Every finding on record at Archie Hendricks Senior Skilled Nursing Facility

Based on interview, record review, and facility document review, the facility failed to: 1.) ensure the right of one of three residents reviewed for advance directives (Resident (R) 28) to formulate and revise advance directives when the resident's code status was changed from Full Code to Do Not Resuscitate (DNR) based on consent from a family member without documented legal authority to make health care decisions; and 2.) provide written information regarding advance directives for one of three residents reviewed for advance directives (R40) out of a total sample of 19 residents. This placed residents at risk of not having advance directive decisions established, revised, or implemented in accordance with their wishes. Findings include: Review of R28's Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included fracture of the left femur, spinal stenosis, epilepsy, major depression disorder, chronic pain, and dementia. R28 was listed as her own responsible party. Review of R28's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] and located in the MDS tab of the EMR, revealed R28 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was moderately cognitively impaired. Review of the admission Consent, dated [DATE] and located in the Miscellaneous documents tab of the EMR, indicated R28 signed as her own legal representative. The Responsible Party/Resident Representative was left blank. Review of a Social Service Progress Note, dated [DATE] and located in the Progress Notes tab of the EMR, revealed R28 requested to be full code, had no Power of Attorney (POA), and no Living Will. Review of a Social Service Progress Note, dated [DATE] and located in the Progress Notes tab of the EMR, revealed R28's advance directive was updated to Do Not Resuscitate (DNR) per family request. There was no evidence located in the EMR of a POA for R28. During an interview on [DATE] at 12:56 PM, R28 stated she did not know who her POA was and that her family handled those matters. R28 appeared confused when asked additional questions and was unable to respond. During an interview on [DATE] at 9:04 AM, Social Service Worker (SSW) 12 stated that they did not have a POA signed for R28, and they received phone consent from the family member to change R28's code status from a full code to a DNR status due to her rapid decline. During an interview on [DATE] at 7:15 AM, the Administrator stated the facility had a difficult time obtaining family signatures for POA. The Administrator stated that families would give verbal consent but were reluctant to sign papers. A review of the facility document titled, Advance Directives, dated [DATE], indicated the POA is a document that delegates authority to a legal representative to make health care decisions if the resident becomes incapacitated. For Resident 40: Review of R40's admission Record revealed the facility admitted R40 on [DATE] and was listed as her own responsible party. Diagnoses included left sided weakness following a stroke, heart failure, unspecified dementia, and glaucoma. An Advanced Directive Statement dated [DATE] and signed by the resident's daughter and the facility Social Services (SS) # 12, the form included lines to indicate one's preferences for directives such as a Health Care Power of Attorney (HPOA), Cardiopulmonary Resuscitation (CPR) , and a Living Will, it did not indicate if residents or their representatives were provided education on Advanced Directives, nor did it include their wishes for formulating the directive titled Advanced Directives. The form documented R40's daughter wished to complete a Living Will. Review of another Advanced Directive Statement dated [DATE] indicated the daughter did not wish to complete a HPOA, CPR, or Living Will. The signature line indicated the daughter's first name via phone, and was signed by SS # 12. Interviews: Interviewed SS #50 on [DATE] at 1:18 PM about their process for notifying residents of their right to formulate an Advanced Directive. SS #50 explained when presenting the different types of advanced directives with residents and their families, he (or SS #12) would verbally explain each type in their language, and they did not utilize written pamphlets. SS #50 stated, residents don't really want the paper. SS #50 pulled a copy of a booklet titled Arizona Advanced Health Care Directives out of the filing cabinet and confirmed he did not provide that to residents when discussion their options. SS #12 was not available for interview. Surveyors requested any documentation that the residents or their representatives were provided with written information about their right to formulate advanced directives for R40 and R55. SS #50 stated, 'No, they would not have that.' On [DATE] at 10:48 AM the Administrator confirmed SS should be providing the Advanced Directive education/document to the resident when discussing their options and wishes. Review of facility policy titled Advanced Directives with review/revision date [DATE] revealed The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on interview, record review, and policy review, the facility failed to provide written notice of the bed hold policy upon transfer to the hospital for one of three residents (Resident (R) 28) reviewed for hospitalizations out of a total sample of 21. R28 was transferred to the hospital four times, and there was no evidence the facility's bed hold policy was provided in writing to the resident or her representative for any of the transfers. This failure had the potential to prevent the resident or representative from being informed of bed-hold rights and the facility's policies regarding readmission following hospitalization.Findings include: Review of R28's Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included fracture of left femur, spinal stenosis, epilepsy, major depression disorder, chronic pain, and dementia. R28 was listed as her own responsible party. Review of R28's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/26 and located in the MDS tab of the EMR, revealed R28 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was moderately cognitively impaired.A review of R28's EMR revealed R28 was transferred to the hospital on [DATE] due to a fall. There was no evidence in the EMR indicating a written notice of transfer or the bed hold policy was provided to the resident or her representative at the time of transfer. A review of R28's EMR revealed that R28 was transferred to the hospital on [DATE] due to increased pain in R28's left hip. There was no evidence in the EMR indicating a written notice of transfer or the bed hold policy was provided to the resident or her representative at the time of transfer. A review of R28's EMR revealed R28 was transferred to the hospital on [DATE] due to a hip surgery complication. There was no evidence in the EMR indicating a written notice of transfer or the bed hold policy was provided to the resident or her representative at the time of transfer. A review of R28's EMR revealed R28 was transferred to the hospital on [DATE] due to gastrointestinal issues. There was no evidence in the EMR indicating a written notice of transfer or the bed hold policy was provided to the resident or her representative at the time of transfer. During an interview on 07/23/26 at 8:59 AM, Social Worker (SW)12 stated they would notify representatives of hospital transfers and bed hold policy by phone. SW12 stated they do not send written notices because their facility form indicated it was an option and they could make phone notifications in place of written notices. During an interview on 07/24/26 at 7:15 AM, the administrator stated that many representatives do not have the ability to receive mail and that facility staff are not always successful in reaching them by mail. The Administrator stated that R28's representative did live in an area likely to have secure mail but did not know if the facility had been able to mail any documents to her. A review of the facility policy titled, Bed Holds and Returns, dated 05/29/26, indicated residents and representatives are notified of the bed hold policy in writing.

Based on interviews, record review, and policy, the facility failed to ensure that 2 of 3 residents reviewed under Preadmission Screening and Resident Review (PASRR) received a Level I screening after the expiration of a 30-day exception period and/or following the addition of a new qualifying diagnosis (Residents (R)36 and 33). This deficient practice had the potential to result in residents with mental disorders (MD) and/or intellectual disabilities (ID) remaining in the facility without the required evaluation and not receiving care and services in the most integrated setting appropriate to their needs.Findings include:For R36:Review of the Admissions Record revealed R36 was admitted to the facility on [DATE] with diagnoses which included encounter for surgical aftercare following surgery on the circulatory system and legal blindness, as defined in the USA.Review of the PASRR Level I screening dated [DATE], Section A - Exemptions and Categorical Determinations, revealed the resident met the criteria for the 30-day convalescent care. The documentation was signed by a Social Work Case Manager.Continued review of the resident's record revealed R36 was still residing in the facility on [DATE], the date the 30-day convalescent care exception expired. Further review revealed no evidence that a Level I PASRR screening had been completed after the exception period lapsed.Further review of the Admissions Record - Diagnosis Information revealed additional diagnoses were added to the resident's profile on [DATE] (hallucinations, unspecified, the term used when a person experiences false sensory perceptions - such as seeing, hearing, or feeling things that are not real - but the specific type or underlying cause has not been detailed or classified) and [DATE] (bipolar disorder, current episode depressed, severe, with psychotic features, a serious mental health condition in which a person has intense mood shifts of extreme mania or deep depression along with a loss of touch with reality, such as hallucinations or delusions). Review of the clinical record revealed no evidence that a Level I PASRR screening had been completed following the addition of these diagnoses.Review of the clinical record revealed R36 had not received a Level I PASRR screening since the original screening dated [DATE], despite the expiration of the 30-day convalescent care exception on [DATE] and the subsequent addition of two qualifying psychiatric diagnoses.During an interview and concurrent record review with the Director of Nursing (DON) on [DATE] at 1:32 PM, she reviewed R36's PASRR dated [DATE] and stated it did not meet her expectation. She stated the resident had been admitted to the facility for longer than 30 days and, per her review, indicated the resident had new psychiatric diagnoses. She stated their process would include submitting for a Level II screening. She reviewed the resident's record and stated she was not finding one. She stated that if the resident needed Level II services, the PASRR Level II would show what services the resident needed.For R33:Review of the Admissions Record revealed R33 was admitted to the facility on [DATE] with diagnoses that included depression, unspecified (a clinical diagnosis used when a person has symptoms of depression that cause distress or problems in daily life but do not fit the exact criteria for a more specific diagnosis, such as major depressive disorder or persistent depressive disorder).Review of a PASRR Level I screening dated [DATE], Section A - Exemptions and Categorical Determinations, revealed the resident met the criteria for the 30-day convalescent care exception. The documentation was signed by an Admissions Director.Review of the resident's Minimum Data Set (MDS) assessment revealed the resident discharged from the facility on [DATE] and was subsequently readmitted on [DATE] with diagnoses that included; anxiety disorder, unspecified (a mental health condition involving excessive, ongoing fear and worry that do not go away and make it difficult to complete daily tasks); panic disorder (a mental health condition characterized by unexpected panic attacks, ongoing fear of future attacks, and behavioral changes to avoid triggers); and unspecified psychosis not due to a substance or known physiological condition (a diagnosis used when a patient shows a loss of touch with reality, but the provider does not have sufficient information or time to make a more specific mental health diagnosis; common symptoms include hallucinations, delusions (strong false beliefs that do not match reality), and disorganized thinking (difficulty speaking, organizing thoughts, or behaving in a predictable manner)).Review of the clinical record revealed no evidence that a new Level I PASRR screening had been completed following the resident's readmission on [DATE] or following the addition of the anxiety, panic disorder, and psychosis diagnoses.During an interview conducted on [DATE], with the Social Services Director (SSD), he stated the purpose of PASRR screening was to determine the level of care a resident needed and whether they had any type of disability, and that it was usually included in the admission packet. When asked what was meant by the 30-day Convalescent Criteria section on the form, he stated, That means the facility filling out the form - that's their recommendation for the resident. He further stated that this sometimes changed once the resident was admitted , adding, If they stay longer than the 30 days, we don't do anything to update the PASRR to say they are going to stay longer. He stated the facility had never had to do that for any resident, stating, We have never sent it to anyone else; we don't update it, and we don't contact the state.On [DATE] at 1:27 PM, an interview and concurrent record review were conducted with the DON. She stated the facility received the PASRR upon admission and that the admissions nurse reviewed it for accuracy. She stated she believed residents did not have to have a Level I PASRR screening if they were going to be in the facility less than 30 days, adding, If the resident stays longer than 30 days, they will complete one, indicating that social services was responsible for completing it. She stated it would not meet her expectation for the Level I to not be completed, and that the purpose was to ensure residents were provided with appropriate care. She reviewed R33's record and stated that the PASRR Level I should be included in his medical record and that it should accurately reflect his admission status.Review of the facility policy titled, Resident Assessment - Coordination with PASARR Program, revised [DATE], included this facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or a related condition receives care and services in the most integrated setting appropriate for their needs. A record of the pre-screening shall be kept in the resident's medical records. Exceptions to the preadmission screening program, dependent upon State requirements, include those individuals who: are readmitted directly from a hospital, requiring nursing facility services for the conditions for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. If a resident who was not screened due to an exception above and the resident remains in the facility for longer than 30 days: The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. The Level II resident review must be completed within 40 calendar days of admission. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious MD, ID, or related condition will be referred promptly to the State mental health or intellectual disability authority for a Level II review.

