Every finding on record at Alta Mesa Health and Rehabilitation

Based on facility documents, staff interviews and facility policy, the facility failed to ensure the Daily Staff Postings for nursing staff was accurate and completed for the number of staff hours scheduled and hours worked. This deficient practice could result in an inflation or deflation of facility metrics which can impact actual staffing needs. Findings Include: A review of the 2024 Alta Mesa Health and Rehabilitation Facility Assessment addressed the staffing plan, charts, and assignments for the facility. According to the assessment, the facility utilized information collected in the resident profile to identify the care and services needed for the residents. The assessment included a sample staffing chart which calculated that the services of 1-2 registered nurses were appropriate for Long-Term Care and Short-Term Care (skilled) residents. The assessment further stated that staffing is ultimately is determined by the census, resident acuity and needs. A review of the PBJ Staffing Data Report for Fiscal Year Quarter 3, 2024 (April 1-June 30), identified the facility as having an excessively low weekend staffing finding. Review of the Daily Staff Posting dated July 6, 2024 revealed no evidence of the registered nurse assigned to the unit as a charge nurse. Further review of the posting revealed 3 Licensed Practical Nurses (LPN) worked the 6 am to 6 pm shift, with scheduled hours worked, and actual hours worked of 33.41 hours, after recalculation with the coordinator, it was determined the value was approximately 37.6 hours actually worked. The Daily Staff Postings dated from October 21, 2024 thru November 6, 2024 posting failed to include the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. The hours reflected in the Time Tracking: Daily Punch Details, did not correspond to the postings The Daily Staff Postings dated November 13, 2024 during the 6 am to 6 pm shift revealed 4 RN's were scheduled to work 36 hours, with an actual worked hour of 35.95 hours. Punch details are listed below: -RN #1 total of 7.62 hours -RN #2 total of 12.18 hours -RN #3 total of 11.57 hours Cumulative Hours of 31.37. On this date there was a total of 3 RN's with an actual worked hour of approximately 31.37 ours. There is a 4.58-hour difference between the posting and punch details. According to the Center for Medicare Services (CMS website) as of November 20, 2024, the facility has a below average (two star) rating for staffing. The Registered Nurse hours per resident per day on the week average for the weekend was recorded at 23 minutes. The national average was 28 minutes. The Arizona average was 30 minutes. Observed with the staffing coordinator the miscalculations transcribed on the Daily Staff Posting dated July 6, 2024. Observed with the coordinator the Daily Staff Postings dated from October 21, 2024 - November 6, 2024, where the actual hours worked column were left blank. On November 18, 2024 during the initial pool screening, multiple alert and oriented residents complained of long wait times for care and voiced the following concerns: -One resident stated being at for facility for a total of 4 months, and feels short staffing is definitely a problem. The resident feels the facility should have a better backup plan in place because things are not getting done like they are supposed to on the weekends. Resident stated they were so short staffed this weekend, his vital signs were only taken once, instead of the usual three times a day. -One resident stated it took 3 hours to get to the commode and is frustrated because they are always short staffed. -One resident stated that he prefers to go to the bathroom to have a bowel movement, but because of his decreased mobility, he has to consistently defecate in his adult brief. -One resident feels they are extremely slow in answering call bells. -One resident's spouse stated frustration with the facility staffing and stated You cannot expect one CNA to take care of everyone! One CNA for 28 residents is ridiculous! - One resident admits to having to call the front desk to get assistance because the staff takes to long to answer call lights. An interview was conducted with CNA (Staff #39) on November 19, 2024 at 9:23 a.m. The CNA stated that she is usually takes care of about 15-17 residents depending on needs. She states some responsibilities of her day includes grooming, and dressing, giving showers, assisting residents with whatever is needed. The CNA feels she has enough time to complete her required assignments during her shift. In regards to the weekend shift, she stated she doesn't work on the weekend. She also feels 4 CNA's and a shower aid optimal staffing for the CNA's. A joint interview with the staffing coordinator (Staff #31) and the administrator (Staff # 83) was conducted on November 20, 2024 at approximately 1 pm, to address the actual hours worked discrepancies, and to discuss concerns about staffing. The staffing coordinator stated that staffing is done according to acuity and census. She included that resident's that require 2-person care are also considered in staffing decisions. The staffing coordinator stated the average census for the last 3 months is between 55-63. As far as direct care resident staff, there are typically 4 CNA's, and 3 licensed nurses for the building. The administrator voiced his appreciation for the hospitality aides that assist the residents and provides support to the staff. The administrator and coordinator admit sometimes the staffing coordinator has a tendency towards not catching mathematical errors and any mathematical errors are unintentionally transferred to the Daily Staff Posting. The administrator explained that in case of direct care staff call outs they always have someone to fill in. The administrator admitted to feeling fortunate that registry staff were not utilized at the facility. He states that some of the staff live within a 10-minute vicinity to aid if needed. The administrator stated they do sometimes receive complaints about staffing and long call light wait times. He explained they conduct call light audits and they take an in-depth look into each complaint. After the investigation concludes, often times the actual wait times were not as long as initially perceived. The administrator stated they are definitely not understaffed, and to ensure that, they always have recruitment efforts going on. In regards to the Center for Medicare Services (CMS) 2-star staffing rating, the administrator believes the rating is actually higher, but they unfortunately did not submit some employee data correctly. A follow up interview was conducted with the staffing coordinator on November 20, 2024 at approximately 14:00. The coordinator acknowledged on the day of July 6, 2024 the facility census was 68. During the interview, the surveyor and coordinator used daily punch details, staff sign in-sheet, and the daily staff posting for July 6, 2024 to verify discrepancies in the posting. The coordinator identified missing time punches as a barrier in tabulating the final actual hours worked column correctly She states staff are always encouraged to properly clock in and out. The facility policy titled ADL's calls for the facility to provide residents with the appropriate treatment and services to attain or maintain the highest level of resident well-being. The facility policy titled Sufficient Staffing ensures the facility is to have sufficient nursing staff with the appropriate competencies and skillsets, in accordance with the facility assessment.

Based on resident and staff interviews, clinical record review, policy review and observations, the facility failed to ensure that one of one sampled resident (#510) was administered oxygen as ordered. The deficient practice could result in the resident having low oxygen saturations. Findings include: Resident #510 was admitted on [DATE] with diagnoses that included influenza due to novel influenza A virus with other respiratory manifestations. A physician ' s order dated November 16, 2024 revealed an active order for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) continuous, may titrate to 5 LPM to keep oxygen saturation above 90%. Review of the November 2024 Medication Administration Record (MAR) revealed evidence that oxygen had been administered via NC at 2LPM between November 16, 2024 to November 20, 2024. A care plan dated November 18, 2024 revealed a focus for oxygen therapy related to ineffective gas exchange, and the interventions included giving medications as ordered by the physician, and to monitor/document side effects and effectiveness. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Mental Interview Assessment (BIMS) score of 15 which indicated no cognitive impairment. The MDS was in progress and there was no evidence of assessments in other areas. During an initial observation conducted on November 18, 2024 at 8:53 a.m. of resident #510 who was sitting up in bed and there was no evidence that the resident was being administered oxygen; nor was there evidence of oxygen related supplies in her room (ex. Nasal cannula, tubing, or oxygen tank and/or concentrator). A second observation of the resident was conducted on November 20, 2024 at 10:50 a.m. and the resident was observed to be sitting up in her bed and there was no evidence that she was being administered oxygen nor had oxygen related supplies in her room. A final observation of the resident was conducted on November 20, 2024 at 1:19 p.m. and there was no evidence that the resident was receiving oxygen. An interview was conducted on November 20, 2024 at 10:50 a.m. with Resident #510, who stated she had not been administered oxygen since admission An interview was conducted on November 20, 2024 at 11:06 a.m. with a Certified Nursing Assistant (CNA/Staff #61). Staff #61 revealed that the facility process for administering oxygen would be to ensure that the resident is being administered the right dosage and ensure that the system is functioning properly. The CNA stated she was familiar with the patient and did not recall ever seeing her on oxygen. The CNA then entered the room and confirmed the resident was not currently being administered oxygen. An interview was conducted on November 20, 2024 at 11:55 a.m. with a Licensed Practical Nurse (LPN/Staff #113), who stated that the process for administering oxygen would be to obtain a physician ' s order and administer as written, as this is the facilities expectation.The LPN stated the risks of not administering oxygen as ordered could result in low oxygen saturation which could lead to harm. Staff #113 reviewed the physician's order and verified an order to administer oxygen at 2LPM via NC continuously and to change the oxygen tubing weekly. She then stated that it was her first time working with Resident #510 and she was unaware if she had been administered oxygen but had not seen the resident on oxygen that morning. An interview was conducted on November 20, 2024 at 1:06 p.m. with the Assistant Director of Nursing (ADON/ Staff #76), who stated that oxygen is administered according to physician ' s orders. The ADON reviewed Resident #510 ' s clinical record and verified that the resident had an order for continuous oxygen, and verified that it was being charted in the November 2024 MAR that the resident had been receiving oxygen. The ADON stated that his expectations would be to administer oxygen as ordered. The ADON identified that the risks of not administering oxygen as ordered could lead to respiratory issues such as hypoxia. Review of facility policy titled, Oxygen Administration, revealed that oxygen therapy is ordered by physician and the resident's clinical record will include: that oxygen is to be administered, and oxygen concentrators will be maintained in room when oxygen ordered. Review of another facility policy titled, Physician Orders, revealed