Every finding on record at Ahwatukee Post Acute

Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed within the required time frames for 30 residents. The universe was 139. The deficient practice could result in the care and treatment of residents being delayed.Findings include: - Regarding Resident #19Resident #19 was admitted on [DATE], with diagnoses including aphasia following cerebral infarction, parkinsonism, and epilepsy.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 30 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN (Registered Nurse) Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #21Resident #21 was admitted [DATE], with diagnoses including osteomyelitis, cellulitis, and parkinsonism.A review of the MDS assessment revealed the most recent MDS was a quarterly MDS dated [DATE]. Further review revealed that the quarterly MDS was in progress and 26 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #29Resident #29 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, and malignant neoplasm of the lung and brain.A review of the MDS assessments revealed the most recent MDS was a Discharge Return Not Anticipated MDS dated [DATE]. Further review revealed the discharge MDS was in progress and 50 days overdue.A review of the Discharge Return Not Anticipated MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #9Resident #9 was admitted on [DATE], with diagnoses including metabolic encephalopathy, severe sepsis, and dysphagia.A review of the MDS assessments revealed the most recent assessments were a Significant Change MDS dated [DATE], and a Discharge Return Anticipated MDS dated [DATE]. Further review revealed both MDS assessments were in progress and 27 days overdue.A review of the Significant Change MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank.A review of the Discharge Return Anticipated MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #43Resident #43 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, asthma, and dorsalgia.A review of the MDS assessments revealed the most recent MDS was an annual assessment dated [DATE]. Further review revealed that the annual MDS was in progress. However, the clinical record did not indicate how many days overdue the assessment was.A review of the annual MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #53Resident #53 was admitted on [DATE], with diagnoses including metabolic encephalopathy, type 1 diabetes mellitus, and dementia.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 34 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #56Resident #56 was admitted on [DATE] with diagnoses including encephalopathy, muscle wasting and atrophy, and dementia.A review of the MDS assessments revealed the most recent assessments were an End of PPS (Prospective Payment System) Part A Stay MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE]. Further review revealed that both assessments were in progress and 18 days overdue.A review of the end of PPS Part A Stay MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #60Resident #60 was admitted on [DATE], with diagnoses including anoxic brain damage, rhabdomyolysis, and psychotic disorder.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 35 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #62Resident #62 was admitted on [DATE], with diagnoses including sepsis, history of transient ischemic attack and cerebral infarction, and dysphagia.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 27 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #67Resident #67 was admitted on [DATE], with diagnoses including transient cerebral ischemic attack, hemiplegia, and type 2 diabetes mellitus.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 39 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #68Resident #68 was admitted on [DATE], with diagnoses including hypokalemia, acidosis, and muscle wasting.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE] Further review revealed that the quarterly MDS was in progress and 20 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #94Resident #94 was admitted on [DATE], with diagnoses including cerebral infarction, gastrostomy malfunction, and contractures of the right and left ankle and the left and right wrist.A review of the MDS assessments revealed the most recent MDS was an annual assessment dated [DATE]. Further review revealed that the annual MDS was in progress and 36 days overdue.A review of the annual MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #100Resident #100 was admitted on [DATE], with diagnoses including cerebrovascular disease, hemiplegia and hemiparesis, and type 2 diabetes mellitus.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 30 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #109Resident #109 was admitted on [DATE], with diagnoses including dementia, history of transient ischemic attack, and muscle weakness.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 30 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #111Resident #111 was admitted on [DATE], with diagnoses including acute appendicitis with perforation, type 2 diabetes mellitus, and acute respiratory failure with hypoxia.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 43 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #118Resident #118 was admitted on [DATE], with diagnoses including cerebral infarction, history of traumatic brain injury, and bipolar disorder.A review of the MDS assessments revealed the most recent MDS was an annual assessment dated [DATE]. Further review revealed that the annual MDS was in progress and 36 days overdue.A review of the annual MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #120Resident #120 was admitted on [DATE], with diagnoses including post-traumatic stress disorder, peripheral vascular disorder, and chronic pain.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 37 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #121Resident #121 was admitted on [DATE], with diagnoses including fracture of one rib, dementia, and dysphagia.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 20 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #128Resident #128 was admitted on [DATE], with diagnoses including end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 24 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #132Resident #132 was admitted on [DATE], with diagnoses including autism disorder, cognitive communication disorder, and acute cholecystitis.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 37 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #133Resident #133 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, and hypokalemia.A review of the MDS assessments revealed the most recent MDS was a Significant Change assessment dated [DATE]. Further review revealed that the Significant Change MDS was in progress and 49 days overdue.A review of the Significant Change MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #135Resident #135 was admitted on [DATE], with diagnoses including cerebral infarction, type 2 diabetes mellitus, and hemiplegia and hemiparesis.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 35 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #140Resident #140 was admitted on [DATE], with diagnoses including metabolic encephalopathy, sepsis, and chronic obstructive pulmonary disease.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 47 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #148Resident #148 was admitted on [DATE], with diagnoses including cardiomegaly, type 2 diabetes mellitus, and bipolar disorder.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 51 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #151Resident #151 was admitted on [DATE], with diagnoses including orthopedic aftercare following surgical amputation, osteomyelitis, and acute kidney failure.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 31 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #153Resident #153 was admitted on [DATE], with diagnoses including spinal stenosis, neuromuscular dysfunction, and hearing loss.A review of the MDS assessments revealed the most recent MDS assessments were a quarterly assessment dated [DATE], and a Discharge Return Not Anticipated MDS dated [DATE]. Further review revealed that both MDS assessments were in progress and 49 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank.A review of the Discharge Return Not Anticipated MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #179Resident #179 was admitted on [DATE], with diagnoses including encephalopathy, respiratory failure with hypoxia, and dementia.A review of the MDS assessments revealed the most recent MDS was an annual assessment dated [DATE]. Further review revealed that the annual MDS was in progress and 45 days overdue.A review of the annual MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #183Resident #183 was admitted on [DATE], with diagnoses including anemia, rheumatoid arthritis, and history of traumatic brain injury.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 42 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #189Resident #189 was admitted on [DATE], with diagnoses including spinal instabilities, acute respiratory failure with hypoxia, and bipolar disorder.A review of the MDS assessments revealed the most recent MDS was a Discharge Return Not Anticipated assessment dated [DATE]. Further review revealed that the discharge MDS was in progress and 29 days overdue.A review of the Discharge Return Not Anticipated MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. - Regarding Resident #208Resident #208 was admitted on [DATE], with diagnoses including osteomyelitis of the left ankle and foot, pressure ulcer of the sacral region, and quadriplegia.A review of the MDS assessments revealed the most recent MDS was a quarterly assessment dated [DATE]. Further review revealed that the quarterly MDS was in progress and 25 days overdue.A review of the quarterly MDS dated [DATE] revealed that Section Z0500, titled Signature of RN Coordinator Verifying Assessment Completion, was blank. An interview was conducted on July 23, 2026 at 2:10 P.M., with the MDS coordinator/ Licensed Practical Nurse (LPN/ Staff #156). Staff #156 stated that the process for completing the MDS includes completing resident interviews for each section, completing care plans based on the care area assessments, adding pertinent diagnoses and any high-risk medications, and having a RN sign and lock the MDS when it is completed. Staff #156 stated it is her responsibility to ensure the MDS assessments are completed on time. Staff #156 used an admission assessment as an example and stated that these assessments are due 14 days after a resident's admission, but added that the process is the same for quarterly and annual assessments as well. Staff #156 further stated that it is important that a MDS assessment is completed on time because it ensures that care is provided accurately and timely for all residents. Staff #156 accessed the most recent MDS, dated [DATE], for Resident #19 and confirmed the MDS was not complete. Staff #156 asked to refer to her resource and continue the interview later when asked why it was not completed. The interview concluded at 2:20 P.M. An interview was conducted on July 23, 2026 at 2:37 P.M., with the Director of Nursing (DON/ Staff #58). Staff #58 stated she had been aware of an MDS issue for a few weeks and had looked into hiring another full-time MDS Coordinator to remedy the issue. An interview was conducted on July 23, 2026 at 3:17 P.M., with Staff #156 and Staff #58. Staff #58 stated that the MDS assessments were not being completed on time because the facility census had grown too rapidly for one staff member, and that they had been in the process of hiring a new full-time staff member to complete MDS assessments. Staff #156 stated that, on average, MDS assessments had been 30 days overdue since June 2026. An interview was conducted on July 24, 2026 at 11:20 A.M., with Staff #58. Staff #58 stated that she had been aware that Staff #156 had asked for assistance in completing the MDS assessments and the facility was in the process of hiring a new full-time employee. However, she was not aware that MDS assessments were not being completed and submitted in the required time frame. Staff #58 further stated that it had never been communicated to her what the extent of the concern was when Staff #156 had asked for help. Staff #58 stated her expectation is that MDS assessments are completed in the required time frame, and expected staff to communicate with her if they were unable to meet those time frames. An interview was conducted on July 24, 2026 at 11:59 A.M., with the Executive Director (Staff # 91). Staff #91 stated that he had not been made aware that MDS assessments were not being completed. Staff #91 stated that he was aware that Staff #156 had asked for assistance, but she had not disclosed that she was unable to complete MDS assessments. Staff #91 stated that this did not meet his expectation that MDS assessments are submitted within the required time frame. A facility policy titled, Comprehensive Assessments, revealed that comprehensive assessments are conducted in accordance with the time frames established in the Resident Assessment Instrument (RAI) User Manual. A review of the Minimum Data Set 3.0 Resident Assessment Instrument User Manual, version 1.20.1, published October 2025 by the Department of Health and Human Services, revealed that in accordance with the requirements at 42 CFR S483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must have MDS assessments completed no later than 14 days after the assessment reference date, date of significant change, or date of entry or discharge.

Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure that cigarettes and lighters were secured and maintained by designated staff in accordance with the facility's smoking policy for 3 of 26 sampled residents (Residents #87, #169, and #242). The deficient practice could put the residents at risk for accidents or smoking-related injuries. Findings include:-Regarding resident #87:Resident #87 was admitted to the facility on [DATE], with diagnoses that include tobacco use, anxiety disorder, cannabis use, and hypoglycemia.A review of the smoking policy on May 07, 2026, revealed the resident signed the facility's smoking policy acknowledging the policy regarding smoking.A review of the resident's care plan initiated on May 08, 2026, revealed a problem focus indicating that the resident has a need for activities that are consistent with abilities and interest. Meaningful activities to the resident include, but are not limited to, newspapers, one-on-one visits, reminiscing, and smoking.Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 12, indicating moderate cognitive impairment.-Regarding resident #169:Resident #169 was readmitted to the facility on [DATE], with diagnoses that include traumatic subdural hemorrhage with loss of consciousness, emphysema, acute pulmonary edema, acute and chronic respiratory failure with hypoxia.A review of the resident's care plan initiated on February 23, 2026, in the problem focus revealed that the resident is a smoker and is at risk for smoking-related injury.A review of the smoking policy signed by the resident on April 13,2026, revealed the resident signed the facility's smoking policy acknowledging the policy regarding smoking.Review of the annual MDS assessment dated [DATE], revealed that the resident had a BIMS score of 13, indicating intact cognition.-Regarding resident #242:Resident #242 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease, muscle weakness, dysphagia, oral phase, nicotine dependence, hyperlipidemia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a BIMS score of 13, indicating cognitively intact.A review of the resident's care plan initiated on July 13, 2026, in the problem focus revealed that the resident is a smoker and is at risk for smoking-related injury.A care plan intervention initiated on July 13, 2026, included explaining the smoking policy and times to the resident and family.A review of the smoking policy signed by the resident on July 12, 2026, revealed the resident signed the facility's smoking policy acknowledging the policy regarding smoking.On July 20, 2026, at 10:27 AM, during the initial screening, the surveyor interviewed resident #87, and during the interview, a pack of cigarettes and a lighter were observed in the resident's bedside table. The resident stated that he smoked, and he always kept the smoking paraphernalia with him, but he was aware that he has to turn his cigarettes and lighter over to the activity staff because he was not allowed to keep them. He stated he chose to keep the cigarettes and lighter with him so that he didn't have to ask the staff all the time.On July 20, 2026, at 10:40 AM, during the initial screening interview with resident #242, a lighter was observed at the resident's bedside table. The resident stated that she smoked and sometimes kept her cigarettes and lighter with her. The resident stated that the staff let her keep the cigarettes and lighter in her possession.On July 20, 2026, at 2:00 PM, Resident #169 was walking toward the courtyard to smoke during the screening interview. The resident stated that she smoked, and she kept the cigarettes and the lighter in her possession. The resident unzipped the pocket on her four-wheeled walker, and a pack of cigarettes was observed. The resident stated that the staff tried to take the cigarettes and smoking paraphernalia away from her, but she didn't let them.A second interview with resident #242, during the smoking observation on July 23, 2026 at 11:00 AM. The resident stated that the staff asked her if they could take her lighter away from her and keep it in the secure box (taco box). The resident added that the staff wanted to take the lighter from her because State surveyors were in the facility and it was going to be a problem if she won't surrender the lighter.On July 22, 2026, at 2:48 PM, an interview with resident #169, who stated that a staff member went to her and asked her to take her cigarettes and her lighter away from her. The resident stated that she refused to hand the cigarettes and lighter to the staff, and told the staff that she has every right to keep all her personal belongings if she chooses. The resident stated that the staff wants to take her cigarettes and lighter away because the State surveyors were here for a survey, and it's going to cause a problem if she keeps the items.On July 23, 2026, at 1:16 PM, another interview with the resident #87 was conducted, who stated that the staff tried to take the cigarettes away from him after the resident was interviewed during screening. The resident stated that it's his right, as a resident of the facility, to keep his personal things with him. The resident stated that they have a smoking schedule and residents have a scheduled 20-minute smoking session. The resident added that the activity staff kept the cigarettes and lighters secure in the secure box (taco box), then during smoke break, activity staff is assigned to supervise the residents, and staff provide each resident with one cigarette and light the cigarettes for the residents.On 07/23/26 at 8:40 AM, an interview was conducted with the Certified Nursing Assistant (CNA, staff #191), who stated that it's the activity staff who assist the residents during smoke breaks, not the nurses or CNAs.On July 23, 2026, at 2:05 PM, an interview was conducted with the Activity Assistant (staff #102), who stated that residents' families bring the cigarettes and give them to the residents. She added that residents should surrender the cigarettes and the lighter to the activity staff. The staff added that they keep the cigarettes and lighter in the secure box (taco box). She added that some residents become upset when staff attempts to take cigarettes and lighters, so staff allows the residents to retain them to avoid confrontation. She stated that there's a designated smoking area for the residents to go during smoke break. She added that at least two staff will be with the residents during smoke break, and staff will be the ones providing the cigarettes and lighting the cigarettes for the residents. She added that the resident cannot keep the cigarettes and lighter with them.On July 23, 2026, at 2:28 PM, an interview was conducted with the Administrator (staff #91), who stated he was unaware that there was a resident who was keeping cigarettes and a lighter in their possession. The administrator added that the resident's family brings cigarettes and a lighter with them when they visit, and activities staff are in charge of keeping that smoking paraphernalia because the residents are not allowed to keep them. The administrator added that residents who were admitted to the facility signed the smoking policy stating that they are not allowed to keep cigarettes and a lighter with them. The administrator stated that during the smoke break, activities staff supervise the residents, including providing the cigarettes and lighting the cigarettes for the resident. The administrator stated that the risks of allowing residents to keep unsupervised cigarettes and lighters could put the residents at risk for accidental fire or smoking-related injury.Review of the policy titled, All Smoking Paraphernalia, revealed that all smoking paraphernalia is to be kept by the activity professional assistant (APA). This includes (but is not limited to) cigarettes, cigars, vape pens, and lighters. Anyone found in possession of smoking paraphernalia who is unwilling to turn it over to staff will have smoking privileges revoked immediately. There is no three-strike policy for those unwilling to turn in smoking paraphernalia.

Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#214) had a level I Pre-admission Screening and Record Review (PASRR) prior to admission or upon admission. The sample size was 2. The deficient practice could result in residents not receiving the appropriate level of care needed to achieve their highest and practicable wellbeing.Findings include:Resident #214 was admitted on [DATE] with diagnoses that included fibromyalgia, bipolar disorder, anxiety disorder, major depressive disorder, and suicidal ideations.Review of the quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #214 had a Brief Interview for Mental Status (BIMS) and scored a 13 which indicated she was cognitively intact. The same MDS also noted that Resident #214 rejected cares every 4 to 6 days during the assessment period. It further noted that she had diagnoses of anxiety, depression, and bipolar disorder. The MDS also indicated that Resident #214 was taking antipsychotics and antidepressants.Review of the order summary report for Resident #214 revealed the following orders: - Cares in pairs - Paroxetine (antidepressant) HCI 10 milligrams (MG) at bedtime for verbalized sadness related to depression- Risperdal (antipsychotic) 2 MG twice a day for severe mood swings related to bipolar disorder- Trazadone (antidepressant) 150 MG at bedtime for sleeplessness related to depression- Valproic Acid Oral Solution (mood stabilizer) 10 milliliters (mL) twice a day for mood swings related to bipolar disorderReview of the clinical record revealed a level I PASRR form with Resident #214's name, date of birth , and Medicare ID number on it. However, the remainder of the form was blank.A Nurse Practitioner Note, dated September 25, 2025 at 3:00 P.M. noted that Resident #214 was sent, from her previous living placement, to the emergency room (ER) on July 2, 2025 for a psychiatric evaluation due to her mental health decompensating. It also noted that she had a Urinary Tract Infection (UTI) and was treated with oral antibiotics. The note further indicated that Resident #214 needed Psychiatry services.An interview was conducted with Social Services Director (Staff #258) on July 22, 2026 at 1:25 P.M. Staff #258 shared that he works with the admissions department to ensure potential new admissions have a level I PASRR. If they did not have one on file then the admissions department would complete the level I PASRR. He further shared that he provided training to the admissions department on how to complete a level I PASRR. Staff #258 shared that he was not able to locate a level I PASRR for Resident #214 in the clinical record. He stated that Resident #214 came to the facility from another skilled nursing facility and that he thinks the admission team thought the PASRR was in the admission packet. Staff #258 was unable to find Resident #214's level I PASRR in the admission packet.On July 22, 2026 at 3:11 P.M. Staff #258 informed surveyor that he had reached out to the State's PASRR team and they had sent him a level I referral from June 2025.A telephonic interview was conducted with Admissions Assistant (Staff #61) on July 24, 2026 at 9:19 A.M. She shared that referrals for admissions need to have a level I PASRR and that certain hospitals do them. She further shared that if a resident comes from another SNF then they will ask the referring SNF to send the PASRR they have on file. If she does not get a level I PASRR then Staff #258 would complete a level I PASRR. Staff #61 also shared that residents are not able to be admitted without a level I PASRR. Staff #61 was not able to recall if she reviewed the level I PASRR for Resident #214.An interview was conducted with the Admissions Director (Staff #199) on July 24, 2026 at 9:37 A.M. She shared she thought the level I PASRR was a pre-screening form to make sure admitting residents are appropriate for the facility's services. Staff #199 added that she would have to ask to make sure that was correct. When asked to review the clinical record for Resident #214, Staff #199 stated the initial admission was on September 22, 2025 and that based on what she was seeing, in the chart, a level I PASRR was not received or completed prior to admission. Staff #199 stated that admitting a resident without a level I PASRR did not meet her expectations because it was required to ensure the resident meets the level of care the facility is able to provide.An interview was conducted with the Director of Nursing (Staff #58) on July 24, 2026 at 9:53 A.M. Staff #53 stated that incoming residents need to have a level I PASRR before they are admitted because they might be needing a referral for a level II PASRR which would inform the care that the resident will need. Staff #58 shared that Resident #214 was admitted to the facility on [DATE] and she did not think that the level I PASRR came with the resident when she was admitted from another SNF. Staff #53 stated that she did not feel that there was a risk to residents if there is no level I PASRR being done prior to admission. However, she acknowledged that not having a level I PASRR did not meet her expectations because it was a federal requirement.Review of the facility's policy titled, PASRR (Pre-admission Screening & Resident Review) revealed that each (resident) will be screened for a mental disorder (MD) or intellectual disability (ID) prior to admission by utilizing the PASRR Level I form. It also directs that the completed PASRR be kept in the resident's medical record. It also indicates that the responsibility of ensuring that the level I PASRR is completed and accurate, prior to admission, lies with the facility.