Based on interviews, record review, and policy, the facility failed to ensure that 1 of 5 residents reviewed for unnecessary medications was monitored for adverse side effects associated with an anticoagulant and received opioid pain medication in accordance with the physician's ordered parameters (Resident (R)13). This deficient practice placed the resident at increased risk for receiving unnecessary medication and for adverse effects, including bleeding, oversedation, and/or respiratory depression.Findings include:Review of the admission Record revealed R13 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with other behavioral disturbance (a progressive decline in memory, thinking, and cognitive function that interferes with daily living) that has not been further classified by type (e.g., Alzheimer's disease, vascular dementia) or by specific stage of severity (mild, moderate, or severe), and is accompanied by behavioral symptoms other than the more commonly categorized disturbances such as agitation or aggression.)Anticoagulant Monitoring:Review of the resident's nursing progress notes dated 06/14/26 at 12:42 AM revealed the resident was found on the floor of her room, behind her door, yelling out for help. The resident stated she had slipped and fallen, and that she thought she had broken her right hip. The note indicated the provider was made aware and gave an order for the resident to be sent out for further assessment and x-rays.A physician's note dated 06/14/26 at 5:48 PM included results of a pan-scan (whole-body computed tomography) showing fractures at T4 and T12 (thoracic spine), the right inferior pubic ramus (front right of the pelvis), the right sacrum (right side, at the base of the spine), and the pubic symphysis (the front of the pelvis where the left and right hip bones connect), all of which were read as chronic and old, with no new fractures identified. The note indicated the resident had limited mobility and a hematoma measuring 5.4 centimeters (cm) by 3.9 cm on the lateral aspect (the outer side) of her hip area. The note further indicated the physician would start the resident on Lovenox (an anticoagulant) 40 milligrams (mg) subcutaneously (SC) daily until the resident became ambulatory.Review of the physician's order dated 06/14/26 revealed for Lovenox injection solution prefilled syringe 40 mg/0.4 milliliters (ml). Inject 40 mg subcutaneously one time a day for deep vein thrombosis (DVT) prophylaxis for 14 days until finished.However, the physician's orders provided no evidence of adverse side effect monitoring related to the anticoagulant.Review of the June 14 - 30, 2026, and July 1, 2026, Medication Administration Records (MAR) revealed Lovenox 40 mg was administered to the resident in accordance with the physician's order, with the exception of four days when the resident refused the medication. However, further review of the resident's clinical record revealed no adverse side-effect monitoring was completed during the timeframe.An anticoagulant care plan initiated on 06/16/26 related to right hip and pelvis fractures had a goal for the resident to be free from discomfort and adverse reactions. Interventions included to administer the medication as ordered and monitoring for side effects and effectiveness every shift.However, review of the clinical record revealed no evidence that shift-to-shift monitoring for side effects or effectiveness, as required by the care plan, had been completed.On 07/23/26 at 3:23 PM, an interview and concurrent record review were conducted with Registered Nurse (RN) 7. She stated anticoagulant monitoring should either be on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), stating, I can't find it. It should be there. She reviewed the resident's orders and stated the monitoring was not included on the orders. When asked what the risks would be to the resident if adverse side effects were not monitored, she stated, There would be risk for bleeding. She stated the monitoring probably got missed, maybe because the order was only for a few days.On 07/24/26 at 10:35 AM, an interview was conducted with the Director of Nursing (DON). She stated that when anticoagulants are administered, there should be a monitoring order in place that tells nursing what to look for. She stated her expectation was for nurses to monitor for adverse side effects when anticoagulants were administered. She stated the risks to the resident would include bleeding, bruising, skin issues, and gastrointestinal (GI) bleeding.Review of the Medication Monitoring policy, reviewed 04/20/26, included the facility takes a collaborative, systematic approach to medication management, including the monitoring of medication for efficacy and adverse consequences. Licensed nurses, with periodic oversight by nurse managers, shall adhere to facility policies and current standards of practice for administering and monitoring of medications. Interventions shall be identified on the resident's comprehensive plan of care for the systematic monitoring of high risk medications to facilitate early identification of adverse consequences.Opioid Administration:Review of a physician's progress note dated 06/25/26 at 9:47 AM included details related to the resident's complaint of nighttime pain. Per the night nursing report, the resident was experiencing significant difficulty sleeping due to uncontrolled nocturnal pain. The note indicated daytime pain was generally well controlled on the current regimen of scheduled acetaminophen (non-opioid analgesic). Nighttime pain, however, was not adequately managed with the current regimen, resulting in sleep disruption. The physician's plan included continuing acetaminophen for breakthrough pain and adding oxycodone (opioid analgesic) 5 mg by mouth at bedtime (scheduled) for 7 days, with reassessment at the end of the 7-day course to determine if continued use was warranted.A physician's order dated 06/25/26 included oxycodone hydrochloride (HCL) 5 mg by mouth at bedtime for pain from fracture for 7 days.A risk for acute pain care plan initiated on 06/26/26, related to compression fractures of the pelvis and right hip, included oxycodone for pain management. The goal of the plan was for the resident to have no interruption in normal activities due to pain. Interventions included monitoring, recording, and reporting to the nurse any signs or symptoms of nonverbal pain.Review of the June 2026 MAR revealed oxycodone HCl was administered in accordance with the physician's order.On 07/03/26 at 2:05 PM, a nursing progress note indicated the resident's pain management had been discussed with the Medical Doctor (MD). According to the note, the resident was evaluated, and new orders were received.Review of the physician's order dated 07/03/26 revealed an order for oxycodone HCl 5 mg, one tablet by mouth every 6 hours as needed (PRN) for pain rated 6-10 on the pain scale.However, review of the July 2026 MAR revealed the resident received oxycodone HCl on 5 of 6 administrations when the reported pain level was below 6, including on 07/11/26, when the reported pain level was 4.During an interview and concurrent record review conducted on 07/23/26 at 3:23 PM, RN 7 stated that before administering an opioid analgesic, she asks the resident to rate their pain level, asks where the pain is located, and asks whether the resident has tried other comfort measures, such as repositioning or acetaminophen. She stated she reviews the order and the parameters, noting that parameters for oxycodone are usually 5-10 or 6-10. She stated she would not administer oxycodone if the resident's pain level was below the parameter, explaining that the parameters are there for a reason, and that she would offer acetaminophen as an alternative. She stated it would be a risk for an unnecessary medication. She reviewed the resident's July 2026 MAR and stated it was not appropriate for nursing to give oxycodone for pain levels of 5 or 4, stating, I would think it was a med error.On 07/24/26 at 10:31 AM, an interview and concurrent record review were conducted with the DON. When asked if all nurses had been educated regarding administering opioid analgesics within the physician's ordered parameters, she stated, Yes. When asked if it was her expectation for nurses to follow the physician's ordered parameters, she stated, Yes. She reviewed the medication administration records and stated she would consider the administrations to be med errors.The Medication Administration policy, reviewed 04/27/26, included medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines included to ensure the six rights of medication administration are followed, including the right dosage. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on interview and record review the facility failed to ensure that clinical records completely and accurately reflected/documented their experience for 2 of 19 sampled residents. (Resident (R) 24 and R52). R24's medical record failed to document whether the provider was notified of a significant weight gain; and R52's medical record failed to document a nebulizer treatment that was given, and discussion with staff about hospitalization for symptoms they were having and R52's refusal. Inaccurate medical records have the potential to cause wrong or delayed treatments, diagnosis, and medical decision making.Findings include: Re: R24 Review of the Admissions Record revealed that R24 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included cellulitis of left lower limb (a common, potentially serious bacterial skin infection affecting the deep layers of the skin and underlying tissues) and chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot properly move oxygen into your blood, leading to persistently low oxygen levels.) A physician's order dated 02/18/26 included furosemide (diuretic) 20 milligrams (mg). Give 20 mg by mouth two times a day for fluid retention. A potential fluid volume overload care plan initiated on 05/20/26 related to disease processes including diabetes mellitus (a chronic condition characterized by high blood sugar resulting from insulin resistance and relative insulin deficiency) and a history of cellulitis to the bilateral lower extremities. The goal for the plan was for the resident to have no signs or symptoms of fluid overload, as evidenced by a decrease in or absence of edema, anxiety, agitation, restlessness, confusion, changes in mood or behavior. Interventions included to monitor vital signs as ordered and record. Notify Medical Doctor (MD) of significant abnormalities. Review of the Weight Summary dated 06/24/26 revealed the resident's weight at 246.0 pounds (lbs.) On 07/02/26, the Weight Summary indicated the resident's weight was 253.5 lbs., reflecting an increase of 7.5 lbs. (approximately 3%) since 06/24/26. However, review of the clinical record did not include documentation to indicate the provider had been notified of the increase in weight. A nursing progress note dated 07/14/26 at 5:53 PM indicated a physician's order for furosemide 20 mg to be given by mouth one time daily for diuresis for 3 days, in addition to the existing furosemide 20 mg twice daily dose, for a total of 40 mg daily for 3 days. Review of the July 14 – 16, 2026 Medication Administration Record (MAR) revealed the increased dose of furosemide was administered to the resident in accordance with the physician's order. On 07/22/26 the Weight Summary revealed the resident's weight had increased to 258.5 lbs., for an increase in 12.5 lbs., or 5.1%, since 06/24/26. However, review of the resident's record did not reveal nursing documentation to demonstrate that the provider had been made aware of the significant weight variance in accordance with the resident's potential fluid volume overload care plan. On 07/23/26 at 3:41 PM an interview and concurrent record review was conducted with a Registered Nurse (RN) 7. She stated that the resident's level of edema, breathing, and pain should be monitored and reported to the physician if there were any problems. When asked if she would look at the resident's weights she stated, Yes. We look at the weights. She stated that usually, residents who take diuretics receive weekly weights. She reviewed the resident's record and noted that the resident had an increase in weight between 06/24/26 and 07/02/26. She stated that she had probably notified the provider verbally, but that she should have put in a note too. She stated that the provider had ordered an increased dose of furosemide to be given beginning 07/14/26 through 07/16/26. She reviewed the resident's weight summary and stated that the resident had continued gaining. She stated that she did not notify the provider. She stated that she did not write it down. When asked if she should have notified the provider she stated, Yes. That was my mistake. I forgot. When asked what the risks of not notifying the provider might include she stated the risks would include breathing issues and fluid overload. During an interview with the Nurse Practitioner (NP) conducted on 07/23/26 at 3:57 PM, he stated that he was not aware of the resident's weight gain, but his legs were enlarged so he assumed it. He stated that he would expect to be notified it the resident's weight had increased. He stated that it would be a good progress note to see on a regular basis. During a follow-up interview and concurrent record review with the DON conducted on 07/24/26 at 10:37 AM, she reviewed the record and noted that they administered the diuretics. She stated as the resident's weight increased, she would expect that nursing would notify the provider and document the increase of weight and notification in the progress notes. For Resident 52: Review of the admission Record revealed the facility admitted R52 on 5/1/26 and re-admitted R52 on 5/10/26. The primary diagnosis for the re-admission was documented as encounter for surgical after care following surgery on the nervous system. Lack of documentation of medication administered: Review of the Nursing Advanced Skilled Evaluations (a comprehensive nursing assessment completed each shift) found on the Assessments tab of the electronic health record (e-HR) revealed on 05/22/2026 08:55 R52's lung sounds were clear, R52 did not have difficulty breathing, though a cough was noted. Later that same day at 15:57 a Health Status Note documented a change in R52's respiratory status. It read, spoke with provider [name of the Nurse Practitioner] regarding an episode of shortness of breath. received orders for PRN [as needed] DuoNeb [a prescription combination medication containing albuterol sulfate and ipratropium bromide, used as an inhalation solution via a nebulizer treatment to open the airways], and to continue monitoring for shortness of breath. Both notes were authored by Registered Nurse (RN) 9. During an interview and concurrent record review on 07/22/2026 at 2:12 PM in the Director of Nursing (DON)'s office with the DON and RN9, RN 9 recalled R52. After reviewing the 5/22/26 notes RN9 recalled R52 was 'struggling for breath' because the oxygen saturations were dropping. RN9 stated they 'immediately called the provider,' and were able to stabilize R52 after nebulizer treatment with oxygen saturation then reading at 95%. When asked how R52 responded to the breathing treatment RN 9 stated good. During a follow-up interview and record review with the DON on 07/23/2026 at 4:09 PM, R52's Medication Administration Record (MAR) was reviewed. Order dated 5/22/26 for Ipratropium-Albuterol Solution (DuoNeb) 0.5mg-2.5 mg/3ml (milliliter) with directions for 3 ml, inhale orally every 4 hours as needed for shortness of breath or wheezing via nebulizer was selected for review on the MAR for the month of May 2026. The MAR lacked documentation that a nebulizer treatment had been given on any day in May 2026. The DON also pulled up the nursing notes and stated she did not see where RN 9 had documented the administration, He forgot to document that he gave it. Review of facility policy titled Medication Administration with review date 4/27/26 under Policy Explanation and Compliance Guidelines point 20 read, Sign MAR after administered. Lack of documentation of offer and refusal to go to hospital: Additional review of R52's e-HR revealed R52 continued to have breathing issues. Supplemental oxygen was ordered on 5/23/26. The Nurse Practitioner's follow-up note dated 05/26/2026 16:06, documented the following: Patient was evaluated over the weekend by the nursing staff. On Friday he was noted to have tachypnea (rapid, shallow breathing) with some shortness of breath. [R52's] spine injury appears to be's [sic] more complicated than we expected. It appears to involve more of the spine [than] just his thoracic area. We are going to continue to closely monitor him for aspiration event [an accidental occurrence where food, liquid, saliva, or stomach acid enters the windpipe and lungs instead of going down the food pipe] or complications which would require rapid evaluation by an acute care hospital. During an interview and concurrent record review with the Nurse Practitioner (NP) on 07/22/2026 at 3:19 PM, R52's care was reviewed. NP recalled the events over the holiday weekend of 5/22/26 and his follow up visit on 5/26/26. NP described R52 started having some congestion in his lungs, we put him on nebulizer treatments and oxygen. He stated he offered to send R52 out for higher level of care to complete an evaluation. NP said that R52 declined to be sent out to the hospital. When asked if he included the discussion of potential hospitalization and resident refusal in his notes he stated he did not think so. During an interview with the Medical Director (MD) on 07/24/2026 at 9:31 AM he stated that NP had mentioned there was some discussion about hospitalization with R52, however he was not informed of that at the time. When asked if that discussion and subsequent refusal should be documented in the chart, MD stated, Absolutely. Lack of documentation of NP evaluation of right arm edema (swelling caused by excess fluid trapped in the body's tissues): During the NP interview on 07/22/2026 at 3:19 PM, the Nursing Adv Skilled Evaluation dated 5/26/26 22:04 was reviewed. In the Special Care section indicated R52 had a PICC line. Under the Cardiovascular heading it documented a new issue, Edema Issue #001: New. Location: Right forearm. Non-pitting. New onset edema: Unknown. Edema is dependent upon positioning. The evaluation did not indicate the NP had been notified of the new issue. Review of the Nursing Adv Skilled Evaluation dated 5/27/26 10:12 indicated the Edema Issue #001 location was on the right forearm. NP reviewed his notes dated 5/26/27 16:06 and 5/27/26 12:04 and stated he did not recall being notified of that, there was nothing documented in his physical assessment about it. He described that if they called him at night, nursing would put that in their note. When asked if he would want to have been notified, he stated, Yeah, I like to know whenever there is a change. Shortly after the interview at 4:40 PM NP reported to the surveyor that after reflection he did recall looking at R52's right extremity swelling and thought that someone had told him about it. He added he did not, however, document that. During the interview on 07/24/2026 9:31 AM with the MD, he stated that new onset edema in an extremity with a PICC line could be a sign of a deep vein thrombosis and should be evaluated. MD added that R52 was on a blood thinner which made a DVT less likely. During an interview on 07/23/2026 at 4:09 PM the DON concurrently reviewed the progress notes entered on and after 5/26/26 and did not see where notification was documented. She confirmed she would expect nursing to document if they notify a provider of changes.

Based on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was completed with the type of service, the required Quality Improvement Organization (QIO) name and contact information for 3 of 3 residents reviewed for beneficiary notices (Resident (R) 3, 37, and 56). As a result, there was the potential for residents who wished to file an appeal to be unable to do so in a timely manner.Findings include: Review of the NOMNC forms provided by the facility for R3, R37, and R56 revealed the forms included placeholder language instead of the required QIO information. The forms directed residents who wished to appeal the decision or had questions to contact the QIO. Review of R3's NOMNC indicated their current Medicare Part A coverage would end on 6/26/26. The form stated, Your provider and/or health plan determined that Medicare probably won't pay for your {insert type} services after the above date. You may have to pay for any services you get after this date. The next section of the form provided information about the residents' right to appeal the decision. Under the section titled, How to ask for an immediate appeal, it stated, .Call your QIO at {insert QIO name and toll-free number of QIO} to appeal, or if you have questions. The space to insert the QIO's name and contact information was not completed. Review of R37's NOMNC indicated their current Medicare Part A coverage would end on 4/10/26. The form stated, Your provider and/or health plan determined that Medicare probably won't pay for your {insert type} services after the above date. You may have to pay for any services you get after this date. The next section of the form provided information about the residents' right to appeal the decision. Under the section titled, How to ask for an immediate appeal, it stated, .Call your QIO at {insert QIO name and toll-free number of QIO} to appeal, or if you have questions. The space to insert the QIO's name and contact information was not completed. Review of R56's NOMNC indicated their current Medicare Part A coverage would end on 3/19/26. The form stated, Your provider and/or health plan determined that Medicare probably won't pay for your {insert type} services after the above date. You may have to pay for any services you get after this date. The next section of the form provided information about the residents' right to appeal the decision. Under the section titled, How to ask for an immediate appeal, it stated, .Call your QIO at {insert QIO name and toll-free number of QIO} to appeal, or if you have questions. The space to insert the QIO's name and contact information was not completed. During an interview on 7/23/26 at 2:00 PM, Social Worker (SW) 50 concurrently reviewed the NOMNC forms for R3, R37, and R56. He confirmed the forms were incorrect because the QIO information had not been completed. He stated that his fellow social worker was responsible for downloading the NOMNC document and preparing it for use. He further stated that the old forms they used to use had that information on them. When they started using the forms that had to be downloaded, he had not noticed they were incomplete. SW 12 was not available for interview before the end of the survey. During an interview on 7/24/26 at 10:42 AM, the Administrator confirmed the QIO information must be included on the NOMNC because it informs residents of their right to appeal. Review of the facility policy titled, Advanced Beneficiary Notice, dated 4/26/26, paragraph 5, subsection C, reads, A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare-covered service(s) are ending, regardless of whether the resident is leaving the facility or remaining in the facility. This informs the resident how to request an appeal or expedited determination from their Quality Improvement Organization (QIO).

Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when:a. Glucometers (a device used to check the blood sugar) were not cleaned and disinfected after use.b. Staff did not perform hand hygiene before putting on gloves. Failure to implement infection prevention practices may contribute to cross contamination of infection that can jeopardize the health and safety of residents and staff. Findings:In an observation on 07/23/2025, at 11:04 AM, Licensed Practical Nurse (LPN) 1 entered the room of R7. LPN1 don on gloves without performing hand hygiene and proceed to check R7's blood sugar. After checking the blood sugar, LPN stored the glucometer in the black casing and did not clean and disinfect the equipment.In another observation on 07/23/2025 at 12:08 PM, LPN1 don on gloves without performing hand hygiene and checked R40's blood sugar. LPN1 then placed the glucometer back in the black casing and did not clean and disinfect the equipment. In an interview on 07/23/2025 at 12:25, LPN1 acknowledged the findings and stated, Sorry I missed it. LPN1 also confirmed glucometer brand as [NAME] and facility was using Micro-kill disinfectant wipes and Sani-Cloth wipes to clean the glucometer.Review of [NAME] Quintet AC Blood Glucose Meter Owner's Manual 89115-0055-01 under Cleaning and Disinfecting Procedures indicated, Indirect transmission of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) during the delivery of healthcare services has been increasingly reported. Persons using blood glucose monitoring systems have been identified as one risk group due to sharing of lancets, lancing devices, and blood glucose meters. The cleaning procedure is to remove dust, blood and body fluid from the surface and should be performed whenever the meter is visibly dirty. The disinfecting procedure is necessary to kill pathogens such as HIV, HBV and HCV on the device. NOTE: the cleaning procedure can only remove visible contaminates from surfaces. Only the disinfecting procedure can eliminate non-visible pathogens. The meter MUST be cleaned and disinfected after use on each patient. Review of facility policy titled Hand Hygiene Policy dated 08/28/24 indicated, 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.According to Center for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Setting guidelines retrieved from https://www.cdc.gov/handhygiene/providers, on 08/28/25, Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis. Under Glove Use indicated, Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves.