that it is policy of this facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs. Further review revealed, it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on observations, staff interviews, and facility policy and procedures, the facility failed to ensure chemicals were safely stored. The deficient practice could result in residents being physically injured. Findings include: During the initial tour of the kitchen conducted on September 11, 2023 at 9:00 a.m. with the dietary supervisor (#11), chemicals were observed being stored on an open shelf in the kitchen to the right of the dishwasher. Staff #11 stated that they were not using the chemicals and he didn't know why they were on the shelf or who put them there, but he is responsible for ensuring that chemicals are secured. He also stated that as long as the kitchen door, located directly to the left of the dishwasher, leading to the dining room is closed and kitchen staff are present, it is alright to store the chemicals on the lower shelf. During this time, the kitchen door was observed to be open. The chemicals observed on the shelf included: -Sure Clean Aerosol Cleaner -Ajax Oxygen Bleach Cleaner -Ecolab Keystone Glass Cleaner -Ecolab Virasept Disinfectant -Ecolab Monogram Clean Force Delimer -Gen X Flatware Presoak -Shine-Up Lemon Furniture Polish -De-Scale Ultra Cleaner -Comet Cleaner with Bleach -Stainless Steel Aerosol Cleaner -Watermark Fabulous Apple Air Freshener -[NAME]-Brz Odorant -HDIC Ultra Cleaner -Airkem Vivid Glass Cleaner -Orange Force Multi-Surface Cleaner Degreaser -A spray bottle with no label containing approximately 3 ounces of a clear liquid that smelled like a chemical. -A spray bottle with no label containing more than 24 ounces of a red/orange colored chemical. An interview was conducted on September 14, 2023 at 8:28 a.m. with the Administrator (#188), who stated that he oversees the campus and supervisors the dietary supervisor. He stated that it is his expectation that staff follow the facility policy about safely securing and storing chemicals. He stated that the door leading from the dining room to the kitchen is not always locked and sometimes it is open because staff are doing things and coming and going. The facility's policy, Chemical Storage dated January 2023 states that it is the policy of this facility that all products containing a hazardous chemical or substance will be properly labeled for use by employees and stored in a secured manner to ensure a safe, hazard free environment for residents.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan for bathing was implemented for one resident (#17). The deficient practice could result in residents developing skin issues and poor hygiene. Findings include: Resident #17 was admitted on [DATE], with diagnosis that included multiple sclerosis and functional quadriplegia. A Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact. It also included that the resident needed one to two-person extensive assistance with personal hygiene, one-person physical assistance with bathing, extensive assistance with dressing and total dependence with Hoyer lift transfers. Review of care plan initiated on June 15, 2023, included resident is totally dependent on dressing and transfers, but did not reveal a care plan for bathing. Review of the Case Area Assessment (CAA) dated August 30, 2023, included that the resident was totally dependent in the area of bathing. An interview was conducted with the MDS Coordinator (staff #7) on September 09/12/23 at 9:54 AM. Staff #7 stated that if a resident requires any assistance with bathing or assistive devices, it should be included in the care plan. Staff #7 reviewed the care plan for resident #17 and stated that there was no care plan for bathing. An interview was conducted with the Director of Nursing (DON/staff #12) on September 12, 2023 at 11:01 AM. Staff #12 stated that showers are scheduled twice a week for each resident. She acknowledged that resident #17 needed assistance with showers and it should have been care planned. Staff #12 reviewed the care plan and stated that there was not a care plan for bathing. The facility's policy Nursing Administration dated August 2012 and revised May 2023 stated that the baseline care plan will include minimal healthcare information necessary to properly care for a resident.

Based on clinical record review, interviews, policy and procedure, and observation of current practice, the facility failed to ensure on resident (#215) received treatment and care in accordance with professional standards. Findings included: Resident #215 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, acute on chronic combined systolic and diastolic heart failure. A hospital discharge summary dated July 16, 2023 revealed resident was discharged with a diagnosis of osteomyelitis. Instructions stated if resident is on vancomycin, then Vancomycin trough on day #3, then weekly after is checked, keep the level between 15 and 20, and Skilled Nursing Facility Pharmacist to dose per their protocol. Review of the physician order revealed an order for vancomycin hydrochloride intravenous solution 500 milligram (mg)/100 milliliter (ml) to use 1.25 mg intravenously one time a day for osteomyelitis for 8 weeks initiated on July 16, 2023. Review of a progress note dated July 16, 2023 regarding the above order that the dose failed a general dose range check based on drug inputs and/or information provided and that the drug's dose should be adjusted based on renal function. The physician order also revealed an order for vancomycin trough one time only for 1 day to draw 30 minutes prior to the 4th dose, initiated on July 20, 2023. The medication was transcribed in the MAR (Medication Administration Record) and revealed vancomycin hydrochloride was administered from July 17, 2023 to July 23, 2023. In addition, the vancomycin trough was marked as complete on July 21, 2023 at 8:27 AM. A lab results reported on July 21, 2023 at 3:02 PM revealed a vancomycin serum trough level of 49.6 microgram (?g)/mL, which was flagged as a critical result. The report stated the result was called to the facility on [DATE] at 6:27 PM. Review of records revealed no documentation that the pharmacy or the physician was notified upon receipt of the critical lab result. A progress note dated July 24, 2023 at 6:20 AM stated the patient was found unresponsive and cardiopulmonary resuscitation was initiated. The noted also stated the resident had a time of death at 6:58 AM in the hospital. An interview was conducted on September 12, 2023 at 12:31 PM with an LPN (Licensed Practical Nurse/Staff #60 who stated vancomycin trough was monitored for residents who are on vancomycin because the medication was a harsh chemical for the body. Staff #60 stated that trough is regulated every 4th dose to maintain certain level, drawn before the 4th dose and the dose adjusted if necessary. Staff #60 stated that if trough is elevated then the Assistant Directors of Nursing (ADON) are notified, who then notifies the Director of Nursing, who will reach out to the provider and wait for instructions to either change the dose or hold the medication. The LPN (staff #60) stated that the provider is notified because they are medicine and their purview. Further, he stated that he would reach out to the ADON and inform them of the labs and help navigate and would hold the next dose until he receives clarification. When asked what the risks were for giving the next dose when trough levels were high, staff #60 stated he was unsure but his next action was to notify the physician. An interview was conducted on September 12, 2023 at 12:42 PM with an ADON (staff #102) who stated that trough levels were monitored for residents being treated with vancomycin. He said that depending on the infectious disease provider what is monitored such as kidney functions and other labs. The ADON stated that pharmacy monitored and adjusted the dose for vancomycin for therapeutic levels. Further, before the resident received the next dose, pharmacy would give recommendation on the dosage. The ADON stated that if there were reports of elevated trough level then the next action would be to notify pharmacy to fully integrate and get the next dosage. He stated that the medication was not skipped until guidance from pharmacy was received. Staff #102 said if the trough level was critically high or low, the provider was notified immediately and get orders. Further, he stated that the medication is not held but actions were based on the provider's instructions. He stated, the notification was noted on the resident's record as either lab, change of condition, change to order, and recommendation from pharmacy. Per the ADON, the normal level for trough was on the high end of 15 and if it was elevated it was up to pharmacy's discretion, per provider order. He stated that the risk of not notifying the provider of elevated trough was that the resident can experience side effects of red man's syndrome. In addition, his expectation was to notify the provider for high lab results because it could affect kidneys-vancomycin toxicity. An interview conducted on September 12, 2023 at 1:05 PM with the DON (Director of Nursing/Staff #12) who stated that when a resident was receiving vancomycin, trough, weekly labs, and toxicity levels were monitored and managed by pharmacy. The DON stated that staff drew the labs and pharmacy doses the medication. The DON stated that process for monitoring trough was that the lab will call the facility and fax results to the resident's electronic health record, integrated with pharmacy. Then pharmacy will make their recommendation of what the patient needs. The DON said that the risk of elevated trough included renal issues, toxicity, and ringing in the ears. Her expectations were to notify the provider, which was sometimes charted, get orders from provider, and make sure pharmacy is aware since they dose the medication. The DON stated that if communication with the provider or pharmacy was not charted, the communication probably happened. The DON verified that the vancomycin trough levels for resident #215 was approximately 49, which she stated was extremely high. She stated that resident #215's nurse working that day [July 21, 2023] received the report. The DON said that lab will call the facility and ask for the nurse for the resident and report the lab value of the patient. The DON verified resident's records that there was no documentation that the provider or pharmacy were notified immediately after receiving the critical lab value. The DON stated that there was a note from the Nurse Practitioner on July 24, 2023 and stated, but that is late. The DON verified the MAR that there were no changes on the vancomycin dosage after July 21, 2023 and that medication was never held after July 21, 2023. The DON stated that a staff was written up for not verifying lab values before the administration of vancomycin to resident #215. The DON provided staff record titled, On the Job Training for staff #84 that noted that staff failed to confirm lab value prior to administering medications and that she was educated on lab values particularly vancomycin trough and the contraindications when elevated.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value. Findings include: During the initial tour of the kitchen conducted on September 11, 2023 at 9:00 a.m. with the Dietary Supervisor (#11), the following observations were made in the large walk-in refrigerator and freezer: -a full pan of diced cantaloupe, honeydew melon, and watermelon with a discard date of September 13. 