension, osteoarthritis, weakness, and repeated falls. A review of the Minimum Data Set (MDS) revealed a staff assessment of the resident, for Brief Interview Mental Status (BIMS) of 14. Meaning the resident was cognitively intact. A review of the Comprehensive Care Plan revealed a focus on the resident's risk of falls due to the history of falls with dates of February 20, 2024, April 26, 2024, October 14, 2024. The problem start date was December 08, 2022. The date of admission. A new long term goal was updated on August 22, 2024. No major injuries from falls thru next review. New intervention was made on October 14, 2024. Replace with correct size mattress. A review of documentation in resident #1's electronic health record (EHR), by Licensed Practical Nurse/staff #5 (LPN) on October 14, 2024, 0520 AM, stated the resident slipped out of her bed, but the CNA assisted her to the floor. The nurse heard resident #1 make a noise as to be in pain, while outside of the room. The resident was assessed for injuries at that time and none were noted. How ever there was a complaint of pain in the feet. A review of documentation in resident's #1 EHR dated October 14, 2024 at 0234 PM by Director of Nursing (DON) Staff member #2, as per Interdisciplinary team (IDT), mattress was replaced to fit better. The provider gave an order for an xray of the left foot on October 15, 2024. The results were returned on October 16, 2024 with Acute to subacute impacted fracture necks of 2nd, 3rd, and 4th metatarsal bones. On November 01, 2024 at 1039 AM, observed resident #1 sitting in a chair, in their room with the lights off while watching TV. Both legs elevated off the floor resting on a pillow on another chair. Noted for no brace/boot on resident's lower left leg/foot. Positive for wearing nonslip yellow socks. Attempted to ask resident questions regarding the injury. Resident looked over briefly then continued to watch TV. An interview was conducted with CNA/staff #1 on November 01, 2024, at 1043 AM. Was not working when the resident fell , but was aware of the incident. Knows that the residents are fall risks, by observing mats in the room, yellow socks. Fall risk and band on hand and label on chairs. The interventions that are working include putting the bed down, a safe place for the bedside table, an arranging the room to prevent falls. Keep the call light close. If a resident refuses interventions, you need to let them know that they could break bones and tell them in a way they will understand. If a resident falls, or if a resident is found on the floor, notify the nurse right away. An interview was conducted with Licensed Practical Nurse/Staff member #4 (LPN) on November 1, 2024 at 1046 AM. Was not working during the shift of the fall, but later that day. When a patient fall, you assess them first to make sure they are not hurt. Basically assess the situation, do you need to call 911? Call the family, the doctor, get any orders. Let the supervisors know. Attempted to interview DON/staff member #2, how ever was informed that they were off for the day, took a vacation day. Senior Director of Health Services/staff member #3 stated that they could answer questions. An interview was conducted with Senior Director of Health Services/staff member #3 on November 01, 2024 at 1117 AM. Staff have education to prevent falls, including the yearly Relias, education is provided if a specific event that takes place and rounding with staff two to three times per month. Was familiar with the resident's fall. Could not remember what was wrong with the mattress to the bed. It could be it does not fit right, could be too long, too short, worn, a dip in it or could be a tear in it. The resident did have an injury and was not aware of any prior injury to the same foot. They implement interventions to help prevent further falls. The IDT will meet and look at the entire scenario, with a focus on prevent the reason why, if safety is an issue, the CNA is educated immediately, making sure interventions are put in. What is the root cause of the fall and the people who were associated with the fall get educated immediately.

Based on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that resident (#1) was not abused by a staff (#42). The deficient practice could result in residents being abused by staff. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, alcohol cirrhosis of the liver, depression, and acute kidney failure. The minimum data set date July 10, 2024 included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident ambulates in a wheelchair. The care plan dated July 16, 2024 revealed that the resident needs assistance at times with activities of daily living (ADLs) due to cirrhosis of the liver with ascites, asthma, diabetes mellitus, and fracture of the back. Interventions included to assist the resident with ADL care with toileting, and eating. The resident may fluctuate in the amount of care needed, assist or cue the resident to reposition frequently while seated or lying down, and monitor skin integrity during daily care, weekly rounds, and as needed. Review of a psych progress note dated August 14, 2024 revealed that the chief complaint is major recurrent depression severe severity without psychotic features. The resident seen for follow-up. Resident is seen in his room. He is smiling and relaxed. The resident is alert and oriented times four. He has had an improvement in mood and is reporting that he is hopeful for the future and has been making long-term plans. The resident was able to find multiple positives in a situation, this is an improvement from the patient's chronic negative thoughts. Review of a psych progress note dated August 19, 2024 revealed that the resident was seen for follow-up. The resident was seen in his room. Today the resident was resting in bed and was not participating as fully as normally. The resident reports that his mood is meh? today. Resident has had a breakup with his girlfriend and is wanting to rest and nap. The resident is alert and oriented times four. The resident has good eye contact, calm, and staff report baseline mood with some lability. The facilty training dated August 20, 2024 included Resident/Relationships and the curriculum included, Inappropriate Behavior - Employee to Resident which stated that inappropriate behavior from employee to resident includes, but is not limited to, verbal abuse, sexual harrassment/conduct, inappropriate touching, and aggressive behavior. If an employee engages in, or observes another employee engaging in, such behavior towards a resident, immediately report the incident(s) to human resources or a community support team member. The facility does not permit employees to enter into intimate relationships with residents. Inappropriate behavior can be grounds for discipline and/or termination of employment and removal of the person from the facility campus. Review of the 5-day written investigation dated August 22, 2024 revealed that on August 16, 2024 at 1:27 p.m. resident #1 reported that he had been having a relationship with a certified nursing assistant (CNA/staff #42) or three months. He stated that the relationship began in the shower room and they kissed. The resident stated that he gave staff #42 two gift cards, worth $50.00, that he had won at the facility, and they were going to go out to eat. Resident #1 revealed that the he and staff #42 had spent the 4th of July together. He stated that the relationship became serious in July 2024 and they had discussed moving in together, getting married in Mexico, she had talked to his grandbabies. Resident #1 stated that he had been calling staff #42 for a few days without a response, until this morning, when staff #42 told him that they cannot be together, it is not good for the resident's health or hers, and she didn't want to deal with his baby mama. Resident #1 reported that he was devastated and his heart was broken. The resident reported that he doesn't want anything done, the relationship was concentual and he still loves staff #42. The resident had text messages and pictures of staff #42 on his phone and stated that they had been in constant contact for weeks. The resident reported being upset and stated that he would try to use a support network for emotional stablization; he cried during the interview. Staff #42 was suspended pending an investigation. Staff #42 left a message that she would not be returning to work because she quit. Facility staff were educated on the code of conduct: romatic/inappropriate relationships with residents is prohibited and can result in termination. An interview was conducted on August 30, 2024 at 1:53 p.m. with resident #1, who stated that four months ago, (CNA/staff #42) was assisting him with a shower and he pulled her towards him and kissed her. He stated that at first she pulled away and then she kissed him. He told staff #42 that he was starting to fall in love with her and she said that she should not do this because she works here. He stated that they never did anything more than kiss at the facility, but he went to her place and they had relations. He stated that she told him that no other man has ever done this to her, sex, the way that he has done it to her. He stated that staff heard him and another male resident (#13) talking about his relationship with staff #42. He was upset because he thought that she was breaking up with him and resident #13 was telling him to be careful because he could get hurt. He stated that the staff told him that if he didn't report it, she would have to report it to the Administrator, and this is why he reported it in the first place. He was not willing to identify the staff. He stated that staff #42 has returned to Arizona and they are back together, she told him that she loved him. They are still planning on getting married. He stated that they have been out to dinner and gone back to her place since she quit her job. He stated that he gave her two gift certificates that he got from the facility, but she has given him things when he was broke. He was not able to name anything that staff #42 had given to him. The facility did not have a policy for Staff and Resident Relationships. The facility had documentation for employees Inappropriate Behavior - Employee to Resident which stated, Inappropriate behavior from employee to resident includes, but is not limited to, verbal abuse, sexual harassment/conduct, inappropriate touching, and aggressive behavior. If an amployee engages in or observes another employee engaging in, such behavior towards a resident, immediately report the incident(s) to Glencroft Human Resources and or Community Support team member. Glencroft does not permit employees to enter into intimate relationships with residents. Inappropriate behavior can be grounds from discipline and/or termination of employement and removal of the person from the Glencroft campus. The document was dated December 2022.