Based on observation interview, record review, manufacturer's manual review and facility policy review, the facility failed to ensure oxygen (O2) orders were in place for one of three sampled residents (Resident (R)32). In addition, maintain O2 concentrators filters free of dust and nasal cannulas were placed in bags while not in use for two of three sample residents (R32 and R33).This deficient practice had the potential to allow an increased chance of unnecessary respiratory treatment and infection. Findings include:Review of the facility's policy titled Medication Orders, revised 04/25/25 revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders. 3. Oxygen orders- When recording orders for oxygen, specify the rate of flow, route, and rationale.Review of the undated user manual for the concentrator page 23, revealed Cleaning the Cabinet Filter: Caution: DO NOT operate the concentrator without the filter installed. 1. Remove the filter and clean at least once a week depending on environmental conditions.Review of the facility's policy titled Oxygen Administration revised 04/25/25 revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure. 22. Store oxygen tubing in a bag while not in use.1. Review of R32's undated Administration Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 06/22/17 and indicated a diagnosis of respiratory disorders and congestive heart failure.During an observation on 07/21/25 at 10:50 AM, R32 was wearing a nasal canula and the oxygen tubing was connected to the concentrator which indicated two liters per minute (L/min). During the same observation, the cabinet filter was noted to have a visible layer of dust on it.Review of the physicians' orders under the Orders tab in the EMR revealed no order for oxygen.During an observation on 03/22/25 at 2:25 PM, the cabinet filter had a visible layer of dust on it. The nasal canula was placed on top of the concentrator.During an interview on 07/23/25 at 10:04 AM, Registered Nurse (RN)1 was asked to look at the oxygen concentrator. RN1 stated, I guess this filter is dirty. RN1 stated the filter should be cleaned but was unsure who would clean the filters. RN1 was asked about whether the nasal canula should be left to open air. RN1 stated, It should be bagged.During an interview on 07/23/25 at 10:15 AM, the Director of Nursing (DON) was asked about the dusty filter and nasal canula in the open air. The DON stated, The filters should be cleaned as needed by the Durable Medical Equipment Specialist (DMES) and the nasal canula should be bagged when not in use.During an interview on 07/23/25 at 10:17 AM, the DMES stated the filter should be maintained monthly and changed out as needed.During an interview on 07/23/25 at 12:00 PM, the DON was asked about R32's oxygen order. The DON confirmed there was no oxygen order. It must have been missed when the resident came back from the hospital in June.2. Review of R33's undated Administration Record located in the EMR under the Profile tab, revealed an admission date of 09/07/24 and indicated a diagnosis of acute respiratory failure with hypoxia.Review of the physicians' orders under the Orders tab in the EMR, revealed on 05/11/25 Oxygen at 1-2 L/min Via Nasal Canula prn [as needed] to keep Sats [oxygen saturation in the blood] at or above 90%.Observation on 07/21/25 at 11:03 AM, revealed no filter on the cabinet of the concentrator and the nasal canula was placed on top pf the concentrator to open air.During an observation on 07/22/24 at 2:30 PM, no filter on the cabinet of the concentrator and the nasal canula was placed on top pf the concentrator to open air.During an observation on 07/23/25 at 9:56 AM, R33 was wearing a nasal canula and the concentrator was set on two L/min and there was no filter on the cabinet.During an interview on 10:10 AM, RN1 was asked about the filter. RN1 looked and stated, There should be a filter on the machine. I did not realize some machines did not have internal filters.During an interview on 07/23/25 at 10:15 AM, the DON was asked to look at R33's concentrator. The DON stated, It should have a filter to prevent anything from entering the machine.During an interview on 07/23/25 at 10;17 AM, the DMES was asked about the filter and stated, All concentrators should have a clean filter.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of one of ten residents (Resident [R]5) observed for medication pass when Omeprazole (used to treat heartburn and indigestion) was administered after meal instead of before meal as ordered for R5.These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R5.Findings:On 07/24/2025, at 08:51 AM, a medication administration observation to R5 was conducted with Registered Nurse (RN) 1. RN 1 administered medications to R5 including 1 tablet of Omeprazole 20 mg.Review of R5's physician's order dated 07/10/2025 indicated an order for Omeprazole Oral Tablet Delayed Release 20 milligram to give one tablet by mouth in the morning for GERD (Gastroesophageal Reflux Disease) to Administer 30-60 minutes prior to meals.In an interview on 07/24/2025, at 10:29 AM, R5 stated that he had eaten breakfast at 7 AM before R1 administer the medication. In an interview on 07/24/2025, at 10:31 AM, RN1 acknowledged that Omeprazole should be given before R5 had his breakfast.Review of facility policy titled, Administering Medications with revision date of 04/25/2025 indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observations, interview and record review the hospital failed to ensure a Registered Dietitian (RD) or qualified nutrition professional provided frequent oversight of food and nutrition services which resulted in deficient practices related to the competency of foodservice staff for the safe storage of refrigerated foods and ensuring sanitary condition of walk-in refrigerator (Refer to F812). These failures had the potential to lead to foodborne illness in a highly susceptible population of 45 residents who received food from the facility kitchen. Findings: In an interview on 09/24/24 at 10:00 AM, Acting Dietary Manager (ADM) explained that she assumed the position of Dietary Manager four months ago and the previous Dietary Manager (DM) is now assigned at the Assisted Living. ADM added, she is in the process of completing the required training for Dietary Manager certification (also known as CDM). The Dietary Manger Consultant stated that she is responsible to oversee (ADM) while she's in training. During initial tour of the kitchen on 09/24/24 at 10:04 AM, the following was observed: 1. Inconsistent labelling of food items such as: a. Bread cubes for Puree Bread labeled with use-by date of six (6) days after preparation, Cut-pineapple and open canned oranges labeled with use-by date of six (6) days after preparation or opening, Cut-peaches and honeydew labeled with use-by date of five (5) days after preparation, Canned cherries labeled with use-by date of three (3) months after opening. b. Raw sausages and meat patties covered with plastic wrap kept in a sheet pan was not labelled with prepare date and use by date. During concurrent interview, ADM stated, The cook prepared the sausage yesterday [09/23/24]. The practice is to write a date when it was prepared and used by date. c. At the bottom rack inside the walk-in refrigerator, a [NAME] Sweet and Sour Sauce was labeled that read, OP 8/14/24 and Use by 9/14/24. During concurrent interview, ADM stated, OP means open date. It's outdated. 2. The lower portion of the storage rack had a large amount of thick gray, black, whitish powder-like substance. In addition, the following items were also covered with thick gray, black, whitish powder-like substance. i. Grey Poupon Dijon Mustard 48 oz with opened date of 06/20/24. bottle covered with thick gray, brown whitish powder-like substance. ii. 1-gallon Kens Balsamic Vinaigrette iii. 4 gallons of [NAME] Honey Mustard iv.1-gallon of Teriyaki Marinate sauce with opened date 04/1/24 During concurrent interview at 1010 AM, the DMC stated, It's a mold referring to the thick gray, black, whitish powder-like substance. In an interview on 09/24/24, at 10:22 AM, ADM stated that cleaning of the kitchen including walk-in refrigerator is the responsibility of everyone. ADM explained that she is in the process of creating a schedule for each dietary staff to complete specific task such as cleaning the walk-in refrigerator. In an interview on 09/25/24, 01:31 PM, Registered Dietician (RD) stated that she was made aware of the presence of molds and it is not acceptable especially it's in the fridge. The RD also stated that it is an educational opportunity. We (facility) already provided an in-service to all staff. In an interview on 09/27/24, at 01:58 PM, the Administrator stated (ADM) is not the Manager. She doesn't have CDM (Certified Dietary Manager) cert (certification) yet. The Dietary Manager in the assisted living does the oversight. The DM who was also present during the interview explained that she was also providing oversight to ADM. The DM added, I manage the assisted living. Honestly, I am not here every day, but I speak to (ADM) at least twice a week. I rely much to her. The Administrator further stated, the facility hired DMC to help on mentorship of ADM, Unfortunately, she did not provide the appropriate leadership. Review of facility policy titled, Registered Dietician dated 03/27/24, under Primary Responsibility indicated, The Registered Dietician oversees the dietary supervisor and makes recommendations to the Administrator and Director of Food and Nutrition Services orally and through monthly reports. Specific responsibilities included, 2. Develop managerial and planning skills of supervisory staff, e.g. [example], purchasing procedures, specifications, inventories and records, completing Competency Checklist for dietary supervisor . Review of the facility Dietary Manager job description, dated 09/2022, indicated an essential function of Dietary Manager including 1. Maintain kitchen sanitation in compliance with applicable rules and regulations. 2. Supervise dietary staff .23. Staff must ensure that their department is maintained in a clean and safe manner by assuring that all necessary equipment and supplies are maintained .

Based on observation, interview, and record review, facility failed to ensure food safety standards when 1) there was lack of consistent labeling of preparation date and use-by date for foods capable of foodborne illness 2) storage of food items outside the shelf life and 3) food storage practices that may promote cross contamination as evidence by presence of molds in the walk-in refrigerator. Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. Foodborne illness and cross contamination may result in gastrointestinal distress and in severe instances may result in death. The use of expired ingredients may result in a food product that is unpalatable, resulting in decreased meal intake. This had the potential to affect 45 residents who received meals from the facility. Findings: 1a.During initial tour of the kitchen on [DATE] at 10:04 AM, the following food items were labelled as follows: i. Bread cubes for Puree Bread with prepare date of [DATE] and use by within six (6) days on [DATE] ii.Peaches with prepare date of [DATE], and use by within five (5) days on [DATE]. iii.Honeydew with prepare date of [DATE], and use by within five (5) days on [DATE]. iii.Cherries with prepare date of [DATE], use by within three (3) months on [DATE]. iii.Orange with prepare date of [DATE] and use by within six (6) days on [DATE]. iv. Pineapple with prepare date of [DATE] and use by within six (6) days [DATE]. 1b. At 10:07 AM, further observation inside the walk-in refrigerator, there was a sheet pan containing raw sausages and meat patties covered with plastic wrap with no prepare date and use by date. During concurrent interview, Acting Dietary Manager (ADM) stated, The cook prepared the sausage yesterday [[DATE]]. The practice is to write a date when it was prepared and used by date. 2. At the bottom rack inside the walk-in refrigerator, a [NAME] Sweet and Sour Sauce was labeled that read, OP [DATE] and Use by [DATE]. During concurrent interview, ADM stated, OP means open date. It's outdated. 3. The lower portion of the storage rack had a large amount of thick gray, black, whitish powder-like substance. The following items were also covered with thick gray, black, whitish powder-like substance. i.Grey Poupon Dijon Mustard 48 oz with opened date of [DATE]. bottle covered with thick gray, brown whitish powder-like substance. ii.1-gallon Kens Balsamic Vinaigrette iii. 4 gallons of [NAME] Honey Mustard iv.1-gallon of Teriyaki Marinate sauce with opened date [DATE] During concurrent interview at 1010 AM, the Dietary Manager Consultant (DMC) stated, It's a mold referring to the thick gray, black, whitish powder-like substance. During an interview on [DATE], at 10:22 AM, ADM stated that cleaning of the kitchen including walk-in refrigerator is the responsibility of everyone. ADM explained that she is in the process of creating a schedule for each dietary staff to complete specific task such as cleaning the walk-in refrigerator. During an interview on [DATE], 01:31 PM, Registered Dietician (RD) stated that she was made aware of the presence of molds and it is not acceptable especially it's in the fridge. Review of the facility policy titled, Food Storage dated [DATE] indicated, Procedure: All products should be inspected for safety and quality and be dated upon receipt and when prepared. Use Use-By date on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Charts .Any expired or outdated food products should be discarded . Under Raw Meat indicated, Hamburger and fresh chicken should be cooked within one to two days of purchase Other fresh meats should be cooked or frozen within three to four days of purchase depending on the type of meat. For Fresh Fruits, Fresh fruit should be checked and sorted for ripeness . Most fruits should be used within 3 to 5 days . Review of the facility policy titled, Cleaning Schedules dated [DATE] indicated, Policy, The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services and other clinically qualified nutrition professional . According to USDA Food Code, 2022, Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. Shoes carry contamination onto the floors of food preparation and storage areas. Even trace amounts of refuse or wastes in rooms used as toilets or for dressing, storing garbage or implements, or housing machinery can become sources of food contamination. Moist conditions in storage areas promote microbial growth. Furthermore, The possibility of product contamination increases whenever food is exposed. Changing the container(s) for machine vended time/temperature control for safety food allows microbes that may be present an opportunity to contaminate the food. Pathogens could be present on the hands of the individual packaging the food, the equipment used, or the exterior of the original packaging. In addition, time/temperature control for safety foods are vended in a hermetically sealed state to ensure product safety. Once the original seal is broken, the food is vulnerable to contamination .

Based on interview and record review, the facility failed to ensure one of 12 sampled residents (R42) was provided assistance in formulating an advance healthcare directive when they expressed a desire to create one. This failure put the resident at risk for not having their wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored. Findings: Review of the electronic medical record (EMR) revealed R42 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/19/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R42 had no cognitive impairment. Review of the advance healthcare directive acknowledgment form signed by R42 upon admission indicated that R42 wished to complete a healthcare power of attorney. Review of the EMR failed to show a copy of R42's advance healthcare directive. On 09/26/24 at 10:57 AM, an interview was conducted with Social Worker (SW) 1. SW 1 acknowledged that when R42 was admitted in June 2024, R42 expressed a wish to complete a healthcare power of attorney. SW 1 stated when residents express a desire to develop an advance healthcare directive, the procedure was to assist the resident as soon as possible. SW 1 explained that they typically provide the resident with copies of the forms to review in advance and invite a notary to complete the paperwork. When asked if this process was completed, SW 1 stated that it was not. SW 1 verified that R42 was capable of making healthcare decisions. On 09/26/24 at 11:44 AM, an interview was conducted with R42 in her room. R42 stated that she remembered the facility staff asking her when she came to the facility in June if she wanted to formulate an advance healthcare directive. R42 stated she wished to designate a family member as her healthcare power of attorney. However, no one followed up, so I forgot about it. According to the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives (undated), It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.

Based on interview and record review, the facility failed to notify one of three residents (R31) reviewed for hospitalization, or their representatives in writing and send a copy of the notice to the ombudsman of the reason for the transfer. This had the potential for the resident and/or their representative to be unaware of their rights and posed the risk of the ombudsman not being aware of the circumstances should appeals be filed by the resident or their representative regarding the transfer/discharge. Findings: Review of the electronic medical record (EMR) revealed R31 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 03/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R31 had no cognitive impairment. Review of a physician's order dated 02/17/24 revealed an order to send R31 to the acute care hospital for evaluation and treatment. Review of the Progress Notes revealed a Health Status Note dated 02/17/24, indicating R31 was admitted to the acute care hospital for cellulitis (bacterial skin infection). Review of the EMR failed to show documentation that R31 and/or his representative was provided with a written notice of transfer, nor a copy of the notice was sent to the Office of the Long-Term Care Ombudsman. On 09/25/24 at 01:41 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 verified R31 was transferred and admitted to the hospital on [DATE]. LPN 1 stated she could not find any documentation of a written notice of transfer provided to R31 and/or his representative. LPN 1 mentioned that she would need to check with the medical records department. On 09/25/24 at 02:52 PM, an interview was conducted with the Director of Nursing (DON). The DON verified the above findings and stated that R31 and/or his representative was not provided a written notice of transfer when he was transferred and admitted to the hospital on [DATE], but should have been. On 09/27/24 at 01:58 PM, an interview was conducted with Social Worker (SW) 1. SW 1 stated they send emails to the ombudsman at the end of the month to notify them of admissions, transfers, and discharges. When asked if they send a copy of the notice of transfer/discharge to the ombudsman, SW 1 stated no.