2023 in the walk-in refrigerator was covered with Saranwrap and there was a hole approximately two by two inches in size located at one corner of the pan. -a gallon size plastic bag of mixed salad with a discard date of September 13, 2023 was not sealed and some of the salad was brown and wilted. -a frozen bag containing 17 to 18 hash browns not sealed. Staff #11 stated that the purpose of covering/sealing food is to maintain freshness, prevent contamination from other food particles, prevent freezer burn, and maintain the quality of taste. An interview was conducted on September 14, 2023 at 8:28 a.m. with the Administrator (#188), who stated that he oversees the campus and supervises the dietary supervisor. He stated that food should be covered with saran wrap or put in a bag and sealed. He stated that the purpose for sealing food is to preserve freshness. The facility's policy, Alta Mesa Health and Rehab, Policy & Procedure Manual Food Storage states that food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed for one resident (#10) and failed to ensure two residents (#4 and #21) who remained in the facility longer than 30 days, level 1 screening was updated. The sample size was 3 residents. The deficient practice could result in specialized services needed not being identified and provided for residents. Findings include: -Resident #10 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record did not reveal a level I PASARR. -Resident #4 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a PASARR dated February 7, 2022 that the resident met the admission criteria for a 30-day Convalescent Care. The PASARR also revealed the facility must update the level 1 at such time that it appears the resident's stay will exceed 30 days. However, review of the clinical record did not reveal any update to the level 1 PASARR once the resident's stay exceeded 30 days. -Resident #21 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a PASARR dated March 1, 2022, which stated the resident met the admission criteria for 30-day Convalescent Care. However, continued review of the clinical record did not reveal any update to the level 1 PASARR or another level 1 PASARR once the resident's stay exceeded 30 days. An interview was conducted on August 4, 2022 at 1:20 PM with the Activities/Social Services Supervision (staff #54). She stated she is responsible to monitor and complete the PASARR screening and request level 2 evaluations. Staff #54 stated resident #4 should have had another PASARR completed once resident #4's stay in the facility exceeded 30 days. She stated she did not complete another PASARR for the resident. Staff #54 stated resident #21 was admitted on [DATE] and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated resident #21 has a PASARR dated March 1, 2022. She stated the PASARR does not include the resident having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #54 stated the resident has been in the facility over 30 days. She further stated the resident should have been referred for a level 2 evaluation and a referral has not been completed. She stated the PASARR was not accurate for the resident and she should have completed a new PASARR. She stated when a resident is admitted to the facility, she reviews the PASARR to determine if it accurately reflects the resident and if it does, she does not complete another PASARR. She stated if the PASARR does not accurately reflect the resident, she completes another PASARR. She further stated if a PASARR states the resident met the admission criteria for 30-day Convalescent Care and stays long-term, she will also complete another PASARR for the resident that stays over 30 days on day 40 of the resident's stay. Staff #54 stated resident #10 was admitted on [DATE]. She stated she was unable to locate any PASARR in the resident's medical record. She stated the resident has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated the resident had not been referred for a level II evaluation. An interview was conducted on August 4, 2022 at 1:30 PM with the Executive Director (staff #66). He stated Social Services is responsible for maintaining the PASARR process. He further stated the PASARR should be redone after 30 days if the resident stays in the facility over 30 days. Review of the facility policy titled, Preadmission Screening and Resident Review (PASARR) revealed all residents entering a Medicaid certified nursing facility must be screened for cognitive disability and or serious mental illness. The PASARR is a two-level screening process. The level 2 screening determines whether the resident can be appropriately treated in a nursing facility setting. .

Based on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to one resident (#4). The error rate was 8.57%. The deficient practice could result in further medication errors. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of medication administration for resident #4 was conducted on August 3, 2022 at 9:06 a.m. with a Licensed Practical Nurse (LPN/staff #110). The LPN was observed to administer medications which included: One aspirin 81 milligram (mg) chewable tablet; Two [MEDICATION(S)] 400 microgram tablets (mcg); and One Multivitamin with minerals. Review of the physician's orders dated February 8, 2022 revealed: -Aspirin EC ([MEDICATION(S)] coated) tablet/delayed release 81 mg one time a day. However, the medication administered was not EC/delayed release. -[MEDICATION(S)] 1 mg tablet one time a day. However, the medication administered was two 400 mcg tablets which would equal 800 mcg or 0.8 mg. -Multiple Vitamin Tablet one time a day. However, the medication administered included minerals, which was not ordered for the resident. An interview was conducted on August 3, 2022 at 12:04 p.m. with the LPN (staff #110). He stated he was expected to follow the physician's orders as written. He stated that he gave the chewable form of the aspirin because he did not have the ordered form in his cart. The LPN stated that he should not give the wrong medication when he does not have a supply in his cart, but that he should look for the medication in the medication room. The LPN stated that if he is still unable to find the medication ordered, he should notify the Assistant Director of Nursing (ADON) that he did not have the ordered medication. The LPN also stated that he should notify the physician if he was unable to give the medication. He stated he did not give the [MEDICATION(S)] as ordered, that it was a medication error and that he had notified the physician. He stated he gave a multivitamin with minerals, but that the medication ordered was a multivitamin. He stated the wrong medication was administered and that was a medication error. The LPN stated that if he did not give medications as ordered, there is a risk to the residents of side effects or complications. An interview was conducted on August 3, 2022 at 12:18 p.m. with the Director of Nursing (DON/48). She stated she expected staff to follow the physician's orders as written. The DON stated if the resident did not receive the right medication, dose, or form of the medication, there were risk factors of adverse reactions. Review of the facility policy for Medication Administration/Administration of Drugs included: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration: right resident, right time, right medication, right dose, right route, right documentation, and right diagnosis.

Based on personnel file review, staff interviews, and policy review, the facility failed to implement their policy regarding the hiring process for a Certified Nursing Assistant (CNA/staff #3). The deficient practice could result in staff being hired that have been found guilty of neglect or abuse. Findings include: Review of the personnel file for staff #3 revealed a hire date of June 20, 2022. Further review of the personnel file for the CNA revealed a CNA certification issued to staff #3 with an original issue date of August 3, 2017 and an expiration date of July 31, 2023. The certification status was active and disciplinary action stated yes. The report stated the discipline/final orders state is Arizona, and the date action was taken was November 6, 2012. Review of the Arizona State Board of Nursing Findings of Fact, Conclusions of Law and Order dated September 20, 2012 stated staff #3 CNA certificate was revoked. The report included documentation to support staff #3 was found guilty of violations that included neglect or abuse of a patient or resident physically, verbally, emotionally, or financially. During an interview conducted on August 4, 2022 at 9:26 AM with the Director of Nursing (DON, staff #48), she stated Human Resources (HR) completes the licensure/certification verification and background checks for all employees, and follows through with the process of determining disciplinary actions. An interview was conducted on August 4, 2022 at 9:31 AM with the Human Resources Director (staff #20). She stated she is responsible for verifying certification/licensure and background checks on all employees. Staff #20 stated she did verify staff #3's CNA certification and was not aware the verification included a past disciplinary action. She stated if the State Board lists a certification or license as valid and active she should be able to hire the individual. She further stated it is policy for her to be aware a potential employee has a previous disciplinary action but it is not her responsibility to review any disciplinary actions. In another interview conducted with the DON (staff #48) on August 4, 2022 at 10:53 AM, the DON stated the DON and ED (Executive Director) should be notified by HR if a potential employee has any prior disciplinary actions identified on the certification/licensure verification. She stated she was not aware of any prior disciplinary for staff #3. The DON stated she would not have hired staff #3 if she had been aware of staff #3's history of disciplinary action. She stated there is a risk to the residents when the process of pre-employment background screening and licensure verification is not followed per policy. An interview was conducted with the ED (staff #66) on August 4, 2022 at 11:19 AM. He stated HR is responsible for ensuring everything is taken care of during the hiring process for a potential employee. He stated he would expect to be notified if a potential employee has a prior disciplinary action attached to their license. The ED further stated he was not aware staff #3 had a prior disciplinary action prior to August 4, 2022. He stated he would have expected HR to have notified him or the DON to review staff #3's file prior to hiring staff #3. He further stated HR would not be the person to determine the hiring status with any potential employee with previous disciplinary action. The facility's Abuse: Prevention of and Prohibition Against Policy reviewed January 2022, stated that screening of prospective employees included that prior to hire, the facility will review documentation status of and any disciplinary actions for licensing or registration boards and other registries. The policy also stated the facility will not hire any person who has been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law, has had a finding entered in the State Nurse Aide Registry or Office of Inspector General database concerning abuse, neglect, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on personnel record review, staff interviews, and policy review, the facility failed to ensure a Certified Nursing Assistant (CNA/staff #3) was not hired with a finding of resident abuse or neglect from the State professional licensing board. The deficient practice could result in residents being subjected to abuse. Findings include: Review of the personnel record for a CNA (staff #3) revealed a hire date of June 20, 2022. Continued review of the personnel record for the CNA (staff #3) revealed an Arizona State Board of Nursing Primary Source Board of Nursing Report Summary dated June 30, 2022. The report included documentation of an Undeclared Certified Nursing Assistant (UCNA) certification with an original issue date of December 1, 2006 and expiration date of November 6, 2022, including