Based on clinical record review, staff interviews, facility documentation, policy and procedures, the facility failed to ensure that one resident (#4) was free from abuse of another (#17). The deficient practice could result in further abuse of residents. Findings include: -Resident #4 admitted on [DATE] with diagnoses of supranuclear ophthalmoplegia, depression and unspecified anxiety disorder. A care plan dated September 13, 2022 included the resident had signs and symptoms of mood distress related to verbalizations of feeling down, depressed or hopeless. Goal was for the resident to not exhibit signs of isolation. Interventions included to administer medications. Review of the MDS admission assessment dated [DATE] revealed a BIMS score of 15 indicating the resident had intact cognition. Per the assessment, the resident required limited to extensive assistance with ADLs and displayed indicators of hallucinations, but did not exhibit any other behaviors. The clinical record revealed the resident was receiving psychotropic medications for anxiety, depression and psychosis. Review of the MAR revealed medications were documented as administered as ordered. A nursing progress note dated November 1, 2022 at 5:33 p.m. included the resident was in a physical altercation with another resident following an argument; and that, the other resident slapped her causing a small fingernail sized scratch that had dry blood around the area. According to the note, the nurse assessed the resident who denied pain; and that, both residents were quickly separated and the resident's family, nurse practitioner, ADON (Assistant Director of Nursing) and clinical manager were informed. Another nursing progress dated November 1, 2023 at 5:51 p.m. revealed that both residents had been separated and had been staying in their room(s). The note also included that resident #4 had a small scratch above her lip and had been monitored with staff on the floor for safety. -Resident #17 readmitted on [DATE] with diagnoses of unspecified dementia, psychotic disturbance and bipolar disorder. A physician order dated September 28, 2021 included behavior monitoring for anxiety as evidenced by yelling out and fixating on other residents. The order included opportunities for nursing documentation for the 6:00 a.m. through 6:00 p.m. shift and the 6:00 p.m. through 6:00 a.m. shift - including the number of behavior episodes, non-pharmacological interventions utilized (i.e., redirection) and the outcomes. A care plan dated July 29, 2022 included the resident had bipolar disorder. The goal was for the resident to interact appropriately with staff, residents and visitors. Interventions included to maintain a calm environment and approach to the resident. A physician order dated September 23, 2022 included for buspirone (anxiolytic) 15 mg (milligrams) twice a day (upon arising and at dinner) for anxiety as evidenced by yelling out and fixating on other residents' behaviors. The quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4 indicating resident had severe cognitive impairment. According to the assessment, the resident displayed no behaviors and was independent with (ADLs) Activities of Daily Living. A psych note dated October 28, 2022 included the resident was seen for follow up and stated that her mood was good but that her anxiety levels were elevated at times due to other residents and continued with elevated anxiety that interfered with activities. According to the documentation, staff encouraged resident to go to her room to nap or decompress and that helped; and that, the resident's symptoms of anxiety were less with medications. Goals included to prevent high levels of anxiety and for positive socialization with others. Review of the MAR (Medication Administration Record) for October 2022 revealed medications were administered and behaviors were monitored as ordered by the physician. The documentation in the MAR on November 1, 2022 revealed resident #17 had 8 behavior episodes, including fixating on other residents. A reportable event record/report narrative dated November 8, 2022 included that on November 1, 2022 at 4:45 p.m. a CNA (certified nursing assistant) reported to the nurse that resident #17 slapped another resident (#4) causing a small scratch on her face. According to the report, at 3:25 p.m. on November 1, 2022 resident #4 had just returned back to the facility from the hospital after sustaining a fall; and, both residents (#4 and #17) were both in the day room. The report included that the CNA witnessed and heard both residents arguing right before dinner was served; and that, the CNA witnessed both residents (#4 and #98) raise their arms and attempt to hit each other. Further, the report included that resident #17 hit the face of resident #4 who sustained a small fingernail-sized scratch on the face. A witness statement by a CNA (staff #183) and dated November 1, 2022 included that residents (#4 and #17) were arguing prior to the incident; and that, the CNA asked both residents to leave each other alone. The CNA included that dinner was served and everyone was quiet; however, at around 4:45 p.m. the two residents had a few words at each other again. The CNA stated he was behind the small kitchen putting away empty trays when all of a sudden both residents (#4 and #17) were exchanging words and were throwing swings at each other. According to the statement, resident #17 landed a hit right by resident #4's upper lip area and left a mark by the resident's left nose. During an interview conducted with a CNA (staff #114) on May 4, 2023 at 1:25 p.m., the CNA stated that when a resident starts to become agitated, she will ask if the resident needs to use the restroom, offer snacks and/or provide additional activities; and that, sometimes residents are sleepy and would like to take a nap. The CNA stated that if two residents begin to argue, she will separate them and put them at different tables. She stated that CNAs receive in-service, classroom and online training on implementing behavioral interventions. She stated that if two residents are arguing, she did not think telling the residents to knock it off would be helpful. Further, she stated that if one resident hit another resident it would be considered as resident-to-resident abuse and it would be reported. An interview was conducted with a Licensed Practical Nurse (LPN/staff #163) on May 4, 2023 at 1:39 p.m. The LPN stated there were residents with behaviors on the unit; and that, resident behaviors should be included in their care plan. She stated that some residents receive medications when they are becoming agitated; otherwise, staff will try to redirect and separate that resident from the others. She stated it would not be appropriate to allow residents to argue in the day room; and that, this would agitate the other residents as well. The LPN said that telling the residents to leave each other alone would just agitate them more; and that, it would be appropriate to separate or redirect residents who are arguing with each other. She stated the risks for not separating residents would include having them hit each other. A phone interview was conducted on May 4, 2023 at 2:02 p.m. with an LPN (staff #146) who stated that when residents become agitated with each other they should immediately be separated. Regarding the incident between residents #4 and #17, the LPN stated that he remembered the incident; and, he was in another resident's room when the incident happened. He stated that resident #4 would talk a lot and yell and that would result in anger of some of the other residents. He stated residents #4 and #17 were yelling at each other; and, he should have separated resident #17 from resident #4 because resident #17 was the one that was being aggressive. The LPN said that resident #17 had multiple episodes of behaviors that day; however, he did document this in the clinical record. Further, the LPN said that more could have been done; and that, not everything that could have been done was done to prevent the altercation. During an interview with the ADON (staff #121) conducted on May 4, 2023 at 2:23 p.m., the ADON stated that some of the residents on the secured dementia had behaviors. She stated that staff have dementia training and should know how to work with residents with behaviors. The ADON said that the expectation was for staff to immediately separate the residents who are arguing; and that, staff would try to do something. She stated that staff could ask the residents to stop arguing; however, she would expect staff to intervene and separate the residents. Regarding the incident between residents #4 and #17, the ADON stated that the CNA (staff #183) who was working on the evening of the incident informed her that the CNA was in the kitchen and that the interaction happened very fast. The Freedom from Abuse, Neglect, and Exploitation policy, effective December 6, 2019, included that it is their policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse . Additionally, the policy stated that each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone.

Based on documentation, staff and resident interviews, and policy and procedures, the facility failed to ensure adequate supervision and fall preventive measures were provided to one resident (#20) assessed as high risk for fall. The deficient practice could result in falls and resident injuries. Findings include: Resident #20 was admitted on [DATE] for respite care with diagnoses of Alzheimer's disease and anxiety disorder. A nursing note dated August 17, 2022 included the resident was alert and oriented x 2; and that the POA (power of attorney) reported that the resident can walk using a walker with stand-by assist. The nursing note dated August 18, 2022 revealed the resident was alert and oriented to self with confusion and was at baseline related to Alzheimer's disease, required one-person assistance for ADLs (activities of daily living) and transfer, and was a high fall risk due to unsteady gait. According to the documentation, the resident was in her wheelchair during the shift report and kept trying to get up and walk; and that, the resident was repeatedly redirected with no success. It also included that the resident verbalized statements about leaving and going back to her place; and, was wandering the unit with no rational purpose and attempted to go inside other resident rooms. Further, the documentation included that the resident was assigned 1:1 care throughout the shift. A fall risk assessment dated [DATE] revealed a score of 13 which indicated the resident was a moderate fall risk. Interventions included a fall prevention program. The elopement risk assessment dated [DATE] revealed the resident was at risk for elopement and placement in a secured unit with interventions that included behavior management program, and redirection. The fall care plan initiated on August 18, 2022, revealed the resident was high fall risk due to history of fall, reduced self-awareness and muscle weakness. Interventions included to keep bed locked and at the level that allows the resident to keep her feet flat on the floor when sitting on the edge of the bed; to assess ability to use call light; proper fitting shoes or slippers with non-slip soles when ambulating; and, to clear pathway to bathroom and bed room doors. A nursing note dated August 19, 2022 included the resident was not able to be left unattended; and that, whenever the elevator door opened, the resident moved towards it and attempted to get in. Per the documentation, the resident repeatedly gets up from her chair trying to walk independently; was somewhat steady but was not able to ambulate independently without fear of falling. It also included that the POA reported that the resident was unable to be left alone for any amount of time. The nursing note dated August 19, 2022 included the resident would be moving to another unit. Another nursing note dated August 19, 2022 revealed the resident was transferred to another unit. Per the documentation, the resident was alert with confusion, was very anxious, cannot keep still, attempted to get up from her wheelchair without assistance, was a high fall risk and required 1:1 care. Review of a nursing note dated August 19, 2022 included the resident had high energy with confusion and had multiple attempts to stand unassisted. It also included that 1:1 care was provided and needed for resident safety. The nursing progress note dated August 21, 2022 at 1:36 a.m. revealed the resident was alert to self with confusion and attempted to enter peers' rooms in search of exit doors; and that food/fluids and alternate activities were provided for redirection but had ineffective results. The documentation that the resident was with one on one care. In another nursing note dated August 21, 2022 at 9:48 a.m. it included that at around 7:00 a.m. the nurse heard a loud noise and found the resident sitting upright on the floor, close to her bed. Per the documentation, the resident had a skin tear to the residents left elbow and a left knee abrasion; and that, the resident reported that she was trying to get up and fell . The documentation also included that neurologic checks were initiated due to an unwitnessed fall and resident confusion. The fall risk observation assessment dated [DATE] included a score of 12 indicating the resident was a moderate fall risk. Per the documentation, the resident was disoriented x 3, had diminished safety awareness, had balance problem while standing/walking, had impaired mobility and had neuromuscular/functional and psychiatric/cognitive conditions. Review of another nursing note dated August 21, 2022 at 1:41 p.m. revealed that the resident was difficult to redirect even with 1:1 care; and, the resident repeatedly stated that she wanted to go home and needed the bus to pick her up. The documentation included that staff redirected the resident several times. The fall care plan was updated on August 22, 2022 to include an intervention of frequent monitoring and 1:1 care. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed that the resident was assessed with severely impaired cognitive skills for daily decision making, behaviors of disorganized thinking. The assessment also revealed that wandering behaviors had occurred, and one fall had occurred since admission with a major injury. The facility report dated August 23, 2022 included an unwitnessed fall; and that, at around 7:00 a.m. the nurse heard a noise from the resident's room and found the resident sitting upright on the floor next to her bed. Per the documentation, the resident was assessed and had sustained a skin tear on the left elbow and abrasion on the left knee. It also stated that the resident woke up around 7:00 am and tried to get up, but fell due to weakness and poor safety awareness. The report included that the resident was put on 1:1 care for the duration of her respite stay. The report included a written statement dated August 21, 2022 from a licensed practical nurse (LPN/staff #100) who wrote that she heard a noise in the resident's room and found the resident sitting upright on the floor close to her bed; and that, the resident reported that she was trying to get up and fell . Per the statement, the LPN found a 2x2 centimeter (cm) skin tear to the left elbow and an abrasion to her left knee; and, neuro checks were initiated due to unwitnessed fall and resident confusion. Continued review of the report revealed an email correspondence dated August 22, 2022 from a registry certified nurse assistant (CNA/staff #181) who wrote that on August 21, 2022 she was doing 1:1 care with resident #20 who was asleep when another resident began screaming and yelling for help. Per the statement, the CNA walked off to assist the patient that was yelling; and that, as she was heading back towards the room of resident #20, the nurse informed her that resident #20 had fallen. She further stated that she provided care to resident #20 during the time of the fall. An interview was conducted on May 4, 2023 at 10:12 a.m. with the LPN (staff #100) who stated that staff who are assigned to residents for 1:1 care were expected to stay with the resident at all times, even if they are sleeping. Regarding the fall of resident #20, the LPN stated she was the nurse on the unit at the time of the fall on August 21, 2022. She stated resident #20 had 1:1 care and a registry CNA (staff #181) was assigned to resident #20 for supervision that day. The LPN said that the CNA left the resident's bedside to go out in the hall; and, at that time she heard a noise in the resident's room and found the resident on the floor next to the bed. She stated the CNA left the resident unsupervised in the room, and the resident fell from the bed, sustaining injuries to the left elbow and left knee. She stated this did not meet the facility expectations; and that, the risk of not supervising residents requiring 1:1 care at all times could result in falls and injuries. In an interview with a CNA (staff #74) conducted on May 4, 2023 at 10:33 a.m., staff #74 stated that 1:1 care included resident supervision by a CNA at all times. She also stated that CNAs were expected to be at the resident's side at all times, including when the resident is in bed sleeping. She stated that if the assigned CNA needed a break, the CNA was to inform the nurse and someone else would relieve the CNA. Staff #74 stated that if the assigned CNA hears another resident in the hallway yelling, the CNA was to text the nurse on a call light for assistance; and, the CNA cannot leave the resident he/she was assigned to stay with. Further, the CNA stated the risk of leaving a resident assigned for 1:1 care unsupervised could result in falls and injuries. During an interview with the Director of Nursing (DON/staff #82) conducted on May 4, 2023 at 12:27 p.m., the DON stated that the facility does not have a policy regarding 1:1 care; however, the expectation was that the person providing the 1:1 care was to remain with the resident at all times and provide necessary assistance with ADLs. A review with the clinical record was conducted with the DON during the interview. The DON stated the resident's fall could have been avoided if the staff member did not leave the resident's bedside. An interview was conducted on May 4, 2023 at 12:50 p.m. with the Administrator (staff #53) who stated that the facility does not have a policy regarding 1:1 care and/or respite care. She further stated that their policy on Admission of a Resident would be followed for all residents admitted for respite care. The facility policy on Fall Prevention Program revealed that each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. The policy included that for low/moderate risks protocol, the facility will implement universal environmental interventions that decrease the risk of resident falling and implement frequent rounding schedule. High risk protocol included to indicate fall risk in care plan, implement interventions from low/moderate risk protocol, provide interventions that address unique risk factors measured by the risk assessment tool and provide additional interventions as directed by the resident's assessment. Review of a facility policy titled, Elopements and Wandering Residents, revealed that the facility ensures that residents who exhibit wandering behavior and/or the risk for elopement receive adequate supervision to prevent accidents. Adequate supervision will be provided to help prevent accidents or elopements.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that one resident #33 was free from medication error. The deficient practice resulted in resident receiving another resident's medication. Findings include: Resident #33 was admitted on [DATE] with diagnoses of Alzheimer's disease, essential primary hypertension; difficulty in walking, generalized muscle weakness and urinary tract infection (UTI). A care plan dated March 8, 2023 included the resident had hypertension, was on antibiotic therapy for UTI and required assistance with my activities of daily living (ADL) due to weakness. Intervention included administer medications as ordered and to evaluate/record/report effects and adverse reactions. A nursing progress note dated March 8, 2023 at 6:44 p.m. included the resident was admitted to the facility with UTI and to continue antibiotic therapy for 5 days, was alert times 2-3 and was able to make her needs known. Per the documentation, a call was placed to the physician for order clarification and the orders were faxed to the pharmacy. The clinical record revealed physician dated March 8, 2023 for the following medications: -Acetaminophen (analgesic) 325 mg (milligrams) 2 tablets oral by mouth every 6 hours PRN (as needed) and not to exceed 3 grams/24 hours; -Amlodipine (calcium channel blocker) 5 mg; oral, once a day upon arising; -Donepezil (cholinesterase inhibitor) 5 mg, oral, once a day upon arising; and, -Nitrofurantoin macrocrystal (antibiotic), 100 mg, oral, four times a day. The late entry nursing progress note dated March 8, 2023 at 9:06 p.m. revealed the agency nurse (staff #170) gave on March 8, 2023 at approximately 9:06 p.m. accidentally administered to resident #33 the medications meant for another resident. Per the documentation, resident #33 was confused; and, the following night medications were scheduled to be taken by the other resident but was given to resident #33 instead: 650 mg of Tylenol (brand name for acetaminophen, analgesic), Lactobacillus (probiotic), Atorvastatin 10 mg (cholesterol-lowering agent), Calcium Carbonate (antacid) 400 mg, Vitamin D3 (supplement) 5,000 units, Ferrous Sulfate 325 mg (supplement), Metoprolol Tartrate (antihypertensive)12.5 mg, Pramipexole (dopamine promoter) 0.5 mg and Gabapentin (anticonvulsant and nerve pain) 900 mg. It also included that the registered nurse (RN) supervisor was immediately notified at 9:15 p.m., and every 15-minute assessments and checks was started. The documentation included that the physician and family were notified of medication error; and that, the physician ordered for the resident to be sent to the hospital for observation, non-emergent. Further, the documentation included the resident was alert with stable vital signs, drowsy and disoriented, but responded to name and was informed that she was being sent to the hospital for evaluation. Per the documentation, the resident left the facility at 12:30 p.m. via an ambulance; and, follow-up made included that the resident was admitted to the hospital for observation due to the high dosage of Gabapentin. Another nursing progress note dated March 8, 2023 at 10:30 p.m. included the hospital reported that the resident was notably disoriented and drowsy with pinpoint pupils; and that the resident was admitted to the hospital for observation. Review of the facility report dated March 15, 2023 included that an incident of medication error happened on March 8, 2023 at 9:06 p.m., The report included that the registry nurse (staff #170 gave resident #33 her medication for the night; and that, when staff #170 checked the eMAR (electronic medication administration record), staff #170 realized that the medication she administered were for a different resident. It also included that when staff #170 realized she made a mistake, she immediately notified the clinical manager, physician and family; and that, the physician ordered for resident #3 to be sent to the ER (emergency room ) for evaluation. The report also included every 15-minute checks were done while waiting for the paramedics to arrive. The facility report included a written statement from the registry nurse (staff #170) dated March 8, 2023. The statement included that staff #170 checked identifiers and had conversed with resident #33 over medications being administered. According to the documentation, when staff #107 returned to the computer she realized that she gave resident #33 the medications meant for another resident. Further, staff #170 wrote that there was no resident identifier on the doorway for resident #33. The LPN wrote that she immediately notified the RN supervisor and every 15-minute checks were initiated until paramedics arrived. A phone interview with the registry licensed practical nurse (LPN/staff #170) was attempted on May 4, 2023 at 1:07 p.m. but was unsuccessful because the call was not answered and the LPN never returned the call. During an interview with an LPN (staff #40) conducted on May 4, 2023 at 1:20 p.m., the LPN stated she was working when the resident #was admitted to the facility around 5:15 p.m. on March 8, 2023. The LPN said that when the resident was admitted there were no medications with resident #33; and that, she contacted the pharmacy to get the medications delivered. She stated her relief nurse who was the registry nurse (staff #170) came on shift and she gave report to staff #170 the resident's medication had not yet arrived from the pharmacy. She then stated that when she returned to work the next day she was told about the medication error. The LPN stated that prior to giving medications, she checks the resident's name band to make sure it is the right resident, check if it is the right medication, the right dosage, the right route and the right time. In an interview with another LPN (staff #87) conducted on May 4, 2023 at 1:40 p.m., the LPN stated that prior to giving a resident medication, he always checks for the resident's name, medication, dose, route and correct time of administration. The LPN also said that he would check the resident thirty minutes to an hour after medication administration to see if the resident was benefiting from the medication. An interview was conducted on May 4, 2023 at 2:45 p.m. with the assistant director of nursing (ADON/staff #66) who stated that the expectation was that staff would check for the resident's name, the medication, the dose, the route and the time prior to giving any medication. Regarding the incident, the RN stated that the resident #33 and the registry nurse (staff #170) who was passing medications were new to the facility. The RN said that staff #170 did not check the name band of resident #33 who was speaking to her. The RN said that once staff #170 realized she had given the wrong medication to resident #33, staff #170 immediately notified the clinical manager who informed the physician; vital signs every 15 minutes was started until EMS (emergency medical services) arrived to transport resident #33 to the hospital for evaluation as ordered by the physician. Further, the RN stated that after the incident the registry nurse (staff #170) was not allowed to return to the facility. During an interview with the director of nursing (DON/staff #82) conducted on May 4, 2023 at 3:02 p.m., staff #82 said that the expectation was that staff would follow basic nursing practice; and that, staff would check to ensure that the right medication with the right dose at the right time is administered to the right resident. She further stated the registry nurse (#170) was no longer allowed back in the facility after the incident. Review of facility policy on Medication Occurrences revealed that the facility shall ensure medications will be administered according to physician's orders, in accordance with accepted standards and principles which apply to professionals providing services; and must ensure that is it free of medication error rates or 5% or greater as well as significant medication error events. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: right medication, dose, route and time of administration; and right resident and right documentation. The facility policy Medication Administration included that the nurse should identify the resident by photo in the Electronic Medical Record and to review the Electronic Medical Record to identify the medication to be administered.