Based on observation, interview, and facility record review, the facility failed to maintain a safe, clean, and sanitary kitchen environment and failed to ensure dietary aide staff used clean cloths when wiping dishes. This deficient practice could increase the risk of cross-contamination and foodborne illness for all residents. Findings:An initial kitchen observation was conducted on July 20, 2026, at 8:30 AM. Upon entering the kitchen, the surveyor observed that the kitchen floor was wet and soiled with food crumbs and coffee grounds. A wet wiping cloth was left on greasy countertops. Pots, pans, and dishes on the counters and in the sink contained visible food residue. Thick grease accumulation and food debris were observed on the fryers, ovens, and stove hoods. Trash containers were overflowing and had not been emptied.On July 20, 2026, at 8:45 AM, an interview was conducted with the Dietary Director (staff #206), who stated that the kitchen was short-staffed the previous evening and that the dietary staff working were very busy. Staff #206 stated there was a lot going on and staff did not have sufficient time to clean the kitchen before leaving. Staff #206 added that the kitchen had experienced significant staff turnover since the last survey.Another observation was conducted on July 22, 2026, at 11:46 AM. When entering the dishwashing area, the surveyor observed food crumbs on the floor, and the floor remained wet. On July 22, 2026, at 12:00 PM, during trayline, the surveyor observed Dietary Aide #30 wipe three clean plates with the same white cloth that had previously been used to wipe the hot food table and pick up food crumbs from the kitchen floor while meal trays were being prepared. Staff #206 immediately corrected staff #30. On July 22, 2026, at 1:46 PM, an interview was conducted with the Dietary Director (staff #206), who confirmed staff #30 wiped clean plates with the same white cloth that had been used to wipe the hot food table and pick up food crumbs from the kitchen floor. Staff #206 stated this practice creates a high risk for cross-contamination and foodborne illness. Staff #206 stated that staff in the kitchen receive training with food preparation and handling annually and as needed, and Staff #206 stated dietary staff receives annual training on food preparation and handling, as well as additional education as needed, and Staff #206 also added that the Infection Preventionist (IP) also provides infection control training to dietary staff.On July 22, 2026, at 1:17 PM, A phone interview was conducted with Staff #30. Staff #30 stated he did not remember using the same cloth to wipe clean plates after using it on the hot food table and kitchen floor during tray-line. Staff #30 stated he understood that doing so could cause cross-contamination and said he would never intentionally do that. When informed that both the surveyor and staff #2206 witnessed the incident, Staff #30 continued to state he did not remember doing so.On July 23, 2026, at 2:33 PM, an interview was conducted with the Administrator (Staff #91), who stated he oversees kitchen operations, expects the dietary department to maintain a clean kitchen, and confirmed all dietary staff receive infection control training. He stated that maintaining a clean kitchen is important because it is where food is prepared and helps prevent cross-contamination and foodborne illness. He further stated he was unaware that the kitchen had been short-staffed or left unclean the previous evening. He stated that he expects all facility staff, including the dietary staff, to maintain cleanliness. He stated that all facility staff, including the kitchen staff, received infection control training.Review of the kitchen policy titled Policy and Procedure Manual revealed that food items will be prepared and kept free of harmful organisms and substances. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate.

Number of residents sampled:3Number of residents cited:3The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 3 of 3 sampled residents (#142, #147, and #150). The deficient practice could result to residents not being able to access an advocate who can inform them of their options and rights related to discharges. Based on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for three discharged residents (#142, #147, and #150). The deficient practice could result to residents not being able to access an advocate who can inform them of their options and rights related to discharges.Findings include:-Regarding Resident #150:Resident #150 was admitted to the facility on [DATE] with a diagnosis that included hypertension and status post recovery from incarcerated/strangulated inguinal hernia repair.Review of admission/readmission progress note dated February 28, 2025 revealed resident was able to communicate needs and wants effectively. Resident verbalized understanding. admission consent forms were signed by the resident's representative/family at bedside.Review of nursing progress notes dated March 2, 2025 revealed a change of condition relating to resident was unhappy with the food and resident was requesting to be discharged back home.Review of provider progress notes dated March 3, 2025 revealed resident's family member was requesting for resident to go home by Friday and case management was aware of the request.Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3.0, severe impairment.Review of nurse progress note dated March 7, 2025 revealed resident was discharged against medical advice (AMA), and resident's representative/family wanted resident to return back home. Staff educated the resident and resident's representative on leaving AMA and the risk involved. The staff notified resident's provider of resident discharging AMA.Resident #150 was discharged from the facility on March 7, 2025.-Regarding Resident #142:Resident #142 was readmitted to the facility on [DATE] with a diagnosis that include anxiety, depression, and chronic back pain.Review of BIMS clinical assessment dated [DATE] revealed a score of 15.0, cognitively intact.Review of Interdisciplinary Team (IDT) progress notes dates March 14, 2025 revealed Resident #142 was bedbound, required minimum assistance for transfers and required contact guard assistance for activities of daily living.Review of progress notes revealed Resident #142 has an order for Gabapentin 100 mg (milligram), methocarbamol 500 mg, and Morphine Sulfate Oral Tablet 15 mg for pain management. Review of progress note dated March 18, 2025 revealed Resident #142 left the facility AMA, left without medication, and was picked up by the resident's family member. The progress notes revealed that the resident was educated on risks of leaving AMA including worsening of illness. The Director of Nursing (DON) and the resident's provider were notified of resident leaving AMA.Resident #142 was discharged from the facility on March 18, 2025.-Regarding Resident #147:Resident #147 was admitted to the facility on [DATE] with a diagnosis that includes Coronary Artery Disease (CAD), Heart Failure, Hypertension, Diabetes Mellitus (DM), Malnutrition, and Anxiety DisorderReview of records revealed Resident #147 was under the care of hospice from April 24, 2025.Review of care plan initiated on April 28, 2025 revealed Resident #147 requires hospice care, and at risk for rapid decline in activities of daily living function, sudden onset or worsening of skin integrity, weight loss, nausea/vomiting, pain, abnormal breathing, and impaired psychosocial wellbeing. The interventions include to administer medication as ordered, assist with activities of daily living, establish a daily routine, and coordinate resident's needs with hospice staff.Review of admission MDS assessment dated [DATE] revealed resident had a BIMS score of 7.0, severe impairment.Review of care plan dated May 1, 2025 revealed resident has nutritional risk related to type 2 diabetes, chronic gout, decreased by mouth intake related to progression of disease and resident was under the service of hospice care.Review of records revealed resident's blood sugar were checked at least three times a day from May 9, 2025 through June 26, 2025.Review of case management progress note dated June 26, 2025 revealed that Resident's Power of Attorney (POA) was upset and was demanding to speak with someone who could help get the resident out of the facility. The resident's POA stated the facility was not providing therapy services. The POA was informed that the resident was admitted to the facility for long term care, and during the care conference it was explained to the POA that the resident was on hospice services which meant therapy services were not available. In addition, the progress note revealed that the resident's POA was educated by the director of nursing and case management that the facility's dietician monitors all risk related to decline in nutrition risks, all diabetic concerns were monitored based on physician's order, symptoms and medication management; monthly activity calendars were given to residents, activity calendars were placed around the facility at the start of the month; and the activity director along with the activity assistant visits residents who were not able to attend. The POA was informed that the provider gave order to discharge resident home per POA request with hospice care. The progress note revealed resident would be liable for private pay at daily charge if resident would like to stay. In addition, the progress note revealed that the resident's provider was notified regarding resident leaving without hospice and the discharge of the resident was not a safe discharge. The resident's POA signed the AMA form and removed Resident #147 out of the facility.Resident #147 was discharged from the facility on June 26, 2025.An interview was conducted on August 7, 2025 at 12:44 PM with Case Manager/Staff #59. Staff #59 stated that every month there should be notification of discharge sent to the Ombudsman. The notification of discharge usually is sent on the last day of each month or the beginning of the next month. Staff #59 stated that she sent the June and July 2025 notification of discharges to the Ombudsman this week. In addition, Staff #59 stated that the facility went through different case managers for the last three months. Staff #59 stated that she just started last week and Staff #600 was the case manager last month. Furthermore, Staff #59 stated that the type of discharges she encounters include residents that were discharged to home, assisted living, resident leaving the facility AMA, and these types of discharges are send to the Ombudsman. Staff #59 stated that there was no notice of discharges sent to the Ombudsman for seven months. In addition, Staff #59 stated that for residents discharging AMA, she will meet with the resident and talk to the resident because the resident is leaving without medication, equipment, and or home health care services. Staff #59 stated that if a resident leaves without signing the AMA form, it should be documented in the progress note because some resident refused to sign the AMA form. And, if resident is not alert or oriented and wants to leave AMA, she will notify the resident's doctor, family, and the director of nursing (DON). Staff #59 stated that she recently spoke with the Ombudsman and the Ombudsman informed her that she has not received any notice of discharges since December.An interview was conducted on 08/08/2025 8:35 AM to Ombudsman (Staff #700). The Ombudsman stated that she received the December and November 2024 Notice of Discharge from the facility but did not receive the other notices for this year except the one Staff #59 send her couple days ago.An interview was conducted on August 8, 2025 at 10:58 AM with the Social Service Director (Staff #152) in his office. Staff #152 stated that he has been in the social service director position for three weeks and his responsibilities include managing all long-term care (LTC) residents, he conducts admission assessment such as BIMS, he is the main contact for LTC insurance companies, he completes Preadmission Screening and Resident Review (PASRR) for review, he manages grievances, and conducts all care plan meetings. Regarding resident discharges such as transferring to another facility, he stated that he will send an email or contact the Ombudsman. Staff #152 stated that he will contact the Ombudsman when there is a change in the level of care such as resident transferring or discharging to an assisted living home, group home, or to a detox facility because it is part of the discharge process. He will send every month notice of discharges to the Ombudsman. He stated that the case management is responsible in sending the notice of discharges to the Ombudsman. Furthermore, Staff #152 stated that the risk if the notice of discharge list was not sent to the Ombudsman, such as for instance the discharge was not a safe discharge or resident was not in agreement with the discharge, it could lead to rehospitalization, unsafe environment and potential abuse of the resident. Staff #152 stated that is why he starts discharge planning on day one to try to find alternatives and to make sure the discharge is safe.Additional interview was conducted on August 8, 2025 with Case Manager (Staff #59) and Unit Manager/Infection Preventionist (Staff #109) in the social service director's office. Staff #59 stated that her responsibility includes helping with discharges, making sure residents have everything they need. Staff #59 stated that after residents are discharged , she follows up with them within thirty days, the discharged resident list is sent to the Ombudsman at the end of the month, and Staff #59 stated that she sent one notice of discharge to the ombudsman for the month of June and July 2025 discharge list on August 6, 2025 because she has to do it and this week she did not know who was the Ombudsman representative covering for their facility. Staff #59 stated that the importance of sending the discharge list to the Ombudsman is to make sure residents have a safe discharge and the Ombudsman can follow up with the discharged residents. During the interview, Staff #109 stated that she was assigned to cover case management for the months of April, May and June. Staff #109 stated that she honestly did not sent the notice of discharge to the ombudsman. The case management was not her full-time position. Staff #109 stated that since she was made aware of the importance of sending the notice of discharge to the Ombudsman, she stated that her facility sent a notice of discharge to the Ombudsman this week. Staff #109 stated that the previous months from January through May 2025, the facility did not sent notice of discharge to the Ombudsman. Staff #109 stated that the facility had multiple case management staff turnover and she had no access to what was sent to the Ombudsman. Staff #109 stated that the risk if a notice of discharge was not sent to the Ombudsman is that the resident won't have an advocate to follow up with their needs.Review of facility's document titled, Admission/Discharge To/From Report, revealed that from January 2025 through June 2025, the facility had a total of 245 discharges.An interview was conducted on August 8, 2025 at 11:33 AM with the DON (Staff #66). The DON stated that regarding discharges, their case manager assists in setting up discharges, the resident's provider is notified of discharges, and the Ombudsman is notified of discharges at the end of the month. The DON stated that her case manager was not sending notice of discharges to the Ombudsman, and her facility went through different case managers previously. The DON sated that there is no risk if the Ombudsman was not notified of a resident's discharge.Review of facility's policy titled, Resident Rights, with a revision date of February 2021 revealed (1.) Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to (x.) communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter.

Number of residents sampled:6Number of residents cited:3The facility failed to ensure three residents necessary medications were ordered and available for use.Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for three residents (#5), (#43), and (#7). The deficient practice could result in not receiving medications that are physician ordered and necessary. Findings include:-Resident #5 was admitted to the facility on [DATE] with diagnoses that include a cerebral infarction, hemiplegia, aphasia, anemia, bipolar disorder, schizophrenia, and epilepsy.A review of the Quarterly MDS (Minimum Data Set) dated June 22, 2025 noted the resident had a BIMS of 99, indicating severe cognitive impairment. The care plan revised September 16, 2024 revealed the resident uses antidepressant medication related to poor appetite. With a goal of resident will be free from discomfort or adverse reactions related to the antidepressant therapy and with a noted intervention of give antidepressant medications as ordered by the physician.Review of the physician's orders dated March 5, 2025 revealed Mirtazapine oral tablet 7.5mg milligrams with instructions to give 2 tablets by mouth one time a day for depression as evidenced by poor appetite.A review of progress notes dated May 14, 2025 at 3:10 p.m. revealed that Mirtazapine 7.5mg medication was not given and coded as Other / see nursing notes, however the note related to the administration did not provide a reason. A review of progress notes dated May 15, 2025 at 2:00 p.m. revealed that Mirtazapine 7.5mg medication was not administered due to pending from pharmacy. A review of progress notes dated May 16, 2025 at 5:57 p.m. revealed the Mirtazapine 7.5mg medication was not administered due to pending delivery from pharmacy. -Resident #43 was admitted to the facility on [DATE] with diagnoses that include hemiplegia, aphasia, diabetes mellitus type 2, anemia, anxiety, hyperlipidemia, depression, and hypertension.A review of the admission MDS (Minimum Data Set) dated April 29, 2025 noted the resident had a BIMS of 3, indicating severe cognitive impairment. The care plan revised April 23, 2025 revealed that the resident requires anti-depressant medication, with a goal of medication use will result in the maintenance in the resident's functional status, with a noted intervention of administer antidepressant medication as ordered by the physician.Review of the physician's orders dated April 23, 2025 revealed Mirtazapine oral tablet 15mg with instructions to give 1 tablet by mouth one time a day for depression as evidenced by decreased appetite.A review of progress notes dated July 10, 2025 at 8:27 p.m. revealed that Mirtazapine tablet 15mg was not administered due to N/A awaiting from pharmacy. A review of progress notes dated July 10, 2025 at 8:32 p.m. revealed that atorvastatin calcium tablet 80mg medication was not administered due to N/A awaiting from pharmacy. A review of progress notes dated July 11, 2025 at 9:28 p.m. revealed that atorvastatin calcium tablet 80mg medication was not administered due to N/A awaiting from pharmacy. A review of progress notes dated July 11, 2025 at 9:30 p.m. revealed that Mirtazapine tablet 15mg medication was not administered due to awaiting from pharmacy. A review of progress notes dated July 12, 2025 at 10:03 p.m. revealed that Mirtazapine tablet 15mg medication was not administered due to awaiting delivery. -Resident #7 was admitted to the facility on [DATE] with diagnoses that include osteomyelitis, muscle wasting, depression, diabetes mellitus type 2, hypertension, chronic kidney disease, anemia, and anxiety.A review of the admission MDS (Minimum Data Set) dated June July 9, 2025 noted the resident had a BIMS of 15, indicating no cognitive impairment. The care plan revised July 4, 2025 revealed the resident uses antianxiety medication related to anxiety disorder as evidenced by restlessness. With a goal of medication use will result in the maintenance of the resident's functional status, and a noted intervention of administer medication as ordered by the physician.Review of the physician's orders dated July 22, 2025 revealed buspirone HCI oral tablet 7.5mg with instructions to give two tablets by mouth every 12 hours for anxiety as evidenced by restlessness.An interview conducted with a Licensed Practical Nurse (LPN/staff #64) on August 8, 2025 at 10:25 p.m., the LPN state that residents running out of medications happens a lot unfortunately. The LPN further stated that when they notice a resident is low or out of medications, they notify the provider and call the pharmacy. The LPN stated further that sometimes it's a pharmacy issue, being reordered too soon, or because of a cost control. The LPN stated that when they will document about the pharmacy being called but it kind of depends on who you work with on who to relay it to and who follows up on that medication. The LPN stated that it does get overlooked often unfortunately. The LPN concluded that if they had to guess, the missing medications were pulled from other residents, borrowing from them rather than getting them refilled correctly. An interview conducted with resident #7 on April 8, 2025 at 10:30 a.m., The resident stated that He has been here probably a month and a half. He states that often the nurses come into his room and state they don't have his medications. He further states it doesn't feel like it's ever addressed, and that his medications are missing often, sometimes 2-3 days in a row. He states the buspar is the biggest one, but that he has also had issues with his pain medicine. The resident concluded that he also ends up waiting long periods for pain medications, long after they are due. An interview was conducted on October 20, 2023 at 11:00 a.m. with the Director of nursing (DON/staff #66). The DON stated that when a resident is admitted they are assessed head to toe, assessments are performed and medications are activated in the system which then gets pinged to the pharmacy and should be delivered within a couple of hours. The DON stated that they get 2-3 pharmacy deliveries a day. The DON stated that if a medication is missing the nurse is supposed to put the medication on hold and notify a provider. The DON further stated that missing medications and the nursing staff not reordering appropriately did not meet her standards. The DON concluded that what bothers her is that the nurses know the protocol, but don't always notify the management staff when there is a problem, and that she will be more cautious in the future. A review of facility policy titled 'Administering medications' revised April 2019 revealed that the director of nursing services supervises and directs all personnel who administer medications and/or have related functions. The policy also revealed that medications are administered in accordance with prescriber orders, including any required timeframe.A review of facility policy titled 'Medication and Treatment orders' revised July 2016 revealed that the drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy to ensure that refills are readily available.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that their abuse policy was implemented regarding major injury that one resident (#5) sustained. The deficient practice could result in other facility policies not being followed. Findings include: Resident #5 was initially admitted to the facility of December 26, 2018 with a diagnosis of dementia, major depressive disorder, hyperlipidemia and gout. Review of the progress note dated December 18, 2024 states resident laying on right side of bed, stating pain in the right upper leg. Assessment completed and 911 call, resident transferred by gurney to ER. Review of an IDT Note dated December 20, 2024 states Resident had fall with injury. Resident has dementia and became increasingly agitated. Upon speaking with the nurse she stated that the resident has not walked for years but kept telling the LN that she was leaving and wanted to leave this place. LN sent out resident immediately. Family and provider notified. Review of the hospital History and Physical dated December 23, 2024 stated the resident had sustained a left periprosthetic femur fracture and a right hip fracture. Review of SA (State Agency) Database revealed that there was no evidence found that the facility reported Resident's (#5) major injury to the SA. An interview was conducted on March 5, 2025 at 1:03 PM with the DON (Director of Nursing, Staff #20) and the ADON (Assistant Director of Nursing, Staff #50). Staff #20 stated that resident #5 fell from her bed, the nurse went into the resident's room and the resident was on the floor beside the bed and she called 911. Staff #50 stated that she was informed from the insurance representative that resident #5 was discharged to another facility. Staff #50 contacted the resident's daughter, primary contact for the resident, who stated she choose the facility because it was closer to her home. Staff #50 stated that resident was denied therapy and her daughter had her transferred to another facility. Staff #50 stated the second facility therapy was also denied and the daughter had resident #5 readmitted to the facility on [DATE]. Staff #50 stated that Resident #5 was denied therapy here also but was under her long-term care insurance. Staff #50 also stated that the resident was on palliative care and had been for years. An interview was conducted on March 5, 2025 at 2:07 PM with Staff #20 who stated the injuries resident #5 sustained were not witnessed. Her conclusion is that this resident fell out of bed due to the statement the resident made to the nurse that found her I want to go home. I don't want to stay here. The only investigation that was completed by staff #20 was speaking to the nurse that found the resident. She stated that she did not feel this incident should have been reported to the state. She does submit any allegations of abuse and those are investigated. Staff #20 also stated that she can understand how the situation could be looked at in a different way. She stated However I do see what you are saying and the way you are looking at this from an outside person. The staff know this resident because she's been here for so long and just concluded there is no other explanation for her on the floor. I get what you are saying. Review of the facility's policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 2001 with a revision on April 2021, states upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Immediately is defined as: within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to report a major injury that one resident (#5) sustained. The deficient practice could result in other injuries of unknown origin to residents. Findings include: Resident #5 was initially admitted to the facility of December 26, 2018 with a diagnosis of dementia, major depressive disorder, hyperlipidemia and gout. Review of the progress note dated December 18, 2024 states resident laying on right side of bed, stating pain in the right upper leg. Assessment completed and 911 call, resident transferred by gurney to ER. Review of an IDT Note dated December 20, 2024 states Resident had fall with injury. Resident has dementia and became increasingly agitated. Upon speaking with the nurse she stated that the resident has not walked for years but kept telling the LN that she was leaving and wanted to leave this place. LN sent out resident immediately. Family and provider notified. Review of the hospital History and Physical dated December 23, 2024 stated the resident had sustained a left periprosthetic femur fracture and a right hip fracture. Review of SA (State Agency) Database revealed that there was no evidence found that the facility reported Resident's (#5) major injury to the SA. An interview was conducted on March 5, 2025 at 1:03 PM with the DON (Director of Nursing, Staff #20) and the ADON (Assistant Director of Nursing, Staff #50). Staff #20 stated that resident #5 fell from her bed, the nurse went into the resident's room and the resident was on the floor beside the bed and she called 911. Staff #50 stated that she was informed from the insurance representative that resident #5 was discharged to another facility. Staff #50 contacted the resident's daughter, primary contact for the resident, who stated she choose the facility because it was closer to her home. Staff #50 stated that resident was denied therapy and her daughter had her transferred to another facility. Staff #50 stated the second facility therapy was also denied and the daughter had resident #5 readmitted to the facility on [DATE]. Staff #50 stated that Resident #5 was denied therapy here also but was under her long-term care insurance. Staff #50 also stated that the resident was on palliative care and had been for years. An interview was conducted on March 5, 2025 at 2:07 PM with Staff #20 who stated the injuries resident #5 sustained were not witnessed. Her conclusion is that this resident fell out of bed due to the statement the resident made to the nurse that found her I want to go home. I don't want to stay here. The only investigation that was completed by staff #20 was speaking to the nurse that found the resident. She stated that she did not feel this incident should have been reported to the state. She does submit any allegations of abuse and those are investigated. Staff #20 also stated that she can understand how the situation could be looked at in a different way. She stated However I do see what you are saying and the way you are looking at this from an outside person. The staff know this resident because she's been here for so long and just concluded there is no other explanation for her on the floor. I get what you are saying. Review of the facility's policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 2001 with a revision on April 2021, states upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Immediately is defined as: within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to investigate a major injury that one resident (#5) sustained. The deficient practice could result in other injuries of unknown origin to residents not being investigated thoroughly. Findings include: Resident #5 was initially admitted to the facility of December 26, 2018 with a diagnosis of dementia, major depressive disorder, hyperlipidemia and gout. Review of the progress note dated December 18, 2024 states resident laying on right side of bed, stating pain in the right upper leg. Assessment completed and 911 call, resident transferred by gurney to ER. Review of an IDT Note dated December 20, 2024 states Resident had fall with injury. Resident has dementia and became increasingly agitated. Upon speaking with the nurse she stated that the resident has not walked for years but kept telling the LN that she was leaving and wanted to leave this place. LN sent out resident immediately. Family and provider notified. Review of the hospital History and Physical dated December 23, 2024 stated the resident had sustained a left periprosthetic femur fracture and a right hip fracture. An interview was conducted on March 5, 2025 at 1:03 PM with the DON (Director of Nursing, Staff #20) and the ADON (Assistant Director of Nursing, Staff #50). Staff #20 stated that resident #5 fell from her bed, the nurse went into the resident's room and the resident was on the floor beside the bed and she called 911. Staff #50 stated that she was informed from the insurance representative that resident #5 was discharged to another facility. Staff #50 contacted the resident's daughter, primary contact for the resident, who stated she choose the facility because it was closer to her home. Staff #50 stated that resident was denied therapy and her daughter had her transferred to another facility. Staff #50 stated the second facility therapy was also denied and the daughter had resident #5 readmitted to the facility on [DATE]. Staff #50 stated that Resident #5 was denied therapy here also but was under her long-term care insurance. Staff #50 also stated that the resident was on palliative care and had been for years. An interview was conducted on March 5, 2025 at 2:07 PM with Staff #20 who stated the injuries resident #5 sustained were not witnessed. Her conclusion is that this resident fell out of bed due to the statement the resident made to the nurse that found her I want to go home. I don't want to stay here. The only investigation that was completed by staff #20 was speaking to the nurse that found the resident. She stated that she did not feel this incident should have been reported to the state. She does submit any allegations of abuse and those are investigated. Staff #20 also stated that she can understand how the situation could be looked at in a different way. She stated However I do see what you are saying and the way you are looking at this from an outside person. The staff know this resident because she's been here for so long and just concluded there is no other explanation for her on the floor. I get what you are saying. Review of the facility's policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 2001 with a revision on April 2021, states upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are thorougly investigated. The individual conducting the investigation as a minimum: a. reviews the documentaion and evidence:; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and othr residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors.