a revoked license status and no discipline action noted. The report further included a CNA certification issued to staff #3 with an original issue date of August 3, 2017 and an expiration date of July 31, 2023. The certification status was active and disciplinary action stated yes. The report stated the discipline/final orders state is Arizona, and the date action was taken was November 6, 2012. Review of the Arizona State Board of Nursing Findings of Fact, Conclusions of Law and Order dated September 20, 2012 stated staff #3 CNA certificate was revoked. The report included documentation to support staff #3 was found guilty of violations to include neglecting or abusing a patient or resident physically, verbally, emotionally, or financially. An interview was conducted on August 4, 2022 at 9:26 AM with the Director of Nursing (DON/staff #48). She stated Human Resources (HR) completes the licensure/certification verification and background checks for all employees and follows through with the process of determining disciplinary actions. An interview was conducted on August 4, 2022 at 9:31 AM with the Human Resources Director (staff #20). She stated she is responsible for verifying certification/licensure and obtaining background checks for all employees. She stated if the employee has a previous employment history or is a current employee with the corporation, transfer paperwork is completed by the employee, returned to her, and the form is then sent to the corporate service center. She stated the service center transfers the employee file to the current facility. She stated staff #3 was a transfer from a facility in the corporation but was not a current employee at the time of the transfer. Staff #20 stated staff #3 was considered a rehire. She stated she did verify staff #3's CNA certification and was not aware the verification included a past disciplinary action. She stated if the State Board lists a certification or license as valid and active she should be able to hire the individual. She further stated it is a policy for her to be aware if a potential employee has a previous disciplinary action but it is not her responsibility to review any disciplinary actions. Another interview was conducted with the DON (staff #48) on August 4, 2022 at 10:53 AM. She stated the DON and the Executive Director (ED) should be notified by HR if a potential employee has any prior disciplinary actions identified on the certification/licensure verification. She stated she was not aware of any prior disciplinary for staff #3 and is now aware and reviewed the Conclusions of Law and Order dated September 20, 2012. The DON further stated she would not have hired staff #3 if she had been aware of staff #3 disciplinary action history. She stated when she is notified by HR of a potential employee with a past disciplinary action, she reviews it and discusses it with the potential employee prior to determining if the individual can or cannot be hired. The DON stated there is a risk to residents when the process of pre-employment background screening and licensure verification is not followed per policy. An interview conducted on August 4, 2022 at 11:19 AM with the ED (staff #66). He stated HR is responsible for ensuring everything is taken care of during the potential employees hiring process. He stated he would expect HR or the corporation service center to notify him or the DON if a potential employee has a prior disciplinary action attached to their license. The ED stated he would interview the potential employee to determine if it was appropriate to hire the individual. He stated if the potential employee transfers from a different facility in the corporation, they do not always get the information immediately as the facilities are all independent and they are not aware unless the employee discloses they worked at a previous facility. He further stated he was not aware staff #3 had a prior disciplinary action prior to August 4, 2022. The ED stated he would have expected HR to have notified him or the DON to review staff #3's file prior to hiring staff #3. He stated they would have discussed the disciplinary action with the employee before determining hiring eligibility. He further stated HR would not be the person to determine the hiring status with any potential employee with previous disciplinary action. The facility's policy regarding screening for prospective employees stated that prior to hire, the facility will screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit such abuse, neglect, exploitation, or misappropriation of resident property. The policy stated the facility will not hire or retain any person, directly or indirectly, who has disciplinary action in effect against his or her professional license by a State licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on clinical record review, observations, resident and staff interviews, and review of policy and procedure, the facility failed to ensure medication administration met professional standards of quality for two residents (#34 and #217). The deficient practice could result in adverse medication effects. Findings include: -Resident #217 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders revealed an order dated July 24, 2022 for [MEDICATION(S)] 5 milligram (mg) tablet by mouth one time a day for DM. Review of the care plan revealed a focus dated July 25, 2022 for Diabetes Mellitus with goals that included the resident would be free from any signs or symptoms of hyper/[CONDITION(S)] and would have no complications related to diabetes. The interventions stated to give diabetes medications as ordered by the physician and to educate regarding medications and importance of compliance. Review of the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medication blister card for [MEDICATION(S)] 5 mg tablet revealed a sticker that stated: Take this medicine 1/2 hour before a meal. An observation of medication administration was conducted on August 3 2022 at 8:13 a.m. with a Licensed Practical Nurse (LPN/staff #106). He administered a [MEDICATION(S)] 5 mg tablet to resident #217. The resident was observed to have eaten part of the breakfast meal at the time of the observation. An interview was conducted on August 3, 2022 at 11:45 a.m. with the LPN (staff #106). He stated it was important to follow the pharmacy directions on the medication card. The LPN acknowledged that the resident was mostly done with the meal at the time of the medication administration. He stated he tried to split up the medication administration for a resident if some medications needed to be given with a meal or before a meal. He stated the risk to the resident was that the medication may not be completely effective. -Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders included an order dated July 3, 2022 for [MEDICATION(S)] 112 microgram (mcg) tablet in the morning for low [CONDITION(S)]. Review of the [MEDICATION(S)] 112 mcg tablet medication bubble card for resident #34 included a direction sticker to: Take this medicine on an empty stomach, preferably 1/2 to 1 hour before breakfast. Review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of medication administration was conducted on August 3, 2022 at 8:38 a.m. with an LPN (staff #110). He was observed to administer [MEDICATION(S)] tab 112 mcg to resident #34. An interview was conducted with the resident on August 3, 2022 immediately following the medication administration. The resident stated that she had already eaten her breakfast. An interview was conducted on August 3, 2022 at 12:04 p.m. with the LPN (staff #110). He stated it was important to follow the pharmacy instructions when administering medications. He stated that he remembered resident #34 had already had breakfast and stated the resident was supposed to get the [MEDICATION(S)] before breakfast. The LPN stated the medication was less effective if not given on an empty stomach. In an interview conducted on August 3, 2022 at 12:18 p.m. with the Director of Nursing (DON/staff #48), she stated she expected staff to follow the pharmacy directions for administering medications. The DON stated that not following the pharmacy direction could impact the effectiveness of the medication. Review of the facility policy for Medication Administration/Administration of Drugs included: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications may not be set up in advance and scheduled medications must be administered within the facility time frame. Before and/or after meal medication orders must be administered as ordered.

Based on observation, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#350) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #350 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Initial Admission Record dated April 1, 2021 at 2:10 p.m. revealed the resident's oxygen saturation level was 93% on oxygen via nasal cannula. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status, indicating the resident had intact cognition. The assessment also revealed the received oxygen therapy. Review of the Daily Skilled notes dated April 2 through 13, 2021 included administration of oxygen via nasal cannula at 2-3 liters per minute continuously. During an observation conducted on April 13, 2021 at 12:35 p.m., the resident was observed receiving oxygen via nasal cannula at 3 liters per minute. However, review of physician's orders did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On April 13, 2021 at 1:51 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #44). Staff #44 stated that the resident has been on continuous oxygen since admission. The LPN stated that he believed the resident was receiving oxygen at 2.5 liters per minute via nasal cannula, with orders to titrate to keep oxygen saturation above 90%. An interview was conducted on April 14, 2021 at 10:23 a.m. with an LPN (staff #10). The LPN stated that the admitting nurse will transcribe physician's orders into the resident's electronic record. She stated that the Director of Nursing (DON) and the Assistant DON (ADON) review resident records to ensure they have been transcribed accurately and completely. She stated that the MDS nurse would probably catch any inaccuracies after that. On April 14, 2021 at 11:00 a.m., an interview was conducted with a Registered Nurse (RN/staff #76). Staff #76 stated that the admitting nurse is responsible to transcribe physician's orders into the resident's record. The RN stated that if a resident was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on April 14, 2021 at 2:09 p.m. with the DON (staff #66). She stated that the admission process begins with nursing receiving a verbal report prior to the arrival of the resident. Staff #66 stated that during the report, the admitting nurse would obtain information regarding whether or not the resident had been on oxygen at the hospital. Staff #66 stated that if the resident had been receiving oxygen, she would anticipate that the resident would receive oxygen at the facility. She stated that the physician's final orders come with the resident and those orders are to be transcribed into the electronic record. The DON stated that the day after the resident is admitted , the ADON will review the resident's orders to ensure they are complete. The DON reviewed the resident's orders and stated that she had been made aware that the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy titled Oxygen Administration reviewed July 2020 stated that it is the policy of the facility that oxygen therapy is administered by a licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained. The resident's clinical record will include that oxygen is to be administered, when and how often oxygen is to be administered, the type of oxygen device to use (i.e., mask, nasal cannula), any special procedures or treatments to be administered, and charting and documentation related to oxygen use.