Based on clinical record reviews and staff interviews, the facility failed to ensure two residents (#33 and #97) were administered medications as ordered. The deficient practice could result in the underlying condition not being treated and the condition could worsen or persist. Findings include: -Resident #33 was admitted on [DATE] with diagnoses of Parkinson's disease, bipolar disorder, generalized anxiety disorder, and major depressive disorder. The Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 8 indicating a mild cognitive impairment. Review of the clinical record revealed the resident have the following medications were prescribed: -Dioxin (anti-arrhythmic); -Atorvastatin (anti-cholesterol agent); -Acetaminophen (analgesic); -Buspirone (anti-anxiety; -Doxepin (antidepressant); -Eliquis (anticoagulant); and, -Gabapentin (anticonvulsant). The Medication Administration Record (MAR) dated April 2023 revealed the Atorvastatin, acetaminophen, buspirone, doxepin and Eliquis were not administered as ordered on April 7, 2023. The clinical record revealed no evidence these medications were administered on April 7, 2023, the reason why they were not administered and that the physician was notified. -Resident #97 was admitted on [DATE] with diagnoses of dementia without behavioral disturbance, psychotic disturbance, and anxiety. The MDS assessment dated [DATE] included a BIMS score of 3 indicating a severe cognitive impairment. Review of the clinical record revealed the resident have the following medications prescribed: -Atorvastatin; -Enoxaparin (anticoagulant); -Melatonin (hormone replacement); -Memantine (anti-Alzheimer's); -Oxycodone (narcotic analgesic); -Valproic acid (anti-seizure); -Trazodone (anti-depressant/sedative) Review of the MAR for April 2023 revealed that these medications were not administered as ordered on April 3 and 7, 2023. Further review of the clinical record no evidence that these medications were administered on April 7, 2023, the reason why they were not administered and that the physician was notified. An interview was conducted on May 12, 2023 at 8:50 a.m. with a licensed practical nurse (LPN/staff #149) who stated that when a medication is administered and documented in the MAR. The LPN stated that if administration of medication/s were not documented in the clinical record, then the medication/s were not administered. In an interview with the Director of Nursing (DON/staff #135) conducted on May 12, 2023 at 9:33 a.m., the DON stated that a physician order was needed to administer a medication to a resident. She also stated that the nurse documents on the MAR when a medication is administered to a resident. The DON further stated that if there was no documentation in the clinical record, it meant that the medication was not given. She stated that the risks for residents not receiving a medication included the underlying condition is not treated and the condition could worsen or persist.

Based on clinical record review, staff interviews, and facility policies and procedures, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR) Level I screening was completed for one resident (#7). The deficient practice could result in residents not receiving the appropriate service they need. Findings include: Resident #7 was admitted on [DATE], with diagnoses of rheumatoid arthritis, obesity, depression, bipolar disorder and anxiety disorder. Review of a PASRR Level 1 dated February 1, 2023, revealed that the resident did not have serious mental illness (SMI) such as schizophrenia, major depression, and bipolar disease. According to the documentation, no referral to level II PASRR was necessary. The admission MDS (Minimum data Set) assessment dated [DATE] revealed the resident was not considered to have SMI and/or intellectual disability (ID). However, active diagnoses in the MDS included anxiety disorder, depression and bipolar disorder. It also included that the resident received antipsychotic, antianxiety and antidepressant medications during the last 7 days of the assessment. Continued review of the clinical record revealed no evidence that a referral for Level 2 PASRR found. An interview with the admissions coordinator (staff #118) was conducted on May 11, 2023 at 11:22 a.m. Staff #118 stated the PASRR level 1 is reviewed as soon it is received; and that, the PASRR is then reviewed by leadership who ensures that the diagnosis are current and/or up-to-date. Staff #118 stated that if it was not up-to-date social services would complete a new PASRR. An interview was conducted on May 11, 2023 at 11:28 a.m. with the Director of Social services/Case Management (staff #143) who stated the PASRR level I is received from the facility the resident was coming from. She stated they had not been reviewing new admission PASRRs for accuracy; and that, the expectation was if the resident had a diagnosis of bipolar disease depression and anxiety disorder, the PASRR would marked yes for resident having a SMI/mental disorder. During the interview, a review of the clinical record was conducted with staff #143 who stated that resident #7 was admitted on [DATE] and had a diagnoses of bipolar disorder, anxiety disorder and depression at that time. She stated the PASRR was dated February 1, 2023, and she would have expected that an updated PASRR would have been completed to include the resident's mental illness and mental disorders. Staff #143 stated that she would have expected that a level 2 PASRR would have been sent for review. Further, staff #143 that this inaccurate PASSR and failure to send for level II PASRR review did not meet the facility process/or expectations and did not follow the State regulation on PASRR. She stated that the risk could result in the resident not receiving the proper services in the proper setting. Further, the social service director stated that the resident's PASRR should have been checked for accuracy, and updated. During an interview with the Director of Nursing (DON/staff #135) conducted on May 11, 2023 at 11:45 a.m., the DON stated new admission PASRRs are received upon admission. She stated that the expectation would be that a PASRR is reviewed for accuracy when received, and updated if required. A review of the clinical record was conducted with the DON who stated that resident #7 was admitted on [DATE] with diagnoses that included bipolar, depression and anxiety disorder; and that, the resident's Level 1 PASSR screening dated February 1, 2023 did not document the diagnosis of bipolar disorder as an SMI and diagnoses of depression and anxiety disorder were not documented as mental disorders. The DON stated that expectation was that a new level 1 PASRR screening would have been completed to add the diagnoses of bipolar, depression and anxiety disorder; and that, she would have expected that be a level II PASRR was completed and it was not. She stated this could result in the resident not receiving care necessary and seeing a provider to monitor the proper medication. Review of the facility policy on Preadmission Screening and Resident Review (PASRR)included that it is their policy to complete the level one PASRR before or at the time of admission, and to request a level two PASRR in a timely fashion when indicated.