Based on clinical record review, observations, staff interviews, and review of policy and procedure, the facility failed to protect the residents' (#128, #161 #15 and #14) rights to be free from abuse by another resident (#15, #11, #17). The deficient practice could result in residents not protected from further abuse. Findings include: Regarding incident between resident #128 and resident #15 -Resident #128 (alleged victim) was admitted on [DATE] with diagnoses of cerebrovascular disease involving cognitive function following cerebral infarction, dementia with behavior disturbance and other personality and behavioral disorders. The care plan dated September 22, 2021, revealed the resident had an enteral feeding tube to meet nutritional needs related to cerebrovascular accident with dysphagia with interventions including aspiration precautions, dietary evaluation and monitoring, feedings at room temperature, feeding tube changes per order, feeding tube site care as ordered, and tube feeding formula administered per orders. Another care plan for resident #128 dated September 22, 2021 revealed the resident had impaired communication as evidenced by difficulty making self-understood and difficulty understanding others with interventions that included to use short phases that required yes/no answers; speaking in a normal tone voice clearly and slowly; gain the resident's attention and eye contact before speaking to the resident, and allowing sufficient time for the resident to process and respond. A physician order dated September 5, 2023 for feeding tube formula Jevity 1.5 at 60 ml (milliliters) per hour with water flushes at 20 ml per hour for 20 hours per day through the feeding tube; administer continuously through pump, begin at 12:00 p.m. and stop at 8:00 a.m. The progress notes dated October 16, 2023 at 8:41 a.m. revealed the facility attempted to contact the resident's family regarding the need for a new feeding tube. Per the documentation, at 9:00 a.m., the resident was moved to a new room for safety and the wound care doctor was notified to replace the feeding tube. The SBAR (Situation-Background-Assessment-Recommendation) dated October 16, 2023 included the resident had a verbal altercation with roommate; and that, when the roommate was re-directed away from resident, the resident's feeding tube was missing and later located near him. Per the documentation, the resident's tube site was assessed and was found with redness but no bleeding or other injury. At 5:30 p.m., the feeding tube was replaced and waiting for x-ray confirmation. Night shift was to wait for confirmation of x-ray results prior to resuming medication administration and feeding. A physician order dated October 16, 2023 included for a STAT x-ray to confirm feeding tube placement. A progress note dated October 17, 2023 revealed that the x-ray was completed; and, at 8:40 a.m., confirmation was received for the feeding tube placement was correct. -Resident #15 (alleged perpetrator) was admitted on [DATE] with diagnoses of traumatic subdural hemorrhage without loss of consciousness, unspecified injury of head, unsteadiness on feet, difficulty walking and need for assistance with personal care. The care plan dated August 22, 2023 revealed the resident exhibited or had the potential to exhibit physical behaviors related to history of harm to others, assaultive actions towards other residents, and resident-to-resident altercation. Interventions included to evaluate the nature and circumstances of the physical behavior with the resident or his representative; discuss the findings with the resident and family members and adjust care accordingly; evaluate the need for a psychiatric/behavioral health consult; encourage resident to seek staff support for distressed mood; remove the resident from the environment while speaking in a calm, reassuring voice; provide a calm, quiet well-lit environment; and, divert the resident by giving alternative objects or activities. A progress note dated October 16, 2023 at 8:45 a.m. revealed the facility attempted to contact the resident's family regarding the resident's behavior toward another resident (#128). Per the documentation, at 8:58 a.m. the facility notified state agencies regarding the altercation, the provider and psychiatry were notified with orders received; and resident #15 was placed on 15-minute checks. The SBAR dated October 16, 2023 included that resident #15 had a change in condition for behavior symptoms of agitation and psychosis of physical/verbal aggression. Per the documentation, the resident physical altercation resulted in the roommate's (resident #128) feeding tube being pulled out. Further, the documentation included that resident #15 shoved the CNA. A physician order dated October 16, 2023 included for laboratory test including blood and urine and psychiatric evaluation and treatment for increased behaviors. The care plan was revised on October 16, 2023 to include that the resident was at risk for decreased psychosocial well-being and adjustment issues, emotional distress, and ineffective coping skills, poor impulse control, adverse effects on function, mental physical, social, or spiritual well-being related to increased behaviors, verbal or physical altercation with other residents. Interventions included to assess clinical issues that may cause or contribute to mood pattern, encourage expression of feelings/concerns, maintain calm slow understandable approach, observe for signs and symptoms of depression/emotional distress, notify physician as needed, and refer to psychology/psychiatry as ordered. The facility investigation included that during their interview conducted with resident #15 on October 16, 2023 at 5:57 p.m., the resident stated that his roommate (resident #128) was talking and talking and he got mad, transferred himself into his wheelchair from the bed and went to the side of his roommate's bed. Per the documentation, resident #15 denied pulling out his roommate's feeding tube. The report also included that the facility was not able to interview resident #128 on October 16, 2023 at 6:13 p.m. Continued review of the report included a written witness statement by licensed practical nurse (LPN/staff #12) dated October 16, 2023. The statement included that the LPN was passing morning medications when resident #15 was heard yelling. per the documentation, the LPN went to the resident's room and saw resident #15 leaning over and was pulling at resident #128; and that, the LPN told resident #15 to stop and yelled for help. The documentation included that two other CNAs and another nurse came into the room; and resident #15 continued to yell and shove one of the CNAs as the CNAs redirected him. It also included that resident #15 threw something and sat down; and, the LPN noticed resident #128 was missing his feeding tube and then located the feeding tube next to Resident #128. The report also included a written witness statement dated October 16, 2023 by Certified Nursing Assistant (CNA/staff #29) who stated that the CNA heard the nurse scream for help; and the CNA ran in and saw that the feeding tube of resident #128 was removed. The documentation also included that resident #15 continued to be uncooperative and tried to push the CNA when he was asked to sit down. An interview with an LPN (staff #12) was conducted on February 29, 2024 at 1:40 p.m. The LPN stated that the LPN was at the medication cart when resident #15 was heard yelling. Per the documentation, the LPN went to see and found resident #15 sitting in his chair and yelling at resident #128 who was lying in bed with the feeding tube laying in the bed next to him. The LPN said that resident #128 was non-verbal and could pull at tubes but was not ambulatory. Further, the LPN said that there was verbal yelling in the room; but the LPN was not in the room to know exactly what happened between resident #128 and resident #15. During an interview with CNA (staff #29) conducted on February 29, 2024 at 1:45 p.m., the CNA stated the CNA was in the hallway and heard resident #15 yelling at resident #128; and that, the CNA and the nurse (staff #12) ran into the room at the same time. The CNA said when they when they walked into the resident's room, the CNA saw resident #15 pull resident #128's feeding tube; and that, resident #15 threw the feeding tube in the air when staff entered the room. The CNA also stated that resident #15 continued to be angry and aggressive; was saying that resident #128 was cussing; and that, resident #15 was telling resident #128 to shut up. However, the CNA stated that resident #128 just mumbled and was not able to speak. Further, the CNA stated that resident #15 was moved to another room after the incident. Regarding incident between resident #15 and #11 -Resident #15 (alleged victim) was admitted on [DATE] with diagnoses of traumatic subdural hemorrhage without loss of consciousness, unspecified injury of head, unsteadiness on feet, difficulty walking and need for assistance with personal care. The care plan dated August 22, 2023 revealed the resident exhibited or had the potential to exhibit physical behaviors related to history of harm to others, assaultive actions towards other residents, and resident-to-resident altercation. Interventions included to evaluate the nature and circumstances of the physical behavior with the resident or his representative; discuss the findings with the resident and family members and adjust care accordingly; evaluate the need for a psychiatric/behavioral health consult; encourage resident to seek staff support for distressed mood; remove the resident from the environment while speaking in a calm, reassuring voice; provide a calm, quiet well-lit environment; and, divert the resident by giving alternative objects or activities. A progress note dated August 8, 2023 at 8:48 a.m. revealed that the resident continued to display agitative behavior when he does not have cigarettes or nicotine available to him and this anger could be displayed toward other residents and he wants to act out and needs to be intercepted before temper escalates. The progress note dated August 16, 2023 at 11:09 a.m. included that the resident displayed physical aggression. A late entry progress note dated August 17, 2023 at 8:55 a.m. revealed that there was a commotion heard in the dining room; and when the DON entered the dining room, the activities staff was standing between residents #11 and #15. Per the documentation, both residents were immediately separated and escorted to their rooms; and that, resident #11 had struck resident #15 in the face; and, resident #15 had a laceration to his bottom lip. Resident #11 had struck resident #15 in the face. The care plan was revised on August 22, 2023 to include the resident exhibited or had the potential to exhibit physical behaviors related to history of harm to others, assaultive actions towards other residents, and resident-to-resident altercation. Interventions included staff were to evaluate the nature and circumstances of the physical behavior with the resident or his representative; discuss the findings with the resident and family members and adjust care accordingly; evaluate the need for a psychiatric/behavioral health consult; encourage resident to seek staff support for distressed mood; remove the resident from the environment while speaking in a calm, reassuring voice; provide a calm, quiet well-lit environment; and divert the resident by giving alternative objects or activities. -Resident #11 (alleged perpetrator) was admitted on [DATE] with diagnoses of major depressive disorder, adjustment disorder with disturbance of conduct, unspecified mental disorder, unspecified signs and symptoms involving cognitive functions and awareness, and alcohol use with unspecified alcohol induced disorder. The BIMS score dated July 19, 2023 was 14 indicating the resident had intact cognition. The care plan dated February 4, 2021 revealed the resident had potential to demonstrate verbal behaviors related to history of verbal outbursts directed toward others, ineffective coping skills, and psychiatric disorders. Interventions included to monitor medications for side effects and response contributing to verbal behaviors; evaluate nature and circumstances of verbal behaviors; evaluate need for psychiatric/behavioral health consultation, and explain all care before initiating care. The SBAR dated on August 16, 2023 revealed that activities staff got supervisors to break up fist fight between two residents. Per the documentation, resident #11 punched another resident in the face. A late entry note dated August 17, 2023 included that a commotion was heard in the dining room; and when the DON entered the dining room, the activities staff was standing between residents #11 and #15. Per the documentation, both residents were immediately separated and escorted to their rooms; and that, resident #11 was seen striking resident #15 in the mouth with his fist. A progress note dated August 17, 2023 at 12:49 p.m., resident #11 was sent out to the emergency room for psychiatric evaluation; and that, the resident returned to the facility at 10:00 p.m. with no new orders. The care plan was revised on August 17, 2023 to include that the resident exhibited or had the potential to exhibit physical behaviors related to poor impulse control. Interventions included to evaluate the need for psychiatric/behavioral health consult. The facility report included that the facility was not able to interview resident #11 due to cognitive deficit. It also included a written witness statement by staff #33 who reported that resident #15 was on his way to use the restroom when he bumped resident #11's table. Per the statement, resident #11 got mad, yelled at and punched resident #15 in the mouth. The report also included a written statement dated August 16, 2023 from staff #4 who wrote that resident #15 accidentally bumped resident #11 due to limited space as he was trying to get through; and that, resident #11 hit/punched resident #15 in the face. 49319 Regarding resident #161 and #17 -Resident #161 (alleged victim) was admitted on [DATE] with diagnoses of end stage renal disease (ESRD), hemorrhage of anus and rectum, large intestine cancer and depression. -Resident #17 (alleged perpetrator) was admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD), major depressive disorder, myocardial infarction and history of falls. A progress note dated May 1, 2023 included that staff #12 could hear resident #17 yelling out explicit language and threatened another resident. Per the documentation, she looked outside in the smoking area and could see resident #17 sitting across from resident #161; and that, resident #17 was telling resident #161 that he was going to f--k resident #161 up while kicking resident #161 who told resident #17 to stop. However, the documentation included that resident #17 continued to kick resident #161. A progress note dated May 2, 2023 included that a licensed nurse (staff #8) reported to an officer around 6:00 p.m. that resident #17 kicked another resident (#161). Review of the facility 5-day report revealed that resident #17 kicked resident #161 while they were sitting next to each other; and that, they were immediately separated and assessed for injury. Per the documentation, there were no injury found. Regarding resident #14 and #3 -Resident #14 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side and major depressive disorder. A progress note dated August 12, 2023 included that the resident was punched in face by roommate. Per the documentation, the resident was sitting in wheelchair facing the door and the roommate (resident #3) was facing the resident; and that, both residents were yelling and cussing at each other. It also included that the staff went in between both residents; and, blood was noted running down from both sides of nose and a cut over right eye was noted. Further, the note included that the both residents was kept resident apart with the certified nurse assistant (CNA) assistance. -Resident #3 was admitted to the facility on [DATE], with past medical history of cerebrovascular disease, hypertension, hepatic failure, unspecified sequelae of cerebral infarction and adjustment disorder with disturbance of conduct. The progress note dated on August 12, 2023 that the resident #3 punched roommate (resident #14) in face; and that, the resident was standing over the roommate's face and both residents were yelling and cussing at each other. Per the documentation, the staff saw the right hand of resident #3 dropping down away from roommate's (#14) face. In an interview with resident #14 conducted on February 14, 2024 at 10:11 a.m., the resident stated that he left his room to smoke a cigarette and came back, was upset that his call light was on. Resident #14 said that resident #14 hit him. Resident #14 said there was no witness to the incident. Resident #14 further stated that he had injuries on his forehead; however, he did not go to the hospital. He also stated that he called the cops; and, had reported to an LPN (staff #104) that resident #3 had threatened him. In an interview with resident #3 on February 29, 2024 at 2:15 p.m., resident #3 stated that he punched resident #14. In an interview conducted on February 21, 2024 at 11:10 a.m., the LPN (staff #97) stated he had been the facility two weeks, was taught the abuse policy via on-line module required before working with residents. He defined abuse to include - physical, mental, financial, seclusion, sexual, exploitation and neglect. The LPN stated that he must report allegations immediately but no longer than two hours after the incident; and that, he would report to supervisor and executive director. Further, he stated that he would also follow up to ensure that something was done. An interview was conducted on February 21, 2024 at 11:30 a.m. with a CNA (staff #57) who stated that abuse was mental/emotional, physical, ignoring person, not answering call light timely; and that, she would report abuse to DON, supervisor and administrator within two hours. During an interview with the DON conducted on February 22, 2024 at 3:00 p.m., the DON stated that for abuse and neglect, the expectation was allegations of abuse are reported to her or the administrator (staff #106) within two hours. In an interview with the administrator (staff #106) conducted on February 29, 2024 at 2:28 p.m., the administrator stated that he was the abuse coordinator and was responsible for investigating allegations of abuse; and, he monitors for potential or actual reported allegations of abuse in several ways such as in-service, daily discussion and grievances. He said that he and the DON track all the self-reports. The administrator also said that abuse was not tolerated; and, if the facility suspect abuse, they will address it directly, terminate or write up staff, conduct in-service training for all staff and always address if there are difficult residents. The administrator stated that if an incident involved resident-to-resident, staff separate the two involved residents from each other; and if abuse allegation involved staff, the staff will be suspended pending investigation. A review of the facility's policy titled Resident Rights dated December 2016, revealed that the policy stated that the resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on clinical record reviews, staff interviews, State Agency (SA) intake database and review of facility documentation, policies and procedures, the facility failed to have evidence that an allegation of abuse for two residents (#174, #125) and misappropriation of narcotics for three residents (#134, #135, #136) were thoroughly investigated. The deficient practice could result in further abuse and misappropriation of narcotics not prevented and appropriate actions not taken. Findings include: Regarding resident #174 and #11 -Resident #174 was admitted on [DATE] with diagnoses of COVID-19, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, schizophrenia and bipolar disorder. The care plan dated February 1, 2021 revealed the resident had a tendency to exhibit sexually inappropriate behavior related to cognitive loss/dementia, psychiatric disorder-schizophrenia and bipolar. The BIMS (brief interview for mental status) score dated March 9, 2021 was 15 indicating the resident was cognitively intact. -Resident #11 (alleged perpetrator) was admitted on [DATE] with diagnoses of major depressive disorder, adjustment disorder with disturbance of conduct, unspecified mental disorder, unspecified signs and symptoms involving cognitive functions and awareness, and alcohol use with unspecified alcohol induced disorder. The care plan dated February 4, 2021 revealed the resident had potential to demonstrate verbal behaviors related to history of verbal outbursts directed toward others, ineffective coping skills, and psychiatric disorders. Interventions included to monitor medications for side effects and response contributing to verbal behaviors; evaluate nature and circumstances of verbal behaviors; evaluate need for psychiatric/behavioral health consultation, and explain all care before initiating care. Review of the SA intake database revealed that on May 7, 2022, a self-report was received. Per the documentation, resident #11 was verbally abusive to resident #174 on March 16, 2021 at 12:15 p.m.; and that, resident #11 was yelling at resident #174 and calling him foul names. Further, the self-report included that resident #174 reported the incident to staff who reported it to the facility administrator and director of nursing. The BIMS score dated July 19, 2023 was 14 indicating the resident had intact cognition. However, there was no evidence found that a 5-day investigative report was submitted to the SA. There was no evidence found that the incident between resident #174 and #11 was thoroughly investigated. Regarding resident #125 and staff -Resident #125 was admitted on [DATE] with diagnoses of metabolic encephalopathy, sepsis, cellulitis of right lower limb, embolism and thrombosis of arteries of lower extremities, urinary tract infection, acquired absence of right leg above knee, legal blindness, acute kidney failure, diabetes type 2, and heart failure. The care plan dated April 21, 2022 revealed the resident exhibited or had the potential to exhibit psychosocial distress secondary to infection prevention practices related to restricted visitation, changes in room or roommate, isolation, and absence of communal activities. Interventions included that staff were to evaluate the need for a behavioral health consult, assist the resident with communicating with family and friends, provide emotional support as needed, and provide the resident with individualized diversional activities. The BIMS score on April 23, 2022 was 9 indicating the resident had moderate cognitive impairment. A progress note dated May 5, 2022 at 6:33 p.m. revealed that the resident had verbal behaviors toward others, experienced agitation, restlessness and delusions. Review of the SA database revealed a facility a self-report was received on May 7, 2022 at 9:48 a.m. Per the documentation, resident #125 reported that a staff member kissed her; and that, resident #125 asked for staff to kiss her but the staff refused. Further, the documentation included that the facility will begin their 5-day investigation. However, the SA database revealed no evidence that a 5-day investigative report was submitted by the facility. There was also no evidence that this incident was thoroughly investigated. Regarding misappropriation of narcotics for 3 residents (#134, #135, #136) -Resident #134 was admitted on [DATE] with diagnoses of metabolic encephalopathy, sepsis, major depressive disorder and anxiety disorder. The clinical record revealed the resident was prescribed with oxycodone (narcotic) -Resident #135 was admitted on [DATE] with diagnoses of paraplegia, chronic pain, anxiety disorder, major depressive disorder and insomnia. The clinical record revealed the resident was prescribed with oxycodone. -Resident #136 was admitted on [DATE] with diagnoses that included ileostomy status, ventral hernia, Guillain barre syndrome, anxiety disorder, and severe protein-calorie malnutrition. The clinical record revealed that resident was prescribed with oxycodone and Percocet (narcotic). Review of the SA database revealed that a self-report from the facility was received on April 26, 2022 at 9:23 a.m. Per the documentation, there narcotics were missing from at least three residents (#134, #135, and #136), the investigation was still in progress, and one staff member had been suspended pending the investigation. However, the SA database revealed no evidence that 5-day investigative report was submitted by the facility. There was no evidence found that misappropriation of narcotics for residents #134, #135 and #136 was thoroughly investigated. Further, the facility was not able to provide narcotic count sheets and documentation of their investigation regarding the allegation of misappropriation of narcotics. An interview with the administrator (staff #106) was conducted on February 21, 2024 at 1:00 p.m. The administrator stated they were having difficulty locating the documents for these incidents as there was a facility change in ownership on September 1, 2023. In another interview with the administrator conducted on February 29, 2024 at 2:00 p.m., the administrator stated that they did not have the 5-day investigation reports requested if they had not already provided them; and that, they were not able to find any other 5-day investigative reports or documentation from the previous owner. An interview with the Director of Nursing (DON/staff #69) was conducted on February 29, 2024 at 4:00 p.m. The DON stated they did not have the investigative reports that remained missing or the narcotic count sheets. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022, included that upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator was responsible for determining what actions if any were needed for the protection of residents. All allegations were to be thoroughly investigated and that the administrator was responsible for initiating the investigation. The investigation was to include: reviews of documentation and evidence; reviews of the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observations of the alleged victim; interview of the person reporting the incident; interviews of any witnesses to incident; interviews of the resident or resident representative, the resident's attending physician, staff members on all shifts who have had contact with the resident during the period of the alleged incident, the resident's roommate, family members, and visitors; review of all events that lead up to the incident; and document the investigation completely and thoroughly. Within 5 business days of the incident, the administrator was to provide a follow-up investigation report. The follow-up investigation report was to provide sufficient information that described the results of the investigation, and indicate any corrective actions taken if the allegation was verified. Review of the facility's policy titled Protection of Residents During Abuse Investigations revised April 2017, included that within 5 working days of the alleged incident, the facility was to give the state survey and certification agencies a written report of the findings of the investigation and a summary of corrective action taken to prevent such incident from recurring.