Based on observations, resident and staff interviews, facility documents and policy, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure infection control standards were followed regarding personal protective equipment (PPE), isolation signage, and hand hygiene. The census was 42. The deficient practice could result in the spread of infection. Findings include: Regarding PPE -During an observation conducted on April 12, 2021 at 9:25 a.m., a Registered Nurse was observed to enter a resident's room on isolation precautions without donning a gown. The RN was wearing a surgical mask and regular glasses. The RN did not don gloves. An interview was conducted with the RN (staff #9) on April 14, 2021 at 9:25 a.m. Staff #9 stated that there are gowns hanging in the residents' room that staff are to don every time they go into a resident's room. The RN stated there are times that she has just popped into a resident's room without donning a gown. The RN also stated that she had been putting her goggles on top of her head and forgot to wear them in the resident's room. -During an observation conducted on April 12, 2021 at 11:58 a.m., a Hospitality Aid (staff #60) was observed to don PPE and enter a resident's room to give the resident's their lunch tray. However, staff #60 did not tie the gown at the waist and the mask covered her mouth and chin but not her nose. -On April 12, 2021 at 11:30 a.m., a resident who was on isolation precautions was observed in their room receiving therapy from a therapist who was not wearing a gown or gloves. -During an observation conducted in the laundry room on April 13, 2021 at 12:03 p.m., a laundry staff (staff #59) was observed with her mask hanging off her face exposing her nose. Immediately following this observation, an interview was conducted with staff #59. During the interview, staff #59 was observed to remove the mask multiple times to speak. Staff #59 stated that she is required to keep her mask on in the laundry area. Staff #59 stated that she tried to keep the mask on, but that the mask falls off her nose because she has a narrow face. -An observation was conducted on April 14, 2021 at 11:34 AM of a kitchen staff member who stuck his head out of the kitchen passthrough into the dining room. The kitchen staff mask was observed on his chin exposing his mouth and nose. -During an observation conducted on April 15, 2021 at 8:18 a.m., a housekeeper (staff #70) was observed cleaning a dining room with her mask positioned below her nose. -A RN (staff #76) was observed at the medication cart on April 15, 2021 at 08:20 a.m. with her mask positioned below her nose. An interview was conducted on April 14, 2021 at 12:43 PM with the Infection Control Nurse (staff #53), who stated staff that are in residents' rooms that are on isolation precautions, should be wearing a gown and gloves, in addition to the mask and goggles. An interview was conducted on April 15, 2021 at 9:34 a.m. with an RN (staff #75), who stated the gown should be tied at the neck and the back. The RN stated that it is wrong to not don PPE and wrong to not tie the gown. In an interview conducted with the Director of Nursing (DON/staff #66) on April 15, 2021 at 10:54 a.m., the DON stated her expectations is that a mask covers the staff's mouth and nose, and fit well. The DON said that not wearing goggles or not wearing a mask that covers the nose and mouth, is incorrect. The DON also stated that not wearing a gown or wearing a gown that is not tied is incorrect. The facility's policy regarding PPE stated the purpose is to ensure staff use PPE as needed. Proper use of PPE can prevent spread of disease. The policy included masks should cover the nose and mouth and to tie the gown belt strings in the back. The policy also included eye glasses can be worn under goggles as needed. The CDC Using Personal Protective Equipment (PPE) updated June 9, 2020 instructs that when donning an isolation gown, tie all of the ties on the gown. The guidance included respirator/facemask should be extended under the chin and both the mouth and nose should be covered. Do not wear respirator/facemask under your chin. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated February 23, 2021 stated put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the resident's room. Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes or sprays. Regarding signage During multiple observations conducted during the survey, it was observed that residents on 14-day isolation had a sign outside their room containing their name, a green dot, and a date. No signs were observed posted outside the residents' rooms instructing what type of isolation the residents were on or what PPE needed to be worn. An interview was conducted on April 14, 2021 at 12:43 p.m. with the Infection Preventionist (IP/staff #53), who said that they place a green dot by a resident's door when the resident tests negative for COVID-19. The IP stated the date posted by the resident's name is the date the resident can come off the 14-day isolation. The IP stated visitors or outside healthcare professionals are given a gown for each person they are there to see as soon as they enter the facility. Staff #53 also stated that the visitors and healthcare professionals are educated that they need to gown for each person. The IP said that she understood how it could cause confusion and that she would make signs. An interview was conducted on April 15, 2021 at 10:54 AM with the DON (staff #66), who said that she would want signs detailing what PPE to use in residents' rooms on isolation precautions who are new admissions. The DON stated that the staff has been educated regarding the use of PPE. The DON stated that the protocol for visitors or laboratory technicians, is that staff give them a gown and goggles for that resident's room. The facility's policy titled New admissions/14-day observation updated March 1, 2021 stated the purpose is to ensure that all new admissions entering the facility with unknown COVID-19 results will be placed on COVID-19 precautions for a period of 14 days. A name tag will be placed outside the resident's room with the date that the 14 days expires. The policy also stated that once cleared of COVID-19, a green sticker will be placed over the date indicating clearance of strict COVID-19 precautions. The policy did not include placing signage indicating the type of PPE required. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated February 23, 2021 stated take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places to provide instructions about wearing a well-fitting form of source control and how and when to perform hand hygiene. The CDC Interim Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated March 29, 2021 stated facilities should have policies and procedures addressing which PPE is required in which situations (e.g., residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, residents placed in quarantine) and recommended sequence for safely donning and doffing PPE. A CDC guidance titled Transmission-Based Precautions revealed examples of signs for contact and droplet precautions that can be posted outside patient rooms. These included droplet precautions and contact precautions and denoted the PPE required to enter the room. The guidance included providing instructional materials for patients and visitors on the application of Transmission-Based Precautions. Regarding Hand Hygiene A Licensed Practical Nurse (LPN/staff #72) was observed to provide wound care to a resident on April 13, 2021 at 9:39 a.m. Staff #72 entered the resident's room, washed her hands in the resident's bathroom and retrieved the prepared supplies from the top of the wound cart that was outside the resident's room. The LPN laid the supplies on top of a blue disposable pad and donned clean gloves. The LPN then removed the dressing on the left calf, donned clean gloves, cleaned the wound with normal saline, donned clean gloves and applied the Santyl ointment and a new dressing. Staff #72 then removed the gloves, and donned clean gloves. The LPN then cleaned the sacral wound with normal saline, changed her gloves, applied Santyl ointment to the dressing with a tongue depressor and applied the dressing to the sacral wound. Staff #72 then doffed the gloves, and applied clean gloves to reposition the resident. After the resident was repositioned, the LPN removed the gloves, washed her hands in the resident's restroom and exited the room. The LPN was not observed to perform hand hygiene between any of the glove changes. On April 13, 2021 at 9:56 a.m., an interview was conducted with the staff #72. The LPN stated that she had left the hand sanitizer on the wound cart in the hall. The LPN stated that she normally brings the hand sanitizer in the resident's room with her and that it was her mistake. An interview was conducted with the DON (staff #66) on April 15 ,2021 at 9:18 a.m. The DON stated the expectation is that the wound nurse washes her hands upon entry to the resident's room and use hand sanitizer between glove changes. The DON stated the wound nurse is to change gloves and use hand sanitizer between dirty to clean on any wound, and between wounds. An interview was conducted on April 13, 2021 at 12:52 p.m. with the wound Nurse Practitioner (NP/staff #93). The NP stated that she would expect the nurse to change gloves between each wound being treated and any time the nurse moved from a dirty area to a clean area of a wound. The NP further stated that hand washing between glove changes is recommended but hand sanitizer is acceptable between glove changes if washing hands is not an available option. The facility provided guidance used as a training tool at the facility skills fair that stated hand hygiene is to be performed before starting wound care for each resident and after doffing gloves. The guidance further stated that alcohol-based hand rub should be accessible throughout the wound care process. The guidance stated that gloves are to be worn during all stages of wound care including when applying new dressings. Gloves are to be donned after performing hand hygiene. The guidance further stated that during a resident's treatment, gloves are to be doffed every time when going from dirty to clean surfaces or supplies. The CDC guidance titled Hand Hygiene in Healthcare Settings revealed that gloves are not a substitute for hand hygiene. If a task required gloves, hand hygiene should be performed prior to donning gloves and before touching the patient or the patient environment. Hand hygiene should be performed immediately after removing gloves. The guidance further revealed that gloves are to be changed and hand hygiene performed during patient care if gloves become damaged, visibly soiled with blood or body fluids, following a task, moving from a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.