Based on interview and record review, the facility failed to ensure one of three residents (R31), reviewed for hospitalization, and/or their representative were provided with written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. This failure had the potential for R31 or their representative to be unaware of their right to request a bed-hold and their right to return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the electronic medical record (EMR) revealed R31 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 03/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R31 had no cognitive impairment. Review of a physician's order dated 02/17/24 revealed an order to send R31 to the acute care hospital for evaluation and treatment. Review of the Progress Notes revealed a Health Status Note dated 02/17/24, indicating R31 was admitted to the acute care hospital for cellulitis (bacterial skin infection). Review of the EMR failed to show documentation R31 and/or his representative was provided information regarding the facility's bed-hold policy at the time of transfer to the acute care hospital. On 09/25/24 at 01:41 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 verified R31 was transferred and admitted to the hospital on [DATE]. LPN 1 stated she could not find any documentation R31 was provided information regarding the facility's bed-hold policy at the time of transfer. On 09/25/24 at 02:52 PM, an interview was conducted with the Director of Nursing (DON). The DON verified the above findings and stated that R31 and/or his representative was not provided written information regarding the facility's bed-hold policy when R31 was transferred and admitted to the hospital on [DATE], but should have been. According to the facility's policy titled Bed-hold and Returns revised 04/11/24, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy . Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. the rights and limitations of the resident regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan (Medicaid residents); c. the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. the details of the transfer (per the notice of transfer).

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment for two of 12 sampled residents (R23 and R29) accurately reflected the residents' status. *R29's weight loss and anticoagulant use were coded incorrectly. *R23's active diagnosis of depression was not coded in the MDS. These failures had the potential for the residents to not receive an individualized plan of care based on their specific care needs. Findings: For R29: Review of the electronic medical record (EMR) revealed R29 was admitted to the facility on [DATE] with diagnoses including hypertension and coronary artery disease. Review of the MDS with assessment reference date of 07/26/24 revealed Section K, which addresses weight loss of 5% or more in the last month or 10% or more in the last 6 months, was marked as Yes, indicating R29 was not on a physician-prescribed weight loss regimen. However, a review of R29's weights showed that R29 did not experience a weight loss of 5% in the last month or 10% in the last 6 months. Further review of the MDS revealed that R29 was coded as taking an anticoagulant medication with an indication noted. However. Review of the Medication Administration Record for July 2024 failed to show any evidence that R29 was receiving an anticoagulant. On 09/27/24 at 12:00 PM, a telephone interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed the medical record and verified the above findings. The MDS Coordinator stated R29's MDS was coded inaccurately for both weight loss and anticoagulant use. 36814 Resident 23 R23 was admitted with diagnoses including hypertension, muscle weakness, and pneumonia. Review of R23's physicians order dated 03/14/24, indicated R23 was receiving Prozac (antidepressant) for Depression, AEB [as evidence by] self isolation. Review of R23's Quarterly MDS assessment dated [DATE], under Section I Active Diagnoses indicated the diagnosis of Depression was coded NO. In an interview on 09/26/24, at 02:17 PM, RN1 confirmed that R23 was receiving Prozac. RN1 also stated, R23 was admitted with Prozac for withdrawn behavior prior to him coming to nursing home. In an interview on 09/27/24, at 12:13 PM, MDS Coordinator stated,(R23) is getting antidepressant. MDS Coordinator explained the diagnosis of depression should be coded as yes. He added, It is incorrect, it should be coded yes for diagnosis. According to MDS 3.0 Resident Assessment Instrument (RAI) Manual, under Section I defined Active Diagnoses as Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident ' s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

Based on interview and record review, the facility did not ensure that the resident's drug regimen was free from unnecessary drugs when Midodrine HCL (used to treat low blood pressure) was administered outside the parameters for one of one sampled resident (Resident [R] 41). This failure resulted R41 receiving unnecessary medication that could negatively affect his health and well-being. Findings: R41 was admitted with diagnoses including Parkinson's Disease (chronic and progressive movement disorder), muscle weakness, and orthostatic hypotension (low blood pressure [BP] that happens when standing after sitting or lying down). Review of R41's physician order, dated 07/29/24, indicated an order for Midodrine HCl 10 milligram 1 tablet three times a day for Orthostatic Hypotension to Hold for Systolic Blood Pressure (SBP) less than 110. SBP is the measure of pressure within the arteries while the heart beats. Review of R41's August 2024 Medication Administration Record (MAR), indicated a Midodrine HCl Oral Tablet 10 MG was administered outside the parameters on the following dates: 08/01/24 at 2PM for SBP of 122 08/05/24 at 2PM for SBP of 135 08/09/24 at 6AM for SBP of 148 08/15/24 at 6AM for SBP of 140 08/15/24 at 10PM for SBP of 157 08/17/24 at 2PM for SBP of 142 In an interview with Registered Nurse (RN)1 and review of R41's August 2024 MAR on 09/25/24, at 02:46 PM, RN1 verified that R41 was given a dose of Midodrine outside the parameters. RN1 stated, If there's a check that means it was given out of parameters. Review of facility's policy titled, Administering Oral Medication with revised date of 04/11/24, indicated, 6. Check the label on the medication and confirm the medication name and dose in the MAR .8. Check the medication dose. Recheck to confirm the proper dose .

Based on interview and record review, the facility failed to ensure the as needed order for psychotropic medications (drugs that affect brain activities with mental processes and behavior) for one of six residents (R) reviewed for unnecessary medications (R45) had the documented rationale from the physician for the appropriateness of extending the medication beyond 14 days. This failure had the potential for R45 to experience adverse effects or receive unnecessary psychotropic medications. Findings: Review of the electronic medical records (EMR) showed R45 was admitted to the facility on [DATE], and was receiving hospice services. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating R45 had severe cognitive impairment. Review of the Order Summary Report showed the following physician's orders dated 09/09/24: - LORazepam [antianxiety medication] oral concentrate Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml orally every 1 hours [sic] as needed for Anxiety AEB [as evidenced by] increased HR [heart rate] for 90 Days Give 0.5 mg= 0.25 ml. end of life care - LORazepam [sic] Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml orally every 1 hours [sic] as needed for severe Anxiety AEB increased HR and SOB for 90 Days Give 1 mg=0.5 ml. end of life care Review of R45's medical record failed to show the physician or prescribing practitioner documented a rationale for the appropriateness of extending the as needed order for lorazepam beyond 14 days. On 09/26/24 at 11:51 AM, an interview and concurrent medical record review was conducted with Registered Nurse (RN) 1. RN 1 reviewed R45's medical record and could not find a documented rationale from R45's physician of the rationale for the appropriateness of extending the as needed orders for lorazepam beyond 14 days. On 09/27/24 at 12:42 PM, the Director of Nursing (DON) was informed and acknowledged the above findings.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 12%. Three medication administration errors were identified out of 25 opportunities during medication administration observation on 09/26/24 as follows: *RN 2 administered a medication to Resident (R) 20 that was ordered to be administered before a meal, but instead, it was administered after R20 had already eaten breakfast. *RN 2 administered two different eye drops to R20 without allowing the required 3-5 minute wait between drops, as outlined in their policy and standard of practice. These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R20. Findings: On 09/26/24 at 08:43 AM, a medication pass observation to R20 was conducted with Registered Nurse (RN) 2. RN 2 was observed preparing medications for R20 which included calcium acetate (medication used to lower high phosphate levels in patients with kidney disease) 667 milligrams (mg) 3 capsules, brimonidine (eye drops used to treat glaucoma or high eye pressure) 0.2%, and dorzolamide (eye drops used to treat glaucoma or high eye pressure) 2%. On 09/26/24 at 0850 AM, RN 2 administered the oral medications to R20, which R20 swallowed without difficulty. On 09/26 24 at 08:53 AM, RN 2 administered one drop of brimonidine to both eyes and then immediately applied one drop of dorzolamide to both eyes without waiting 3 to 5 minutes between eye drops. After completing the medication pass to R20, RN 2 was interviewed. RN 2 verified that she administered the eyedrops without allowing time in between for absorption. RN 2 stated that she always administered the eyedrops this way and added they were scheduled at the same time. When asked if she needed to wait between drops, she responded, it does not say that in the order. Review of R20's physician's orders and Medication Administration Record for September 2024 revealed an order dated 08/12/24 for calcium acetate oral tablet 667 mg, give 3 tablets by mouth before meals. The medication label had a sticker that stated take with food. On 09/26/24 at 09:36 AM, an interview was conducted with R20 in his room. R20 stated when RN 2 administered his medications, he had already eaten breakfast. On 09/26/24 at 09:41 AM, a follow up interview was conducted with RN 2. RN 2 stated when administering the medications, she follows the physician's order. RN 2 verified she did not administer the calcium acetate before meals as ordered by the physician. RN 2 stated she knew R20 had eaten breakfast when she gave the medications. On 09/26/24 at 01:59 PM, a telephone interview and concurrent medical record review was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated for calcium acetate where the bottle instructions state to give it with food but the doctor's order says to administer it before meals, the Consultant Pharmacist stated that they have to follow the physician's order. The Consultant Pharmacist stated I'm looking at the medications right now, I don't see any indication that this resident had a stomach irritation concern. The Consultant Pharmacist was also asked about the administration of two different eyedrops, to which she stated there should be a 3 to 5 minute wait between them. The Consultant Pharmacist noted that this is part of the pharmacy's standard of care policy. According to the facility's policy titled Medication Administration Eye Drops dated 05/16, While the eye is closed, use one finger to compress the tear duct in the inner [NAME] (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately three minutes .If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 3 to 5 minutes for optimal absorption then repeat procedure above.

Based on observation, interview, and record review, the facility failed to provide safe respiratory care to meet the needs of two of 12 sampled residents (R16 and R28). * The facility failed to ensure the licensed nurses documented the administration of supplemental oxygen to R16 according to the physician's order. In addition, the facility failed to notify R16's physician when he was refusing to wear his CPAP (continuous positive airway pressure, is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) according to the physician's order. * The facility failed to ensure R28 was administered oxygen in accordance with the physician's order. These failures posed the risk of the residents not being provided the appropriate respiratory care and treatment. Findings: 1. On 09/12/23 at 08:47 AM, an observation and concurrent interview was conducted with R16 in his room. R16 was observed receiving oxygen at 2 liters per minute via a nasal cannula (a small, flexible tube that contains two open prongs for oxygen delivery intended to sit just inside the nostril). R16 stated he received oxygen continuously during the day. When asked how long has he been receiving oxygen continuously during the day, R16 stated .ever since it's been months. Review of the electronic medical record (EMR) revealed R16 was admitted to the facility on [DATE]. Review of the History and Physical examination dated 06/07/23, revealed R16's diagnoses included congestive heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs) and obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep). Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/08/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R16 had no cognitive impairment. Review of the Order Summary Report revealed physician's orders dated: - 05/01/23, for oxygen at 0.5 to 3 liters via nasal cannula PRN (as needed) for SOB (shortness of breath)/low oxygen level. - CPAP at 9 cm (centimeter) of pressure every night shift for sleep apnea. Apply prior to sleep. If resident refuses please inform provider and write a progress note. a. Review of the Medication Administration Record and Treatment Administration Record for September 2023 revealed R16's oxygen saturation monitored every shift ranged from 90 to 98%. There was no documentation R16 was administered oxygen as ordered by the physician. Review of the Progress Notes revealed nursing entries showing R16 was administered oxygen. For example, on 09/02/23 at 07:40 AM, R16's oxygen saturation was 94% on oxygen via nasal cannula; on 09/04/23 at 07:11 AM, R16's oxygen saturation was 95% on oxygen via nasal cannula; and on 09/05/23 at 07:27 AM, R16's oxygen saturation was 94% on oxygen via nasal cannula. On 09/12/23 at 11:37 AM, an interview and concurrent medical record review was conducted with Registered Nurse (RN) 107. RN 107 verified the above findings and stated R16 received oxygen at 2 liters per minute continuously during the day. RN 107 stated oxygen administration should have been documented every time it was administered to the resident. b. Review of the Medication Administration Record and Treatment Administration Record for August and September 2023, revealed R16 had been refusing to wear the CPAP at bedtime. For example, for the month of August 2023, R16 used the CPAP five out of 31 days. From 09/01/23 to 09/11/23, R16 used the CPAP once for 4 hours on 09/06/23. There was no documentation the physician was notified when R16 refused the CPAP. Review of the Progress Notes revealed the following nursing entries dated: - 09/06/23 at 11:00 PM, showing RESIDENT CALLED FOR ASSISTANCE WITH CPAP HEAD PIECE .WENT INTO RESIDENT'S ROOM AT THIS TIME. RESIDENT STATED HIS CPAP NOSE/FACE PIECE WAS NOT ON CORRECTLY. Another entry on the same date at 11:15 PM revealed LPN WENT INTO RESIDENT'S [sic] AGAIN TOASSIST [sic] HIM. ONCE IN RESIDENT'S ROOM, HE STATED THAT HE WAS NOT GETTING ANY AIR FROM CPAP NOSE/FACE PIECE. - 09/07/23 at 01:38 AM, showing R16 called the licensed nurse that he did not want the CPAP because it was not on correctly. On 09/13/23 at 11:29 AM, an interview and concurrent medical record review was conducted with Licensed Practical Nurse (LPN) 29. LPN 29 reviewed the medical record and was unable to show documentation R16's physician was notified about the resident's refusal to wear the CPAP. When asked what the reason was for R16's refusal to wear the CPAP, LPN 16 stated .he just did not want it .he just didn't like it. On 09/13/23 at 12:11 PM, an interview was conducted with R16 in his room. R16 stated he had been refusing the CPAP because it was .too loose the air goes everywhere, it doesn't go to the nose. R16 stated he had been telling the licensed nurses about this and to check .if the measurement had changed .if it fits perfectly I'm going to wear it, that's what I told them. R16 stated he wanted to wear the CPAP and .I slept well when I used it. According to the facility's policy titled Oxygen Administration revised 07/21/22, After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure. the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. According to the facility's policy titled CPAP/BIPAP Support revised 07/21/22, notify the physician if the resident refuses the procedure. 42306 2. Resident # 28 was admitted on [DATE] with diagnoses that included spinal stenosis (narrowing of the spine which puts pressure on the spinal cord & nerves & can cause pain), lumbar region without neurogenic claudication (when nerves get pinched within the center of the lumbar spine, causing intermittent leg pain), chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and obstructive sleep apnea. Review of the record revealed a provider order dated 4/12/23 included to use CPAP (continuous positive airway pressure) at 8 cm (centimeters) of pressure one time a day for sleep apnea, apply prior to sleep. If resident refuses please inform provider and write a progress note. Review of the record revealed another provider order dated 4/12/23 included to apply oxygen, 1-5 L (liters) via NC (nasal cannula) as needed to keep O2 (oxygen) saturation greater than 90% as needed for low oxygen saturation. Review of a care plan revised 8/16/23 for bi pap at night for sleep included a goal that R28 will be free from signs and symptoms of respiratory infections. Interventions for this goal included oxygen via mask at 2 liters at night with CPAP. Review of record for 9/3, 9/4, and 9/5/23 revealed that the CPAP was not functioning properly and R28 was placed on 4l/NC (liters per nasal cannula) each night. Review of the record did not reveal documentation of an oxygen level below 90% on 9/3, 9/4, 9/5/23. The record did not reveal an order to apply oxygen at 4l/NC overnight for a CPAP not functioning properly. Review of a Health Status note dated 9/10/23 at 10:30 PM included that R28 was Placed on oxygen at 3l/NC pending verification that CPAP is working correctly, MD aware. Review of the record did not reveal documentation of an oxygen level below 90% on 9/10/23. The record did not reveal an order to apply oxygen at 3l/NC overnight for a CPAP not functioning properly. During an interview conducted on 9/14/23 with the Director of Nursing (DON) and ADON99, ADON99 stated oxygen administration is care planned for based on a provider order. ADON99 stated that she was under the impression that leadership was aware of the issues with R28's CPAP and that a respiratory therapist would be coming to assess the unit. ADON99 that the staff need to have an order to provider oxygen to a resident. When ADON99 and DON were asked if there was an order for the staff to apply oxygen at night on 9/3, 9/4, 9/5/23 and 9/10/23, both stated, no, there was no order for the oxygen. Cross reference F656

Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (R38), who required dialysis (a treatment to rid the body of toxins when the kidneys no longer function), received care and services consistent with professional standards of practice. The facility failed to assess and document care of R38's dialysis access site. This failure posed the risk of not detecting problems such as bleeding or other complications that would require immediate notification of the physician. Findings: On 09/11/23 at 10:10 AM, an observation and interview was conducted with R38 in his room. R38 was observed sitting on his wheelchair. R38 stated he was waiting for his transport to dialysis. When asked where his dialysis access site was, R38 stated he had a fistula (arterio-venous fistula, access is created by surgically connecting an artery and a vein) on the left upper arm. Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/07/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R38 had no cognitive impairment. Review of the physician's order dated 08/17/23, showed R38 was to receive dialysis every Monday, Wednesday, and Friday at a dialysis center. Fistula site at the left upper extremity was to be monitored for bruit (a sound or murmur heard in auscultation) and thrill (the vibration felt over the arterio-venous fistula when blood flows through the narrow space) every shift. Review of the EMR failed to show documentation R38's fistula at the left upper extremity was assessed for bruit and thrill every shift according to the physician's order. Review of the plan of care failed to show a care plan problem was developed to address R38's dialysis and care of his access site (fistula). Cross reference to F656, example #1. On 09/13/23 at 11:18 AM, an interview and concurrent medical record review was conducted with Licensed Practical Nurse (LPN) 29. LPN 29 stated R38's dialysis access site was a fistula on his left upper arm. LPN 29 stated she monitored for bruit by .listening and for thrill, she .feels the vibration. LPN 29 stated dialysis access site should be monitored every shift on non dialysis days, and before going and upon return from dialysis. When asked to show documentation of the assessment or monitoring of R38's fistula, LPN 29 was not able to find one and stated normally it should be in the TAR [Treatment Administration Record]. LPN also verified there was no care plan developed to address R38's dialysis and care of the dialysis access site. On 09/14/23 at 01:41 PM, an interview was conducted with the Director of Nursing (DON). The DON was informed and acknowledged the above findings. The DON stated the dialysis access site should be monitored every shift and as needed, and pre and post dialysis. The DON stated a care plan should have been developed to address dialysis and care of the access site. According to the facility's policy titled Hemodialysis Access Care revised 07/21/22, care of arterio-venous fistula includes Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access.

Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance to prevent accidents. Finding includes: Resident 48 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed that Resident 48 had moderate hearing difficulty and unclear speech, but was usually understood and able to understand. The MDS noted that while a brief interview of mental status (BIMS) was not conducted, the resident however, was described as having short and long-term memory problems; was dependent on staff for most activities of daily living, and required extensive assistance with 1-person assist. During an interview on 8/05/19, an unlicensed staff (CNA2) stated that the resident was not interviewable and was cognitively impaired. Review of the medical record revealed that Resident 48 has had many falls in the facility. From January 2019, for example, nurse progress notes documented the following falls: 1. On 1/01/19, at 9:50 a.m., Resident 48 was found on the floor near the table where he usually eats. The resident was examined and while no findings were noted, the resident reacted to his left knee when touched by a licensed staff. The note added that the resident was also observed Last afternoon (on 12/31/18) by the same licensed staff as he was bending over to pick up the confetti that had fallen on the floor, and that it concerned the staff that the resident could fall. Accordingly, the resident was reminded to adjust his position in the chair and he complied. There was no indication however, that the concern identified by the staff was acted upon. While the fall documentation (noted above) did not include how the fall occurred, a follow-up Fall Charting by another licensed staff on 1/01/19 at 8:30 p.m. noted that the resident had a non-injury fall attempting to pick up something up from the floor. 2. On 3/12/19, at 8:15 p.m., another progress note revealed that the resident fell in the hallway by the men's bathroom between the dining area and the therapy (room). According to the note, the resident (after church service) was observed standing without his wheelchair in the hallway between the dining room and the therapy area; and that an activity staff took the resident's wheelchair to the area in an attempt to get him to sit back down in his chair. The resident lost his balance and fell after the activity staff turned around when the resident placed his hands on her back. The resident complained of pain on his right hip and back of his head right side. The MDS assessment dated [DATE] noted that Resident 48 required limited assistance when walking in the corridor with 1-person physical assist. There was no indication in nurse progress notes that the resident was supervised or monitored to prevent the unassisted transfer or ambulation resulting in the fall. In a follow-up fall note, the documentation did not include the resident's transfer to an acute care hospital, but another progress note dated 3/13/19 at 11:58 a.m. indicated that the resident returned to the facility (from the hospital) with complaints of pain for which Tylenol 500 mgs and later, [MEDICATION NAME] 5 mgs, a narcotic [MEDICATION NAME] agent, were administered. An x-ray examination revealed that the resident had sustained an acute [MEDICAL CONDITION] superior and inferior pubic ramus including the right pubic. According to the facility's account of the incident, Resident 48 was cleared for weight bearing and was able to wheel himself around the common areas. 3. Further record review revealed that Resident 48 had another fall on 5/06/19 when the resident, while being assisted to the bathroom, unexpectedly stood up and then fell to the floor. The resident who was not hurt was unable to say what happened, according to the progress note. 4. Less than two weeks later on 5/17/19, another progress note at 2:25 a.m., revealed that Resident 48 unfortunately had an unwitnessed fall tonight. The note indicated that while there were no visible injuries, the resident looks like he has increase pain when bearing weight on (the) right extremity. The same note added that the resident had a previous pelvic (fracture) so the pain may be from the same site, referencing the fall on 3/12/19. 5. On 6/07/19, at 10: 15 p.m., the medical record revealed that Resident 48 had another fall when a licensed staff who was in another room rendering care to a resident heard a sound from outside the room, and saw (Resident 48) lying supine on the hallway floor outside his room (about 3 doors away) with his head against the door frame. While an assessment revealed that the resident did not have any signs of injury he, however, complained of pain to back of his head and right hip. The resident was subsequently transferred to an acute care hospital for a CT scan of the head and x-ray examination of the right hip. A review of the fall by the facility revealed that Resident 48 had sustained a right [MEDICAL CONDITION] and that he was, according to a nurse progress note dated 6/07/19, scheduled for surgery of the right femur (fracture). On 6/19/19 at 8:30 p.m., Resident 48 was readmitted to the facility according to an admission summary note by a licensed staff dated 6/20/19 at 12:07 a.m. after a 12-day at the hospital. The note indicated that the resident had two sets of staples on the right leg, the upper with 5 staples and an incision of about 6 cms x 0 cm, and the bottom had 2 staples with an incision that measured approximately 3.0 cm x 0 cm. Review of the medical record revealed that while the facility was documenting and investigating the falls, there was no indication that an assessment of the resident's need and level of supervision was conducted particularly in light of the resident's severely impaired cognition, impulsiveness, no safety awareness, and poor physical functioning. In separate interviews during the survey, unlicensed staff members were also concerned that Resident 48 was not only impulsive but was also difficult to redirect. During an interview on 8/05/19, CNA2 stated that Resident 48's behavior escalates if you tell him to do something he doesn't want to do, such as don't get up (from the wheelchair), or reminding him to eat his food. CNA2 added that the resident would push or swat her arms away. In another interview on 8/06/19, an unlicensed staff (CNA53) stated that Resident 48 was also quick to move, quick to stand so that they have to be near to be able to physically redirect the resident. CNA53 added that while the resident can be aggressive, he is not, however, with other residents; just at staff when he is asked or told to do something he wouldn't want to do. Review of the medical record review including nurse progress notes do not always document interventions implemented to prevent Resident 48 from further falls. While progress notes, for example, frequently document vital signs, potential drug interaction precautions, results of assessments conducted, and fall follow-ups, interventions to protect Resident 48 from further falls were often not, including those in place at the time of the fall. The care plan revised on 1/03/19, for example, included an intervention to perform Frequent hall rounds to anticipate and meet (the resident's) needs. Progress notes however, do not always document these, including when more frequent rounds were needed. 6. On 7/08/19, a nurse progress note revealed that Resident 48 was being transferred by staff to his bed using a Sara lift (a mechanical transfer device) at 12:15 a.m. when he suddenly stood up and put his arms over the sling and slid out from the lift. The resident landed with his bottom on the floor beside his bed. While the progress note indicated that fall precautions were maintained, a review of the MDS dated [DATE] indicated that Resident 48 required 2-plus person physical assist for transfers as he was totally dependent on staff. No reference about this was made until the care plan was revised on 7/17/19. 7. On 7/28/19, the resident was found sitting on the floor next to his bed at 10:50 a.m., according to another progress note. The incident which was unwitnessed described Resident 48 as having become agitated and combative when approached for morning care. The resident, according to the progress note was not hurt. It was not until 5:43 p.m. on 7/28/19, following this fall, that 1:1 monitoring was provided for Resident 48 to ensure the resident's safety, according to the medical record. 8. On 8/05/19, at 3:50 a.m., another progress note revealed that Resident 48 rolled and fell out of bed at 2:45 a.m., according to the sitter who witnessed (the resident) fall. The impact (was) on left side of his body, and that the resident was being combative to staff, and kicking at staff and refuse to have his vital signs taken. Progress notes did not document how the fall had occurred with a 1:1 sitter in the room. Further review of the medical record revealed that the care plan revised on 1/03/19 included an intervention to track all falls for location, time of day, cause, and similarities. This intervention, however, was not always being implemented. Review of progress notes revealed that of 8 falls from 1/01/19 through 8/08/19, four occurred on the night shift two of which were unwitnessed. There was no indication that an analysis of the falls was conducted to determine whether the resident needed more supervision or monitoring at night, and what, for example, might have caused the falls; and how monitoring could be improved. In addition, five of the falls were identified as witnessed with 2 occurring during supervised organized activities. The medical record, however, did not indicate that a review of witnessed falls was conducted as to why staff were unable to prevent the fall. During the same interview, AD1 stated that Resident 48 was on a 1:1 monitoring program and that transfer of the resident to an appropriate health care setting had been initiated with the resident's responsible party.

Based on observation, interview and record review the facility failed to ensure a resident who had a substantiated incident of staff mistreatment did not develop psychosocial disturbance for one of seven current resident's involved in allegations of abuse/neglect, mistreatment or injury of unknown origin (Resident # E-8). This deficient practice resulted in [MEDICATION NAME] emotional disturbance for Resident # E-8 . Relevant Intake ID# AZ 196. Findings: Beginning on 6/18/2018 at approximately 8:40 AM a tour of the facility to observe current residents who were included in the facility reported incidents and staff interaction with and care of residents. AZ 196 - Resident #E-8 had resided in the facility for about two years and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS = an assessment tool) dated 7/14/2017 indicated the residents Brief Interview for Mental Status (BIMS) score was 15 indicating the resident had full functional capacity. The MDS dated [DATE] recorded a BIMS score of 13. His vision and hearing were adequate and he was able to make his needs known and understand others. He required extensive assistance for ADLs including toileting; however was mostly continent of bowel and bladder. Observation on 6/18/2018 at 9:10 AM, resident was seated in his wheelchair in his room. He was alert and oriented to person, place, date/time and situation and was able to speak and understand English. When asked how he felt about the way facility staff treated him and took care of him, Resident E-8 stated with tears in his eyes, Last year there was an aide who is not here anymore, she wouldn't take me (to the bathroom). I couldn't hold it. He began to cry, stating I didn't feel right when asked what he meant by that, he stated, I feel ashamed. He also stated that he felt bad that the nurse was let go because of him. He further stated that he had problem with frequently needing to use the toilet and when he had to go, he needed to go right away. He continued stating that there was another time that the same certified nurses assistant (CNA) took him to the bathroom before a meal and left him on the toilet for about an hour and he therefore missed his meal. Regarding the incident from last year, he stated he recalled needing to let the CNAs know ahead of time that he needed to go to the bathroom so he would have to time to go to the bathroom and then get to the dining room to eat, so he had called ahead. When the CNA came to help him, he recalled her warn him that if he went the bathroom right then, he would miss his meal. She did not take him to the toilet. She wheeled him into the dining room where he stated he was unable to hold it and he soiled himself. He again teared up and stated, I was embarrassed. When asked how he felt about this now, he began crying again and stated, I still feel so ashamed. When asked if he felt that way at the time of the incident, he stated, Yes. When asked if anyone at the facility knew about the incident he stated, Yes, they fired her. When asked how he felt now, approximately 10 months later, he stated, I still feel so ashamed. I hate to bother the nurses, but I can't do this for myself. I need help He began crying again. During interviews with social service staff beginning on 6/19/2018 at approximately 9 AM, when asked what kind of assistance the facility provided to Resident E-8 to help him cope with his feelings about the incident, Staff B5 stated that he visited the resident daily; however did not provided therapeutic intervention regarding this particular incident. social service staff stated they had not been notified of this particular incident. When asked what their role was in the facility's Abuse Protocol, Staff B5 and B6 stated they treated complaints as grievances and kept a record in the Grievance log as well as wrote the grievance report. Administration sent abuse report to CMS, Tribal APS and other required agencies and the social services department staff were not always involved at all. When asked how social service staff thought Resident E-8 was doing now, Staff B5 stated (Resident E-8) was still very emotional and having a hard time adjusting to his dependence on staff for help. When asked what kind of psychosocial service the facility provided to residents who had been mistreated/abused/neglected or taken advantage of, Staff B5 stated they would refer the resident to the contracted mental health service provider. When asked if that service had been provided to Resident E-8, Staff B-5 stated, 'NO. review of the resident's medical record revealed [REDACTED]. No notes of how the resident responded or any psychosocial service, treatments, or intervention the resident received to help him cope with the emotional distress he experienced after the incident. The care plan was not updated and the incident was not documented in the treatment team meeting notes, nor reflected in the subsequent MDS assessments. Review of the facility's policy and procedure titled Abuse, Neglect and Exploitation dated (MONTH) 27, (YEAR) with revision date (MONTH) 14, (YEAR) read in pertinent part as follows: .Policy Explanation and Compliance Guidelines: .Types of Abuse .H. Mental(Emotional) Abuse includes, but is not limited to, Humiliation, harassment, threats of punishment or deprivation 8. Resident protection after Alleged Abuse, Neglect and Exploitation - The facility will make efforts to protect all residents after alleged abuse, neglect, and/or exploitation. Examples of ways to protect a resident from harm during an investigation of abuse,, neglect and exploitation may include, but are not limited to . There was no guidance in the Policies and Procedures for psychosocial support after alleged abuse, neglect, and/or exploitation.