Based on closed clinical record review, staff interviews, review of facility documentation, policy and procedures, and through observation of current practice. the facility failed to adequately provide activity of daily living (ADL) care for two residents (#127 and #137). The deficiency could result in residents not maintaining good personal hygiene. Findings include: -Resident #127 was admitted on [DATE] with diagnoses of neurocognitive disorder with Lewy bodies, dementia and abnormal weight loss. discharge date was October 25, 2021. Review of the clinical record revealed the resident was admitted for a hospice respite stay; and that, the resident required assistance from staff for toileting and personal hygiene (washing face, combing hair, and brushing teeth). The Brief Interview for Mental Status (BIMS) score dated October 15, 2021 revealed a score of 4 indicating the resident had severe cognitive impairment. The care plan dated October 20, 2021 included the resident was at risk for oral health or dental problems. Interventions included to brush or clean dentures, brush teeth and gums twice daily and as needed, and for staff to provide verbal cues. The October 2021 hospice documentation of ADL (activities of daily living) care on October 21, 2021 revealed that bathing and dressing was documented as activity did not occur or left blank from October 22 through 25, 2021. There was no documentation found in the clinical record that the resident was bathed or dressed for four days nor received oral care for three days. Further, the clinical record revealed no documentation that the resident refused care. During an interview with the Director of Nursing (DON/staff #69) conducted on February 22, 2021 at 10:23 a.m., the DON stated that the facility was responsible for providing care and assistance to the resident when hospice was not in the facility. Further, the DON was not able to provide additional documentation to show that ADL care or shower was provided for resident #127. - Resident #137 was admitted on [DATE] with diagnoses that included cerebral palsy, bullous pemphigoid, local infection of skin and subcutaneous tissues and immunodeficiency. The care plan dated April 30, 2021 revealed that it was important to the resident that she chose between a shower and bed bath. A review of the progress note dated October 7, 2021 revealed the resident refused bathing. The certified nursing assistant (CNA) documentation for October and November 2021 revealed that bathing was scheduled on October 31 and November 3, 2021. However, bathing was not marked as administered on October 31 and November 3, 2021. The clinical record revealed no documentation that the resident refused bathing or showers from October 27 through November 3, 2021. The BIMS score dated November 1, 2021 was 15 which indicated that the resident was cognitively intact. During an interview with the Director of Nursing (DON/staff #69) on February 29, 2024 at 4:00 p.m., the DON stated the facility did not have shower sheets for the requested time frame of October and November 2021. A review of the facility's policy on Hospice Program dated July 2017 revealed that hospice was responsible for managing the resident's medical and spiritual care related to terminal illness and related conditions and was to provide necessary medical supplies, medications, and equipment necessary for the palliation of pain and symptoms. The policy also stated that the facility was responsible for meeting the resident's personal care and nursing needs in coordination with the hospice representative. The facility policy on Supporting Activities of daily living (ADLs) dated March 2018 revealed that residents who were unable to carry out their ADLs independently were to receive the appropriate care and services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services were to include appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) and toileting.

Based on record review, staff interviews, resident interview, review of facility documentation and policy, and through observation of current practice the facility failed to ensure care and services related to pressure ulcer was provided for one resident (#171). The deficient practice could result in new or worsened pressure injuries. Findings include: Resident #171 was admitted on [DATE] with diagnoses of encephalopathy, traumatic hemorrhage of cerebrum, convulsions, traumatic subdural hemorrhage, and traumatic subarachnoid hemorrhage. The care plan dated April 30, 2022 revealed the resident was at risk for skin breakdown. Interventions included that staff were to provide preventive skin care; apply barrier cream with each cleansing; observe skin for sign and symptoms of skin breakdown such as redness, cracking, blistering, decreased sensation, and skin that does not blanch easily; off load/float heels while in bed; utilize a device to assist the resident with turning or positioning to reduce friction/sheer; and complete weekly wound assessments to include measurements and description of wound status. A physician order dated May 1, 2022 requested that a moisture barrier was applied every shift and as needed to peri-area and buttocks. The physician order dated May 15, 2022 included an order to float heels while in bed; and, to apply skin prep to bilateral heels every day shift. The Braden scale assessment dated [DATE] included a score of 12 indicating the resident was at high risk for skin breakdown. Weekly skin checks dated June 4, 11 and 18, 2022 revealed the resident had an abrasion to his left buttock. The weekly skin checks dated June 25 and July 2, 2022 included that the resident did not have any wounds The progress notes dated July 5, 2022 revealed the resident had a change of condition, was very lethargic with a low-grade fever, was not eating or drinking but would open his eyes. Per the documentation, resident was administered with medication, the physician was notified and orders for laboratory test and urine analysis were received. The weekly skin check dated July 6, 2022 revealed that the resident had a blister and non-blanchable redness. However, the documentation did not include the location or size of the skin issue. The progress note dated July 6, 2022 revealed that the resident was seen by the physician; and that, at 12:00 p.m., there was a change of condition regarding skin wound or ulcer. Per the documentation, the resident had redness and blisters to bilateral lower extremities. A physician order dated July 7, 2022 revealed the following orders for the following wounds: -Wound #1 Right inner ankle - Monitor blister and cover with Opti foam for protection every day shift; -Wound #2 Outer ankle - Clean with wound cleanser and cover with dry dressing every day shift. The documentation did not specify which outer ankle was the order for.; and, -Wound #3 Right outer ankle- Monitor redness and cover with Opti-foam The orders for wound #2 was transcribed onto the TAR (treatment administration record) for July 2022. However, review of the TAR revealed that the treatment for wound #1 (right inner ankle) and #3 (right outer ankle) were not transcribed and not documented as administered. The clinical record revealed no evidence treatment was provided to the wounds to the right inner and right outer ankle. There was also no evidence found why treatment was not administered as ordered; and that, the physician was notified. The clinical record revealed that resident was discharged to the hospital on July 10, 2022. An interview with the DON (staff #69) was conducted on February 29, 2024 at 2:45 p.m. The DON stated that the wound care orders for should have been entered in the TAR or MAR (medication administration record). During the interview, a review of the clinical record was conducted with the DON who stated that stated the physician treatment orders for the resident's (#171) wounds #1 and #3 should been entered as other orders in the MAR/TAR; however, the record revealed that treatment had not been completed due to them not appearing on the TAR or MAR. In an interview with the wound care nurse (staff #46) conducted on February 21, 2024 at 10:45 a.m., the wound nurse stated there was one wound care nurse that does all complex dressing changes; and that, the floor nurses were trained to do simple dressing changes. Further, the wound nurse stated that all wounds were examined by the physician on a weekly basis. The facility policy on Wound Care revised in October 2010 revealed that the nurse was to verify that there was a physician's order for the procedure prior to completing the procedure.

Based on closed record review, staff interviews, resident interview, review of facility documentation and policy and the 2010 Clinical Practice Guidelines for Clostridium difficile (C-diff) Infection in Adults, the facility failed to ensure infection prevention and control practices related to C-diff precautions were implemented for one resident (#123). The deficient practice could result in transmission of infection to residents and staff. Findings include: The resident #123 was admitted on [DATE] with diagnoses of sepsis due to Serratia and enterocolitis due to C-diff. The progress notes dated June 18, 2022 at 5:09 p.m., revealed the resident was receiving oral antibiotics for a C-diff infection. The progress note dated June 23, 2022 at 9:16 p.m. included the resident was on contact isolation due to a C-diff infection and was taking an antibiotic. A physician order dated June 17, 2022 revealed an order for the following medications: -Meropenem (antibiotic) solution 500 mg (milligram) IV (intravenous) every 6 hours for blood infection for 5 days; and, -Vancomycin (antibiotic) suspension 125 mg by mouth every 6 hours for C-diff, completed on July 2, 2022. There was no evidence found in the clinical record of any physician order for isolation/contact precautions for the C-diff infection. There was also no evidence found in clinical record that the resident was on isolation/precautions for C-diff infection. Further review of the clinical record revealed that the resident was discharged on [DATE]. An interview was conducted on February 22, 2024 at 1:10 p.m. with the Director of Nursing (DON/staff #69) who stated that there was no physician order to place resident #123 on isolations precautions for the C-diff infection. The DON stated that the admissions nurse was responsible for setting up the room, placing signs and PPE, and for obtaining orders from the doctor. In another interview with the DON on February 22, 2024 at 3:00 p.m., the DON stated that for infection control related to urinary tract infection, the expectation was that staff do not need to don a gown or glove unless providing personal care to the resident. Review of the facility's policy on Infection Control revised on October 2018 revealed that the objectives of infection control policies and practices included prevent, detect, investigate, and control infections in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. The Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America dated March 10, 2010 stated healthcare workers and visitors must use gloves and gowns on entering a room of a patient with a C-diff infection.

Based on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that residents representatives were notified of significant changes in condition for one resident (#120). The deficient practice could result in resident representatives not being informed of the change and decisions regarding treatment. Findings include: Resident #120 was admitted on [DATE] with diagnoses of heart failure and atherosclerosis of coronary artery bypass graft. Review of the clinical record revealed the resident was admitted for a hospice respite stay for five days. The face sheet for the clinical record revealed a family member was listed at the emergency contact #1 as well as medical power of attorney (MPOA). A progress noted dated [DATE] at 6:25 p.m., revealed that hospice was notified in the morning that resident was not at baseline; and that, hospice was to come in the facility to evaluate the resident. Per the documentation, the resident was not responsive later during the shift; and that, staff called 911, started CPR (cardiopulmonary resuscitation) and the resident was taken to the hospital. The progress notes dated [DATE] revealed that gabapentin (anticonvulsant), baclofen (skeletal muscle relaxant) and Ativan (antianxiety) were held due to lethargy. A progress note dated [DATE] at 6:44 p.m., included that the supervisor notified hospice of a change in condition. However, the documentation did not indicate that the resident's MPOA was notified of the change in condition. Review of the clinical record revealed that the resident was discharged from the facility on [DATE]. An eINTERACT summary for physicians dated [DATE] revealed the resident had a change in condition for cardiac arrest. It also included that the resident had a full code status and the resident was sent to the hospital. Further review of the clinical record and facility documentation revealed no evidence that the resident's representative/MPOA was notified of the change in condition. During an interview with a licensed practical nurse (LPN/staff #5) conducted on February 9, 2024 at 11:00 a.m., the LPN stated when there is a change in condition in resident's status, a progress note and a change in condition form will be completed and the physician and family will be notified. The LPN said that hospice will also be notified if the resident was on hospice. The LPN stated that it was his responsibility as a nurse to notify hospice, family, and physician and enter any orders into the computer when there is a change in resident's condition. Further, he stated that he would notify hospice and the physician and the director of nursing (DON) if needed, of the resident's vital signs and what he saw. During an interview with the DON (staff #69) conducted on February 9, 2024 at 11:43 a.m., the DON stated that when there is a change of condition, it was expected that staff would document in the progress notes the last time the patient was seen, what time the resident was found and by whom, physician contact, family contact, details of what occurred, when, and by whom. Review of the facility policy titled Acute Condition Changes - Clinical Protocol revised on [DATE], included that the nurse was to notify the resident's physician regarding a change in condition. However, the policy did not include notification of the resident's representative.

Based on clinical record review, staff interviews and policy and procedure, the facility failed to ensure consistent treatments were provided to one resident (#82) with pressure ulcers. The deficient practice could result in worsening of pressure ulcers. The facility census was 89, and the sample was 18 residents. Resident #82 was admitted on [DATE] with diagnoses that included atrial fibrillation, leukemia, type 2 diabetes mellitus, pressure ulcer of buttock, adult failure to thrive, depression, need of assistance with personal care. Review of the clinical record revealed the resident currently had six wounds: -#6 genital region new #6 pressure unstageable -#5 Right gluteus medial - Pressure - Unstageable - #4 Coccyx medial - pressure unstageable - present on admission -#3 Right Ischial Tuberosity lateral and middle - present on admission -#2 Right lateral Calf - pressure, unstageable -#1 right shin, medial - pressure, unstageable Review of a care plan revealed the following areas of focus: -Actual skin breakdown, with interventions that included to provide treatment to skin tear per MD (medical doctor) order and observe for signs of infection. The assessment also revealed that the resident had 1 stage 2 ulcer, and 2 unstageable ulcers present at admission. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Staff Assessment for Mental Status assessment that indicated her cognitive skills were moderately impaired. Review of physician's orders revealed the following orders: -Wound #5 RLE posterior: Cleanse with WC, pat dry. Apply honey and calcium alginate, Cover with abd (abdominal pad) and wrap with kerlix every day shift dated 7/27/2023 -Hospice evaluation and treatment, dated 7/18/2023 -Wound #1 Coccyx: Cleanse wound with WC, pat dry. Soak gauze in dakins and pack to wound. Cover with abd. and dry dressing. Apply barrier cream on the surrounding skin. every day shift and PRN, dated 7/5/2023 -Wound #2 Right Ischial tuberosity/right buttock: Clean with WC, pat dry. Apply zinc/barrier cream. every day shift dated 7/6/2023 -Wound #3 Right Heel: Paint with betadine and Cover with foam dressing for protection/comfort every day shift every day shift, dated 7/6/2023 -Wound #4 right inner thigh: Cleanse with WC, pat dry. Apply zinc/barrier cream and every day shift AND PRN (as needed), dated 7/5/2023 -Wound # 6 Right 4th toe: Cleanse wound with WC and pat dry. Paint with Betadine. Leave open to air, every day shift, dated 6/27/2023 -Wound #7 right foot lateral: Cleanse wound with WC, pat dry. Paint with betadine. Cover with foam dressing for protection every day shift, dated 6/27/2023 -Low air loss mattress to bed every day and night shift, dated 6/23/2023 -Wound(s): Monitor site(s) Daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable Additional Documentation in NN (nursing notes) if needed every day and night shift, dated 6/22/23 Review of the July 2023 Medication Administration Record revealed the following: -Wound #6 right 4th toe - no evidence of completion on 5 shifts -Wound #1 coccyx - no evidences of completion on 5 shifts. -Wound #2 right ischial wound - revealed no evidence of completion on 5 shifts. -Wound #3 right heel - revealed no evidence of completion of 5 shifts. Wound #4 right inner thigh, - revealed no evidence of completion on 5 shifts. -Wound #5 RLE posterior - revealed no evidence of completion on 2 occasions -Wound #7 right foot lateral - revealed no evidence of completion on 5 occasions. -Wounds: Monitor site daily for status of surrounding tissue and wound pain. Monitor for status of dressings, if applicable additional documentation in NN (nursing note) if needed every day and night shift - revealed no evidence of completion on 7 shifts. Review of the clinical record revealed no evidence of physician notification regarding the reason that the wound treatments were not completed as ordered. An interview was conducted on August 2, 2023 at 10:31 AM with a Licensed Practical nurse (LPN/staff #3), who stated that she was covering as wound nurse at this time. She also stated that the expectation is that wound treatments would be documented on the TAR every time they are completed, and if the resident would refused the treatment. She further stated that the expectation is to follow physician orders as written. She reviewed the July 2023 TAR and stated that there is no evidence that the wound treatments had been completed as ordered for all wounds. She further that the risk of not providing wound treatments as ordered could result in the risk of a possible wound infection. An interview was conducted on August 2, 2023 at 2:11 PM with the Director of Nursing (DON/staff #34), who stated that the facility policy is to follow physician orders as written, including treatments. She reviewed the clinical record and stated that the dressings were not applied as ordered in July 2023, and that the wound monitoring was not completed as ordered. Review of a facility policy titled, Medication Administration, revealed that staff will follow the prescriber's directions. Review of a facility policy titled, Skin Integrity and Wound Management,( revised 2/1/23) revealed to perform daily monitoring of wounds or dressings for presence of complications or declines. Document daily monitoring of ulcer/wound site with or without dressing. Implement pressure injury prevention for identified, modifiable risk factor. Implement special wound care treatments as ordered.