Based on observation, staff and resident interviews, clinical record review, and policy review, the facility failed to ensure one out of 12 sampled residents (#150) was assessed to safely self-administer medications. The census was 42. The deficient practice could result in residents unsafely administering medications. Findings include: Resident #150 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status assessment dated [DATE] at 1:43 p.m. revealed a score of 15, indicating the resident had intact cognition. The Initial Admission Record dated April 6, 2021 at 1:57 p.m. stated that the resident did not have a desire to self-administer drugs. Review of the baseline care plan dated April 6, 2021 at 1:57 p.m. did not reveal for self-administration of medications. An Opioid Risk Tool dated April 6, 2021 at 3:34 p.m. revealed the resident was scored at a 6, indicating the resident was at moderate risk for aberrant behaviors. Review of an opioid care plan dated April 7, 2021 related to pain management with a potential for adverse outcome, had a goal the resident would be free from adverse reactions related to opioid use. Interventions included to administer opioid as prescribed. A potential for mood problem care plan dated April 7, 2021 related to tobacco use and opioid abuse, had a goal the resident would have improved mood state (happier, calmer appearance, no signs or symptoms of depression, anxiety, or sadness). Interventions included to administer medications as ordered and to monitor/document for side effects and effectiveness. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 2 tablets every 4 hours as needed for pain of 4-10 on a pain scale. An observation of resident #150 was conducted on April 12, 2021 at 9:25 a.m. A nurse was observed to enter the resident's room, hand the resident a medication cup that contained 2 tablets, and exit the room before the resident had taken the medication. Review of an electronic medication administration note dated April 12, 2021 at 9:26 a.m. revealed the resident received [MEDICATION(S)]-acetaminophen 5-325 mg, 2 tablets for a pain level of 10 out of 10. However, review of the clinical record did not reveal the resident had been assessed to safely self-administer her own medications. On April 12, 2021 at 12:45 a.m., an interview was conducted with resident #150. The resident stated that she never takes medications on her own. She stated that the nurses always stay in the room with her and watch her swallow her medications. The resident stated that she does not even take liquid nutritional supplements without being observed. An interview was conducted with a Registered Nurse (RN/staff #9) on April 14, 2021 at 8:49 a.m. The RN stated that she could have left the room before the resident took her medication. The RN stated that she did not see the resident take the tablets. Staff #9 said she had been busy with other residents and that she probably did walk out of the room before the resident took the medication. Staff #9 stated that she knew she did not want the resident saving the tablets up. The RN stated that she did not know whether or not the resident had a care plan regarding self-administration of medications. The RN stated that she had 20 residents on the hall and that was a lot of residents to keep track of. On April 14, 2021 at 2:32 p.m., an interview was conducted with the Director of Nursing (DON/staff #66). The DON reviewed the resident's assessments and stated that the resident had not been assessed to safely administer her own medications. Staff #66 stated that the nurse leaving the medication with the resident without observing the resident take the medication was bad. The DON stated that it did not meet her expectations. The facility's policy titled Self-Administration of Medications stated the purpose is to determine the ability of alert residents to participate in self-administration of medications and to maintain the safety and accuracy of medication administration. The policy stated that if the resident is a candidate for self-administration, this will be indicated in the chart. The policy also included nursing will be responsible for monitoring self-administered doses in the resident's medication administration record.

Based on clinical record review, observation, staff interviews, and review of policy and procedures, the facility failed to ensure a baseline care plan was developed for the use of oxygen for one resident (#350). The facility census was 42. The deficient practice could result in baseline care plans not having the necessary information to meet residents' needs. Findings include: Resident #350 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Initial Admission Record dated April 1, 2021 at 2:10 p.m. revealed the resident's oxygen saturation level was 93% on oxygen via nasal cannula. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status, indicating the resident had intact cognition. The assessment also revealed the received oxygen therapy. Review of the Daily Skilled notes dated April 2 through 13, 2021 included administration of oxygen via nasal cannula at 2-3 liters per minute continuously. During an observation conducted on April 13, 2021 at 12:35 p.m., the resident was observed receiving oxygen via nasal cannula at 3 liters per minute. However, review of the Initial Care Plan initiated April 1, 2021 at 2:10 p.m. did not include for oxygen administration. On April 13, 2021 at 1:51 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #44), who stated that the resident has been on continuous oxygen since admission. An interview was conducted on April 14, 2021 at 10:23 a.m. with an LPN (staff #10). The LPN stated that the admitting nurse will transcribe physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #10 stated that the Director of Nursing (DON) and the Assistant DON (ADON) review resident records to ensure they have been transcribed accurately and completely. The LPN also stated that the MDS nurse would probably catch any inaccuracies after that. On April 14, 2021 at 11:00 a.m., an interview was conducted with a Registered Nurse (RN/staff #76). The RN stated that it is the responsibility of the admitting nurse to create the initial care plan. Staff #76 stated that if the resident had been utilizing oxygen in the hospital, she would anticipate that the resident would have an order and a care plan for oxygen in the facility. The RN stated that the risks of not having an oxygen care plan may include a lack of anticipating respiratory issues, such shortness of breath. An interview was conducted on April 14, 2021 at 2:09 p.m. with the Director of Nursing (DON/staff #66). The DON stated that when the admitting nurse receives the initial report for admitting a resident, they will also obtain information regarding whether or not the resident is using oxygen. Staff #66 stated that if the resident has been using oxygen, she would anticipate the resident would be receiving oxygen in the facility. Staff #66 stated that once the admission assessment has been done, a baseline care plan will be triggered. The DON stated that the use of oxygen would require a care plan. Staff #66 reviewed the resident's care plan and said there was no oxygen care plan. The DON stated that it did not meet her expectation for the resident to receive oxygen without a care plan. The facility's policy titled Comprehensive Person-Centered Care Planning stated the interdisciplinary team will develop and implement a baseline care plan for each resident, within 48 hours of admission that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#11) was free from an unnecessary drug, by failing to ensure adequate monitoring was done for medications that were blood thinners. The census was 42. The deficient practice could result in residents being at risk for unidentified adverse reactions related to medications. Findings include: Resident #11 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on February 16, 2021 revealed the resident was receiving anticoagulant therapy related to [CONDITION(S)]. The goal was the resident would be free from discomfort or adverse reactions related to anticoagulant use. Interventions included monitoring and reporting signs and symptoms of [CONDITION(S)], acute onset of shortness of breath, pleuritic chest pain, cough, coughing up blood, [CONDITION(S)] and anxiety. Additional interventions included monitoring, documenting and reporting to the physician as needed signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headache, bruising, bleeding, and blurred vision. Further review of the care plan initiated on February 16, 2021 revealed the resident had a cerebral vascular accident (stroke) related to embolism. The goal was that the resident would be able to communicate needs daily. Interventions included giving medications as ordered by physician, and monitoring and documenting side effects and effectiveness of the medications. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate impaired cognition. The assessment included the resident received anticoagulant medications during the lookback period. A review of the Medication Administration Records (MARs) for March 2021 and April 2021 revealed the resident was administered [MEDICATION(S)] and [MEDICATION(S)] as ordered. However, review of the MARs and the Treatment Administration Records (TARs) for March 2021 and April 2021 did not reveal documentation that the resident was being monitored for side effects or symptoms of adverse reactions related to [MEDICATION(S)] and [MEDICATION(S)]. A review of the weekly skin assessments revealed no evidence the resident was assessed for bruising or bleeding from the medications. An interview was conducted on April 14, 2021 at 9:52 a.m. with a Registered Nurse (RN/ Staff #76), who stated all residents receiving anticoagulants are monitored for bleeding and bruising at least every shift. The RN stated that Every time you go in to assist the resident, you would want to look for any abnormal bruising or bleeding. Staff #76 stated monitoring should be documented on MAR or TAR. Staff #76 reviewed the MAR and TAR for resident#11 and stated there was no documentation for monitoring on the TAR or MAR. The RN stated monitoring is a nursing order and can be implemented by nursing. An interview was conducted with the Director of Nursing (DON/staff #66) on April 14, 2021 at 12:10 p.m. The DON stated all anticoagulants are care planned to monitor for side effects like bruising and bleeding. Staff #66 stated the nurse will document in the progress notes if they observe any bruising or bleeding. Staff #66 stated monitoring is not documented on the TAR. The DON stated that if it is care planned that the monitoring should be documented, then the monitoring should be documented every shift. Staff #66 stated it was not the facility's current practice to document routine monitoring for side effects from anticoagulants even though it is care planned. The DON acknowledged that if monitoring is not documented, then there is no proof monitoring was done. The DON stated staff should be documenting monitoring for side effects/adverse reactions every shift. The facility's policy regarding the management of anticoagulant therapy revised March 2020 stated it is the policy of the facility that management of anticoagulant therapy involves use of the Medication Administration Record. This tool may be adapted to ensure accurate and appropriate administration of these medications. The procedure of the policy included for [MEDICATION(S)] therapy but did not include other anticoagulants.