Based on interview and record review the facility failed to provide adequate supervision to prevent falls with severe injury based on Entity Reported Incidents (ERIs- facility self-reports of incidents) submitted to CMS for five of 7 sampled residents when: 1. Resident 1 who had a history of [REDACTED]. 2. Resident 2 had several falls culminating in an unwitnessed fall resulting in a severe leg fracture, requiring extended hospitalization ; 3. Resident 3 had an injury of unknown origin resulting in a fractured femur (thigh bone), requiring surgical intervention; 4. Resident 4 had a witnessed fall resulting in cervical fractures and other injuries, requiring hospitalization with subsequent death; 5. Resident 6 had several falls resulting in repeat right leg fractures, requiring surgical intervention. Findings include: 1. Resident 1 was admitted to the facility originally on [DATE] and was re-admitted on [DATE] per face sheet with [DIAGNOSES REDACTED]. An entity reported incident Addendum received from the facility on [DATE] indicated on the morning of the fall on [DATE], Resident 1 had slurred speech, drooling, and that her left arm was more flaccid, however she was still able to follow verbal commands, her vital signs were stable, no tongue deviation and her right eye was PERRLA (she had no left eye due to enucleation due to cancer of her sinus). Resident 1 was dressed and placed in her wheelchair and taken to the common area just before the fall occurred. A report was received from (the acute care hospital) stating Resident 1 sustained an intraparenchymal hemorrhage, a left clavicular fracture, and shoulder dislocation. In the days prior to the fall she was ambulating up to 200 feet with verbal cue from restorative nursing. On [DATE] word was received that Resident 1 had expired. The admission minimum data set (MDS - comprehensive assessment tool) dated [DATE] indicated: - the BIMS was not conducted because resident was rarely/never understood - moderate difficulty with hearing, hearing aids not used - was sometimes understood - rarely/never understands - moderately impaired vision, corrective lenses not used - cognitive decisions for daily decision making were moderately impaired-decisions poor; cues/supervision required - had fluctuating behaviors of : inattention, disorganized thinking, and altered level of consciousness - required one/two person physical assist for ADLs - balance for walking and turning, the activity did not occur - balance was not steady, only able to stabilize with staff assistance for moving from seated to standing position, moving on and of toilet, and surface-to-surface transfer - no mobility devices were normally used - no impairment in range of motion for upper and lower extremity - was always incontinent of bladder and bowel, using toilet program for bowel continence The recent MDS showed some improvement The quarterly dated [DATE] indicated: - the brief interview for mental status was 00 (,[DATE]) - moderate difficulty with hearing, hearing aids not used - was usually understood - sometimes understands - moderately impaired with vision, corrective lenses not used - had fluctuating behaviors of inattention and disorganized thinking - required one person physical assist for all ADLs - used a walker, wheelchair - balance for walking and turning around, was not steady-only able to stabilize with staff assistance - balance for moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer: was not steady but able to stabilize without staff assistance - had no impairment in range of motion for upper and lower extremity - was occasionally continent of bladder and always continent of bowel Progress notes dated [DATE] indicated: - 5:05 am Pt (patient) noted with moderate slurry speech and drooling, left arm is more flaccid. (Resident 1) is alert to name and can still follow verbal commands. VS (vital signs) stable. PERRLA (pupils equal round reacting to light and accommodation), no tongue deviation noted .Message sent to (physician) RE: (regarding) neuro observations. Will continue to monitor. - 6:30 am Corrected entry: 5:06 am (Resident 1) Right pupil round, and reactive to light and accommodation. Left eye enucleated in past medical history. Pt (patient) still with moderate fair hand grasp, shes (sic) able to stand with moderate assist. Monitored. - 7:50 am Sent to ER. - 3:37 pm staff alerted to crashing sound in common area in front of nurss (sic) station at 6:20 am. apparently resident disconnected her self-releasing belt and fell forward out of wheelchair striking her head on the floor. patient was found lying on her left side and was complaining of head and back pain. comfort measures were taken while observing cervical spine precautions while EMS was dispatched at 6:35 am. D.O.N. was present, provider notified and order to send received. message left for brother .spoke with daughter and was informed of this incident . On [DATE] at approximately 12:30 pm, Employee 6 (nurse consultant) reported what she knew of the incident with Resident 1 and revealed Somewhere around 5:00 am looked like she (Resident 1) had a stroke. I don't remember the date but she (Resident 1) had a change of condition. The nurse messaged the doctor. Noted the mouth was drooling. Someone said she does it all the time. There were people near her and she fell and hit the floor. She was heard. The sequence was she fell , they called the doctor and family and ended up in (acute care hospital) and life flighted to Phoenix. I'm looking at it as no abuse/neglect and doing education. She was a DNR (do not resuscitate) and when she got to Phoenix (acute care hospital), she had a parenchymal bleed. They got her a hospice bed and she died . They did not do neuro checks. I am not responsible. Employee 3 is working with the nurses. Employee 3 is the Director (of Nursing) and is supposed to be doing that. He became the Interim DON at the end of June, beginning of July. On [DATE] at approximately 2:05 pm, Employee 7 (medical director) revealed when falls occur in the facility, the nurse reports the falls and makes an assessment of minor fall or major fall. If there's a head injury, EMS is contacted. If a fall is significant, it is reported to DHS-CMS. Regarding Resident 1 what occurred and what could have prevented it will be discussed in a meeting next week. Resident 1 was on antipsychotic medication but became lethargic. We placed her on a gradual dose reduction and was no longer on that medication anymore and Resident 1 became more alert and active after the antipsychotic was discontinued. On [DATE] at approximately 8:30 am Employee 3 (DON) was asked what could have prevented Resident 1's subsequent fall. Employee 3 was asked should Resident 1 have been gotten up when she presented with signs and symptoms of weakness in the left arm, drooling and placed in the common room. Employee 3 responded, No. When asked what was expected, and what should have happened, Employee 3 responded staff should have called and not messaged the doctor reporting the signs and symptoms. When asked what should not have happened, Employee 3 responded the staff may not have sent Resident 1 to the hospital since she was a DNR and they should have called the family first to discuss what they wanted to do. On [DATE] at 8:50 am Employee 1 (CNA) indicated she was working the day of the incident with Resident 1, came in around 6:00 am that day. Employee 1 revealed, I was running late and I just happened to come in. I saw someone standing, then heard a thud. She got up and fell down and fell on left side. I ran over and she said she was ok but started crying, saying she wanted to get up. The wheelchair brakes were on, the wheelchair alarm did not go off, and she was using a seatbelt as a reminder to call for help. Sometimes Resident 1 turned the wheelchair alarm off. She may have turned it (the alarm) off. She was improving for awhile and worked with PT (physical therapy). She had a self releasing seat belt because every now and then she slid down from the chair. When asked why she was gotten up so early in the morning, Employee 1 stated Resident 1 liked to be part of the group that sits in the common room every morning, so she usually got up that early. Maybe she was trying to get a cup of coffee, but a CNA wasn't there so no one was monitoring residents. Employee 1 expressed concern over Resident 1 hitting the left side of her head against the floor because Resident 1 reportedly had surgery in her head with left eye enucleation due to diagnosed cancer. Employee 1 stated that was her soft side (of Resident 1's head) . if only she was protected there. On [DATE] at 9:05 am Employee 2 (RN) indicated, I got report that morning ([DATE]) at 6:,[DATE]:20 am. I was told Resident 1 had signs and symptoms the night nurse was concerned about and messaged the doctor, weakness on the left side and drooling and had not heard back from the doctor. My plan was to call the doctor, assess her. When asked if he would have gotten Resident 1 up as usual, without further evaluation and assessment, Employee 2 responded, No. Knowing her from the past, her condition was bad but she was doing better lately. Since the Risperdal was stopped, she was much more alert. Care plans were reviewed and indicated Resident 1 was high risk for falls and had actual falls related to unaware of her safety needs, vision/hearing problems, and gait/balance problems; poor safety awareness, turns off alarms, removes alarms, and at times refused placement of alarms. Preventive interventions were as follows: - to anticipate the resident's needs - to ensure a safety officer is present when attending outside/outdoor activities - to make sure the resident was wearing appropriate footwear - to ensure bathroom door alarm, pressure alarm in bed and wheelchair are working and in place - to ensure the call light and personal items were within reach, floors free from clutter, the bed in low position, adequate glare-free light - to check seat belt for proper working order Documents titled Change of Condition Evaluation dated [DATE] were reviewed with several areas incomplete: Changes in condition - Increasing flaccidity left arm and moderate drooling; Functional status evaluation - generalized weakness Describe the change in general weakness - not described, options not checked Describe the functional status signs or symptoms - not described, area left blank Pain evaluation areas left blank Neurological evaluation left blank. What do you think is going on with the resident? RN I think the problem may be - area blank LPN The resident appears - area blank The Request section was left blank which had options to select: monitor vital signs, labwork, x-ray, EKG, provider visit, transfer to the hospital, or other new orders. Name, Date and time of family notification was blank as was the date and time of clinician notification. When asked for a policy on change of condition, the following policy was provided: Administrative and Department Policies dated [DATE], indicated to complete alert charting for resident falls, change of condition, antibiotic administration, resident incidents, change of behaviors, and other relevant patient concerns or issues. Additionally, during interviews with Employee 1, Employee 2, and Employee 3, there were suggestions that the facility could have used a helmet for protection to the head; the facility could have kept Resident 1 in the bed for further observation and assessment; someone could have been present in the common room to continue observation to monitor for worsening signs and prevent actions to cause a subsequent fall. 2. Review of an ERI submitted on [DATE] regarding an injury of unknown origin for Resident 3 revealed the report consisted of four brief Health Status Notes. The first note dated [DATE] at 4:44 pm (documentation unclear if this was the first time injury noted) revealed the resident was seen by a provider for an inflamed right knee and was ordered to be transported to the local hospital. The second note dated [DATE] at 7:19 am indicated the resident was transferred to a higher care level for a possible right femur fracture. Review of consultation notes from the acute care hospital, on or about [DATE] Resident 3 originally sustained a fracture of the right distal femur when she tripped and fell at a store. An open reduction and internal fixation of comminuted fracture of the right distal femur was done on [DATE]. On [DATE], Resident 3 was admitted to the facility with an immobilizer placed on the right leg in which Resident 3 could not bear weight and the immobilizer was not to be removed. The resident was supposed to be on a non-weight bearing status for her right leg. The facility's investigation of the ERI revealed Employee 11 (CNA) stated Resident 3 was always putting her weight on her R (right) leg, always. Another interview with Employee 1 (CNA) revealed Resident 3 wedges herself between the toilet and the wall. She states the first week , they used the Hydro .The second week, she was transferring better, the CNAs started using her bathroom where she wedged herself in between the toilet and the wall . Employee 1 and other CNAs reportedly reminded Resident 3 not to stand on her right leg when it looked as though Resident 3 started to use the right leg and the CNAs indicated the immobilizer was never removed. Staff denied Resident 3 had any falls and was not dropped. It was not addressed whether or not Employee 11 instructed Resident 3 not to bear weight on her right leg. The issue of the staff allowing Resident 3 to wedge herself in between the toilet and the wall versus using the hydro room was not addressed. A consult note dated [DATE] stated the daughter relates to me that her mother who only speaks (blank) asked the caregivers at the nursing care facility out in Sells if she can get up on her own and go to the bathroom, they responded yes, took off the brace and let her to get up, she immediately fell and refractured her femur and was transferred to (name of acute care hospital). The operative report dated [DATE] revealed under Indications and Findings indicated The patient is an [AGE] year old female who is about a month or so status [REDACTED]. When seen by me in my Sells Clinic last week she was doing well. According to her daughter who speaks (blank), this is the patient's only language. The patient asked to get up in the nursing home to go to the bathroom, they removed the brace, let her walk out of bed, and she immediately had refracture of her femur through the hardware . The facility's Abuse and Neglect Record indicated Uncertain where injury took place. One possible place is when Resident 3 is transferring in the bathroom. She holds on to the bar, but instead of pivoting to place herself at the front of the toilet, she just sits sideways on the toilet and her right leg is wedged between the wall and the toilet. It could have twisted as she repositioned on the toilet. An internal investigation report by the previous DON documented the following: All staff verbalized about knowing the order to not remove the RLE (right lower extremity) immobilizer and the resident's non weight bearing status. In addition, CNAs verbally explained how resident was transferred during toileting which followed the non weight bearing status. In addition, reviewed the TAR which indicates resident did have RLE immobilizer on at all times except for dressing changes .our findings conclude the impression as stated by the radiologist of the Failed Internal Fixation with refracture. There is no evidence of any wrongdoing by the staff . The conclusion by the DON failed to acknowledge and address so that corrective measures and recommendations could be made: - Employee 11's statement that Resident 3 put weight on her right leg - Staff admitted that Resident 3 wedged herself between the toilet and the wall and the staff proposing this may have contributed to re-injury. Also, the staff referred to using the hydro room for bathroom transfers the first week but on the second week they used the resident's bathroom which is where the resident would wedge herself. The care plan for ADL self care performance deficit and limited mobility of her right leg initiated [DATE] indicated : - Make sure resident keeps her leg brace on at all times - During toileting, please use the toilet in the hydro room as it will be easier for client and will allow more room for toileting and maneuvering The care plan failed to specifically state the resident was to be non weight bearing of the right leg. 3. The facility submitted an ERI on [DATE] regarding a fall with injury for Resident 2 occurring on [DATE] at 1:05 pm. Review of the report indicated the resident had been assisted to the toilet by a CNA (Certified Nursing Assistant), then placed into his wheelchair and left alone to wash his hands. Shortly after this another CNA heard a noise and the resident was observed on the floor of his bathroom on his back with his head underneath the sink and his right leg in a flexed position with lower leg in disalignment. The resident was trying to get up and the CNA instructed him to lie still. The charge nurse assessed him, noticed his right leg was misaligned so called EMS (Emergency Medical Services) and the resident was transported to an acute care hospital. Review of the Admission Record revealed Resident 2 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] he returned to the facility following a brief hospitalization with a [DIAGNOSES REDACTED]. Review of an at risk for falls Initial Care Plan initiated [DATE] revealed factors of a fall risk score of 30 (moderate risk), unsteady gait, and dementia, with a goal to miminize risk of fall related injuries. Interventions were to educate on using the call light and ask for assistance, and for staff to assist with transfers/ambulating. Review of a Nursing Progress Note dated [DATE] at 1:24 pm revealed at 0640 (6:40 am) resident had an unwitnessed fall. He was found on the floor in his room between the w/c (wheelchair) and closet. Resident states that the brakes did not work. Resident was first assessed on the floor. No injuries noted. Resident states he hit the back of his head. No swelling, redness, or painful spot found at this time. The brakes on the w/c appear to be working well .Alarm was placed on the chair for couple days until resident returns to his pre-hospitalization level. Review of care plans revealed no revisions were made. Review of a Nursing Progress Note dated [DATE] at 3:31 pm revealed while in the activity room, a staff member was pushing this patients wheelchair into position when resident slid forward, staff member tried to prevent him from sliding but was unable to and resident ended up in the sitting position on the floor. Review of care plans revealed no revisions were made. Review of the Admission Minimum Data Set (MDS - a comprehensive assessment tool) dated [DATE] revealed Resident 2 was cognitively intact. The Functional Status assessment revealed he required extensive assistance with all functions except eating with one person physical assist, had unsteady balance during transitions and walking requiring staff to assist with stabilization, and ROM (range of motion) impairment of the upper and lower extremity. The two falls without injury were included in the report. The Care Area Assessment revealed Falls was one of the triggered problems, and required development of a complete care plan within seven days. Review of Occupational Therapy (OT) Plan of Care notes dated [DATE] revealed he was assessed and treated for [REDACTED]. Nursing has noticed a decrease in self care/ADL (Activities of Daily Living) ability for several days, resulting in decreased safety and an increased need for assistance . Review of the Care Plan High Risk for Falls r/t (related to) Impaired Balance initiated [DATE] revealed a goal to not sustain a fall-related injury through the target date of [DATE]. Interventions included to: - anticipate and meet the resident's needs; - educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; - encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: Restorative Nursing for progressive ambulation, daily group activities; - ensure a Safety Officer is present when attending outdoor/outside activities; - follow facility fall protocol; - PT evaluate and treat as ordered and as needed; - keep the environment safe (no spills on the floor, keep bed low at night, glare-free light, personal items in reach). The care plan did not address level and extent of assistance required. Review of the Care Plan (Resident 2) has had two (2) actual falls with no injury since his admission initiated [DATE] had a goal of will resume usual activities without further incident through the review date. Interventions were: - continue interventions on the at-risk plan; - monitor/document/report as needed for 72 hours for pain, bruises, change in mental status, or new onset of confusion, sleepiness, inability to maintain posture, agitation; - provide activities that promote exercise and strength building where possible; - provide 1:1 activities if bedbound; - vital signs as per current orders. Review of a Care Plan Conference Note dated [DATE] revealed the resident has right sided weakness related to an old CVA and requires extensive assistance, and that he participates in a Restorative Program where he walks 150 feet twice a day three to five days a week. There was no mention of the two falls. Review of Restorative Program Notes between late [DATE] to [DATE] revealed the resident routinely walked 200 feet twice a day with moderate to minimal assist with standing and transfers. Review of the Quarterly MDS dated [DATE] revealed Resident 2 now had moderately impaired cognition. The Functional Status assessment was unchanged for transfers, walking, dressing, and toilet use, as were the balance and ROM assessments. Review of Nursing Progress Notes dated [DATE] at 7:36 PM revealed Resident was found leaning to the right side of the toilet seat. With four people assist, resident was eased down to the floor and up to his w/c. Resident did not hit his head. Resident said that while transferring from the w/c to the toilet seat, he tried to hold on to the grab bar on his right side but lost his grip, leaned to his right side and could not get back. There was no injury, no bruise, no skin tear. As per resident, he has this pain on his right shoulder since two weeks ago . (Nurse Practitioner) ordered for PT (Physical Therapy) to evaluate declining independence in mobility. Review of the High Risk for Falls Care Plan revealed a hand-written note dated [DATE] stating (Resident 2) was eased to the floor during toileting when he lost his balance (CNA was (with) (Resident 2)). No injury from easing to floor. The unchanged goal was revised [DATE] with a target date of [DATE]. There were no changes to interventions. A Temporary Care Plan dated [DATE] for Fall had a goal of no fall in 30 days and intervention of PT to evaluate declining independence in mobility. The Actual Falls care plan also had a revised goal date of [DATE] but was otherwise unchanged. Review of an OT Progress Note dated [DATE] at 3:58 PM addressed seating and positioning. The resident reported that when he stood up to manage his clothing after using the toilet his colostomy bag got caught up in his pants and .he lost his balance, staff was present to assist with lowering res. (sic) to floor safely . Review of Restorative Program Notes after the fall revealed his walking distance decreased to 140 - 160 feet. Review of OT Plan of Care notes revealed recommendation for treatment from [DATE] to [DATE] for complaints of pain in cervical and lumbar area of back, .decreased ability to participate in functional transfers and mobility, OT to address pain thru (sic) modalities and increasing ue (upper extremity) strength . Review of Care Plan Conference notes dated [DATE] revealed the CNA reported he required extensive assistance with ADLs and more assistance with transfers between toilet and wheelchair. The decrease in distance walked was mentioned but the most recent fall and his apparent decline in ability was not addressed. Review of a Nursing Progress Note dated [DATE] at 2:38 pm revealed Resident was reported to have change in physical ability to transfer and a stand up lift was used to transfer. Through the day the condition slightly improved: resident requires one to two people assist to transfer, demonstrates right arm weakness to hold on the rail . Review of a Nursing Progress Note dated [DATE] revealed the resident again attempted to transfer himself onto the toilet, a CNA noticed him losing his balance and she eased him onto the floor. He was reminded to ask for help and wait for assistance. Review of the Care Plan showed no revisions were made. Review of OT Progress & Discharge Summary Notes dated [DATE] revealed the resident was discharged from OT due to refusal of therapy. He continued to have inconsistent transfer ability, and was referred to continue the Restorative Program. Review of Restorative Program Notes for April and [DATE] revealed the resident returned to walking up to 200 feet. Review of a Nursing Progress Note dated [DATE] at 1:40 pm revealed Writer was called to residents (sic) room at 1310 (1:10 pm). Resident was observed lying on bathroom floor with an obvious fracture to his right leg. Staff instructed not to move resident. EMS was called. Resident remained alert and awake . The resident was transferred to an acute care hospital where he was diagnosed with [REDACTED]. He remained in the hospital until his discharge on [DATE]. 4. The facility submitted an ERI on [DATE] regarding a fall with injury for Resident 4 occurring on [DATE]. Review of the report indicated .resident was in bed and CNA was removing pajama bottoms. Resident sat himself up, turned and fell over the turning rail onto the floor. He was assessed by the charge nurse and sent to the ER, where he was found to have a C1 (cervical (vertebrae)) fracture and subdural hematoma (brain bleed). He would be required to always wear a Miami J collar (neck brace). He returned to the facility under hospice 19 [DATE] and expired on 20 [DATE]. Review of the Admission Record revealed Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS dated [DATE] indicated highly impaired hearing and vision, he required simple and direct verbal communication, and had severely impaired congnition. The Behavior assessment indicated frequent physical and occasional verbal symptoms directed toward others, and frequent rejection of care. The resident required extensive assistance with two+ person physical assist for bed mobility, transfers and dressing. The resident had one fall without injury during the previous quarterly assessment period. Review of the Nurse Progress Note dated [DATE] at 7:37 pm indicated the resident had a fall, but no other notes addressing this fall or changes to care. An entry dated [DATE] at 6:37 pm noted CNA was providing care for resident at 15:40 (3:40) pm with bed about 3 to 4 feet for comfort. Client accidentally fell from bed to floor injuring forehead with lacerations vertical about 6.5 cm and horizontal 3.5 cm in length. Client was observe (sic) with abrasion to bilateral knees, skin tear to dorsal (back) right hand, laceration to left upper cheek and abrasion to left forearm. Under left eye was swollen shut. Client was assessed for injuries. Pressure was applied to forehead laceration. client was assisted back to bed by this writer and other healthcare staff.ambulance was called immediately. Ice was used to control swelling. ABD pad and kerlix (dressing materials) used to dress forehead wound.ambulance left at 1610 (4:10 pm). An additional note at 18:44 (6:44) pm indicated Client was assisted to bed from floor after assessment of Charge Nurse, ADON (Assistant Director of Nursing) and this writer relating to condition of resident at time of incident. Client was bleeding profusely from forehead. Client was moving all extremities and lifting his head off the ground. No assessed reason not to move client and control his bleeding due to the fact that he was moving all extremities. Client remained awake up until care was handed over to EMS. Review of the document Post Incident Safety Huddle II (tool to review a fall) dated [DATE] at 18:43 (6:43 pm) indicated Ideas to prevent future incidents of this type was to use two person assist. Interventions indicated to ensure two person assist with ADLs. Root Cause Analysis indicated CNA should have had assistance with this resident. Injury Prevention Devices in use at time of incident indicated mats, but on the other side of the bed. Changes noted indicated no change in condition or medications within the previous 48 hours. Investigation- witness account indicated CNA stated client place (sic) his upper body over side rails and I was unable to prevent fall. Investigation - problems with ROM (range of motion) indicated client is bedridden with limited ROM. Investigation- are neurological checks indicated box was checked but no results documented and no vital signs taken due to agitation. The boxes for Was the care plan followed and Was the temporary care plan update (sic) were checked. Review of the attached Morse Fall Scale (tool to predict fall risk) noted a score of 55, indicating high risk. Review of the care plan for high falls risk initiated [DATE] and revised on [DATE] indicated a goal to not sustain a fall-related injury through the review date of [DATE]. Interventions did not address level and extent of assistance needed for any activity. Review of a second care plan for high falls risk contained the same information but was initiated on [DATE]. Review of the hospital radiology reports dated [DATE] at 6:16 pm indicated CT C Spine (CAT scan of the cervical spine) noted fractures of C1 and C2, and CT Head indicated small right frontoparietal convexity (front and top of the skull) subdural hematoma, prominent (severe) right periorbital (around the eye) soft tissue edema (swelling), and right frontal scalp hematoma and laceration. Review of the hospital Admission History and Physical dated [DATE] at 7:11 pm under Assessment/Plan noted given the poor prognosis of this injury, will need to find family and discuss goals of care - no role for neruosurgical intervention. Review of the hospital Trauma Surgery Progress Note dated [DATE] at 3:00 pm indicated the status was discussed with the