Based on observation, interviews and policy review, the facility failed to ensure that one resident's medications were administered as ordered by the provider based on standards of practice for two resident's (#68, #35), medications are not left unattended at the bedside for one resident (#40), and medications are not left unattended on the floor. The deficient practice could result in residents not receiving prescribed does of medications, and residents taking medications that are not ordered. The facility census was 89, and the sample was 18 residents. -Regarding Fluticasone Nasal Spray A medication administration task observation was conducted on August 1, 2023 at 7:20 AM with a Licensed Practical Nurse (LPN/staff #29). At the medication cart the LPN prepared mediation for Resident #35, that included Fluticasone Propronate Nasal Spray. The LPN took the nasal spray and entered the resident's room. She administered 1 puff of the Fluticasone Propronate nasal spray in each nostril. Review of the physician's order revealed Fluticasone Propronate Nasal Spray 50 mcg (micrograms)/ACT, 2 sprays in both nostrils. An interview was conducted on August 1, 2023 at 9:53 AM with LPN (staff #29), who stated that she administered 1 puff in each nostril, and the physician order was for 2 sprays in each nostril. She stated that she had not followed physician orders. An interview was conducted on August 2, 2023 at 2:11 PM with the Director of Nursing (DON/staff #34), who stated that the facility policy is to follow physician orders as written, including treatments/nasal sprays. She further stated that she expected that the nurse would have administered 2 puffs of the nasal spray, or if the resident refused that it would be documented in the Medication Administration Record (MAR). Review of a facility policy titled, Medication Administration, revealed that staff will follow the prescriber's directions. -Regarding administration via g-tube (gastrostomy tube) A medication administration task observation was conducted on August 1, 2023 at 8:04 AM with a Licensed Practical Nurse (LPN/staff #29). At the medication cart the LPN prepared mediation for Resident #68, that included acidophilus with pectin. The medication was observed to be administered orally. Review of a physician's order revealed an order for acidophilus with pectin oral capsule, give 1 capsule via g-tub one time a day for GI (gastrointestinal) prophylactic dated July 10, 2023. Further review of the clinical record revealed that Resident #68 did not have a g-tube in place, or orders for a g-tube. An interview was conducted with the LPN (staff #29), who stated that she had administered the acidophilus orally to the resident. She reviewed the clinical record and stated that the order was written to be administered via a g-tube, but that the resident had never had a g-tube in place. She also stated that she had not administered the medication following physician orders, and that she should have called the provider to clarify. She further stated that normally nurses put the order in when they receive the order. It should have been clarified when received if resident. did not have a g-tube. She stated that the resident has not had a g-tube to her knowledge. An interview was conducted on August 2, 2023 at 2:11 PM with the Director of Nursing (DON/staff #34), who stated that the facility policy is to follow physician orders as written. She also stated that if the provider orders medications to be ordered via g-tube and the resident does not have a g-tube that the nurse would call the provider for clarification. Review of the facility policy titled, General Dose Preparation and Medication Administration, revealed that facility staff should verify each time a medication is administered that it is the correct medication, at the correct rout, rate and time. -Regarding medications left on the unit floor During an observation conducted on August 1, 2023 of the 100/200 unit a medication was observed to be lying on the floor. A resident was sitting in a wheel chair in the hall next to the medication. An interview was immediately conducted with a Registered Nurse (RN/staff #81), who stated that she did not know the process when a medication is found unattended on the floor. She picked up the medication which was marked with D03. She also stated that per the facility policy the nurse should stay and ensure that the resident takes the medication at the time it is administered. She stated the risk of leaving a medication on the floor could result in the medications not being administered as ordered, or another resident taking the medication. An interview was conducted on August 2, 2023 at 2:11 PM with the DON (staff #34), who stated that her expectation is that nurses would ensure that residents take all medications, and that none are dropped/missed. She also stated that the nurse should ensure that all medications were taken by the resident and not leave any at the bedside unattended. She stated the risk of a medication being missed and left on the floor could result in an allergic reaction, may sedate and lower the heart rate, and a resident may not get a prescribed medication. Review of the facility policy titled, General Dose Preparation and Medication Administration, revealed that facility staff should not leave medications unattended. It also stated to observe the resident's consumption of the medication. -Regarding medications left unattended at the bedside During an interview conducted with Resident #40 on July 31, 2023 at 9:15 AM, a medication cup was observed to be sitting on the resident's bed side table. The resident stated that the medications were for thyroid treatment. The resident stated that the nurse did not wake her up to take the medication, but left it on the bedside table. The resident further stated that nurses leave her medication at the bedside all the time. Further observation in the resident's room also revealed a plastic container on the bedside table that contained AZO-D Mannos, urinary pain relief maximum strength, organic cranberry, digestive advantage probiotic, and systane eye drops. The resident also opened her bedside drawer which contained gas-x, Colace, Sudafed and Systane eye drops. The resident stated that she orders these vitamins herself. Resident #40 was admitted on [DATE] with diagnoses that included polyneuropathy, chronic kidney disease, gastro-esophageal reflux disease and venous insufficiency. Review of the clinical record revealed no evidence of an assessment for medication self- administration. Review of the clinical record revealed no evidence of any progress notes or IDT (interdisciplinary team) notes regarding medication self-administration. Review of physician's orders revealed no evidence of an order for medication self-administration. Review of the resident's care plans revealed no evidence of a focus on medication self-administration. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. An interview was conducted on August 2, 2023 at 12:43 Pm with a Certified Nursing Assistant (CNA/staff #79), who stated that she was not aware of the resident having any medications/vitamins in her room. An interview was conducted on August 2, 2023 at 2:11 PM with the DON (staff #34), who stated that the facility policy is to complete a medication self-administration assessment prior to a resident keeping medications/vitamins in the room, and they would need to have a physician's orders for the medications, and to have at the bedside. The DON reviewed the clinical record and stated that eye drops should not be kept at bedside. She also stated that there is no evidence of a physician's order for medication self-administration or to leave any medications at bedside. She also stated that the risk of leaving medications at the bedside could result in other people getting overdose, not accounting for the medications, and allergies unaccounted for. She further stated that it did not meet her expectations to have any medications/vitamins left in the resident's room/bedside table. She further stated that they would need a physician's order that would specify each medication that can be left in the resident's room. The DON stated that there was no evidence in the clinical record of a physician order or self -administration assessment that medications can be left in the resident's room. Review of a policy titled, Self-Administration Medications, revealed that patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer a physician/advanced practice provider is required, and self-administration and medication self-storage must be care planned. Review of the facility policy titled, General Dose Preparation and Medication Administration, revealed that facility staff should not leave medications unattended. It also stated to observe the resident's consumption of the medication.

Based on review of the clinical record, interviews and facility policy, the facility failed to ensure an as needed psychotropic medication was monitored appropriately. The deficient practice could cause prolonged usage of medications intended for an as needed basis without appropriate monitoring. Findings include: Resident #20 was readmitted on [DATE] with diagnoses that included major depressive disorder, lung transplant, immunodeficiency, bipolar disorder, mild cognitive impairment, PTSD, and anxiety disorder. Review of the clinical records revealed that a PRN (as needed) Psychotropic had been administered to the resident since October 21, 2022. Review of a pharmacy consultation report dated October 26, 2021 revealed a recommendation to re-evaluate continued use of PRN Clonazepam. The report was signed by the provider but it contained no evidence of acceptance of the recommendations. A handwritten note revealed a lung transplant patient with rejection depression/anxiety to current treatment. Review of a pharmacy consultation report dated January 24, 2022 revealed a recommendation to discontinue PRN Clonazepam, tapering as necessary. The box to accept recommendation was marked with a note a the bottom revealing that the resident refused decrease. Review of a pharmacy consultation report dated June 24, 2022 revealed a recommendation to discontinue PRN Clonazepam, tapering as necessary. The Prn order has been in place greater than 14 days without a stop date. A box was marked to accept the recommendations Further review of the clinical record revealed that the Clonazepam was continued PRN with no stop date. No evidence of other pharmacy reports in the clinical record. Review of Care Plan areas of focus included: - Resident is resistive to care related to: Mood/Psychiatric Disorder(s):Bipolar disorder and cognitive deficit Date Initiated: 09/01/2022. - Resident is at risk for fluctuating mood symptoms related to: Dx of depression AEB ( as evidenced by) verbalizations of sadness caused by current health status, sleeplessness, recent changes affecting relationships/personal loss/ functional changes, etc.) - Resident is at risk for complications related to the use of psychotropic medications 1. Remeron 2. Seroquel 3. Zoloft 4. Clonazepam Date Initiated: 09/30/2021 Review of active physician orders revealed the following PRN (as needed) for psychotropic orders that included: -Clonazepam Oral Tablet 0.5 MG (Clonazepam) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for Anxiety Give with 1mg to make 1.5mg dose, dated October 21, 2022. -Clonazepam Oral Tablet 1 MG (Clonazepam) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for Anxiety Give with 0.5 mg to make 1.5mg dose, dated October 21, 2022. A review of a lung specialist office visit note dated April 27, 2023 revealed no evidence that the provider reviewed no evidence that the provider reviewed the PRN clonazepam being used. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated moderately impaired cognition. The assessment also revealed the resident had not behaviors during the assessment, and a gradual dose reduction was documented as clinically contraindicated on March 17, 2023. Review of the July 2023 and August 2023 Medication Administration Reports (MAR), revealed that both the above medication orders had been administered to the resident. A review of a psychiatric re-evaluation note dated July 7, 2023 revealed that Clonazepam is managed by the patient's lung specialist. An interview was conducted on August 3, 2023 at 03:15 PM with the Director of Nursing (DON/staff #34), who stated that PRN psychotropic's are used on a 14 day trial, then they are re-evaluated. She also stated that the psychiatric provider should be following the dosing/orders for Clonazepam. She further stated that the risk of neither the psychiatric provider or lung provider following the Clonazepam dosing could result in unnecessary medications. She reviewed the clinical record and stated that psychiatric note stated that the Clonazepam is followed by lung specialist, but there is no evidence that lung specialist okayed the medication. She stated that this did not follow the facility psychotropic usage policy. Review of a facility policy titled, Psychotropic Medication Use, revealed that PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his/her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month.

Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary kitchen; six ventilation exhausts above clean dishware and food prep areas were unclean, food storage for the kitchen area and three nourishment refrigerators were not monitored, maintained and documented for safe food handling. The census was 89. The deficient practice could result in residents becoming ill. Findings include: Regarding dusty ventilation exhausts: The facility's policy, Food and Nutrition Services Policies and Procedures, dated May 01, 2023 states Food and Nutrition Services staff monitors the cleanliness of the pantry/nourishment rooms including refrigerators/freezers, cabinets, equipment, and surfaces. The policy further states Food storage and service equipment and surfaces are routinely cleaned by designated staff. Review of the kitchen's maintenance work order revealed most recent vent cleaning was June 03, 2023 at 10:43 am. On July 31, 2023 at 8:40 a.m., a kitchen inspection was conducted with the Food Service Director (staff #205) and an observation of six air conditioner ventilation grills were covered with grey dust buildup hanging off the blades. Each ventilation grill was above a food prep area or above the clean dish storage area. An immediate interview with staff #205 about the observed dust on the air conditioner ventilation vents above the food prep and clean dish area, she stated the maintenance staff must've over looked the vents and stated that the risk of having dust build up on ventilation vents could lead to contamination on prepared food and clean dishes. Regarding food storage: The facility's policy and procedure manual, Food and Nutrition Services Policies and Procedures, dated May 01, 2023 states that food and beverages are stored and served in safe and sanitary conditions. The facility's policy for Food: Safe Handling for Foods from Visitors, revised July 2019, states the responsible facility staff member will ensure that the food is stored separate or easily distinguishable from the facility food, ensure that foods are in a sealed container to prevent cross contamination, label foods with the resident name and current date, daily monitoring for refrigerated storage duration and discard of any food items that been stored greater or equal to seven days, cleaned weekly. During the kitchen inspection conducted on July 31, 2023 at 8:40 a.m. with the Food Service Director Dietary (staff #205) an observation of two cardboard boxes of sliced bread and a tray of baked rolls were stored on the lower level of food prep table near the kitchen stove approximately 6 above a waste water grate with standing green colored water below in what appeared to be a sewer drain pipe. The waste water grate is approximately 6' in length by 1' wide with rusted metal grate above the what appeared to be a sewer drain line. An interview was immediately conducted and staff #205 stated that contamination could occur from the floor and maybe from up top, I don't know who handles waste water, maybe maintenance. I can see the standing water and it looks yellowish, and the risk of standing water over time can spread disease, bacteria Regarding the Nourishment Refrigerator During the nourishment refrigerator inspection conducted on July 31, 2023 at approximately 9:30 a.m. with the Food Service Director (staff #205) revealed the following: Nourishment refrigerator located in the 100 area near nurse's station: - No name and no date for one Bang Energy Drink with a med pass plastic cup covering opened aluminum can container. - No name and no date for one 1-Liter bag of whole cherries in a local grocery bag tied off by the plastic handle. - No name and no date for one 1-Liter bag of quarter sliced watermelons in local grocery bag tied off by the plastic handle. - No name and no date for one Sonic Milkshake in freezer half empty with red straw in the milkshake container. Nourishment refrigerator located in the 200 area near nurse's station: - No name and no date for one Gatorade 12oz drink in freezer unopened. - No name and no date for one Ore-Ida box of fries in freezer. - No name and no date for one facility kitchen shredded cheese in covered Styrofoam container. - No name and no date for one 6oz clear container with blueberries with visual white fuzzy mold on the blueberries on the bottom of the container. - No name and no date for one uncovered 12oz Styrofoam container with prepared oatmeal that has decayed and dried Nourishment refrigerator located in the 300 area near Nurse Station: - No name and no date for four Tina's frozen burritos in freezer. - No name and no date for one Boba Bubble Tea in clear plastic beverage container in freezer half empty with straw inside. - No name and no date for one box of Kool Pops popsicles in freezer. - No name and no date for one container of half-gallon Dryers Vanilla Ice Cream. - No name and no date for three ice-cream sandwiches un-boxed and individually wrapped stored in open white plastic bowl. - No name and no date for one Taco Bell 30oz drink container half empty with straw in green liquid. - No name and no date for one glass bottled Starbucks Frappuccino half empty in freezer. - No name and no date for one Gold Peak Sweetened Tea in 16oz bottle half empty in refrigerator. - No name and no date for one semi-transparent white plastic container approximately 50oz with blue cap with unknown clear liquid with floating lemon slice. - No name and no date for one cup of whole cherries in stored in uncovered 16oz cup - No name and no date for one Thermos Cooler Lunch Tote Bag black in color with flowers and zipper in refrigerator approximately 14 long X 6 tall X 4 wide with 2 containers of yogurt, 1 package of half empty granola, 1 vent container of blueberries. Interviewed LPN Unit Manager (staff #31), at approximately 10:30 a.m. and asked about who the Thermos Cooler Lunch Tote Bag may belong too, she stated that she did not know who the lunch bag belonged to and did not know the bag was in the resident nourishment refrigerator, she stated that the staff does not put their food in the nourishment refrigerator, when asked about not having food not properly dated of labeled, she responded by stating the risk of cross-contamination count occur, she stated that the kitchen staff goes through the nourishment refrigerator every 7 days.

Based on clinical record review, facility documentation, staff interviews, and review of policy, the facility failed to ensure that 1 out of 18 sampled residents' (#72) needs and preferences were addressed, regarding his wheelchair. The deficient practice could result in residents' needs and/or preferences not being addressed. Findings include: Resident #72 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, muscle weakness, and pain. Review of resident #72's inventory log dated June 13, 2023 revealed that he did not have a wheelchair when he arrived at the facility. However, the inventory log indicated that he had a battery charger for a power wheelchair. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS also indicated that the resident used a wheelchair as a mobility device. A limited mobility care plan initiated on June 13, 2023 revealed that the resident required assistance for ADLs (activities of daily living). Interventions included to arrange resident/patient environment as much as possible to facilitate ADL performance. A meaningful daily routine care plan initiated on June 15, 2023 included that the resident would benefit from accommodation for physical limitations by using his wheelchair. Review of a social service note dated June 14, 2023 revealed that resident #72 informed the Social Worker (staff #204) that he did not have his properties and asked for assistance to obtain his belongings from his previous facility. A subsequent social service note also dated June 14, 2023 indicated that staff #204 called the resident's previous facility. Per the note, the previous facility stated that they would have to determine the whereabouts of the resident's belongings and would call staff #204 back. Review of a social service note dated June 28, 2023 revealed that the Social Services Specialist (staff #38) spoke to resident #72 regarding his motorized wheelchair. Staff #38 called resident #72's previous facility and left a message for them to contact her regarding the resident's wheelchair. Review of the resident's clinical record revealed that the next mention of the resident's wheelchair was not until July 21, 2023. The nursing note documented that the resident informed staff that he was not going to eat until his electric wheelchair was delivered to the facility. The note further indicated that the nursing supervisor was made aware of the resident's comment and that the resident's meal consumption/refusals were going to be monitored. However, there was no mention of what actions if any were made to obtain the resident's wheelchair. A nursing note dated July 22, 2023 at 8:45 a.m. indicated that a message was sent to the resident's physician to inform him of the resident's refusal to eat until his electric wheelchair was delivered to the facility. The note did not indicate what actions, if any, were made to obtain the resident's wheelchair. A subsequent note dated July 22, 2023 at 9:59 a.m. revealed that the last time the resident had eaten was over 24 hours prior. The note documented that the resident stated that he would not eat until his electric wheelchair was picked up, fixed and brought to him for his use. The note indicated that case management was notified and that the electric wheelchair was scheduled to be picked up Monday and would be delivered for repairs. The note stated that resident was aware and refused to eat until it arrived at the facility with all repairs completed. Further review of the resident's clinical record dated after July 22, 2023 did not show any follow-up documentation regarding the status of the resident's wheelchair. On July 31, 2023, an electric wheelchair was observed in resident #72's room. An interview was conducted with the interim Social Services Director (staff #202) on August 3, 2023. He stated that since he is only filling in and only started the day before that he was not entirely familiar with resident #72. During the interview, staff #202 reviewed resident #72's files for social services notes. Staff #202 indicated that a note from June revealed that the resident requested assistance to obtain his property from his previous facility. Staff #202 noted that his job was to make sure to follow-up with requests, but that delays attributed to the previous facility were out of their control. However, staff #202 stated that if the item in question was something the resident needed for his ADLs, such as the wheelchair, they would facilitate to get the issue resolved. He stated that when residents get transferred, delays sometimes occur with regards to obtaining their belongings. However, in the case of a wheelchair, the facility offers a standard wheelchair for the resident so that they can maneuver around. Staff #202 stated that he was not sure if the resident was offered a standard wheelchair in lieu of his electric wheelchair. However, he assumed they did due to a note dated July 13, 2023 which stated that resident was only in a chair for a few hours. Furthermore, staff #202 noted that there was not a form that was filled out for loaner wheelchairs. Staff#202 stated that every resident is equipped/offered a standard wheelchair. He further stated that when it came to an average timeframe to obtain a resident's belongings, every situation is different. However, he stated that they try to get items the same week/weekend, depending on the other facility. Staff # 202 stated that it did take a while for resident # 72 to receive his electric wheelchair. Staff # 202 failed to find any documentation regarding receipt of the electric wheelchair. In addition, staff #202 was unable to state whether there should have been documentation regarding the receipt of the item and was unable to state when the electric wheelchair arrived. An interview was conducted with a Licensed Practical Nurse (LPN/staff #21) on August 3, 2023 at 2:17 p.m. Staff #21 stated that neither the floor nurse or admissions does an inventory of the resident's belongings and stated this is normally done by the charge nurse. Staff #21 stated if there was a concern about a resident's belongings, it would be directed to Social Services and Social Services would take care of getting the issue resolved. Staff #21 also noted that if a resident did not have their wheelchair then one would be provided from therapy. Staff #21 noted that with regards to resident #72 it took a couple of weeks before he got his wheelchair. However, staff #21 noted that she was unsure of when the resident's electric wheelchair finally arrived. She did note that she thought he had a regular wheelchair but was not sure if he used it while waiting for his electric wheelchair to arrive. During an interview with a Certified Nursing Assistant (CNA/staff #79) conducted on August 3, 2023 at 2:33 p.m., staff #79 stated that resident #72 did not have his electric wheelchair when he arrived to the facility. Staff #79 stated that resident #72 got his electric wheelchair last week. She noted that he had a regular wheelchair prior. Staff #79 also stated that she was not aware that resident # 72 not eating because of his electric wheelchair. An interview with the Director of Nursing (DON/staff #34) was conducted on August 3, 2023 at 2:53 p.m. Staff #34 stated that if resident arrives at the facility without their belongings, the staff will reach out and arrange to get their belongings as soon as possible. She noted that in the case of resident #72, he arrived without his electric wheelchair. Staff #34 stated that the resident's electric wheelchair was broken and they had to pick it up last week Monday. She stated that her expectation was that the issue was documented. Staff #34 stated that the resident was initially understanding about the delay but after a few weeks the resident became frustrated and refused to eat. She noted that she was aware of the situation but was told that the resident's wheelchair was being fixed. Staff #34 stated that the resident had a regular wheelchair and that the facility was told that the resident's wheelchair was being fixed somewhere. Staff #34 stated they had to physically go to the resident's previous facility, look for the chair, and send it for same day repair. She stated it was brought it back to the facility same day. She noted that it was not this facility's fault, but rather the previous facility's. However, she did state that as their resident, they are responsible for assisting him with his needs. Review of the facility policy titled Activities of Daily Living revised May 1, 2023 indicated that the facility must provide the necessary care and services to ensure that a resident's ADL abilities are maintained or improved and do not diminish.