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained regarding hand hygiene and donning gloves by an LPN (Licensed Practical Nurse/staff #15) during medication administration. The deficient practice could result in the spread of infection to residents. Findings include: An observation of medication administration conducted on March 9, 2021 from 7:40 a.m. to 9:00 a.m. with an LPN (staff #15), the following was observed: -Staff #15 was observed administering medications which fell on to the resident's beds, by picking up the medications with her bare (un-sanitized hand) and handing the medications to the residents. Each resident was observed to ingest the medication after it had been handled by staff #15 with her bare (un-sanitized) hand. This occurred two times during the observation. -Staff #15 provided medications to multiple residents without sanitizing her hands between residents, after touching the residents and their bedding. -Staff #15 exited the resident's rooms without sanitizing her hands. During an interview conducted on March 9, 2021 at 10:25 a.m. with the LPN (staff #15), she stated that she did not sanitize or wash her hands prior to entering or after leaving the resident's rooms. Staff #15 stated that she should have sanitized her hands before preparing the resident's medications, before entering the resident's rooms, and after leaving the resident's rooms. During an interview conducted on March 10, 2021 at 11:15 a.m. with the DON (Director of Nursing/staff #7) she stated that it is the expectation that nurses sanitize their hands during medication administration, and that the nurse should sanitize hands before preparing resident's medications, before entering resident's rooms, in between each resident, and after leaving the resident's room. The DON stated that if a medication is dropped onto a resident's bed, the medication should be discarded and a new medication be given to the resident. The DON stated that picking up a medication with a bare hand and giving it to a resident is not acceptable. A facility policy and procedure titled Medication Administration included that it is the policy of the facility to accurately prepare, administer, and document oral medications. When preparing medications, wash hands or use hand sanitizer. A facility policy and procedure titled PPE: Personal Protective Equipment included to ensure that staff use PPE as needed, and gloves should be worn when handling any items. The policy included to always remove gloves and perform hand hygiene before leaving the work area.

Based on observations, clinical record reviews, staff interviews and review of policies and procedures, the facility failed to administer medications as ordered by the physician for two residents (#9 and #10), which resulted in a medication error rate of 7.14%. The deficient practice could result in additional medication errors. Findings include: -Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. (milligrams)/Vitamin D 200 units, 1 tablet by mouth two times a day for supplementation. An admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 7 which indicated that resident #9 had severely impaired cognition. A physician's orders [REDACTED]./Vitamin D 200 units, 1 tablet by mouth one time a day for supplementation. During an observation of medication administration conducted on March 9, 2021 at 8:25 a.m., an LPN (a Licensed Practical Nurse/staff #15) administered one tablet of Calcium 600 mg./Vitamin D 400 units to resident #9. Review of the Medication Administration Record [REDACTED]./Vitamin D 200 units one tablet with the morning medication administration, and not a Calcium 600 mg./Vitamin D 400 units tablet that was given to the resident, which was not ordered by the physician. -Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. (micrograms), 1 tablet by mouth in the morning for low [MEDICAL CONDITION] hormone. An admission MDS assessment dated [DATE] included a BIMS) score of 4 which indicated that resident #10 had severely impaired cognition. A physician's orders [REDACTED]., 1 tablet by mouth in the morning for [MEDICAL CONDITION]. During an observation of medication administration conducted on March 9, 2021 at 8:15 a.m., an LPN (staff #15) administered one tablet of [MEDICATION NAME] 25 mcg. to resident #10. Review of the MAR for resident #10 dated March 2021 included an entry that on March 9, 2021 resident #10 was given [MEDICATION NAME] Sodium Tablet, 50 mcg, 1 tablet by mouth with the morning medication administration, and not the tablet of [MEDICATION NAME] 25 mcg. that was given to the resident, which was not ordered by the physician. During an interview conducted on March 9, 2021 at 10:25 a.m. with LPN/staff #15, she stated that when administering medications, she accesses the resident's medical information on the electronic record to access the MAR, then she removes the medication, and verifies the medication with the physician's orders [REDACTED]. Staff #15 stated she did not realize there was a medication error until the surveyor had pointed it out to her. During an interview conducted on March 10, 2021 at 11:15 a.m. with the DON/staff #7, she stated that it is the expectation of the clinical staff that the 5 rights for medication administration must be followed; right resident, right medication, right dose, right route, and right time. The DON stated that if the staff does not have the correct medication or the correct order for the medication the staff should contact the pharmacy or provider to get clarification, and that the medication errors that had been identified on the medication administration conducted the day before had been corrected with new physician's orders [REDACTED]. A policy and procedure titled Medication Administration included that it is the policy of the facility to accurately prepare, administer and document oral medications. The policy included that no medication is to be administered without a physician's written order, and that if there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies the drug's dosage.

Based on clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure 2 of 13 sampled residents (#2 and #11) had the right to choose when they wake up and when they get out of bed in the mornings. This deficient practice has the potential to alter sleep patterns that could affect the overall health and well-being of residents. Findings include: -Resident #11 was admitted on (MONTH) 25, 2019, with [DIAGNOSES REDACTED]. Review of the care plan dated (MONTH) 28, 2019, revealed the resident had self-care performance deficits and required extensive assistance of one staff for dressing. The admission MDS (Minimum Data Set) assessment dated (MONTH) 1, 2019, revealed a score of 14 on the BIMS (Brief Interview for Mental Status), which indicated the resident was cognitively intact. The MDS assessment also included the resident needed extensive assistance of one staff for dressing. During an interview conducted with the resident on (MONTH) 18, 2019 at 9:26 a.m., the resident stated that she is awaken, gotten out of bed, dressed and then is put back to bed by the CNA's (Certified Nursing Assistant) as early as 3:00 a.m. The resident stated that this upsets her because now she is wide awake, breakfast is not served until 7:00 a.m. to 7:30 a.m., and that it makes for a long day. On (MONTH) 20, 2019 at 1:41 p.m., a follow-up interview was conducted with resident #11. Resident #11 stated that the night CNA had gotten her and her roommate up before 3:00 a.m., as recently as last night or the night before. Resident #11 stated that the CNA told her and her roommate that the CNAs were getting residents pre-dressed so the day shift would not have to dress them. -Resident #2 was admitted on (MONTH) 10, 2013, with [DIAGNOSES REDACTED]. A review of the care plan dated (MONTH) 28, (YEAR), revealed the resident had self-care performance deficits and needed extensive assistance of one staff for dressing. A quarterly MDS assessment dated (MONTH) 9, (YEAR), revealed a BIMS score of 12, indicating the resident had moderate cognitive impairment. The MDS assessment also included the resident needed extensive assistance of one staff for dressing. An interview was conducted with resident #2 on (MONTH) 20, 2019 at 1:43 p.m. Resident #2 stated that she did not like the CNA's getting her and her roommate up as early as 3:00 a.m. and dresses them and then puts them back to bed. She also stated that she did not report this to anyone. An interview was conducted with the DON (Director of Nursing/staff #29) on (MONTH) 21, 2019 at 8:25 a.m. Staff #29 stated that she had spoken to residents #2 and #11 and that they stated the CNA's get them up early to dress them and then puts them back to bed. She stated that she would take care of that. On (MONTH) 21, 2019 at 9:21 a.m., an interview was conducted with a CNA (staff #27). Staff #27 stated that the DON had put up a get up early list which listed the residents that were to be dressed by the night shift. A review of the get up list revealed resident #2 and resident #11 were on that list. The list also included, Effectively immediately this is the resident get up schedule. ALL N[NAME] (night) shift CNA staff are expected to follow this schedule NO EXCEPTIONS. If a resident refuses to get up or dressed, please try to swap out that place with another resident. The DON's name was typed under the instructions. An interview was conducted with the Administrator (staff #13) on (MONTH) 21, 2019 at 10:00 a.m. Staff #13 reviewed the get up list and stated that she was not aware of the list. She stated that she did not think it was appropriate to get residents up early and put them back to bed. A follow up interview was conducted with staff #29 on (MONTH) 21, 2019 at 1:33 p.m. Staff #29 stated that the get up list had been the process for many years. The DON stated that it was almost impossible for the day shift CNA's to get everyone up and ready for breakfast, so the night shift staff would get residents up and assist them with dressing around 5:00 a.m. Staff #29 stated that residents and families had discussed wake-up times during the care plan conferences. However, no documentation was provided that this practice had been agreed upon by families or residents. The facility's policy regarding residents' rights revealed the resident has a right to a dignified existence, self-determination, and communication with and access to persons or services inside and outside of the facility. The policy included the facility must protect and promote the rights of each resident including the right to reside and receive services in the facility with reasonable accommodation of the individual needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. The policy also included the resident has the right to choose schedules (including sleeping and waking times) consistent with his or her interests.