Based on observations, staff interviews and policy review, the facility failed to ensure that all the required information was documented on the daily staff posting. The deficient practice could result in residents and visitors not being made aware of the current staffing information. Findings include: A review of the staff postings for March 26, April 30 and May 7, 2023 revealed the following information: -Date; -Number of each nursing staff: RNs (registered nurses), LPNs (licensed practical nurses), CNAs (certified nursing assistants), DON (Director of Nursing) and ADON (assistant DON); and, -Number of hours scheduled for each type of nursing staff. However, the daily staff posting did not include the actual numbers of hours worked by each type of staff. An interview was conducted with staffing coordinator (staff # 51) on May 10, 2023 at approximately 10:30 a.m. Staff #51 stated that the purpose of the daily staff posting was to inform fire marshals of the census; and that, she prepares the daily staff posting and receptionist on duty was responsible for posting it on the wall. Staff #51 also said that the daily staff posting was pre-prepared for the weekend. Staff #51 stated that the posting included the number of each type of nursing discipline (RN, LPN and CNA) and the total number of hours scheduled for each discipline. Staff #51 further stated that the actual number of hours worked by each discipline is not included in the daily staff posting. Further, she stated that if there was staffing changes for the day, the posting was not revised to reflect the change in staffing. During an interview with the director of nursing (DON/staff #135) on May 11, 2023 at approximately 1:30 p.m., the DON stated the purpose of the daily staff posting was to inform visitors of the number of staffs in the building that are providing care to residents. She stated that the staffing coordinator (staff #51) was responsible for completing the daily staff posting and the receptionist was responsible for ensuring that it was posted. The DON said that the daily staff positing must include daily census, the number of RNs, LPNs and CNAs present and the total hours each discipline was scheduled for. Further, the DON said that if there were changes in hours scheduled, the daily staff posting should be changed to actual hours as soon as possible or before it was filed into the system. Review of facility policy on Nursing Staffing Posting Information with an effective date November 29, 2019 revealed the nurse staffing information will be posted on a daily basis and will include: the facility name, current date, current resident census, the total number and actual hours worked by RN's, LPN/LVN's, and CNAs.

Based on clinical record review, staff interview and review of facility policy review, the facility failed to ensure that a pharmacy recommendation for one resident (#7) was implemented as agreed to by the physician. The facility census was 134 residents, and the sample was 26. The deficient practice would result in medication irregularities that go unnoticed or are not acted upon. Findings include: Resident #7 was admitted on [DATE], with diagnoses rheumatoid arthritis, obesity, depression, bipolar disorder, and anxiety disorder. A physician order dated February 17, 2023 revealed for Metoclopramide (anti-emetic) 10 mg tablet three times a day. The consultant pharmacy recommendation to physician form dated March 29, 2023 revealed the following recommendations: -Discontinue Montelukast or document risk versus benefit of continued use; -Evaluate continued use of metoclopramide and discontinue if possible. Continued review of the form revealed that the provider checked the agree option and signed the form on April 11, 2023. Despite documentation the physician agreed with the pharmacy recommendation, the physician order dated April 11, 2023 included for Montelukast (anti-inflammatory) 10 mg (milligram) tablet once a day. There was also no order to discontinue metoclopromide. Review of a Medication Administration Record (MAR) for April and May 2023 revealed the resident was administered metoclopromide from April 1 through 30, 2023 and montelukast from April 11 through May 9, 2023. Despite the inconsistency in the physician order and documentation, the clinical record revealed no evidence the physician was notified of the inconsistency and the orders for Montelukast and metoclopromide were verified with the physician. An interview was conducted on May 12, 2023 at 9:05 a.m. with the Director of Nursing (DON/staff #135) who stated that when a physician marks and signs the MRR, it is reviewed by the Assistant Director of Nursing (ADON) who then updates that physician orders with the changes recommended on the MRR and by the physician. The DON stated that a stop order would be placed in the electronic medical record (EMR) as soon at it was received from the physician. During the interview, a review of the clinical record was conducted with the DON who stated that the physician had indicated in the MRR dated March 29, 2023 that he agreed with the consultant pharmacist in discontinuing the montelukast and metoclopramide on April 11, 2023. However, the DON stated that the MAR for April and May 2023 revealed that both medications were not discontinued on April 11, 2023 and were still being administered. She stated that the expectations was that both these medications were discontinued on April 11, 2023 as recommended by the phramcaist and agreed to by the physician. The DON further stated that the risk of not following the recommendation agreed to by the physician could result in harm to the resident. Review of the facility policy on Medication Regimen Review (MRR) included that MRR is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications. It included review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Review of the facility policy titled, Gradual Dose Reduction of Psychotropic Drugs, included that the attending physician will assume leadership in medication management by developing, monitoring, and modifying the mediation regimen with other professionals.

Based on clinical record review, staff interviews, and the facility policy and procedure, the facility failed to ensure rehabilitation services was provided as ordered by the physician for one resident (#480). The deficient practice could result in residents not receiving rehabilitation needed to maintain or improve their physical health. Findings include: Resident #480 was admitted on [DATE] with diagnoses of rheumatoid arthritis, anxiety disorder and depression. A physician order dated April 27, 2023 revealed an order for PT (physical therapy)/OT (occupational therapy) to evaluate and treat. The nursing progress notes dated April 27, 2023 included the resident was alert and oriented x 3 and was admitted related to weakness and skilled need for PT/OT. According to the documentation, the resident required 2 people assist with transfers and resident reported that due to her arthritis it was difficult for her to stand. It also included that resident was incontinent with bowel and bladder and had complained of pain on the lower extremities which was managed with oxycodone (narcotic analgesic). Review of a care plan dated April 28, 2023 included that the resident needed assistance with activities of daily living (ADL) care due to weakness. Interventions included PT/OT/RNA (restorative nursing assistance) as ordered. The fall care plan dated April 28, 2023 included the resident was high risk for fall due to rheumatoid arthritis and incontinence. Interventions included therapy/RNA referral as needed. The quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief summary interview of mental status (BIMS) score of 15 indicating the resident had intact cognition. Per the assessment, resident required extensive assist of two for completion of activities of daily living (ADL's). A nurse practitioner (NP) progress note dated May 4, 2023 revealed the resident was transferred to the facility for PT/OT secondary to weakness; and, the expectations were that the resident will be working with PT due to the patient's increasing pain and muscle weakness. Despite the physician order for PT/OT, the clinical record revealed no evidence of any PT or OT evaluation or treatments completed. During an interview conducted on May 9, 2023 at 8:52 a.m., resident #480 stated that she was given therapy for the first couple of days after her admission; however, therapy had not seen her since and she did not know why. The resident stated that the certified nurse assistants (CNAs) would not get her up because therapy had to show them how to get her up. Further, resident #480 stated that she would like to go to the dining room for her meals; but, she just stays in bed all day and felt like it was making her worse and weaker. An interview was conducted on May 10, 2023 at 9:53 a.m. with a licensed practical nurse (LPN/staff #27) who stated that resident #480 was a skilled patient and should be receiving therapy services as ordered for evaluation and treatment. However, the LPN stated that she had not seen the resident of bed for a while. The LPN said that she does not know the reason why the resident had not been out of bed. During the interview, a clinical record review was conducted with the LPN who stated that there were no documentations found that the resident received any PT/OT since the resident was admitted at the facility. In an interview with the CNA (staff #59) conducted on May 10, 2023 at 10:22 a.m., the CNA stated that she was informed by PT that resident #480 could not get up until further notice. The CNA stated the resident wanted to get up, was bored in her room and had asked to get up for lunch. However, the CNA stated that she could not assist the resident to get up until PT allowed them to. An interview with the Director of Rehabilitation (staff #201) was conducted on May 10, 2023 at 2:52 p.m. Staff #201 stated that she was responsible for scheduling residents therapy sessions; and that, PT/OT evaluations are done within 72 hours following resident admission. Regarding resident #480, she stated that resident was evaluated on May 2, 2023 and was approved for PT/OT with a frequency of 24 times in 8 weeks. She said that the resident's PT/OT schedule would be based on the frequency that was on the resident's POC (plan of care). Staff #201 stated that the reason the resident #480 had not had any scheduled therapies was due to insurance; and that, the facility was waiting for authorization from the resident's insurance. Further, she said that she had called the insurance for medical authorization and was waiting on the forms for the confirmation from the resident's insurance; and that, the resident's insurance usually takes time to respond. However, staff #201 said that she cannot provide any documentation of the request for authorization as she called the insurance by phone; and that, she did document the events of the call as she did not feel the need to do so. Further, staff #201 said that legally therapy staff cannot show other facility staff how to get a resident up from bed; and, the CNAs have the skill set to do that. Staff #201 further stated that when there was a delay on services, the therapy staff just wait for until they receive the authorization for services they requested from the insurance company. An interview was conducted with RNA (staff #24) on May 11, 2023 at 10:30 a.m. the RNA stated that resident #480 was not listed in their restorative nursing program. The RNA stated that if there was an insurance issue with therapy, the PT will write an order for RNA services; and that the staff development coordinator was responsible for putting the RNA order, care planning the RNA program and providing the RNA staff with the information needed to provide restorative services to the resident. During an interview conducted with ADON (Staff #121) on May 11, 2023 at 10:33 a.m., the ADON stated that if a resident was admitted for long term care (LTC), the therapy department was responsible in receiving the authorization for therapy services; and if the resident was admitted for skilled services, the business office takes care of the orders for therapy. The ADON said that a resident should never have to wait for therapy; and that, before the facility admits the resident, the facility should have orders in place upon resident's admission. The ADON said that if the therapy department was aware that there was going to be a delay in services, the therapy department should have communicated with the nursing department to provide RNA services for the resident. She said that the risks for not providing therapy/RNA needed was that the resident would get weaker with muscle weakness and could become disoriented from lying in bed and possible pneumonia. An interview was conducted with the DON (staff # 135) on May 12, 2023 at 10:16 a.m. The DON stated that the authorization for a resident with orders for therapy would come from the business office at the time of admission; and if the resident was admitted as LTC, nursing staff would notify the therapy department and request an eval for therapy services. The DON said that the expectation was that the therapy department would notify and inform the nursing department of the delay in therapy services and recommend for RNA services while waiting for authorization for those services. She stated that nursing staff would ask that the resident be assessed and have the therapy notify the business office so they could assist in getting the authorization for the resident. The DON said that requests for authorization should be documented in the clinical record; otherwise, there would be no evidence that the request was made. Further, the DON stated that she was not informed by therapy department that there was a delay in the therapy services ordered by the physician for resident #480. The DON said that the risk for the delay in therapy services could result in residents condition getting worse and a deficit to their mobility. Review of the facility policy on Therapy Treatment Procedures for Therapeutic Exercises included that it was their policy to provide therapy treatment procedures for therapeutic exercise as necessary.