Based on clinical record reviews, interviews, facility documentation, and facility policy, the facility failed to ensure one resident's (#2) wounds were consistently assessed, monitored, and treated and the facility failed to ensure staff monitored blood glucose levels for one resident (#1). The sample size was 6 residents. The deficient practice could result in negative resident outcomes. Findings include: -Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to a hospital on September 16, 2020. Review of hospital records from prior to the resident's admission revealed that the resident had the following skin issues on discharge: -A surgical incision to the left knee which was a result a fall and required irrigation, debridement, and laceration repair with wound closure. -An abrasion to the right lower leg -Moisture associated skin damage to the right/bilateral buttocks -A skin tear to the left arm A nursing note dated August 31, 2020 revealed that the resident was identified as having the following skin issues on admission: -A skin tear to his coccyx -A skin tear to his Left Upper Extremity (LUE) -A skin tear to his Right Lower Extremity (RLE) -Redness to both of the resident's legs The nursing note on August 31, 2020 did not include information pertaining to the resident's surgical incision to his left knee. Review of the clinical record revealed no evidence that the resident's skin had been further assessed upon admission as no skin assessments were noted for the resident's surgical wound or his skin tears. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident could not complete the Brief Interview for Mental Status (BIMS) so staff had to assess his cognition. Staff indicated that the resident had problems with short-term memory but not with long-term memory. The resident required extensive assistance with two or more staff for bed mobility, transfers, toilet use, and personal hygiene. The resident had frequent bowel and urinary incontinence. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was identified as being at risk for developing pressure ulcers/injuries but no other skin conditions were identified on the assessment. Review of the resident's care plans revealed no evidence that the resident's skin concerns had been addressed. Regarding the resident's surgical wound to his left knee: No physician orders for care of the resident's surgical wound to his left knee were noted on admission. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note did not include any further information about the resident's surgical wound or provide a plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an assessment note dated September 7, 2020 revealed that the resident was noted to have an incision on the left knee, some drainage, and some of the tissue appeared to be necrotic. A physician's order dated September 8, 2020 was for a wound consult. On September 8, 2020, a physician's order to treat skin tears was noted. No orders were noted to address the resident's surgical wound on his knee. A nursing note dated September 10, 2020 revealed that the resident had a dressing change to the left knee prior to [CONDITION(S)]. The dressing was described as dark in color and that there was a wound consultation pending. Review of the clinical record revealed no evidence of documentation regarding an assessment of the wound including the size of the wound, type of drainage, or type of wound located on the left knee. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note included that the resident had a fairly large dressing over the left knee which was not removed at the time of the exam. The resident had trace bilateral pretibial pitting [CONDITION(S)] with no calf tenderness. The note did not include any further information regarding the resident's knee wound. A physician note dated September 14, 2020 included that the resident was more confused than normal. The note included that the resident had an altered mental status and that this was potentially due to a wound infection. The plan included to start antibiotics. Review of the physician's orders dated September 14, 2020 indicated the following orders: -[MEDICATION(S)] (an antibiotic) 500 milligrams (mg) intravenously every Tuesday, Thursday, and Saturday for right knee wound. -[MEDICATION(S)] solution (an antibiotic) reconstituted 2.25 grams. Use 2250 mg intravenously every 12 hours for right knee wound. -Lab tests including a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and a urinalysis (UA) with culture and sensitivity for the right knee wound. A nursing note dated September 15, 2020, entered at 10:33 pm, included that the nursing staff made multiple attempts to establish intravenous access and was unsuccessful. The note also included that the antibiotics are unable to be started without access. A nursing note dated September 16, 2020 entered at 2:33 pm included that intravenous access had been established and the antibiotics had been started. A wound care progress note from an outside wound care provider, dated September 16, 2020 and signed at 9:46 pm, included the resident had a wound over his knee that was dead with leathery slough/eschar. The note indicated that it was unclear what the treatment plan would be. If the plan was not palliative, then the resident would likely need operative debridement of the left leg as the wound spanned the joint and would need a graft to heal. The resident's comorbidities made him a poor candidate for this. The wound care progress note included an assessment of the resident's left knee. This included that the left knee is an eschar covered trauma wound and had received a status of not healed. Measurements were 9 centimeters (cm) length by 15 cm width with no measurable depth, with an area of 135 square cm. There was no drainage noted. The wound bed had 76- 100% eschar. There was a large displaced skin flap that was closed primarily and the entire flap was now dead. Currently stable eschar but visible dermal degradation. The resident was transferred out of the facility to a hospital on September 16, 2020 at 11:30 pm. with altered level of consciousness. Review of the clinical record revealed no evidence that the resident's surgical wound had been assessed by the facility from the time of admission until the outside wound care note on September 16, 2020. There were no physician's orders to provide wound care to the resident's surgical incision on his knee. As such, it is unknown how this wound progressed over time. Regarding the resident's skin on his coccyx, RUE, and his LLE: The physician's orders revealed an order dated August 31, 2020 to provide a moisture barrier every shift and as needed to the resident's peri-area and buttocks. The order did not indicate if this was in response to the resident's skin condition on his coccyx or was preventative. There were no physician's orders to treat the resident's skin tears on admission. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Review of an assessment note dated September 7, 2020 revealed that the resident had skin tears to the coccyx and on his RLE. There was not further information about these wounds. A physician's order dated September 8, 2020 was for a wound consult. On September 8, 2020 a physician's order indicated to cleanse the resident's coccyx, LUE, and the RLE wounds with Vashe (wound cleanser), pat dry, and apply a bandage. The order was to be completed every day shift. A review of the Treatment Admission Record (TAR) for September 2020 revealed the resident did not receive this treatment on three occasions between September 9 through September 16, 2020. A physician note dated September 14, 2020 included that the resident was more confused than normal. The resident had a wound of the lower extremity that appeared to be scabbed over. Per nursing, the wound on his leg had increased in size. The note included that the resident had an altered mental status and that this was potentially due to a wound infection. The plan included to start antibiotics. A wound care progress note from an outside wound care provider, dated September 16, 2020, signed at 9:46 p.m., included that the resident had developed a right shin wound likely related to multiple factors and it currently appeared to be infected but may just be from excessive retained exudate in bordered gauze dressing. The wound care progress note included an assessment of the wound. This included that the wound was at the right pre-tibial and was a full thickness arterial ulcer and had received a status of not healed. The wound measured 4.5 cm by 2.5 cm width with no measurable depth with an area of 11.25 square cm. There was a moderate amount of purulent drainage noted. The resident reported a wound pain of level 8 out of 10. The wound bed had 67-100% slough. The peri-wound skin (skin around the wound) exhibited: excoriation, denuded, maceration, [CONDITION(S)], and [CONDITION(S)]. The wound dressing was saturated with peri-wound breakdown and there was pain. The resident was transferred out of the facility to a hospital on September 16, 2020 at 11:30 pm. with altered level of consciousness. Review of the clinical record revealed no evidence that the resident's wounds had been assessed by the facility from the time of admission until the arterial ulcer was assessed by an outside wound care note on September 16, 2020. There was no information about the status of the RUE wound or the coccyx wound at all. As such, it is unknown how these wounds progressed over time. It is also unknown if the wound on the resident's leg which was identified as a skin tear on admission was the arterial wound identified by the wound care note or if this was an additional wound that had developed in the facility. Regarding the resident's toes: A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident described it as a pins and needles sensation. The note included that the resident stated this had been going on for several days. The resident described it going past his ankles in a stocking-type distribution and it was happening in both feet. The note indicated that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no information regarding if the resident's circulation in his feet was assessed or what the plan would be to monitor the resident's feet. A physician's order dated September 8, 2020 was for a wound consult. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He said it felt like a gout flare-up but he wasn't sure. The resident was noted to have a history of gout and was on a gout medication to prevent flare-ups. The note goes on to include that this pain was new over the last several days. The resident's feet were examined and there was no swelling of the feet and ankles. The note indicated that the resident might be having a gout flare-up, but that this was unknown for sure. The note indicated to monitor the foot for any swelling or warmth of the toe. The resident had trace bilateral pretibial pitting [CONDITION(S)] with no calf tenderness. The note did not indicate if the resident's circulation in his feet had been assessed. There were no new orders related to the resident's toe and the note did not indicate how the toe would be monitored. A wound care progress note from an outside wound care provider, dated September 16, 2020, signed at 9:46 p.m., included that the resident had new onset of purple-black discoloration of the first three toes of his right foot. The resident had absent pedal (foot) pulses. The note indicated that the resident's provider would need to be alerted to the discolored toes. The resident was transferred out of the facility to a hospital on September 16, 2020 at 11:30 pm. with altered level of consciousness. An interview with a Certified Nursing Assistant (CNA/staff #33) was conducted on March 24, 2021 at 9:42 am. She stated that skin observations are conducted during resident showers and when providing perineal care. She stated that if the resident requires a barrier cream, she applies it after the care is provided. She stated that if any new area of redness or skin discoloration is noted, she puts the information on the shower sheet and informs the nurse. An interview with a Licensed Practical Nurse (LPN/staff #40) was conducted on March 24, 2021 at 10:05 am. She stated that if a resident has any skin issues, she does a complete assessment. She stated a complete skin assessment includes where the wound is located, the type of wound, a description of the wound, and measurements. She stated a wound assessment is done on every shift. She stated if there is a change in the wound a change of condition note is entered and the change is reported to the provider. She stated that a nurse should do an assessment on every resident they care for at least once a shift. An interview with a wound provider (contracted staff #10) was conducted on March 24, 2021 at 1:40 pm. She stated that, while not an employee of the facility, she works with the staff to provide wound care to the residents. She stated that the wound providers round weekly and complete a full assessment. She stated that the staff have to put in a request to her organization to inform them a of resident with wounds. She stated this process is usually completed on admission if the resident is admitted with wounds. She stated the facility staff is responsible for the day-to-day wound care for the residents including assessments and wound care. An interview with the Director of Nursing (DON/staff #21) was conducted on March 25, 2021 at 8:00 am. She stated that a skin assessment is completed on admission. She stated a complete wound assessment includes the type of wound, a description of the wound, the location, and measurements. She stated that wound assessments should be completed daily and as needed with a change of condition. She stated that there is no documentation of any assessments of the wounds for the resident prior to the one completed by the wound provider on September 16, 2020. She stated that there is also no documentation of an assessment made by the clinical staff of the resident's feet during the resident's stay. A facility policy titled Assessment: Nursing, revised November 1, 2019, included that the facility will conduct initial and periodical comprehensive, standardized, or reproducible assessments of resident function. The assessment must accurately reflect the patient's status at the time of assessment. A nursing assessment will be performed by a licensed nurse for all patients within 24 hours of admission. Routine and focused assessments will be performed on an ongoing basis as needed. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. Practice standards included completing a nursing assessment upon admission. Also included was that a change of condition assessment should be completed as needed. The policy included that the assessment data should be utilized to develop the care plan. A facility policy titled Skin Integrity Management, revised January 31, 2020, included the implementation of an individual resident's skin integrity management occurs within the care delivery process. Staff continually observes and monitors residents for changes and implements revisions to the plan of care as needed. The purpose of the this policy is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Under standard practices, a complete comprehensive evaluation will be conducted of the resident upon admission/re-admission to the facility. This will identify the resident's skin integrity status and need for prevention, intervention, or treatment modalities through review of all appropriate assessment information. The policy included to perform skin inspection on admission/re-admission and weekly and to document this on the TAR or in the clinical record. The policy included to perform daily monitoring of wounds or dressings for presence of complications or declines and document. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. For surgical wounds (e.g., flaps, grafts, donors, incisions, etc.), follow specific orders from the surgeon. Document daily monitoring of ulcer site, with or without dressing. For wounds that do not require a daily dressing change, monitor: Status of the dressing (intact and clean), Status of tissue surrounding the dressing (free of new redness or swelling), and adequate control of wound pain. For wounds requiring daily dressing change or wounds without a dressing, monitor for signs of decline in wound status. If unanticipated decline in wound, surrounding tissue, or new or increased wound pain, complete the skin integrity report and notify the provider. -Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's diabetes care plan, created on September 17, 2020, revealed that the goal for this plan was the resident would be free of all signs and symptoms of low and high blood glucose (sugar) such as sweating, trembling, thirst, fatigue, weakness, and blurred vision. Interventions for this plan included to record blood glucose levels and administer medications as ordered. A quarterly MDS assessment dated [DATE] included a BIMS score of 14 indicating the resident was cognitively intact. The resident was coded as requiring insulin every day during the 7-day look-back period. Review of the physician's orders revealed the following orders: -October 27, 2020: Insulin [MEDICATION(S)] Solution 100 units/milliliter (mL) inject 20 units subcutaneously at bedtime for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -December 31, 2020: to check the resident's blood sugar every am and before bed for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . These blood sugars were documented by a Licensed Practical Nurse (LPN/staff #1). The blood sugar result for Thursday evenings were significantly elevated, and in many cases the highest level for the week. The Thursday evening blood sugar is the first blood sugar documented after staff #1 had finished working three night shifts in a row. Review of an investigation report dated March 1, 2021 revealed that a Licensed Practical Nurse (LPN/staff #1) had documented a blood glucose result on February 22 and 23, 2021 that was not actually obtained by the LPN. The facility included that the determination that the two results were falsified was found during investigation of the resident's clinical record and the glucometer memory log. The LPN was contacted, but denied any wrongdoing. An interview with a LPN (staff #40) was conducted on March 24, 2021 at 10:05 am. She stated that she had worked the last year on day shift at the facility. She stated she would follow staff #1 almost every time she worked. Staff #40 stated that she never witnessed anyone ever documenting anything false, however she stated that over the last year there had been many times residents had complained to her about missing medications or treatments from staff #1. She stated it was, on average, 2-3 times a month a resident would tell her they did not receive a medication or treatment on the shift worked by staff #1. She stated that she had told the DON and the Assistant Director of Nursing (ADON) about the concerns. She could not recall if or when there was a time that this applied to resident #1. An interview was conducted with resident #1 on March 24, 2021 at 12:10 pm. She stated that from the time they changed the blood sugar monitoring order from 4 times a day to 2 (December 31, 2020), her blood sugars had not been checked on Monday nights, Tuesday mornings and nights, Wednesday mornings and nights, and Thursday mornings. She stated that those are the shifts that staff #1 would work. She stated that her blood sugar level was always so high on Thursday nights because it was the first sugar level that was checked since Monday early mornings. Resident #1 stated the reason her blood sugars were so high was also related to not receiving her insulin from Monday night to Thursdays. She stated she told the nursing staff and the rehabilitation staff, but they all stated that it was charted as being done so it must have been completed. An interview was conducted with a family member for resident #1 on March 24, 2021 at 12:35 pm. The family member stated that the resident had expressed concerns with the care for many months. The family member stated that around January 10 or 11, 2021 the resident had complained that she had not been getting her blood sugars checked and was not receiving her insulin. The family member stated that she called and talked to the DON and was told that according to the medical record, the resident had been receiving her medications and blood sugar checks as ordered. An interview was conducted with the DON (staff #21) on March 23, 2021 at 1:50 pm. She stated that the resident informed the Nurse Practitioner (NP) that the night staff was not taking her blood sugar. The DON stated she started an investigation into the allegation by reviewing the clinical record, interviews, and reviewing the log on the glucometer. She stated that it was found that staff #1 had been entering results into the clinical record that were not accurate. The results entered into the clinical record were not results from any glucometer in the facility. She stated the staff member was terminated for gross misconduct. An interview with the DON and an ADON (staff #22) was conducted on March 24, 2021 at 11:30 am. The DON and ADON both said they had not been told about the resident not receiving her medications or treatments prior to being notified by the NP. A facility policy titled Diabetic Care Protocol, revised August 17, 2020, included to perform fingerstick blood glucose monitoring as ordered and document those readings. A facility policy titled Nursing Documentation, revised November 30, 2020, included a purpose of the policy which was to communicate resident's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. The policy included that nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's condition, situation, and complexity. Nursing documentation will follow federal and state regulations. The policy noted that nursing staff will not falsify or improperly correct nursing documentation. Nurses will not document services that were not performed.