Based on clinical record reviews, staff interviews, review of facility documentation and policies and procedures, the facility failed to ensure that three resident's (#2, #76 and #226) medications were not misappropriated. Findings include: -Resident #2 was admitted on (MONTH) 10, 2013, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A review of the resident's MAR (Medication Administration Record) for (MONTH) (YEAR), revealed the resident received [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg per the physician's orders [REDACTED]. -Resident #76 was admitted (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a physician's orders [REDACTED]. This order was discontinued on (MONTH) 10, (YEAR). A physician's orders [REDACTED]. This order was discontinued on (MONTH) 14, (YEAR) and replaced with an oral/liquid medication. Review of the resident's MAR for (MONTH) (YEAR), revealed the resident received these medications from (MONTH) 1-18, (YEAR). Review of the facility's investigative documentation regarding the misappropriation of medications for resident #2 and #76, revealed that on (MONTH) 18, (YEAR) a RN (Registered Nurse/staff #15) and a LPN (Licensed Practical Nurse/staff #16) reported that a 30 pill card of MS and the corresponding control sheet for resident #76 was missing from the medication cart, as well as a 30 pill card of [MEDICATION NAME]-[MEDICATION NAME] and the corresponding control sheet for resident #2. A binder belonging to a RN (staff #66) was found and contained the empty bubble pack for the MS, the corresponding control sheet for resident #76 and the control sheet for the [MEDICATION NAME]-[MEDICATION NAME] for resident #2. The bubble pack for the [MEDICATION NAME]-[MEDICATION NAME] was not found. Further review of the facility's investigative report included a written statement from staff #66 dated (MONTH) 19, (YEAR). Staff #66 reported that she had found an empty card of MS ER 15 mg tablets in the bottom of the 300 hall med cart and that there was a corresponding count sheet, which noted that the card was new with 30 tablets delivered. She reported that there was also a count sheet for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, which noted that the corresponding card contained 30 tablets, however the card was not found. The statement included the removal of the card and sheets and that she placed them in a clipboard which holds paperwork, with the intent of bringing them to the DNS (Director of Nursing services/staff #29) upon her return, as she was out of town on a work-related meeting. Staff #66 stated that the clipboard was accidentally left in the CNA (Certified Nursing Assistant) fridge room, where it was apparently found and gone through, and then brought to the attention of Human Resources. Staff #66 reported that she had mentioned to another nurse that the sheets in the narcotic record should be counted, because she felt like maybe some sheets have come up missing and they should be counting them anyway. Per the statement, staff #66 was unsure who to bring this issue to as the management team was away, but was told the DNS would be back on (MONTH) 19, (YEAR). An interview was conducted with the DNS (staff #29) on (MONTH) 19, 2019 at 1:01 p.m. Staff #29 was not able to remember if she was away from the building when the incident was originally reported. Staff #29 said that staff #16 had reported the missing narcotics card and control sheets, as she had been the one who had signed them in the night before. Staff #29 stated that an empty medication card and the corresponding control sheet, as well as another control sheet had been found in a binder belonging to staff #66. Staff #29 stated that when she interviewed staff #66, staff #66 stated that she had found the empty medication card and blank control sheets in the bottom drawer of the 300 hallway medication cart. Staff #29 stated that staff #66 was taken for drug testing which was negative, and that staff #66 was suspended pending completion of the investigation. The investigation was inconclusive as to whether staff #66 had misappropriated the medications, however, the medications were missing. Neither resident #2 or #76 missed any doses of their medications, as the result of this incident. On (MONTH) 20, 2019 at 9:54 a.m. a telephone interview was attempted with staff #66, however; the telephone number had been disconnected. -Resident #226 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed that resident #226 received all scheduled doses of [MEDICATION NAME] as ordered for the month. Review of the pharmacy documentation revealed that on (MONTH) 23, (YEAR), a delivery of [MEDICATION NAME] 10 mg containing 90 tablets for resident #226 was delivered to the facility at 10:14 p.m. The pharmacy documentation showed it was received and signed for by a RN (staff #66). Review of the facility's investigative documentation revealed that on the morning of (MONTH) 24, (YEAR) during the narcotic count at shift change, a bubble pack containing eight [MEDICATION NAME] for resident #226 was missing. Staff #66 who was working the night shift was unable to explain what happened to the medication to the oncoming nurse (staff #30). Staff #30 conducted a search for the missing medication and found the empty bubble pack of [MEDICATION NAME] sitting next to staff #66's belonging in the chart room. Staff #30 then called the Director of Nursing (staff #29) at approximately 7:00 a.m. to notify her of the missing narcotics. Staff #29 instructed staff #30 to contact the Administrator (staff #68). Further review of facility's investigative documentation revealed an in-person interview was conducted with staff #66, by the Administrator and Human Resources (HR/staff #17). Staff #66 stated that the evening RN (staff #15) on (MONTH) 23, (YEAR) told her that the [MEDICATION NAME] for resident #226 was running low and would need to be reordered. Staff #66 stated she removed the card of eight [MEDICATION NAME] from the cart and placed it in the chart room (which is an unlocked room for nurses and CNA's to chart) at that time. Staff #66 stated the [MEDICATION NAME] arrived from the pharmacy immediately afterwards so the medication did not need to be reordered, and that she did not give the card which she had removed from the narcotic box another thought. Staff #66 stated she did not know why she left the medication in the chart room all night. The investigative report included a telephone interview was conducted by the Administrator with the evening RN (staff #15). Staff #15 stated that she did not see staff #66 remove any medications from the medication cart and that she did not see any medications in the chart room. Staff #15 stated she did tell staff #66 that the [MEDICATION NAME] for resident #226 was running low, but it arrived from the pharmacy before she left her shift that evening. The report also included a telephone interview with each of the Certified Nursing Assistants (CNA/staff #4 and CNA/staff #69) working on the night shift. Both CNA's stated that they had not seen any medications in the chart room that night. The facility's investigative documentation also revealed the Administrator had reviewed video footage from the building security cameras from (MONTH) 23, (YEAR)-May 24, (YEAR). The video footage showed the narcotic count between staff #66 and staff #30 on the morning of (MONTH) 24, (YEAR). When staff #30 looks away, staff #66 reaches into the trash can attached to the medication cart and removes what appears to be a bubble pack. The video footage showed that when staff #30 walks away, staff #66 takes the bubble pack into the chart room. All other staff are accounted for on the video and no suspicious activity was noted. All three of the night shift staff (#66, #4 and #69) were drug tested with negative results. Staff #66 was suspended pending the investigation and was later terminated on (MONTH) 29, (YEAR). Continued review of the investigative report revealed that the facility could not state for certain what happened to the missing medications, as no concrete proof could be found. An interview was conducted with the DNS (staff #29) on (MONTH) 19, 2019 at 1:01 p.m. Staff #29 stated that according to the documentation, staff #66 should have never pulled the card for reorder since the medication had already been delivered. A telephone interview was attempted on (MONTH) 20, 2019 at 9:54 a.m. with staff #66, however; the phone number had been disconnected and no other numbers were available. Review of the facility's policy and procedure for Abuse and Neglect dated (MONTH) (YEAR), revealed the purpose was to ensure there is an effective system in place which prevents mistreatment, neglect, exploitation, abuse of residents and misappropriation of resident property. The policy included the resident has the right to be free from abuse, neglect, misappropriation of the resident property and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to employees, other residents, consultants, volunteers, family members, friends or other individuals.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to prevent a fall from a mechanical lift which resulted in injury for one resident (#18). The sample size was seven. Findings include: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's clinical record revealed a Comprehensive Care Plan dated April 19, 2012, which documented "Impaired mobility related to CVA (cerebral vascular accident) with left [DIAGNOSES REDACTED] and contracture bue/ble (bilateral upper extremity/bilateral lower extremity), decreased range of motion ble, bue, dementia with cognitive deficits, poor safety" as a problem. A goal documented for the problem was "Will tolerate transfer via full mechanical lift..." An approach documented was "Transfer with full mechanical lift and assist of 2." The resident's clinical record revealed Interdisciplinary Progress Notes dated May 6, 2012 which documented "Resident fell from mechanical lifting device sling and hit head on floor. Hospice called at 0415. Hospice nurse was in and assessed resident at 0500. Ice placed on forehead through the night 15 minutes on 15 minutes off for swelling. Wound dressed..." The resident's clinical record revealed Interdisciplinary Progress Notes dated May 6, 2012 which documented "...ok to send to ER for evaluation of head injury...ER physician spoke with this nurse reported will suture head wound..." The resident's clinical record revealed Interdisciplinary Progress Notes dated May 6, 2012 which documented "Arrived from (name of hospital). Right frontal head laceration with sutures present..." A review of the resident's clinical record revealed a physician's orders [REDACTED]." The resident's clinical record revealed a physician's orders [REDACTED]." The resident's clinical record revealed a physician's orders [REDACTED]." The resident's clinical record revealed a physician's orders [REDACTED]." The resident's clinical record revealed a physician's Monthly Note dated May 18, 2012 which documented "fell during transfer, Laceration." An interview was conducted with one of the CNA's (certified nursing assistant) who transferred the resident with the mechanical lift when she fell on [DATE]. The CNA stated that because she failed to criss-cross the sling under the resident, the resident fell during the mechanical lift transfer. An interview was conducted with the DON (director of nursing) on June 20, 2012. The DON stated that the CNA was trained on the proper use of the mechanical lifts but that she failed to criss-cross the sling the resident was on which caused the resident to fall to the floor. A review of the facility's policy Mechanical Lift documented "To ensure resident safety, the appropriate sling for the mechanical lift must be used."