Based on interview and record review, the facility failed to ensure the prevention of neglect for 1 of 7 sampled residents (Resident 1). Finding includes: An entity reported incident Addendum received from the facility on [DATE] indicated on the morning of the fall on [DATE], Resident 1 had slurred speech, drooling, and that her left arm was more flaccid, however she was still able to follow verbal commands, her vital signs were stable, no tongue deviation and her right eye was PERRLA (she had no left eye due to enucleation due [MEDICAL CONDITION] of her sinus). Resident 1 was dressed and placed in her wheelchair and taken to the common area just before the fall occurred. A report was received from (the acute care hospital) stating Resident 1 sustained an intraparenchymal hemorrhage, a left clavicular fracture, and shoulder dislocation. In the days prior to the fall she was ambulating up to 200 feet with verbal cue from restorative nursing. On [DATE] word was received that Resident 1 had expired. Resident 1 was admitted to the facility originally on [DATE] and was re-admitted on [DATE] per face sheet with [DIAGNOSES REDACTED]. The admission minimum data set (MDS - comprehensive assessment tool) dated [DATE] indicated: - the BIMS was not conducted because resident was rarely/never understood - moderate difficulty with hearing, hearing aids not used - was sometimes understood - rarely/never understands - moderately impaired vision, corrective lenses not used - cognitive decisions for daily decision making were moderately impaired-decisions poor; cues/supervision required - had fluctuating behaviors of : inattention, disorganized thinking, and altered level of consciousness - required one/two person physical assist for ADLs - balance for walking and turning, the activity did not occur - balance was not steady, only able to stabilize with staff assistance for moving from seated to standing position, moving on and of toilet, and surface-to-surface transfer - no mobility devices were normally used - no impairment in range of motion for upper and lower extremity - was always incontinent of bladder and bowel, using toilet program for bowel continence The recent MDS showed some improvement The quarterly dated [DATE] indicated: - the brief interview for mental status was 00 (,[DATE]) - moderate difficulty with hearing, hearing aids not used - was usually understood - sometimes understands - moderately impaired with vision, corrective lenses not used - had fluctuating behaviors of inattention and disorganized thinking - required one person physical assist for all ADLs - used a walker, wheelchair - balance for walking and turning around, was not steady-only able to stabilize with staff assistance - balance for moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer: was not steady but able to stabilize without staff assistance - had no impairment in range of motion for upper and lower extremity - was occasionally continent of bladder and always continent of bowel Progress notes dated [DATE] indicated: - 5:05 am Pt (patient) noted with moderate slurry speech and drooling, left arm is more flaccid. (Resident 1) is alert to name and can still follow verbal commands. VS (vital signs) stable. PERRLA (pupils equal round reacting to light and accommodation), no tongue deviation noted .Message sent to (physician) RE: (regarding) neuro observations. Will continue to monitor. - 6:30 am Corrected entry: 5:06 am (Resident 1) Right pupil round, and reactive to light and accommodation. Left eye enucleated in past medical history. Pt (patient) still with moderate fair hand grasp, shes (sic) able to stand with moderate assist. Monitored. - 7:50 am Sent to ER. - 3:37 pm staff alerted to crashing sound in common area in front of nurss (sic) station at 6:20 am. apparently resident disconnected her self-releasing belt and fell forward out of wheelchair striking her head on the floor. patient was found lying on her left side and was complaining of head and back pain. comfort measures were taken while observing cervical spine precautions while EMS was dispatched at 6:35 am. D.O.N. was present, provider notified and order to send received. message left for brother .spoke with daughter and was informed of this incident . On [DATE] at approximately 12:30 pm, Employee 6 (nurse consultant) reported what she knew of the incident with Resident 1 and revealed Somewhere around 5:00 am looked like she (Resident 1) had a stroke. I don't remember the date but she (Resident 1) had a change of condition. The nurse messaged the doctor. Noted the mouth was drooling. Someone said she does it all the time. There were people near her and she fell and hit the floor. She was heard. The sequence was she fell , they called the doctor and family and ended up in (acute care hospital) and life flighted to Phoenix. I'm looking at it as no abuse/neglect and doing education. She was a DNR (do not resuscitate) and when she got to Phoenix (acute care hospital), she had a parenchymal bleed. They got her a hospice bed and she died . They did not do neuro checks. I am not responsible. Employee 3 is working with the nurses. Employee 3 is the Director (of Nursing) and is supposed to be doing that. He became the Interim DON at the end of June, beginning of July. On [DATE] at approximately 2:05 pm, Employee 7 (medical director) revealed when falls occur in the facility, the nurse reports the falls and makes an assessment of minor fall or major fall. If there's a head injury, EMS is contacted. If a fall is significant, it is reported to DHS-CMS. Regarding Resident 1 what occurred and what could have prevented it will be discussed in a meeting next week. Resident 1 was on antipsychotic medication but became lethargic. We placed her on a gradual dose reduction and was no longer on that medication anymore and Resident 1 became more alert and active after the antipsychotic was discontinued. On [DATE] at approximately 8:30 am Employee 3 (DON) was asked what could have prevented Resident 1's subsequent fall. Employee 3 was asked should Resident 1 have been gotten up when she presented with signs and symptoms of weakness in the left arm, drooling and placed in the common room. Employee 3 responded, No. When asked what was expected, and what should have happened, Employee 3 responded staff should have called and not messaged the doctor reporting the signs and symptoms. When asked what should not have happened, Employee 3 responded the staff may not have sent Resident 1 to the hospital since she was a DNR and they should have called the family first to discuss what they wanted to do. On [DATE] at 8:50 am Employee 1 (CNA) indicated she was working the day of the incident with Resident 1, came in around 6:00 am that day. Employee 1 revealed, I was running late and I just happened to come in. I saw someone standing, then heard a thud. She got up and fell down and fell on left side. I ran over and she said she was ok but started crying, saying she wanted to get up. The wheelchair brakes were on, the wheelchair alarm did not go off, and she was using a seatbelt as a reminder to call for help. Sometimes Resident 1 turned the wheelchair alarm off. She may have turned it (the alarm) off. She was improving for awhile and worked with PT (physical therapy). She had a self releasing seat belt because every now and then she slid down from the chair. When asked why she was gotten up so early in the morning, Employee 1 stated Resident 1 liked to be part of the group that sits in the common room every morning, so she usually got up that early. Maybe she was trying to get a cup of coffee, but a CNA wasn't there so no one was monitoring residents. Employee 1 expressed concern over Resident 1 hitting the left side of her head against the floor because Resident 1 reportedly had surgery in her head with left eye enucleation due to diagnosed cancer. Employee 1 stated that was her soft side (of Resident 1's head) . if only she was protected there. On [DATE] at 9:05 am Employee 2 (RN) indicated, I got report that morning ([DATE]) at 6:,[DATE]:20 am. I was told Resident 1 had signs and symptoms the night nurse was concerned about and messaged the doctor, weakness on the left side and drooling and had not heard back from the doctor. My plan was to call the doctor, assess her. When asked if he would have gotten Resident 1 up as usual, without further evaluation and assessment, Employee 2 responded, No. Knowing her from the past, her condition was bad but she was doing better lately. Since the [MEDICATION NAME] was stopped, she was much more alert. Care plans were reviewed and indicated Resident 1 was high risk for falls and had actual falls related to unaware of her safety needs, vision/hearing problems, and gait/balance problems; poor safety awareness, turns off alarms, removes alarms, and at times refused placement of alarms. Preventive interventions were as follows: - to anticipate the resident's needs - to ensure a safety officer is present when attending outside/outdoor activities - to make sure the resident was wearing appropriate footwear - to ensure bathroom door alarm, pressure alarm in bed and wheelchair are working and in place - to ensure the call light and personal items were within reach, floors free from clutter, the bed in low position, adequate glare-free light - to check seat belt for proper working order Documents titled Change of Condition Evaluation dated [DATE] were reviewed with several areas incomplete: Changes in condition - Increasing flaccidity left arm and moderate drooling; Functional status evaluation - generalized weakness Describe the change in general weakness - not described, options not checked Describe the functional status signs or symptoms - not described, area left blank Pain evaluation areas left blank Neurological evaluation left blank. What do you think is going on with the resident? RN I think the problem may be - area blank LPN The resident appears - area blank The Request section was left blank which had options to select: monitor vital signs, labwork, x-ray, EKG, provider visit, transfer to the hospital, or other new orders. Name, Date and time of family notification was blank as was the date and time of clinician notification. When asked for a policy on change of condition, the following policy was provided: Administrative and Department Policies dated [DATE], indicated to complete alert charting for resident falls, change of condition, antibiotic administration, resident incidents, change of behaviors, and other relevant patient concerns or issues. Additionally, during interviews with Employee 1, Employee 2, and Employee 3, there were suggestions that the facility could have used a helmet for protection to the head; the facility could have kept Resident 1 in the bed for further observation and assessment; someone could have been present in the common room to continue observation to monitor for worsening signs and prevent actions to cause a subsequent fall. Refer to F 323