Based on record reviews, staff interviews and review of policies and procedures, the facility failed to ensure that one resident (#1) received treatment and care in accordance with professional standards of practice. The survey sample size was one of three residents who received respite care. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An NP (Nurse Practitioner) report dated [DATE] (prior to admission) included resident was incontinent of urine, had a chronic UTI (Urinary Tract Infection), had suffered acute kidney injury in April, 2019 which was associated with dehydration and UTI, and chronic pain affecting the resident's hips, knees and left shoulder. Review of physicians orders dated [DATE] (prior to admission) revealed the following orders: -[MEDICATION NAME] HCL ([MEDICATION NAME]) tablet 8 mg. (milligrams) give 1 tablet every 8 hours as needed for nausea and vomiting. -[MEDICATION NAME] HCL tablet 25 mg give 1 tablet every 8 hours as needed for nausea and vomiting. -[MEDICATION NAME] ([MEDICATION NAME]-a diuretic) Tablet 20 mg. give 1 tablet by mouth one time a day for [MEDICAL CONDITION]. -[MEDICATION NAME] Tablet ,[DATE] mg. give 1 tablet every 4 hours as needed for moderate to severe pain (,[DATE]). A History and physical dated [DATE] included that resident had been admitted for a respite stay and had [MEDICAL CONDITION] arthritis, chronic headaches, ulcerative [MEDICAL CONDITIONS], frequent UTI's and overactive bladder. Review of the MAR (Medication Administration Record) for [DATE] revealed that [MEDICATION NAME] HCL tablet 8 mg. every 8 hours as needed for nausea and vomiting was discontinued on [DATE]. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact, had clear speech, was able to make herself understood and understood others. The assessment included that the resident ate with supervision and set-up assistance, had an ostomy appliance and was frequently incontinent of urine. The assessment also included that the resident had frequent moderate pain and received pain medications PRN (as needed). The comprehensive care plan interventions for nutritional risk related to pain, GERD, overactive bladder and ulcerative [MEDICAL CONDITION] with a goal that the resident would maintain adequate nutrition and hydration status by consuming ,[DATE]% of meals and not exhibit signs of dehydration, and included to monitor intake at all meals, and monitor for signs and symptoms of dehydration. The care plan also included interventions for overactive bladder, ulcerative [MEDICAL CONDITION] and [MEDICAL CONDITION] that included to monitor for signs and symptoms of infection and report to the physician. A nurses note dated [DATE] at 5:30 p.m. by an LPN (Licensed Practical Nurse/staff #14) included that the nurse had received a phone call from the resident's POA (Power of Attorney) who asked that IV (intravenous) fluids be started because the resident had stated to the POA that she did not feel well. The note included that the nurse assessed the resident, who was alert and oriented and complained of pain in her back. The note included that the resident had not eaten her lunch, but oral fluids were encouraged throughout the day and with each medication pass, and that water had been given to the resident with her pain pill. Review of the clinical record did not reveal documented evidence that the nurse had provided any additional assessing of the resident on [DATE] at 5:30 p.m. other than assessing the resident for pain, and although the note included that fluids were being included there was no documented evidence that fluid intakes were monitored. A nurses note dated [DATE] at 4:50 a.m. by an LPN (staff #51) included the resident stated she had pain all over' and had requested a pain pill. The note included that routine medications and a pain medication had been provided with 120 ml of fluids and that fluids were encouraged. Review of the clinical record did not reveal that additional assessing of the resident had been provided on [DATE] at 4:50 a.m. even though the resident had complained of pain all over. A nurses note dated [DATE] at 12:58 p.m. by an LPN (staff #61) included that at 8:00 a.m. the resident was responsive and answered questions appropriately. However, a CNA (Certified Nursing Assistant) who checked on the resident notified staff #61 that the resident appeared very tired and when #61 asked the resident if she was alright, the resident nodded her head yes. The note included when #61 asked the resident if she was in pain, she made eye contact and shrugged her shoulders. Vital signs were temperature 95.5, pulse 76, respirations 16. However, staff were unable to obtain the resident's blood pressure or oxygen saturation percentage. Oxygen at 10 liters was administered via non-re-breather mask, blood sugar was checked, which was 89, and 911 was called. An Interact Nursing Home to Hospital Transfer Form dated [DATE] included that the resident had been transferred to the hospital for Altered Mental Status. Review of the clinical record dated [DATE], through [DATE] did not reveal any additional documented assessments relevant to the complaint from the resident's POA that the resident was not feeling well. There was also no documented evidence that the nurse had notified the physician of the POA's request for IV fluids for the resident. A physician's Emergency Documentation report dated [DATE] included that the resident arrived at the emergency department unresponsive and pulseless. The report included that the resident's POA stated that she had been telling staff at the nursing home that the resident was dehydrated and had a urinary tract infection for three days. A hospital nephrology consultation report dated [DATE] included that the resident had been resuscitated twice and intubated in the emergency room . The resort included that according to the the POA the resident has not been feeling well for last few days and had been complaining (to the POA) of lower abdominal pain, poor appetite and According to her, the patient was getting dehydrated. The report also included that the resident had episodes of acute kidney injury in the past, but had a complete recovery. Review of hospital records revealed multiple physician's reports dated [DATE] which included that the resident had the following critical co-morbidities at the time she was transferred to the hospital: -Ischemic bowel -Acute [MEDICAL CONDITION] -[MEDICAL CONDITION] -Shock suspect secondary [MEDICAL CONDITION] -Lactic acidosis -Acute liver failure -Hyperammonemia (elevated ammonia level of 327) -Acute [MEDICAL CONDITION] -Urinary tract infection A hospital Chemistry report dated [DATE] at 12:17 p.m. revealed multiple abnormal lab values including the following: -Ammonia level: 327.74 (Reference Range: 18XXX,[DATE].00) -BUN (Blood Urea Nitrogen): 102 (Reference range: ,[DATE]) -Creatinine: 4.87 (Reference Range: 0XXX,[DATE].11) -Potassium: 5.8 (Reference range: 3XXX,[DATE].1) -Chloride: 112 (Reference Range: ,[DATE]) A hospital Microbiology Culture report included that blood cultures were drawn twice on [DATE] at 12:27 p.m. and 2:40 p.m. with results verified on [DATE] and final results included that the resident had Coagulase Negative Staph, and Gram Positive Cocci present on both sets of blood cultures. A physician's Consultation report dated [DATE] at 4:24 p.m. included that the resident had been hypotensive when received in the emergency department, and had suffered [MEDICAL CONDITION] twice while in the hospital intensive care unit. A Human Remains Release Form dated [DATE] included that the resident expired on [DATE] at 5:30 p.m. from [MEDICAL CONDITION], and that her remains were not accepted for potential donation due to infection. A Reportable Event Record/Report dated [DATE] included that on [DATE] The resident's POA reported to the Director of Nursing (staff #62) that throughout conversations she had with nurses at the facility she had requested treatment for [REDACTED]. Continued review of the Reportable Event Record/Report dated [DATE] included the following written staff statements: -On [DATE] at 8:00 p.m. when the resident's POA phoned an LPN (staff #102) and asked for the physician to be contacted to order lab tests including a CBC (Complete Blood Count), CMP and a U/A with C&S (Urinalysis with Culture and Sensitivity). The POA stated that the resident gets chronic UTI's and that when the nurse asked the POA why the resident has not told staff anything was going on the POA replied that the resident will not say anything to us, included that the resident was assessed and denied pain or symptoms and did not exhibit symptoms of a UTI. The statement by #102 included that when the resident's chart was reviewed by #102, and a nursing supervisor, the nurses saw the order for Respite and could not do any testing at this time. -On the morning of [DATE] the night nurse reported to an RN (Registered Nurse/#127) that the resident's POA had called and asked for lab work to be done and #127 reported the request from the POA to the physician (staff #63). The statement included when #63 asked if the resident had any problems, #127 replied not that she had noticed. The statement also included that the resident (later) complained of nausea, and she was provided [MEDICATION NAME], and had vomited, complained of right chest pain and was provided [MEDICATION NAME] and included that the resident thought it was a bug. -On [DATE] the resident did not eat lunch and complained of nausea, [MEDICATION NAME] was provided by an LPN #14 and the resident drank a cup of tea. The statement included that at 5:00 p.m. the resident's POA called and told #14 to start IV fluids because the patient told her she did not feel well, and included that #14 assessed the resident, who was alert and oriented and complained of pain in her lower back and that a pain pill was provided. -On the night shift of [DATE] to an LPN (staff #51) that the resident's POA had asked that an order for [REDACTED]. -On [DATE] the Physician (staff #63) was told by a nurse (#127) that the resident's POA had requested lab work including CBC, CMP and UA, the nurse did not know the reason for the request and stated to the physician that the resident was asymptomatic and had no concerns. The physician asked the nurse to find out why the POA had requested the lab testing and later the resident mentioned she was concerned she had caught a bug. The statement included that the resident reported she had right sided chest pain and the physician received no further reports from #127 regarding the resident. An interview was conducted on [DATE] at 1:15 p.m. with #127 who stated that on [DATE] the off-going night nurse reported to her that the POA had asked for lab testing including a CBC, and CMP the previous evening, and that the resident told #127 that she felt fine. Staff #127 stated that she reported the POA's request for lab testing to the physician in the morning, they agreed that the resident was on respite care, and when the physician wanted to know why the lab tests had been requested, #127 told the physician that the resident was fine. Staff #127 stated that later that morning, she heard the resident having dry heaves and provided [MEDICATION NAME] for nausea and #127 stated that later, that the resident had chest pain and pointed to the right side of her chest (during the interview with #127, when asked to point to where the resident had indicated she was having chest pain, she initially pointed to the center of her chest, and then when asked later in the interview, she pointed to the right side of her chest). Staff #127 stated that she notified the physician that the resident was having right sided chest pain and he prescribed [MEDICATION NAME], which she provided. The staff member stated she did not notify the POA that the resident had been nauseous, and was vomiting and having right sided chest pain because the resident was not having a change in condition and stated she did not remember if she checked the resident's vital signs or listened to her bowel sounds due to the resident having nausea and vomiting. Furthermore, #127 stated that she did not provide a head to toe assessment of the resident because it was not her designated day to be assessed on the day shift, and that routine lab work was not done because the resident was receiving respite care. During an interview conducted on [DATE] with the resident's Physician (staff #63), he stated that on [DATE] when the nurse (#127) had told him that the resident's POA had requested a CMP, CBC and UA, he asked the nurse to contact the resident's POA and ask the reason that she wanted lab testing done, and that the nurse never followed up with him regarding the lab tests. The physician stated that #127 told him that the resident was at her baseline, because the resident was clinically stable and that he assumed that the nurse had assessed the resident and checked the resident's vital signs. The physician stated that when a resident says they don't feel well to a resident's family or a POA calls and says the resident doesn't feel well, the nurse is to assess the resident including checking vital signs and is to call him and let him know. The physician stated that due to the long term treatment the resident had received for [MEDICAL CONDITION] arthritis her immune system was affected which put her at high risk for infections, and that the resident was also at high risk for possible ileus due to her medical history. An interview was conducted on [DATE] at 12:30 p.m. with an LPN (staff #14). During the interview, #14 stated that on [DATE] at 5:00 p.m. the resident's POA called and reported to her that the resident had told her (the POA) that she wasn't feeling well, and the POA wanted #14 to give the resident IV fluids, and the POA told #14 that if she didn't give IV fluids to the resident, the POA was going to call 911. Staff #14 stated that after the call with the POA she verbally assessed the resident, and the resident said she felt fine. The nurse stated she gave the resident tea, and a [MEDICATION NAME]. The nurse stated she did not check the resident's vital signs, and when she wrote her note that evening she used vital signs from earlier in the day because it was at the end of her shift and the resident had stated earlier that she felt fine. An interview was conducted on [DATE] at 11:40 a.m. with an LPN (staff #51) who stated that she provided care to the resident on the night shift beginning on [DATE], and ending on [DATE]. The nurse stated that she was told by the off-going day nurse that she needed to encourage fluids because the resident wasn't drinking much. The nurse stated she did not recall if I&O's (intakes or outputs) were being measured. The nurse stated that when the resident complained of pain all over her body she did assess the resident for pain and thought the resident just needed a pain pill so she provided the resident with pain mediation. The nurse stated that when she wrote her note, she used vital signs previously taken during the day, and that if she needed to assess the resident she would have checked the resident's vital signs, and listen to her bowel sounds. An interview was conducted on [DATE] at 12:19 p.m. with the ADON (Assistant Director of Nursing/staff #118) for the sub-acute unit (where the resident had resided), who stated that he had heard that on Saturday ([DATE]) that the resident had been vomiting and she had been assessed by her nurse. The ADON stated that vomiting is a change in condition and when there is any change in condition the nurse is to assess the resident and notify him and the DON (Director of Nursing). The ADON stated that when the nurse assesses the resident they are to check vital signs, and if the resident vomits, the nurse is to do a GI (Gastro-intestinal) data collection which includes listening to the abdomen with a stethoscope and checking vital signs. The ADON stated that based on the resident's symptoms that included vomiting and nausea it was reasonable to have expected the nurse to have done vital signs and check bowel sounds and that she should have done the data collection. The ADON stated that the drink and snack monitoring is used to monitor fluid intake and that I & O's (intake and output) measurements are not provided unless ordered by the physician, and that nothing was reported to him regarding the resident not getting enough fluids. The ADON stated that when a resident is receiving respite care they receive the same care as any other resident who has been admitted with the difference being a shorter stay and that the resident would not need to receive therapy. During an interview conducted on [DATE] at 1:30 p.m. with the ADON (staff #132) for the long term care unit, who stated if a resident or the resident's POA complained that the resident was ill or not feeling well, the nurse would assess the resident including checking vital signs, check for altered mental status and if the resident was nauseous or vomiting the nurse would listen for bowel sounds with a stethoscope and palpate the resident's abdomen. The ADON stated that the nurse would document the assessment online on an Interact assessment, and the nurse would write a nurses note describing whether or not there had been a change in condition. The facility's policy regarding nursing assessment with a revision date of [DATE], reveled the purpose of the policy is to determine a resident's condition and clinical needs. The policy also revealed routine and focused assessments will be performed on an ongoing basis as needed. the policy included the physician will be notified of assessment results as indicated and to document the physician notification and the respone if indicated.

Based on clinical record reviews, facility documentation, staff and resident interviews, and policy review, the facility failed to ensure that one resident (#2) was free from sexual abuse by another resident (#1) and failed to ensure one resident (#3) was free from physical abuse from another resident (#2). The sample size was three residents. The deficient practice could result in the potential for further resident to resident abuse. Findings include: -Resident #2 was admitted on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. A social service note dated (MONTH) 1, 2019 included that resident #2 had delusions as evidenced by verbal expressions usually pertaining to past incidents in her early life which she applied to the present time, and that the happenings in her early life play a role in her present behaviors. The note included that resident #2 was focused on fears brought on by past male relationships and the fear of being harmed. The resident's cognition care plan, initiated on (MONTH) 10, 2019, revealed the resident had impaired cognition related to a [DIAGNOSES REDACTED]. Interventions for this care plan included: -Evaluate behavioral symptoms for underlying causes. -Evaluate the need for a psychiatric/behavioral health consultation. -Redirect/re-orient using external cues as needed. -Approach in a calm, unhurried manner, reassure as necessary. An MDS (Minimum Data Set) assessment dated (MONTH) 29, 2019 included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 2 which indicated that the resident had severe cognitive impairment. The assessment included that the resident had difficulty focusing attention, disorganized thinking, physical behavioral symptoms directed towards others and feeling down, depressed or hopeless. The assessment also included that resident #2 did not walk, and used a wheelchair with one staff person assistance and supervision. A monthly nurse practitioner note dated (MONTH) 17, 2019 included that resident #2 had a chronic problem with continuing behaviors that included auditory hallucinations and paranoia. A physical behavior care plan, initiated on (MONTH) 21, 2019, included a focus that the resident exhibited or has the potential to exhibit physical behaviors related to cognitive loss/dementia and psychiatric disorder. The plan included that resident #2 had a history of [REDACTED]. A nursing note dated (MONTH) 30, 2019 at 1:15 a.m. included that the nurse had been notified by a CNA (Certified Nursing Assistant) at 12:10 a.m. of the following: -Resident #2 had been in the courtyard, seated in her wheelchair and facing away from the door with her back to the door, and a male resident (later identified to be resident #1) had been seated in his wheelchair in a diagonal position with his right hand inside of resident #2's pants. -When the CNA opened the door to the courtyard, the male resident removed his hand from resident #2's pants and followed the CNA out of the courtyard to the nurses station. -When the CNA returned to the courtyard and asked resident #2 how did he touch you she responded by saying that the male resident had touched me here (pointing to the left and right breasts and the vaginal area), and the CNA assisted the resident to her bed. The note also included that when the nurse assessed the resident she was lying in bed with her eyes closed, and when asked if she remembered what had happened in the courtyard, and if she had been touched in her vagina, resident #2 stated (with her eyes closed) no to the questions asked by the nurse. -Resident #1 was admitted on (MONTH) 2, (YEAR) with [DIAGNOSES REDACTED]. An MDS assessment dated (MONTH) 8, 2019 included a BIMS score of 14, which indicated that resident #1 was cognitively intact. The assessment did not include any indicators for mood or behaviors, or that resident #1 had any upper body impairments and included that resident #1 used a wheelchair for locomotion, and with supervision. A nursing note dated (MONTH) 6, 2019 at 10:47 p.m. included that resident #1 had been found in a female resident's room, sitting next to her while she was in bed sleeping and watching her sleep. The resident was asked to leave her room and not to go into her room without her permission. A nursing note dated (MONTH) 7, 2019 at 7:12 p.m. included that earlier in the evening, resident #1 had asked the female resident if he could enter her room and she had refused. However, the note included that during the evening, resident #1 had entered the female resident's room without knocking and without asking permission to enter, and staff had redirected the resident out of the room both times. The note included that each time resident #1 entered the female resident's room, she was sleeping. Review of the clinical record revealed a psychiatric evaluation dated (MONTH) 20, 2019 for a history of inappropriate intimate advances including that the staff had reported and that the resident had displayed daily inappropriate sexual behavior with verbal suggestions and touching others, and intrusive behaviors towards peers. The evaluation included that resident #1 displayed unstable symptoms of adjustment as evidenced by persistent intimate advances towards others, and that mental illness or cognitive impairment did not appear to be a factor in the reported behavior episodes. Review of nurses notes dated (MONTH) 30, 2019 included that the following: -The resident had been found in the courtyard seated in a wheelchair by a CNA (who reported the incident to the nurse) with the wheelchair facing the female resident (#2) in a diagonal position and with his right hand inside the female resident's pants. -When the CNA opened the door she stated to resident #1 I saw what just happened and why are you touching her resident #1 replied I'm sorry it won't happen again and resident #1 followed the CNA to the nurses station. -Police arrived at the facility at 1:30 a.m. and stationed an officer at door to resident #1's room. -Resident #1 was taken into police custody and removed from the facility at 7:15 a.m. Review of an investigative summary dated (MONTH) 1, 2019 included that on (MONTH) 30, 2019 at 12:00 a.m. a CNA (staff #59) had found resident #1 sitting in the courtyard next to resident #2, and resident #1 had his hands in resident #2's pants, and when the CNA opened the door, resident #1 pulled his hands out of the resident #2's pants. The report included that the CNA told resident #1 she had seen where his hands had been, and resident #1 stated he was sorry and that he would not do that again. The report included the CNA assisted resident #2 to her room, reported the incident to the nurse, and resident #1 was instructed to go to his room. The report included the police were notified and resident #2 was transferred to the hospital for a forensic rape examination. The report included that the police had interviewed resident #1 and reported to the facility that resident #1 did not deny hand groping and sexually touching resident #2, and that he did not receive consent from resident #2 prior to touching her breast over her clothes, her vagina over her clothes and that he had inserted his finger into her vagina under her brief. The report included that resident #1 was taken into custody and removed from the facility by the police. An interview was conducted on (MONTH) 3, 2019 at 9:20 a.m. with a CNA (staff #59). During the interview, the CNA stated that on (MONTH) 30, 2019 at 12:00 a.m., she noted during rounds that resident #2 was not in her room. She stated that when she found resident #2 sitting in the courtyard with resident #1, resident #1 had his hands in her pants. The CNA stated that when she opened the door to the courtyard, resident #1 pulled his hands out of resident #2's pants and he stated I'm sorry I won't do that again. the CNA stated resident #1 followed her to the nurses station, then she returned to the courtyard. The CNA stated that resident #2 remained sitting in the courtyard and had a helpless facial expression and looked helpless, as though she had been forced to do something. The CNA stated that resident #2 pointed to her breasts and private area when asked where resident #1 had touched her and said the resident #1 had touched her there. The CNA stated she assisted resident #2 to her room and described resident #2 as subdued and detached and helpless. An interview was conducted on (MONTH) 3, 2019 at 10:00 a.m. with an LPN (Licensed Practical Nurse/staff #56). Staff #56 stated that although she had worked on (MONTH) 30, 2019 on the night shift, she had been temporarily away from the unit when the incident had occurred at 12:00 a.m. Staff #56 stated that upon return to the unit she assessed resident #2, and observed that resident #2 remained in bed and was very quiet for the remainder of the night which was very unusual for her. Staff #56 stated that the normal night time behavior for resident #2 was to be up and awake all night, spending her time in the dining room or out in the courtyard and that it was highly unusual that she remained in her bed. An interview was conducted on (MONTH) 3, 2019 at 12:05 p.m. with an LPN (staff #113). The LPN stated that she had been present at the time of the incident on (MONTH) 30, 2019 at 12:00 a.m. and that resident #1 had wheeled himself to the nurses station. Staff #113 stated that she had spoken to resident #1 and told him that he cannot touch other residents, and when she asked him about the incident in the courtyard he stated that he was depressed and wanted to go home, then he returned to his room. An interview was conducted on (MONTH) 5, 2019 at 9:55 a.m. with a psychiatrist (staff #114). The psychiatrist stated that he had evaluated resident #1 on (MONTH) 20, 2019 and that the behaviors described in the evaluation were behaviors described to him by a staff member, and that resident #1 had behaved inappropriately to staff, but not to other residents. The psychiatrist stated that when he had evaluated resident #1 on (MONTH) 20, 2019 he did not have any concerns that the resident posed a danger to other residents, or that he had posed a risk for sexual or unwanted behaviors to others. An interview was conducted on (MONTH) 5, 2019 at 12:00 p.m. with a case manager (staff #99). She stated that resident #2 had an extensive history of physical and sexual trauma dating back to her childhood that included rape and that resident #2 had told her family member (regarding resident #1), He hurt me and put his mouth on me. -Resident #3 was admitted on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. An MDS assessment dated (MONTH) 1, 2019 included that resident #3 had a BIMS score of 1, which indicated severe cognitive impairment. The assessment also included that resident #3 had inattention and disorganized thinking, and used a wheelchair with supervision for locomotion. Review of nurses notes dated (MONTH) 20, 2019 revealed a note that included at 4:00 p.m. resident #3 had had an altercation with another resident (later identified to be resident #2), and was assessed to have 3 small discolored (areas) on her right hand that were not open. A nurses note at 9:52 p.m. included the resident had been assessed by the nurse at 4:45 p.m. and had 3 small abrasions to the right hand and 1 small abrasion to the left hand. The note included that the resident's behavior was at baseline and she was alert and confused. A care plan, initiated on (MONTH) 20, 2019, included a focus that resident #3 was the recipient of aggressive behavior from another resident and had 3 scratched areas with bruising on her right hand and a scratch on her left hand. Review of a facility investigative report dated (MONTH) 28, 2019 included that on (MONTH) 20, 2019 at 4:00 p.m., while resident #2 and #3 were in the lobby, resident #2 accused resident #3 of having sent men over to her. Resident #2 grabbed resident #3 by the wrists which caused bruising to her wrists. The investigative report included a witness statement dated (MONTH) 20, 2019 that was completed by a case manager (staff #99). The statement included that staff #99 had witnessed resident #2 holding onto the wrists of resident #3. The statement included that the witness was unable to loosen resident #2's grip on resident #3 and resident #2 stated She brought those men in here at me. The statement included that resident #2 was provided reassurance that there were no men in the area who were going to attack her and was then able to loosen resident #2's grip on resident #3 and staff assisted the resident to the nurses station. During an interview with a CNA (staff #39) on (MONTH) 5, 2019 at 10:50 a.m., she stated that although she did not witness the incident on (MONTH) 20, 2019 at 4:00 p.m., she did observe that for 2 days after the incident resident #3 was upset and agitated and made statements that she wanted to go home. An interview was conducted on (MONTH) 5, 2019 at 12:00 p.m. with a case manager (staff #99). The case manager stated that on (MONTH) 20, 2019 at 4:00 p.m. she observed resident #2 gripping and squeezing onto resident #3's wrists. The case manager stated that when approached, resident #2 stated She's bringing those men into my room, they're going to hurt me. The case manager stated that after speaking to resident #2, she was able to separate the two residents. A policy and procedure titled Abuse Prohibition included that the facility prohibits abuse, mistreatment and exploitation for all residents. The policy included the following definitions of abuse: -Sexual abuse is a non-consensual sexual contact of any type with a resident. It includes but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, .slapping and pinching. -Mental abuse includes but is not limited to humiliation, harassment and may occur through conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation. -Exploitation is defined as the act or process of taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. -Mistreatment is defined as inappropriate treatment or exploitation of a resident.