Based on clinical record review, observation, staff interviews and policy and procedure, the facility failed to maintain infection prevention and control during catheter care for one resident (#7). The census was 134 residents, and the sample was 26. The deficient practice could result in transmission of infection. Findings include: Resident #7 was admitted on [DATE], with diagnoses of rheumatoid arthritis, obesity, depression, bipolar disorder, and anxiety disorder, The clinical record revealed documentation that the resident was admitted with a urinary catheter in place. A physician order dated February 17, 2023 included to change foley catheter and drainage bag as needed (PRN) based on clinical indication, such as infection or obstruction. Another physician order dated February 17, 2023 revealed for Foley catheter (16F(French)/10 ml (milliliter). The care plan dated February 22, 2023 revealed the resident had a foley catheter in place related to obstructive uropathy. Intervention included to change foley per CDC (Center for Disease Control) guidelines. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 15 which indicated resident had intact cognition. The assessment also included the resident had an indwelling catheter. An interview was conducted on May 8, 2023 at 1:51 p.m. with resident #7 who stated that she has not received catheter care or assistance with perineal care. Further, the resident stated that she asks for this to be completed after each bowel movement, but the CNAs would not do it; and that, she also told the nurse. An interview was conducted on May 10, 2023 at 11:44 AM with a certified nursing assistant (CNA/staff #173) who stated that catheter care included checking urine output and peri care that was completed every 2 hours. She stated she would provide peri-care every time a brief was changed and after bowel movements. She stated that peri-care and urine output were documented in the electronic clinical record under the bowel movement and toilet use tasks. The CNA also stated that it was implied that peri-care was provided during toilet use or brief changes. In an interview with another CNA (staff #93) conducted on May 10, 2023 at 12:00 p.m., the CNA stated that facility policy for catheter care included peri-care every 2 hours and as needed and after every bowel movement. She also stated that peri-care was documented in the electronic record under the bowel movement task. The CNA also stated that peri-care for a resident with a catheter included cleaning labial folds with a cleaner, wiping from front to back then cleaning the tubing with a peri-wipe from the insertion site downward. A catheter care observation was conducted with a CNA (staff #93) on May 11, 2023 at 8:56 a.m. The CNA introduced herself to the resident and explained the procedure to be performed. She washed her hands and applied gloves and opened a container of peri-wipes. She then sprayed perineal cleanser on perineal area, used a wipe to cleanse the labial folds, wiping from the front to the back and folding the wipe with a new part of the cloth for each side. She then wet clean wipes with water from the sink, wrapped the wipe around the catheter tubing at the insertion site, and wiped downward. The CNA then removed the wipe, placed it again at the insertion site and wiped with the same side, down the catheter tubing a second time. The CNA removed the gloves and sanitized her hands. During an interview with the Director of Nursing (DON/staff #135) conducted on May 11, 2023 at 11:45 a.m., the DON stated that her expectation was that staff complete the catheter care per the policy and after brief change. She stated that her expectation regarding peri-care included wiping the labial folds from front to back, folding the washcloth/wipe with each new area. She said that the catheter tubing should be cleansed with a wipe from the insertion site down once; and that, if the procedure was performed a second time the washcloth/wipe should be folded if it was to be used a second time. The DON stated that the risk of wiping the catheter tubing with the same side of the wipe twice could result in infection, and a higher risk of urinary tract infections (UTI). Review of the facility policy on Catheter Care, revealed that it was their policy to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Catheter care will be performed every shift and as needed by the nursing assistant. Wipe from front to back of the labia with a clean cloth, using a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place.

Based on review of employee trainings, staff interviews and policy review, the facility failed to ensure that two staff members (#150, #116) were provided training on resident rights. The deficient practice could result in residents not being afforded their rights. Findings include: The personnel file of a certified nurse assistant (CNA/staff #150) revealed a hire date of August 25, 2017. The personnel file of a registered nurse (RN/staff #116) revealed a hire date of December 13, 2021. Further review of the personnel records for staffs #150 and #116 revealed no evidence training on resident rights. In an interview with the chief officer (CO) conducted on May 11, 2023 at approximately 8:00 a.m., the CO stated that human resources do not maintain a record of employee trainings; and that, the staff development coordinator (staff #168) would be able to provide information regarding employee trainings. An interview was conducted with staff development coordinator (staff #168) on May 11, 2023 at approximately 10:00 a.m. She stated that training on resident rights was included as part of the facility's new-hire orientation. Staff #168 provided two blank forms employees were expected to sign and verify completion of certain topics that included resident rights after orientation. Staff #168 stated she could not verify how annual trainings were completed prior to her hire date in April 2023; but, she could verify that completion of annual trainings was based on the employee's hire date. The staff development coordinator stated that she was hired in April 2023 and the facility was still in the process of determining how to provide appropriate orientation and annual trainings to their employees. She stated that the facility's computerized training system would be the most current proof of training completion for their employees. The staff development coordinator stated that if an employee was non-compliant with the annual training that employee would be removed from the schedule until compliance was demonstrated. She said that she would refer to human resources to provide a copy of their computerized system training completed for staffs #150 and #116. However, the facility was unable to provide proof of any orientation or computerized system training modules on resident rights for staff #150. The facility provided a copy of the computerized system training for staff #116 that showed staff #116 was assigned training on resident rights; however, staff #116 has not completed the module as assigned. During an interview with the director of nursing (DON/Staff #135) on May 11, 2023 at approximately 11:00 a.m., the DON stated that prior to employment of the staff development coordinator in April 2023, there were multiple people responsible for staff development and training. However, the DON stated that she was directly in charge of staff development from January 2023 until April 2023when the staff development coordinator was hired. In another interview with the DON conducted on May 11, 2023 at approximately 1:30 p.m., she stated that primary competencies upon hire included abuse, infection control and resident rights and any trainings on the matrix (electronic record software). She stated that newly hired staff then have to come to the facility for training; and that, orientation training must be completed within thirty to sixty days of hire. The DON stated the training on abuse, infection control and resident rights need to be completed annually and that was based on the employee's date of hire. She stated that trainings can be completed through the clinical educator, a monthly meeting, huddles or through their computerized training system. Further, the DON said that if an employee did not complete the training on resident rights, it could lead to a risk of injury or harm to the resident. The facility policy on Staff Education and Training included that all staff, volunteer and vendor were required training on resident right; and that all nursing staff receive the training on resident rights. Review of the facility policy on Nursing Training Requirements revised on March 10, 2020 revealed that it was their policy to develop, implement and maintain an effective training program for all new and existing employees. The facility will provide no less than 12 hours of in-service annually based on employment date, not calendar year. Documentation of in-services will be forwarded to the HR or designee, and maintained in the employee's personnel file. Training content included but is not limited to the rights and responsibility of residents, staff and the facility to ensure proper person-centered care and dementia management and care of the cognitively impaired. Training can be assigned and completed in a variety of formats designed by the staff development coordinator. The staff development coordinator maintains a training schedule and documentation system for completed training by all nursing staff. Documentation of required training will be kept in the staff development coordinator's records and will be scanned to the HR department to be placed in the employee's personnel file.

Based on review of clinical records, staff interviews and review of policies and procedures, the facility failed to ensure one resident (#1) was free from staff abuse. The deficient practice could result in further resident abuse. Findings include: Resident #1 was admitted on [DATE] with diagnoses of severe protein-calorie malnutrition, essential hypertension, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The care plan with problem start date of January 20, 2023 included the resident had a potential for prolonged bleeding or unusual bleeding due to use of an antiplatelet; and, had a diagnosis of senile purpura to right shin. Approached included anticoagulant as ordered and observe for signs/symptoms of unusual bruising A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. The assessment included the resident had no impairment of the upper or lower extremities and was totally dependent with one-person physical assistance for bathing. The hospice care plan edited on April 4, 2023 included the resident was receiving hospice due to progression of protein-calorie malnutrition. Interventions included to approach any caregiving task with comfort in mind Review of the hospice visit schedule revealed that on April 5, 2023, the hospice licensed nursing assistant (LNA/staff #77) visited with resident #1. A nursing note dated April 5, 2023 at 6:05 p.m. included the hospice CNA (certified nurse assistant) gave the resident a bed bath with no problems noted. The nursing note dated April 6, 2023 at 10:24 a.m. included the resident had a big bruise on the left upper arm; and that, the resident reported that she got into an argument with the hospice lady; and that, the bruise was painful but she was ok. Per the documentation, the left upper arm was visibly swollen with big bruise. The note also included the provider was notified and an order for left arm x-rays was obtained. Another nursing note dated April 6, 2023 at 10:33 a.m. included that a police officer arrived and interviewed the resident. According to the documentation, the resident stated that this black hospice lady, we got into it. She wanted to work and the resident refused. The note included that when the officer asked how the resident got the injury, the resident replied she did not know and she (referring to the hospice staff) must have pulled me. Further, the note included the officer stated that this incident will be filed as an assault. The nursing note dated April 6, 2023 at 11:35 a.m. revealed that at 8:41 a.m. a CNA reported that resident #1 had a large bruise to the left upper arm; and that, the resident reported to the CNA that the hospice CNA had hit her in the face. The note included the resident was assessed and had the following injuries: a left upper arm bruise that measured 12 cm (centimeters) x 4 cm; scattered purple brushing measuring 6 cm x 2 cm and 2 cm x 2 cm to the right forearm; edema and bruise to left upper shoulder. Per the documentation, the resident reported it hurts a tiny bit; and, when asked how the bruising happened, the resident replied that she had a fight with the hospice woman who hurt her quite a bit. A wound nurse progress note dated April 6, 2023 at 11:44 a.m. included new bruise to left upper arm and shoulder, skin was intact with deep purple and blue bruising noted that measured 4 cm x 12 cm. The documentation included that the resident reported moderate pain to left arm and shoulder; and that, the resident was not able to give a pain scale number but stated it just really hurts. The nursing note dated April 6, 2023 at 12:25 p.m. revealed the resident had a large bruise to left upper arm and reported that the hospice CNA hit her in the face. Per the documentation the when the resident's left arm was moved to examine the injury closer, the resident yelled out in pain and was holding her left arm against her chest. The note included that the resident stated they had been in a fight with that girl yesterday and it was a girl from hospice. Another nursing note dated April 6, 2023 at 3:39 p.m. included the X-ray results came back and revealed new fracture at the base of the compression plate to the left humerus; and that, new orders to send the resident to the ER (emergency room ) for evaluation. Review of the radiology report dated April 6, 2023 revealed that resident #1 had a new fracture at the base of the compression plate of the left humerus and that this was a significant finding. Another nursing note dated April 6, 2023 at 3:39 pm included that the x-ray report came back and resident #1 had a new fracture at the base of the compression plate of the left humerus (upper arm). The note included that there were new orders to send the resident to the hospital for evaluation. The facility investigative report dated April 11, 2023 revealed resident reported that the hospice CNA hit her in the face; and that the resident had large bruise to her left upper arm/shoulder area. In a statement written by the LNA (staff #77) dated April 6, 2023 revealed that resident #1 was given a bed bath; and that, the resident had refused before and had hospice aide stop with no problem. The LNA wrote that today (April 6, 2023), the resident agreed to have a bed bath and as she was cleaning, the resident asked her to stop. The LNA included that she told the resident she would put the brief on the resident and she would be done. The statement included the resident hit her on the arm and she told the resident no hitting, covered the resident up and left the resident clean and resting. Further, the LNA wrote that there were no bruises. A statement from the social service dated April 6, 2023 included that the resident reported she was making a joke and the hospice aide did not take it that way; and that, the resident did not remember if the hospice aide hit her because she was trying to defend herself. Per the documentation, when asked how she got the bruise on her upper left arm and shoulder area, the resident reported that she (referring to the hospice aide) walloped me which meant that the hospice aide had hit her. During an interview with a licensed practical nurse (LPN/staff #22) conducted on April 14, 2023 at 11:35 a.m., the LPN stated a CNA (staff #29) reported the resident's bruising; and that, she assessed the resident and found a large bruise on the arm which was swollen and tender to the touch. Staff #29 stated resident #1 reported that the hospice LNA (staff #77) provided the resident bath the day before and had hurt the resident. Staff #22 stated that the resident was able to describe the hospice LNA and was able to give details of the fight the LNA had with the resident. Staff #22 stated the provider was notified along with the leadership team and x-rays were ordered; and that, the resident had a fracture at the top of the left humerus (upper arm). Attempts were made to conduct a telephone interview with the LNA (staff #77) on April 14, 2023 but was not successful and unable to reach her. An interview was conducted on April 14, 2023 at 12:38 p.m. with Social Services (staff #14) who stated that the day after the incident, she interviewed the resident #1 who gave some story that did not match the other stories; and the resident did not want the hospice aide to provide her care. Further, staff #14 stated that the resident did not want to talk about it. During an interview conducted with a certified nursing assistant (CNA/staff #29) on April 14, 2023 at 1:31 p.m., the CNA stated that resident #1 was pleasant and receptive to care; and, staff had provided bed baths and showers to the resident over many months without any issues at all. Staff #29 stated that the bruise on the resident's upper left arm was big and blue; and that, the resident reported that the day before (April 5, 2023), the hospice lady had beat her up. The CNA said that the resident also told her that the resident and the hospice staff had gotten into a fight that the hospice LNA won. The CNA stated the resident reported that the hospice LNA was rough with her and she was in so much pain moving the left arm. Further, the CNA said that prior to the alleged incident, the resident never had such pain when being repositioned. An interview was conducted on April 14, 2023 at 1:53 p.m. with the Director of Nursing (DON/staff #7) who stated that the alleged LNA (staff #77) informed her that the resident had hit her on the face. During an interview with an Assistant Director of Nursing (ADON/staff #11) conducted on April 14, 2023 at 2:15 p.m. the ADON stated that on April 5, 2023 she was notified of the bruise on the resident's arm; and, resident #1 showed her the bruise and reported that she was hurting. The ADON stated that resident #1 reported she was refusing a bed bath when the hospice LNA got into it with the resident. Further, the ADON said that law enforcement arrived at the facility, took the resident's statement and pictures, and informed the facility that it would be submitted as an assault. The ADON also stated that the hospice LNA was reported to the hospice company; however, the hospice LNA was not reported to the State Board of Nursing. A facility policy titled Freedom from Abuse, Neglect, and Exploitation (effective 12/2019) included that the policy was to maintain an environment where residents are free from abuse. The facility must report alleged violations related to mistreatment or abuse including injuries of unknown source and report the results of all investigation to the proper authorities within prescribed timeframes.