Based on observation, interview, and document review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 13 sampled residents (Residents 2, 13, 7). Findings included: 1. Resident 2 was readmitted on [DATE], with [DIAGNOSES REDACTED]. On 9/11/13 in the morning, the charge nurse revealed Resident 2 fell on [DATE]. Review of the Falls Report Form (dated 3/25/13), completed by the DON, read as follows: --Exact Location: Outdoors in front area. --What was happening at time of the fall: Was participating in an event with activities. --How did the fall occur: Activity staff parked resident near patio area, it appears as resident released brakes, went over curb and fell . --Was an injury incurred? Yes. --If yes, please describe the nature of the injury: She made contact with (sic) pavement as she fell . Fx (fractured) legs. --Treatment required: Yes. hospitalization . --Contributing factors: Res. released her own brakes. --Root Cause: Resident released brakes and went over curb - while outdoors. Review of the statement (dated 3/21/13) written by the activities aide (AA), revealed the AA had wheeled the resident to the front patio for the annual Easter Egg Hunt activity, and locked her W/C brakes. The AA left the resident to assist other resident to hunt for eggs. During an interview with the AA on 9/12/13 (in the afternoon), Resident 2 was anxious to go and find eggs, and without waiting for the AA to return and assist her, Resident 2 unlocked her W/C brakes and began self-propelling her W/C. Her W/C rolled from the patio to the sidewalk and over the curb onto the driveway. Resident 2 fell out of her W/C and onto the pavement with her W/C turned over. An Escort/Driver (in her documented statement of the fall) had written that she happened to turn and saw Resident 2 rolling towards the driveway. She tried to run after her but Resident 2 had already went over the curb. When interviewed (on 9/11/13 at 10:50 AM) regarding the fall, both the DON and Minimum Data Set (MDS) coordinator stated that prior to the fall, they had observed Resident 2 self-release her wheelchair (W/C) brakes and self-propel her W/C. Interview (on 9/12/13 beginning at 11:26 AM) with an Escort and an Escort/Driver revealed that they both have also observed Resident 2 self-release her W/C brakes and self-propel her W/C. Review of the Minimum Data Set (MDS) of 2/26/13, revealed the resident had impairment on both of her lower extremities and used a wheelchair (W/C). The care plan (dated 2/25/13): --Activities of Daily Living (ADL): Need total assist with ADL's due to [DIAGNOSES REDACTED]. Approaches included: Provide W/C for mobility. --Cognition: Has difficulty in making decisions for daily tasks of life. --Fall: Is at risk for falls secondary related to seizure disorder. The care plan did not include documentation that the resident could self-release her W/C brakes and self-propel her W/C. Resident 2's fall occurred with facility staff's awareness that the resident was able to self-release her W/C brakes and self-propel her W/C. 2. Resident 13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review revealed that the resident had a fall on 8/14/2012. The record and Incident/Accident Report (I/A Rpt., documented by the DON), and concurrent interview on 9/12/13 in morning with the activity aide (AA) who observed the fall, revealed the following: The AA was standing in the Archie Cafe (located in the facility), where she had a direct view of the resident self-propelling her W/C out the front door (from the hallway that led from the Archie Cafe). The AA ran to attempt to catch Resident 13 before the resident hit the curb, but could not catch the resident before her fall. She observed the resident go over the curb in her W/C and land on the pavement. The record revealed the resident flipped over the curb, hitting her face on the pavement. A large contusion was noted over the right side of her face with bleeding and swelling. The DON documented that the root cause was "altered depth perception - could not distinguish curb from sidewalk". Review of Resident 13's MDS (dated 5/27/2012) revealed: --She sometimes understands-responds adequately to simple, direct communication only; --Had short and long-term memory problems; --Had severely impaired cognitive skills for daily decision-making; --Had wandering behavior. Review of Resident 13's care plan revealed: --(dated 5/29/2012): Confusion: has attempted to leave facility. Interventions: Monitor whereabouts, Wanderguard Monitor. --(dated 5/29/2012): Other documentation: "...wanderguard watch to monitor her whereabouts. Continues at risk for Elopement, she wanders to the front desk, recepionist (sic) has called the nurses station frequently." Although the facility had implemented a number of interventions, the facility failed to provide adequate supervision and assistive devices to prevent Resident 13 from a fall. 3. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission and quarterly Minimum Data Sets dated 5/21/13 and 8/21/13 respectively revealed Resident 7 needed assistance of 2 staff for ADLs (activities of daily living) and was restricted in range of motion in both upper and lower extremities. The facility's care plan initiated on 5/17/13 and revised 8/28/13 indicated the resident was: - totally dependent on 2 staff to turn and reposition and turn in bed every 2 hours and as necessary - required total assist by 2 staff to provide bath 3 times a week and as necessary - had contractures of the upper and lower extremities and was totally dependent on staff for dressing and on 2 staff for transferring. The interdisciplinary notes dated 9/4/13 indicated a hospice certified nursing assistant (CNA) was changing Resident 7's linens with her in the bed, and the resident's knees slipped off the bed and the hospice CNA was unable to stop the resident's fall. The hospice CNA lowered the resident's upper body to the floor. The resident was reportedly uninjured and the hospice care plan was altered to have 2 people present for linen changes because of Resident 7's inability to assist. Review of the record revealed the hospice care plan had no information regarding the need for the resident to have the assistance of 2 staff, until after the fall on 9/4/13. Interview with the assistant director of nursing on 9/13/13, revealed the facility had separately care planned from hospice. The facility failed to prevent an avoidable fall. 4. During the environmental tour on 9/10/13 (beginning at 1:35 PM) with the Environmental Services Manager (EVS Mgr.), and on 9/13/13 (beginning at 2:15 PM) with the DON, a large weight scale platform in room 806 was observed with pieces of black covering peeling or already peeled from the flat surface where a resident would stand or a resident in a wheel chair would be positioned for weighing. Some of these peeling edges were sticking up or curled back. The EVS Mgr. and DON acknowledged residents could obtain scratches, skin tears, trip, or receive other injuries from the peeled edges.

Based on observation, interview, and record review, the facility failed to protect Resident C1 from serious injury secondary to a fall by failing to provide adequate staffing, by not acting upon a change in the resident's condition that contributed to her fall risk, and by failling to utilize devices designed to protect the resident from fall with injury. Findings: 1. Resident C1 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident's "Initial Nursing Assessment" on 8/7/10 noted the resident to be "modified independence" in cognitive skills, was usually able to understand and be understood and she did not display anxiety nor wandering behaviors. She was not able to move independently and was totally dependent on staff. Her "Fall Risk Assessment" dated 8/7/10 stated "no falls", that she was unable to walk due to a "Rt.(right)BKA(below knee amputation)". On this fall risk assessment, the resident did not trigger for medications, diseases, or other conditions that could have elevated her fall risk and was noted to be able to make her needs known and that she did not have dementia. Her total fall risk score was "14". The resident's active care plan dated 7/20/10 and not updated after this admission noted under "ADLS" the following: "Ms XX requires total assistance with ADL's due to FX of the RLE, but verbalizes her desire to increase independence in ADL's such as dressing & grooming". Under the category of "FALL", the following was noted: "Ms XX is high risk for falls related to poor balance, weakness, poor safety awareness & visual impairment." The approaches listed include physical therapy for strengthening and a bed to be put in its lowest position, but did not include a fall mat. In summary, the documents reviewed presented confusing and conflicting information about the resident's fall risk and indicated the assessment done this admission did not match previous assessments that determined this resident had a significant fall risk. Fall risk interventions did not include a fall mat which could have minimized the impact of potential falls. The resident's room ("bed hold") when viewed on 9/10/10 at 4:30 pm was at the far end of one of the hallways, first bed. The bed was observed in the low position, but measured about 23 inches from the floor. There was a call bell clipped to the bed and there was no fall mat in use for this resident. Pictures of the resident's room and bed, as well as the measurement of top of bed to floor are attached. The report submitted by the facility to CMS noted the resident had an unwitnessed fall on 8/29/10 at about 0820 and was found unconscious momentarily and then responded to questions. The report noted that her head and part of her body were on the floor and her legs were still on the bed. There was blood under her head. 911 was called immediately and the charge nurse kept the resident's head immobile until the ambulance team arrived and took over her care. Family was notified. The resident was transported initially to Casa Grande Hospital for evaluation of head and shoulder trauma and later was transported to Banner Good Samaritan Hospital, Trauma Intensive Care Unit. The facility had no further information about her condition or disposition after this initial period. 2. On 9/17/10, the resident was located by the federal surveyor as an inpatient (second admission)on a Medical-Surgical floor at Banner Good Samaritan Hospital in Phoenix, Arizona and was visited by the surveyor at 5:30 pm. She was resting on her back comfortably in a hospital bed with a low air loss mattress and the cervical collar in place. C1's Registered Nurse noted at 5:15 pm that she was oriented to self only. The nurse also noted she had a Stage IV sacral pressure ulcer which was debrided in a wound clinic. In the resident interview at 5:30 pm, she spoke and answered questions, but her information did not make sense. She did not appear to be in pain, but was receiving intravenous pain management. Hospital records from her first admission to Banner Good Samaritan Hospital, 8/29/10 to 9/11/10 were obtained and revealed the resident was admittted to trauma care in this hospital with complaints of bilateral shoulder and right hip pain. The history and physical noted: "CT (computerized tomography)of the C-spine shows fracture of anterior arch of C1 with no appreciable displacement and a body fracture of C2 with no evidence of dislocation. CT of the abdomen and pelvis shows a possible fracture of the left ninth rib, otherwise no acute intra-abdominal injury". A later CT of the abdomen found only a small fracture of the posterior aspect of the left ninth rib. A subsequent CT of her head/brain without contrast report stated that there was no acute intracranial abnormality present, but there were senescent changes. 3. In an interview conducted by telephone 9/17/10 at 9:50 am with the facility ward clerk on duty 8/29/10 in the morning, the ward clerk stated she witnessed the resident fall while asking for help to get up. She heard the resident yelling out and observed her fall when she--the ward clerk, reached the doorway. She noticed the resident lying on her right side at the very edge of the right side of the bed and then she fell off to the left, twisting as she fell , with her legs and part of her back catching in the sheets. She stated that the resident's head bumped on the floor hard making a very noticeable sound, while her legs remained caught in the sheets. The ward clerk did not assist the resident, but went to find the charge nurse immediately. By the time she was leaving the doorway of the resident's room, others were responding to the sounds from this room. The ward clerk noted there were usually Certified Nurses Assistants (CNAs) in the hallway to assist the residents, but they were all helping to feed residents in the dining room at the time of the resident's fall. She also noted that residents who normally eat in their rooms, eat first before the residents in the dining room. Thus, there were no staff in the immediate area to assist this resident after breakfast and she wanted to get up. 4. In an interview with the Activities Director (AD) at 4:42 pm on 9/10/10, she stated she heard the resident yelling for help to get up around 8 am on 8/29/10. When she arrived at the room, she saw the resident lying on her side yelling for assistance and that she then went to find assistance for this resident. She could not find a CNA to assist the resident, but did find the ward clerk. She stated she has been told not to assist residents in this type of circumstance. In an interview at 5 pm on 9/10/10 with an LPN on duty the morning of the fall, the nurse stated she was at the nurses station finishing medication pass when someone said "XX(resident's name) is on the floor"". She went to the room and others were attending to the resident. She noted that the resident's assigned CNA was holding her head gently, resident was on her back and she saw a large bump, approximately 3 cm above the resident's left eye and also a laceration through the bump that also measured about 3 cms. It was bleeding profusely. She got a towel and some ice and it was applied to the resident's forehead. She stated that the resident is usually "clear", but after the injury,she noticed the resident was somewhat confused. When the LPN was asked about her expectation for CNA care on the ward on a typical Sunday morning, she stated that 3 CNAs are usually there, but at this time all were in the dining room feeding residents. When asked about the resident's normal routine in the facility, she stated the resident would usually eat in the dining room with other residents, but that she was on bed rest due to development of a Stage IV coccyx wound. She was asked when she last viewed the resident's coccyx ulcer and stated it was the night before the accident. She stated the ulcer has worsened quickly from the previous week and was a Stage IV pressure ulcer. 5. In an interview with the wound care nurse on 9/10/10 at 5:50 pm, he stated the resident's coccyx pressure ulcer advanced rapidly from a Stage II 8/16/10 to a Stage IV 8/25/10 and presented pictures and data that documented this conclusion. The nurse also noted the resident had a change of condition --she became more confused between 8/16 and 8/25/10 and that he did notify the charge nurse of this. He stated the resident had been relatively alert and oriented before, but now had mental decline and confusion. He stated that on 8/25/10, she was "acting out of it". 6. In an interview with the DoN on 9/10/10 at 6:50 pm, she said there were no witnesses to the fall. She was asked why the resident did not have a fall mat. The DoN stated it was not considered because the resident was not assessed as a fall risk. When the DoN and the administrator were asked what the facility QAA committee identified as causes for the resident's accident and if anything had changed since the resident's fall with injury the response was they considered she fell due to age and condition and that no new actions had been taken in the facility. There was no awareness on the part of the Director of Nurses (DoN) when she was interviewed at 6:50 pm on 9/10/10 that the resident had a change of condition sometime during the time between 8/16 and 8/25/10 as noted by the wound care nurse. In reviewing the progress notes in the resident's electronic medical record, there were notations on 8/25/10 at 8:16 am and again at 4:02 pm, as well as 8/26/10 at 2:56 pm that the resident was oriented to self only. On 8/26/10, there was an entry in the electronic medical record at 5:38 pm that a phone call had been made to the resident's daughter to inform her of the resident's "increased skin issues as well as increased confusion". In the electronic medical record progress notes, there was an entry dated 8/27/10 7:52 pm from the LPN noting that the resident had a "dramatic worsening in condition of skin on her coccyx and upper posterior thighs". There was a further notation at that time that she was given the maximum dose of Oxycodone allowed by the order. While entries about the resident's worsening condition were made in the resident's electronic medical record, there was no evidence this information was shared with the DoN or interdisciplinary care team, how the change of condition was addressed and why there was confusion about the resident's fall risk and need for measures designed to reduce risk such as a fall mat and supervision. There was no evidence that the resident's care plan changed with her worsening condition or that any new safeguards were discussed or put into place with her change of condition.