Based on clinical record review, staff interviews, facility documentation, hospital records, and policy review, the facility failed to ensure one resident (#12) was free from neglect, as one staff member used a Hoyer lift in an unsafe manner during a transfer. Findings include: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed the resident had moderate cognitive impairment and had poor decision making abilities. The MDS also assessed the resident to require total assistance of two persons with transfers. A review of the activity of daily living care plan revealed the resident had a self care deficit related to impaired mobility and cognitive impairment, secondary to mental [MEDICAL CONDITION]. The goal included that the resident would have their needs met. One of the approaches listed was for staff to use a Hoyer lift for transfers, with the assistance of two staff. Review of the activity of daily living summary dated March 2016 revealed the resident needed two person physical assist for transfers and bed mobility. Review of the nursing progress note dated March 4, 2016 at 4:40 p.m., revealed the resident had a fall at approximately 7:45 a.m. from the Hoyer lift during a one person transfer. Per the note, the sling strap came unhooked from the Hoyer lift and the resident fell from the sling, landing on her knees and then she toppled over on to her face. The resident complained of pain to the right knee and had a small amount of blood from her nose. The physician was notified. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. A nursing progress noted dated March 4, 2016 at 10:20 p.m. included that the results of the x-rays showed the resident had an acute [MEDICATION NAME] distal tibia and fibular metaphases and the resident was to be transferred to the hospital. Review of the hospital documentation dated March 5, 2016 revealed the resident had a distal left tibia/fibular fracture. The recommendation was for a short leg splint and follow up with an orthopedic surgeon on an outpatient basis. A nursing progress note dated March 5, 2016, documented that the resident was back in the facility at 5:30 a.m. Review of the facility's investigative report revealed a CNA (staff #134) hooked the resident up to the Hoyer lift, and one of the straps came off and the resident began to slide out. The resident fell on her hands and knees and hit her face on the leg of the Hoyer lift. Per the report, x-rays of the resident's knees were taken which were negative. However, later that evening more swelling was present and an x-ray was taken of the resident's left tibula/fibula and the resident was sent out to the hospital. The report further included that the CNA had stated this should have been a two person transfer as policy states. Per the report, the CNA was terminated for failure to follow policy during a resident transfer with a Hoyer lift. Review of the in-service documentation dated February 10, 2016 revealed CNA (staff #134) had received training on Safe Patient Handling Hoyer Transfers. Review of the facility's QAPI (Quality Assurance Performance Improvement) documentation revealed that following this incident, the facility's plan included for therapy to observe staff during resident transfers using a Hoyer lift. The observations were done in March and April 2016. The plan also included to continue with at least two observations of staff each month, which was done through July 2016. During the survey, staff #134 was unable to be reached for an interview. On August 11, 2016 at 10:21 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #37). She stated that two people were needed when using the Hoyer lift. She stated that there should have been someone spotting, while the transfer occurred. An interview was conducted on August 11, 2016 at 11:01 a.m., with a CNA (staff #2). She stated that two people are mandatory when using a Hoyer. On August 11, 2016 at 11:08 a.m., an interview was conducted with the Director of Rehabilitation (staff #118). She stated she observes staff using the Hoyer lift on an actual resident and does education on the spot, if needed. She stated that two staff are to be used at all times, when using the Hoyer. She stated that she documents the observations on the transfer observation sheet and gives a copy to the director. On August 11, 2016 at 11:18 a.m., an interview was conducted with the ADON (staff# 37). She stated therapy does the inservice's and will observe four transfers a month and goes over the use of the Hoyer lift, when a new employee is hired. She stated that inservice's on the Hoyer lift are required annually and the Hoyer lift manufacturer comes once a year. On August 11, 2016 at 2:30 p.m., an interview was conducted with the administrator (staff #82). He stated the facility does not have a policy for the Hoyer lift. According to the facility's abuse policy, the purpose was to promote resident's well-being, by providing a safe and supportive environment and that abuse and neglect is a high priority. Per the policy, neglect was defined as the failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness. The following incidents should be assessed for possible abuse (i.e. fracture/falls).

Based on closed clinical record review, staff interviews, and policy review, the facility failed to maintain the resident's highest practicable well-being, by failing to ensure safety devices were in place in order to help prevent falls for one resident (#236). Findings include: Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Fall Risk data set dated [DATE], revealed the resident was at high risk for falls. A care plan for at Risk for Falls dated December 16, 2014, identified that the resident was a fall risk due to impaired mobility, poor safety awareness, and a history of falls. Interventions included the following: bed locked and in lowest position, ensure call light within reach and answered promptly, encourage resident to wait for assistance, ensure a safe, clutter-free environment, physical therapy/occupational therapy (PT/OT) services as indicated, personal safety alarms in bed and on wheelchair, floor mats by bed, and to monitor routinely to ensure safety devices are in place. Review of the Fall Review Report revealed the resident fell on [DATE]. The resident was in the assisted dining room waiting for breakfast, when a dietary staff member and social services found the resident lying face down in front of his wheelchair. There was no documentation that the wheelchair alarm was on or if it sounded at the time of the fall. A nurse's note dated December 18, 2014 included the resident was found lying face down in front of his wheelchair and had sustained a left forehead hematoma. The note also included there was an order for [REDACTED]. A physician's orders [REDACTED]. Per the clinical record documentation, the resident returned back to the facility. Review of a form titled Post-Incident Actions dated December 18, 2014 revealed for a tab alarm monitor to wheelchair when out of bed. However; this intervention was already on the care plan and was supposed to be in use. A physician's orders [REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], documented in Section C. Cognition Status that the resident was rarely/never understood. In Section G. Functional Status the resident required extensive assistance for bed mobility, transfers, locomotion on and off the unit and personal hygiene. The MDS also included that the resident had falls since admission. A nurse's note dated December 25, 2014, documented the resident was found on the floor by his bed and that he had hit his head. Orders were received to send the resident to the hospital for a CT scan. Review of the Fall Review Report revealed the resident fell on [DATE] at 10:11 a.m., when he attempted to transfer from his wheelchair without assistance. There was no documentation as to whether the tab alarm was in place or if it sounded at the time of the fall. According to the Treatment Administration Record (TAR) for December 2014, the physicians order for the bed and wheelchair alarms were included and there were spaces for staff to initial each shift that the alarms were checked. However, there was no documentation that the alarms were in place during the morning shift on December 25. In addition, there were multiple other shifts in December with no documentation that the bed and wheelchair alarms were in place. Per a nursing assessment dated [DATE], the resident was found on the floor and had a cut to the occipital area. A physician's orders [REDACTED]. Review of the emergency room Report dated December 25, 2014, revealed the resident was transferring to the bed and the bed wasn't locked and he fell and hit the back of his head, causing a small skin tear and abrasions to the right occipital scalp. In addition, the hospital Radiology Report dated December 25, 2014, documented that the resident sustained [REDACTED]. The report also stated that the resident had a significant fall and was noted to have a resolving contusion to the left orbit area, a new abrasion of the right scalp, and a peculiar fracture to the right rib. An interview was conducted on May 7, 2015, with a registered nurse (RN). The RN stated that when a resident who is a fall risk is admitted , fall precautions are put into place; such as a low bed, floor mats, and bed and wheelchair alarms. She stated that if a resident has a fall, then they are to complete a fall assessment. She also stated that if the physician orders [REDACTED]. An interview was conducted on May 7, 2015, with the Assistant Director of Nursing (ADON). The ADON stated that the incident report should note if an alarm is in place at the time of the fall. However, the facility was unable to provide documentation that this resident's alarm was in place at the time of the falls. Review of the facility's policy on Fall Assessment/Intervention Process revealed that all residents on any admission, re-admission, and at least quarterly will be assessed for fall risk and appropriate interventions initiated immediately to reduce the risk of injuries with falls. The policy also included that the facility must ensure that a resident's environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Based on a review of the closed clinical record, hospital records, staff interviews, and review of facility policy, the facility failed to provide care and services, in order to prevent the development of a pressure ulcer for one resident (#19). The sample size was 3. Findings include: Resident #19 was admitted on [DATE], for rehabilitation following a hospitalization and surgical repair of a fractured left femur. [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a hospital transfer record dated November 24, 2013, that documented there was a dressing in place to the resident's left lower leg. The record also included the following: -Keep knee immobilizer in place-may remove for bathing and skin checks. -Daily dressing change to the left leg-cleanse with [MEDICATION NAME] solution, apply [MEDICATION NAME] gauze and ace wrap (this area was identified by staff as the surgical site). An admission nursing note dated November 24, 2013, included the resident was admitted with a left distal femur fracture, the left leg incision had staples and the resident had a leg immobilizer. The nursing admission assessment dated [DATE], also included the resident had an immobilizer to the left leg. However, per this assessment, the resident was identified to be at minimal risk for the development of pressure ulcers, despite the use of an immobilizer. The physician admission orders [REDACTED] -Daily dressing changes to the left leg. -Keep knee immobilizer in place-may remove for bathing and skin checks. A care plan for impaired skin integrity initiated on November 24, 2013, included the resident had a left leg surgical incision and was at risk for breakdown, due to status [REDACTED]. A goal included that the skin will remain intact. Some of the interventions included for weekly skin checks, weekly wound monitoring, and to notify the physician of changes as needed. The care plan did not address the use of the immobilizer or the need to remove the immobilizer for bathing or skin checks, as ordered. Further review of the clinical record revealed that weekly skin checks were completed on November 24 and 27, 2013, and no pressure ulcers were present. A review of the November 2013 TAR (Treatment Administration Record) revealed that the dressing changes were done as ordered. However, the documentation regarding the application of the knee immobilizer had been entered on the TAR as an "FYI," and therefore, did not include any documentation that the knee immobilizer had been applied and/or removed. Continued review of the clinical record revealed there was no documentation that weekly skin assessments were completed from November 28, through December 4, 2013. There was also no documentation that the knee immobilizer had been removed for frequent skin checks. According to the physical therapy documentation dated December 5, 2013, the resident now had an open wound (to the left leg) at the distal end of the brace secondary to pressure, which was discovered by therapy. Per the documentation, the resident was immediately brought back to the nursing unit and the LPN (licensed practical nurse) was notified. Despite the discovery of a new open pressure ulcer, there was no evidence that a thorough wound assessment was completed on December 5, nor any documentation that the physician was notified. Review of the impaired skin integrity care plan revealed that it was not updated to reflect the new open pressure area to the left leg. In addition, there was no clinical record documentation of any skin assessments or wound assessments that were completed from December 6 through 18, 2013. There was also no documentation the physician was notified of the open area or that any treatment to the pressure ulcer was provided during this time. The pressure ulcer record dated December 19, 2013, now identified that the resident had a pressure ulcer on the left lower calf. According to the documentation, the pressure ulcer measured 2.8 by 1 cm (centimeter), with sanguineous drainage present. The pressure ulcer stage was identified as UTD (unable to determine). The pressure ulcer record did not include a description of the wound bed. At this time, the physician was notified and treatment orders were obtained. Review of the impaired skin integrity care plan revealed that it was now updated on December 19, 2013, to include that a would treatment to the left leg had been ordered. However, the care plan did not include the resident had a pressure ulcer to the left leg. A physician's wound care report dated December 23, 2013, included that the resident had a new pressure ulcer on the left posterior leg, secondary to the leg brace. The documentation also included that the pressure ulcer measured 2 by 2.5 cm and was yellow and black in color, with slough present. The pressure ulcer was classified as UTD. Review of the TARs for December 2013 and January 2014, again revealed that the knee immobilizer had been entered as an FYI, and did not include any documented evidence that the application and removal of the knee immobilizer had been monitored by the licensed staff. According to the physician's wound care records from January 6, 2014, the pressure ulcer on the resident's left lower calf measured 1 cm by 1.4 cm, had granulation and slough present, and the stage was UTD. The resident was discharged to the hospital on January 11, 2014, for an unrelated condition. An interview was conducted on March 10, 2014 at 7:30 a.m., with the Therapy Director. According to the Therapy Director, if a knee immobilizer is applied correctly, then it does not cause pressure. An interview was conducted with a R.N. (Registered Nurse), who was able to recall this resident. He stated that the resident had developed a pressure ulcer from the knee brace. He said that the CNAs would have applied the brace and nursing staff should have confirmed that the brace was on. An interview was conducted with the DON (Director of Nursing), who confirmed that the resident did develop the pressure ulcer and that the clinical record did not include any documented evidence that the physician had been notified or that a treatment had been obtained on December 5, 2013. The DON also stated that the nursing staff should have documented that the left leg immobilizer was on and that it was applied correctly by the CNA. A facility policy titled, Skin System included the following: "7. On admission and when observed skin is compromised, the Nurse finding the problem will initiate a treatment using formulary product if possible and physician approval, refer to DON and document on 24 hr report...Physician and Family must be notified at time of discovery and notification must be documented in the medical record...8. A weekly skin assessment will be completed by a licensed nurse and kept as part of the medical record. Skin conditions will be updated weekly...if a pressure wound."

Based on clinical record review, assisted living record review, and staff interviews, the facility failed to ensure that one resident (#132) received the care and services necessary to prevent the development of avoidable pressure ulcers. The resident sustained [REDACTED]. Findings include: Resident #132 was admitted to the facility on [DATE], and discharged on [DATE], to an assisted living center with [DIAGNOSES REDACTED]. The interdisciplinary progress notes dated April 27, 2011, documented that the resident had generalized two and three plus [MEDICAL CONDITION] to his lower extremities and open sores on his lower calves. The note also documented that the resident had a "...sacral and anal over skin irritation open and superficial layer..." An admission data set dated [DATE], documented that the resident had a Norton pressure ulcer assessment completed and the resident scored an 11 which indicated that the resident was moderate to high risk for the development of pressure ulcers. Review of the physician orders [REDACTED]. A weekly skin assessment was done on April 27, 2011. This assessment documented that the resident's skin was not intact and identified the sacral area as a problem. A care plan dated April 27, 2011, identified the problem of impaired skin integrity. The problems identified on this document were the resident ' s surgical area of his scalp and the sacral irritation. Approaches included: to report signs of infection, redness, changes in color, to turn and reposition, weekly wound evaluation until healed, prompt, assist resident with offloading position changes as appropriate, and to monitor wounds weekly for the next 30 days. A skin assessment was completed on May 3, 2011, and documented the wound to the resident's scalp and the right lower extremity. There was no mention of the resident's sacral area. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], documented that a formal assessment instrument/tool (e.g., Braden, Norton or other) had been completed, also that the resident was at risk for developing pressure ulcers. Review of the resident's 14 day scheduled MDS dated [DATE], documented that the resident did not have a pressure ulcer at stage I or higher and that there was no pressure ulcer present on prior assessment. A skin assessment was completed on May 10, 2011, and documented the open areas on the resident's scalp and right lower extremities. There was no mention of the resident's sacral area. A physician's orders [REDACTED]. The physician ordered the same for the resident's left heel as well. The physician also ordered heel protectors on at all times for both right and left feet. There was no update to the skin integrity care plan that addressed the newly developed pressure ulcers on the resident's right and left heels. Although there was a physician's orders [REDACTED]. until May 16, 2011, when it was documented that the resident had "Blisters noted on R foot, old blister R heel was burst..." However, there was no documentation that identified the color of the blisters, color of the surrounding tissue of the blisters, the size of the blisters, or if there was drainage present. A nursing assessment dated [DATE], documented that the resident had open blisters to the right and left heels as well as BLLE (bi-lateral lower extremities) and that the left heel was "intact mushy". Another physician's orders [REDACTED]. A new order was obtained to cleanse the open areas on the right foot, right lower leg, and right heel with wound cleanser. The physician's orders [REDACTED]. The assessment completed on May 17, 2011, documented, "RLE open blisters on outer leg, top of foot and R heel". However, there was no documentation that identified the color of the blisters, color of the surrounding tissue of the blisters, the size of the blisters, or if there was drainage present. A progress note from the assisted living center dated May 22, 2011 (same day that the resident was discharged from the facility to the assisted living center), documented by a home health nurse stated that "...Orders received were for medication orders and 02 (oxygen)...No home health orders provided for wound care...Wounds to right lower extremity noted as follows...Right heel blister black noted under skin, part of wound open and draining serous fluid...Left Heel large blister that has opened to one side, blister reaches from one end of heel to the next, black noted underneath, drainage is serous fluid...Wound noted to coccyx area, open, small in size..." However, upon further review of the resident's clinical record there was no documentation on the back of the treatment record that the resident's wounds had deteriorated from the skin assessment of May 17. There was also no documentation to show that the physician was notified that the resident's wounds had deteriorated from blisters to black tissue as noted in the assisted living progress notes dated May 22, 2011. An interview was conducted with the assistant director of nursing (ADON) on October 28, 2011 at 10:05 am. She reported that the facility was working on getting better with wounds. She also stated that there was no initial skin assessment completed and that the skin assessment that was completed on May 17, 2011, was completed in preparation for the resident's discharge. In a later discussion on October 28, 2011 with the director of nursing (DON) and the administrator, the administrator stated that he concurred that there was no documentation of the resident's initial skin assessment in the clinical record. In an interivew conducted with the DON and the administrator, it was stated that a clear blister was considered a stage II pressure sore. In an additional interview on October 28, 2011, conducted with the administrative staff it was stated that as far as policies, they did have the key policies required by the state. It was also reported that for a pressure sore policy they refer to standard nursing practice found in the Lippincott Manual. The facility did not provide a copy of the reference from the Lippincott Manual. The facility's policy on wound measurements stated, "...Q: What is the proper way to measure a wound? A: Wound assessment is an important part of quality wound care. Consistent regularly scheduled measurements contribute to that quality..."