Based on observation, interview and record review the facility failed to assure that the dishwashing machine dispensed sufficient Chlorine sanitizer solution to meet the required concentration during the rinse cycle of 50 - 100 parts per million (ppm) to destroy pathogens. This deficient practice resulted in an Immediate Jeopardy (IJ) situation as it had a high likelihood of putting all residents and staff who eat from the utensils, dishes and beverage containers at risk for food borne illness and infections. On 7/9/2020 at 2:50 PM, the Administrator (Adm), Infection Preventionist (IP) and the Food Service Director (FSD) were notified of the IJ. During observations in the kitchen on 7/9/2020 at 1:40 PM, the FSD checked the concentration of the sanitizing solution for the dishwashing machine. Since the machine is a low temperature machine it requires chlorine sanitizing solution to sanitize the dishes. The litmus test results showed a concentration of less than 50 parts per million (ppm). The required concentration for chlorine solution is 50 - 100 ppm. The staff (Staff 52) responsible to test the concentration of the chlorine solution said she was supposed to test the solution before each dish-washing episode three times per day. She stated she did not test it before the lunch dish-washing episode today. She said she documented a reading of 100 ppm on the Dishmachine temperature log before the lunch dishwashing episode for today. When the dishwashing chlorine solution is less than required the dishes are not sanitized and have a high likelihood of spreading serious infection for all people who eat from the dishes. The facility has 56 residents who have been confirmed positive for COVID19 and 26 deaths as of the week ending 7/5/2020. The IP stated all staff had been exposed to [DIAGNOSES REDACTED]-CoV-2. Had the surveyor not asked to see the testing of the chlorine sanitizing solution it is likely that the staff would not have known the sanitizing solution was not concentrated enough. Many of the lunch dishes were already washed however they were not sanitized had already been put away and ready for use at the next meal. The facility provided a corrective action plan on 7/9/2020 at 4 PM that was not accepted due to several missing elements. A second corrective action plan was provided at 4:30 pm and was accepted. The corrective action taken included but was not limited to the following: 1. Stop using the dishwashing machine and use the three compartment sink to wash, rinse and sanitize the dishes. 2. All dishes in the dish area including dishes that had been put away were re-washed to assure proper sanitation prior to use. 3. The facility immediately called ECOLAB, the company that maintained the dishwashing machine, and the technician came and repaired the machine 7/9/2020 at 3:11 PM. 4. Kitchen employees onsite were re-educated immediately and all kitchen employees not onsite would be re-educated by 7/10/2020. Re-education included the appropriate use of the dish machine including how to test for chlorine concentration and documentation of wash and rinse temperatures and ppm level of chlorine. It included instruction for what to do if the dish machine was not reading properly, i.e., who to report the malfunction to and what to do, such as do not use the dishwashing machine instead use the three compartment sink. On 7/10/2020 at 9 AM, the surveyor observed the dishwashing process and asked Staff 52 to test the chlorine sanitizer concentration. Staff 52 made two attempts to test the solution and did it incorrectly. When asked if the management had provided additional training this morning, Staff 52 stated, Yes. When asked why she had difficulty testing the chlorine concentration, Staff 52 stated, I already know how to do it. The Vice President (VP) of Dining Services tested the concentration and it read 100 ppm. The VP stated they had just trained Staff 52 first thing that morning. Interviewed five other kitchen staff and they acknowledged they had received training that morning and on 7/9/2020 and were able to perform the litmus test. The IJ was abated on 7/10/2020 at 9:46 AM. Findings include: During a tour of the kitchen on 7/9/2020 at 1:35 PM, accompanied by Food Services Director (FSD) and the Dietary Services Supervisor (DSS) and the Infection Preventionist (IP), when asked what kind of dishwashing machine they used the FSD stated a low temperature machine (120 - 150° F(ahrenheit)) which requires a chlorine sanitizing solution to sanitize the dishes. At 1:40 PM, when asked to test the chlorine solution for concentration, FSD inserted a test strip for about 10 seconds into the water at the exit for the dishwashing machine. The test strip showed the concentration as less than 50 parts per million (PPM). When asked if this was ok, the FSD stated, it should be between 50 -100 ppm. Review of the Dishmachine Temperature Log (log) Form 408 where dietary staff document the wash and rinse temperature and ppm (chlorine concentration) revealed for 7/9/2020 before lunch a ppm reading of 100 PPM. When asked where on the dishmachine she tested the solution Staff 52 reached up above the garbage disposal sink to a dispenser labeled ECOLAB ® , indicating she tested directly from the dispenser instead of at the dishwashing machine after the sanitizer mixes with the rinse water where the dishes come out of the machine. Review of the log for July 2020 showed in the ppm column documented a chlorine concentration of between 100 and 103 ppm on every line. Staff 52 stated she was responsible to test the concentration of the sanitizer and the temperature of the water as well as document the results on the log before each dishwashing episode. When asked if this documentation was accurate Staff 52 stated, I didn't check it (before the lunch dishwashing). FSD, DSS, and the IP was present and stated they heard what Staff 52 said. FSD asked Staff 52 if she had documented the numbers on the log before lunch. Staff 52 said, Yes. When asked what part of the dishwashing machine the staff should place the test strip, FSD stated it didn't matter. When asked how she monitored that the documentation of the temperature and chlorine concentration was correct and that the staff were testing appropriately, FSD stated she did spot checks but did not have consistent routine. She said that she rarely checked the sanitizer concentration. When asked what should be done about this the FSD told the staff to stop washing the dishes in the dishwashing machine and switch to the three compartment sink to complete the dishwashing of the lunch dishes and to start re-washing all of the other dishes that had been put away. When asked how often ECOLAB came out to maintain the dishwasher and solution dispensers, FSD stated they come about monthly. She stated they had just been out on 7/6/2020. On 7/9/2020 at 2:50 PM, an Immediate Jeopardy situation was identified and the administrator was informed (See introduction). At 3:50 PM the FSD informed the surveyor that ECOLAB came out and repaired the machine. She stated it now tested at 100 ppm. Returned to the kitchen to observe dishwashing process. The staff in the kitchen at this time were the evening shift staff. Observed kitchen staff continuing to rewash the dishes in the three compartment sink. When asked if he had been trained about testing and documenting the chlorine concentration and water temperature, the evening dishwasher stated he had. He stated they were not to use the dishwashing machine to rewash the dishes. The FSD stated she would continually run the dishwashing machine for about 30 minutes to make sure it maintained the appropriate chlorine concentration and temperature. At 4 PM the administrator provided the surveyor with a corrective action plan. The plan was not accepted as it was missing several elements. The administrator stated she had spoken with the corporate registered dietitian who told her they had been having problems with this machine. When asked how long they have had problems with the machine and how often they've had to call for repairs, the FSD stated for about a year. She stated she had to call about every two to three weeks and it's usually because the chlorine solution wasn't right. She stated the machine was a high temperature machine (150 -165 °F); however it wasn't maintaining the high temperature. ECOLAB installed a chlorine dispenser a in April 2020. When asked if she was aware of the probles with machine, the Admin stated that they did not report it to her. The report these problems directly to the Vice President of Dining Services. She further stated that since the machine broke down so often the facility would consider replacing the machine. At 4:30 PM, the administrator submitted a revised corrective action plan and it was accepted. (See introduction comments) 7/9/2020 - 7/10/2020 Record review revealed the following: Review of the ECOLAB service request for 7/9/2020 at 3:11 PM, revealed that the sanitizer line popped out of the squeeze tube. The technician repaired it so the sanitizer was being delivered at the appropriate concentration. Previous ECOLAB maintainence invoices included Regular Service Call with dates of about every 2 months. The most recent was dated 7/6/2020 that revealed the dishmachine met all measures. Review of the policy and procedures (P&Ps) revealed the following: P&P INS 117 - Dishwashing Procedure revised 11/19/2019 read in pertinent part: Objective: Participants will understand the correct dishwashing procedures and how to record the dishmachine (sic) temperature and ppm 2. Recording of Dishmachine (sic) temperature and ppm: .Record temperatures every shift on Dishmachine (sic) Temperature log(Form 408) .Low temperature dishmachines- wash temperature is 120° - 150° F (and) final rinse temperature is 120° - 150° F . The concentration of the sanitary solution during the rinse cycle is 50 - 100 ppm with Chlorine sanitizer on low temperature dishmachines . P&P INS 126 Criteria for completion of RD's Quarterly Report Sanitation for Long Term Care revised 01/15/2019 read in pertinent part: .Food Preparation Area: 23 - 24 Current Food Code Temperatures available and followed .a. Food Code Temperatures (DOC401) iv. Dishmachine (cold correct ppm .) .d. Check with those who wash pots and pans and . have them test with litmus paper for correct amount of sanitizer .i. Chlorine Sanitizer = 50 - 100 ppm- contact time 7 seconds .86 Dishmachine Temperatures recorded every shift and corrective action noted. a. Check Dishmachine temperature FORM 408 to see if wash and rinse temperatures are recorded 3xday. If it is a cold temperature dishmachine the ppm must be recorded also 3xday. B. if the dishmachine is not working properly, correct action must be noted on the dishmahchine temperature form . Review of the training log indicated Staff 52 attended a training on 2/4/2020 titled How to clean and sanitize pots, pans, utensils and dishes. The training included the following directions: .Test sanitizing sink with litmus strip for prpoer amount of sanitizer. Test wash and rinse water for proper temperature. Record wash/rinse and PPM every shift . This training did not have specific instruction regarding where to test the sanitizer concentration for the dishwashing machine. On 7/10/2020 at 9 AM, the surveyor observed the dishwashing process and asked Staff 52 to test the chlorine sanitizer concentration. Staff 52 made two attempts to test the solution and did it incorrectly. When asked if the management had provided additional training this morning, Staff 52 stated, Yes. When asked why she had difficulty testing the chlorine concentration, Staff 52 stated, I already know how to do it The Vice President of Dining Services tested the concentration and it read 100 ppm. Interviewed five other kitchen staff and they acknowledged they had received training that morning and on 7/9/2020 and were able to perform the litmus test. The IJ was abated on 7/10/2020 at 9:46 AM.

Based on clinical record review, staff interviews and review of policy and procedures, the facility failed to ensure one resident (#98) who was admitted with skin breakdown and a pressure ulcer received the necessary care and treatment to prevent further pressure ulcers from developing. The deficient practice included a lack of timely and thorough wound assessments being completed and the development of three unstageable pressure ulcers. Findings include: Resident #98 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nursing progress note dated October 18, 2019 at 7:23 p.m. stated the resident had been readmitted to the facility, with redness and open areas on the buttocks. Per the note, the area had been cleaned and protective cream was applied. The note did not include what was used to clean the wound. This note also did not contain a description of the wound bed of the open areas on the buttocks, and there were no measurements, no description of the surrounding skin, and no documentation if any drainage was present. An admission skin risk assessment dated [DATE] at 8:38 p.m., included a Braden scale score of 9, which indicated the resident was at high risk for skin breakdown. The assessment included the resident was readmitted with moisture associated skin damage (MASD), new [DIAGNOSES REDACTED] (redness) and a pressure ulcer to the buttocks (no stage was indicated). The pressure ulcer wound bed was described as having [MEDICATION NAME] tissue, with a scant amount of serosanguineous exudate. Skin and ulcer treatments listed included for a pressure reducing device for bed, turning/repositioning plan, nutrition or hydration intervention, application of ointments/medications and in house wound team consult. This assessment did not include any measurements of the pressure ulcer or the size of the area that was macerated or the area which had new [DIAGNOSES REDACTED]. The admission physician orders dated October 18, 2019 included for readmission to the facility followed by hospice and included the following: May use routine skin care protocol, special instructions: Certified Nursing Assistants (CNA's) may apply moisture barrier to buttocks as needed to reduce the risk of skin breakdown. The admission orders [REDACTED]. According to the hospice orders dated October 18, 2019, skilled nursing visits were to be done at least weekly, or more often if indicated to assess current problems and evaluate response to interventions. The orders did not include any specific wound care orders for the pressure ulcer to the buttocks. A hospice nursing progress note dated October 21, 2019 included a care plan for alteration in skin integrity, with a goal to have no further skin breakdown. Interventions were to instruct caregivers to inspect reddened areas daily, and report to Registered Nurse (RN) any changes. Review of the clinical record revealed there was no documentation of any thorough assessments of the open areas/pressure ulcer to the buttocks that were done either by hospice or the facility from readmission on October 18 through October 21, 2019, which included measurements, a description of the wound bed and surrounding skin, and if any drainage was present. There was also no documentation the physician was notified that the resident had open areas to the buttocks, including a pressure ulcer, and the October 2019 Medication Administration Record [REDACTED]. A hospice nursing progress note dated October 22, 2019 revealed the resident now had three unstageable pressure ulcers as follows: -Posterior sacrum pressure ulcer, unstageable, deep tissue injury. Per the note, the wound bed was first observed by the hospice nurse on 10/22/19. The sacrum pressure ulcer was documented as 1 centimeter (cm) in length (no width or depth was included) and had 100% eschar, no drainage, with peri wound intact. Under wound care protocol, it included to clean and cover with occlusive dressing and to perform 1 time as needed. -Posterior right gluteus maximus pressure ulcer, unstageable, deep tissue injury, which was first observed by the hospice nurse on 10/22/19. The wound length was 4 cm (no width or depth was included). The wound bed was described as 100% eschar, with no drainage and peri wound was intact. Under wound care protocol, the documentation included to clean and cover with occlusive dressing and to perform 1 time as needed. -Posterior left gluteus medius pressure ulcer, unstageable, deep tissue injury. The wound dimensions were 1 cm x 1 cm, with no depth. The wound bed was described as 100% eschar, with no drainage. Under wound care protocol, the documentation included to clean and cover with occlusive dressing and perform 1 time as needed. This hospice note further stated that orders were received for wound care. However, there were no physician orders found for October 22, 2019 to cleanse and cover the pressure ulcers with an occlusive dressing and perform 1 time as needed. A wound nurse progress note dated October 23, 2019 included the resident had an open area to the buttock and the hospice nurse was notified. The area to the sacrum measured 7 cm x 7 cm and was dark purple, with scant non-odorous drainage. As only one pressure ulcer was documented, the note did not indicate if the three pressure ulcers as identified the day before had merged into one. The note also included the area was cleansed (did not say what was used to clean the wound) and that barrier cream was applied, with a foam dressing. However, there were no physician orders on October 23, 2019 to cleanse the buttocks wounds and apply a foam dressing. Further review of the October 2019 TAR revealed the following: clean wound to the buttocks (did not specify what to clean the wound with, i.e. wound cleanser, normal saline) and cover with occlusive dressing as needed. Per the TAR, the treatment was initiated on 10/23/19 and was done two times a day through 10/28/19. However, there were no corresponding physician orders to cleanse the wound to the buttocks and cover with an occlusive dressing as needed. There were also no orders to provide wound treatments two times a day as documented on the TAR. A nursing progress note dated 10/28/19 included the pressure sore to the bottom had serosanguineous drainage and that the area was cleansed and an abdominal pad was applied. A hospice visit note dated 10/28/19 revealed the wounds were not addressed. Review of a weekly skin assessment dated [DATE] revealed the resident had a pressure ulcer to both buttocks, which measured 8 cm x 4 cm with no depth. The wound beds were described as having slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. No tunneling or undermining were present, there was scant serosanguineous exudate, surrounding skin had [DIAGNOSES REDACTED] and were macerated, and had induration. The October 2019 TAR included to clean the wound to the buttocks and cover with occlusive dressing twice a day, which was done on October 29, 30 and 31. Per the November 2019 TAR, this same wound treatment was provided twice a day from November 1-7. The wound treatment was not provided on the morning of November 8. A skin integrity/risk for pressure ulcer care plan dated November 7, 2019 related to fragile skin and impaired mobility included a goal that the resident would be free from pressure ulcer development. Interventions included to check skin during daily care, weekly rounds and as needed, report any changes to Nurse Practitioner (NP)/Primary Care Physician (PCP), document measurements and progress each week, and if the resident developed any suspicious areas, notify the wound team and NP/PCP and have the wound care team evaluate for treatment. Continued review of the hospice notes dated November 4, 6, 8, 11, 15, 18, 22, 25, 29 and [DATE] and 9, 2019, revealed no documentation that the resident's wounds were addressed. According to the November and December 2019 TAR, the wound treatment to clean the buttocks wound and cover with occlusive dressing twice a day was provided on the evening shift on November 8, was provided from November 9 through November 30, and from December 1 through 10. Further review of the clinical record revealed there was no documentation of any thorough assessments of the three unstageable pressure ulcers to the sacrum/buttocks area that were done from from November 1 through December 11, 2019, which included measurements, a description of the wound beds, staging of the pressure ulcers, if any drainage was present, and a description of the surrounding skin. A physician's order dated December 11, 2019 now included to cleanse wound to the buttocks with normal saline, pat dry and cover with occlusive dressing foam, and to change every shift and as needed. On December 11, 2019 at 7:43 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #154). He stated that he is the wound care nurse. He stated that he does not perform wound care for resident #98. He said the hospice nurse does the wound care for the resident on Mondays, Wednesdays, and Fridays. He stated that according to the resident's insurance, only the hospice nurse may provide wound care. He said there may be a lack of communication between the facility and the hospice nurse. An interview was conducted on December 11, 2019 at 9:04 a.m., with a hospice nurse (staff #303). She stated that she only sees the resident twice per week. She stated that she cleans and covers the wounds each time, but does not do wound assessments for resident #98. She stated her understanding was that the facility was providing the wound care. On December 11, 2019 at 10:24 a.m., an observation of wound care to resident #98 was conducted with staff #154 and a CNA who assisted. Staff #154 removed the dirty dressing and cleaned the wound with sterile saline and patted the area dry with sterile gauze. The nurse stated the wound was an unstageable sacral wound, with pink granulation tissue to the wound bed, had moderate serous drainage, and no odor. Staff #154 measured the wound which was 1 cm x 2 cm, with no depth. The surrounding skin had redness which was approximately 9 cm in diameter. Staff #154 then applied barrier cream to the surrounding area of the wound and applied an occlusive dressing to the sacrum. On December 12, 2019 at 10:55 a.m., an interview was conducted with the Director of Nursing (DON/staff #159). She reviewed the routine skin care protocol order dated October 18, 2019 (CNA's may apply moisture barrier to buttocks as needed to reduce the risk of skin breakdown) and stated that she would anticipate that the facility nurses would do the dressing changes. She stated the wound doctor should have been alerted about the resident's wounds by either staff #154 or by the nurses on the floor. She said that nurses have two options with wound assessments, they can take pictures of wounds and send them securely to the physician, or they may open an observation and event note in the computer and document in there about the wound. She said that professional standards for pressure ulcer care includes weekly assessments, including description of the wound and measurements. She said that her expectation would be for the hospice nurse to provide an assessment on a weekly basis. She stated that the coordination of services was probably not as she would have expected. She stated there was no nursing documentation to indicate that wound assessments had been done and that the documentation did not necessarily meet her expectation. Review of a facility policy titled, Pressure Injury Documentation revealed it is their policy to have a continuous quality improvement tool to enable medical, nursing, and administrative staff to evaluate and trend the status of every resident's pressure ulcer. When a pressure ulcer is identified, an event is opened and completed in the electronic health record (EHR), which would initiate these processes including to be seen weekly by the wound team for documentation of wound measurements and progression of wounds in the EHR. Review of the Pressure Injury Prevention and Management policy revealed that licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the EHR. Assessments of pressure injuries will be performed by a licensed nurse and documented on the skin assessment form in the EHR. The staging of pressure injuries will be clearly identified to ensure correct coding in the Minimum Data Set assessment. The wound nurse, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. Additionally, the policy stated the attending physician will be notified of the presence of a new pressure injury upon identification, the progression towards healing, or lack of healing of any pressure injuries weekly, any complications (such as infection, development of a sinus tract, etc.) as needed. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. Interventions will be documented in the care plan and communicated to all relevant staff.

Based on staff interviews, clinical record review, facility documentation and policy review, the facility failed to protect the resident from staff abuse as a video of the resident was taken and posted on social media. Findings include: Resident #1 was admitted at the facility on May 8, 2017 with [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment dated [DATE] included that the resident had a BIMS (Brief Interview for Mental Status) of 10 indicating moderately impaired cognition. Active [DIAGNOSES REDACTED]. The facility investigative report included that on November 5, 2017, a licensed practical nurse (LPN/staff #188) took a video of the resident walking down the hallway of 2-North hall and posted the video on social media. The report also included involvement of two certified nurse assistants (CNAs/staff #28 and #189) and the unit clerk (staff #190) in the incident. Per the documentation, the video displayed that the resident was yelling and being laughed at by staff members as she was videotaped using the cellphone of staff #188. It also included that the video clearly displayed staff's #188 name. Continued review of the facility report revealed that during the facility investigation, staff #188 stated that she had been feeling frustrated and video-taped an example of her day to share with her friends. The documentation included that CNA #1 (staff #189) admitted that she had witnessed the video-taping and laughed at the resident's voice. It also included that during the facility's interview with another CNA #2 (staff #28) he admitted that he laughed at the resident's vocal sound but did not know that staff #188 was videotaping the resident. Further, documentation included that the unit clerk (staff #190) received the video taken by staff #188 through the social media. A review of the Request for Correction Action for CNAs (staff #189 and #28) dated November 7, 2017 included that facility determined that both staff (#189 and #28) witnessed the making of the video and participated by laughing at the resident in the video. It also included that both staff were terminated. The Request for Corrective Action for the unit clerk (staff #190) dated November 7, 2017 included that the facility determined that staff #190 received and reviewed the video. The Request for Corrective Action for the LPN (staff #188) dated November 7, 2017 included that during an interview on the evening of November 6, 2017 with staff #188, she confessed that she had indeed video-taped the resident and shared it with her social media contacts. Per the documentation, staff #188 was terminated for violation of company policy on confidentiality and social media. In an interview with the unit clerk (staff #190) conducted on November 8, 2017 at 1:11 p.m., she stated that she received the video sent by staff #188 and viewed it for 3-4 seconds when it was posted on the social media. During an interview with the CNA #1 (staff #189) conducted on November 8, 2017 at 2:15 p.m., she stated that she did not see staff #188 videotape the resident. However, staff #189 stated that staff #188 was overheard saying that she (referring to staff #188) wanted the resident to scream because staff #188 wanted to record the resident. She also said that staff should not take any pictures or videotape a resident or any resident. In an interview with the LPN (staff #188) conducted on November 8, 2017 at 2:46 p.m., she stated that she took a video of the resident for no reason at all and sent it to another person who was supposed to delete the video. However, she stated that the video was not deleted by that person. She said that she was not supposed to take pictures of or video tape any resident. In an interview with another CNA (staff #104) conducted on November 8, 2017 at 3:05 p.m., she stated that taking pictures of resident and/or videotaping residents is not allowed and must not be done by any staff because it is a violation of resident's privacy and rights. She further stated that if she witness or have knowledge of such incident, she will immediately report it to her supervisor. An interview with the Executive Director (ED/staff #187) was conducted on November 8, 2017 at 3:20 p.m. She stated that a copy of the video was sent to the facility's Human Resources (HR) staff on November 6, 2017 by a person that was not an employee at the facility but received the video from staff #188 through social media. A review of the video with the ED (staff #187) was conducted immediately following the interview. It revealed that the video was from staff #188 and it showed resident #1 was walking down the hallway with a text written on the center of the screen Nuuuuuuuuurse all damn day. It also revealed that as the resident got closer to where the camera was, the resident's face was marked with a red circle, a text written on the screen You got my pills? and the resident asking this question repeatedly. Continued review of the video showed the resident was also seen and heard calling a name and a written text on the screen Kiiiirrrk. It also revealed that on the bottom left side of the screen displayed the first name of staff #188 and that it was 20 hours ago. Staff #187 stated that person who sent this video to HR also reported the video to local news. Staff #187 stated that during her interview, staff #188 was whining and wanted to let her contacts know what her day at the facility was like and posted the video on social media. During an interview with another LPN (staff #135) conducted on November 8, 2017 at 3:45 p.m., she stated that taking photos and/or videos of a resident/s and posting them in social media are not allowed and this is a facility policy. An interview with a registered nurse (RN/staff #167) was conducted on November 8, 2017 at 3:51 p.m. She stated that staff are not allowed to use their phone when on duty during their shift unless they have an emergency or are on break. She also stated that it is a standard of practice to not take pictures or video of residents at the facility. During an interview with the Director of Nursing (DON/staff #125) conducted on November 9, 2017 at 8:00 a.m., she stated that during the facility investigation, staff #188 admitted to taking a video of the resident, saving the video and posting the video on social media. The ED (staff #187) joined the interview shortly thereafter and she said that staff #188 admitted to taking the video to show her contacts how her day was on November 5, 2017. She stated that interviews with staff #190, #188, #189 and #28 revealed the following: -The unit clerk (staff #190) admitted to receiving and watching the video, and knew the video was taken at the second floor of the facility. -The CNA #1 (staff #189) admitted to having knowledge that the resident was being videotaped by staff #188 and had participated in laughing at the resident. -The CNA #2 (staff #28) saw that the phone of staff#188 was out but denied knowledge that staff #188 was videotaping the resident. The facility policy titled Freedom from Abuse, Neglect, Misappropriation of Property and Exploitation included that all residents will be protected against abuse, neglect, misappropriation of property and exploitation no matter how minor the occurrence. It also included that all staff will be the residents' advocates in promoting residents' safety and well being. The policy further defined that abuse include abuse facilitated or enabled through the use of technology. The facility Handbook on Re-education included maintaining confidentiality as appropriate for personal and/or organizational information. It also include that employees are required to maintain confidentiality even after leaving employment. Further, it included that employee will not engage in social networking when they are supposed to be working; and, social networking is subject to all of the facility's policies on improper conduct, confidentiality of information and use of technology.

Based on observations, clinical record reviews and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible, by failing to ensure safe water temperatures were maintained in multiple residents' bathrooms. As a result, the Condition of Immediate Jeopardy and Substandard Quality of Care were identified. Findings include: On May 10, 2016 at 11:57 a.m., the Condition of Immediate Jeopardy and Substandard Quality of Care were identified. The Administrator (staff #248) and the Director of Nursing (DON/staff #1) were informed of the facility's failure to maintain safe water temperatures in multiple residents' bathrooms. Observations revealed that the water temperatures in multiple resident rooms were found to be between 130-142 degrees Fahrenheit (F.) The Administrator presented a plan of correction on May 10, 2016 at 2:10 p.m. After reviewing the plan of correction, the Administrator was informed that the plan of correction needed to include how they will monitor the water temperatures in resident's rooms and what type of equipment will be used to ensure accurate water temperature readings. A revised plan of correction was presented at 2:35 p.m. The Administrator was informed that the plan of correction needed to include staff education regarding safe water temperatures, how equipment used to check water temperatures is calibrated, a time frame for monitoring resident bathroom water temperatures and where water temperatures will be documented. At 4:00 p.m., a revised plan of correction was presented and the Administrator was informed that the plan of correction needed to address the process for how staff will ensure safe water temperatures prior to bathing and the time frame for completing more immediate staff in-services. A revised plan of correction was presented by the Administrator at 4:50 p.m. and was accepted at 5:05 p.m. Multiple observations were conducted of the facility implementing their plan of correction, which included maintenance staff testing the water temperatures in multiple residents' bathrooms on different floors, suspension of all showers until safe water temperatures were reached and providing bed baths to residents, and completing ongoing staff in-services. As a result of the facility implementing their plan of correction, the Condition of Immediate Jeopardy was abated on May 10, 2016 at 5:15 p.m. -Resident #221 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had moderate cognitive impairment. The MDS also assessed the resident's functional status as needing assistance, with most activities of daily living. A care plan intervention included to encourage the resident to attempt activities of daily living, including oral hygiene on their own, with supervision. The water temperature from the sink in the resident's bathroom was tested on [DATE] at 3:00 p.m. The temperature was 140 degrees F. The resident shared a bathroom with another resident. -Resident #44 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had no cognitive impairment. The MDS also assessed the resident to require assistance with most activities of daily living. According to a care plan, the resident was able to propel self in a wheelchair, but needed assistance with hygiene. The care plan included that the resident had a fungal infection and had dermatophytosis of the fingernails. An intervention listed included to encourage the resident to wash hands to control symptoms. On May 10, 2016 at 9:46 a.m., the water temperature in this resident's bathroom sink was tested and was found to be 138 degrees F. This resident shared a bathroom with another resident. -Resident #171 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], indicated the resident had no cognitive impairment. This MDS also assessed the resident to be independent with all activities of daily living. Review of a care plan revealed the resident was independent with cares, but needed reminding to use a walker when using the bathroom and to shower twice a week. On May 10, 2016 at 9:48 a.m., an observation was conducted of resident #171's roommate in the bathroom washing her hands. Afterwards, she ambulated back to her room using a walker. Following this observation at 9:50 a.m., the water temperature from the bathroom sink was tested . The temperature was 140 degrees F. An interview with maintenance staff (#242) was conducted on May 10, 2016 at 10:47 a.m. He stated that they do not check the water temperatures in residents rooms. He said they only check the water temperatures from five different places; which included the boiler pump, the storage tank and the mixing valve and that they are checked daily. He stated the water temperature coming out from the boiler is 155 degrees F. He stated they do not have a thermometer for taking water temperatures, only a laser thermometer. He stated the laser thermometer is for hard surfaces and that they should use a thermometer that you would use for a pool. On May 10, 2016 at 10:54 a.m., staff #242 then used a laser thermometer to take the water temperature in the bathroom of resident #221. The water temperature obtained was 125 degrees F. At 10:56 a.m., staff #242 took the water temperature in the bathroom of resident #171, using a laser thermometer. The water temperature obtained was 125.8 degrees F. At 11:00 a.m., staff #242 took the water temperature in the bathroom of resident #44, using a laser thermometer. The water temperature obtained was 122.2 degrees F. At 11:22 a.m., two surveyor thermometers were calibrated to 32 degrees F. for three minutes, by using a cup of ice water. After the thermometers were calibrated, the water temperature in resident #221's bathroom was rechecked at 11:37 a.m. The temperature was 130 degrees F. and the second thermometer showed a temperature of 132 degrees F. At 11:39 a.m. the water temperature in the bathroom of resident #171 was rechecked. The temperature was 140 degrees F. and with the second thermometer the water temperature was 142 degrees F. At 11:43 a.m., the water temperature was rechecked in the bathroom of resident #44 and the temperature was 140 degrees and using the second thermometer the temperature was 142 degrees F. A policy was requested regarding safe water temperatures, however, the Administrator stated they did not have a policy. According to the Federal regulation under F323, Table 1., the time required for a 3rd degree burn to occur is 1 min at 127 degrees F; 15 seconds at 133 degrees F; 5 seconds at 140 degrees F. and 2 seconds at 147 degrees F. The regulation also included that a safe water temperature was 100 degrees F. and that burns can occur even at temperatures below those identified in the table, depending on an individuals condition and the length of exposure.