Every finding on record at Arizona State Veteran Home-Tucson

Based on staff interviews, facility documentation, and policy review, the facility failed to ensure that staffing information (Payroll-Based Journal, PBJ) submitted to the Centers for Medicare and Medicaid Services (CMS) was accurate and submitted in a timely manner. The universe was 23. This deficient practice could have resulted in residents receiving inadequate care due to a potential lack of staffing. Findings included:The PBJ Staffing Data Report for Fiscal Year (FY) Quarter 1, 2026 (October 1-December 31), revealed that the facility failed to submit data for the quarter. A request made during the entrance meeting on April 7, 2026 at 8:38 a.m. for the PBJ staff data for the Quarter 1 FY 2026. The facility provided the data submitted to CMS, which was received by the survey team on April 10, 2026, at 10:00 a.m.An interview was conducted with the Business Office Manager (Staff #64) on April 10, 2026, at 9:48 a.m. Staff #64 stated that she was the qualified personnel responsible for processing and submitting this data. Staff #64 stated that the PBJ staffing data had been submitted on February 13, 2026. She stated that the due date for submission of quarter 1 for the fiscal year 2026 PBJ staffing data to CMS was February 14, 2026. Staff #64 further stated that, upon later review of feedback from CMS, the PBJ data had been rejected and the submission period had closed. Staff #64 indicated that the file submitted was not the correct file and reiterated that, by the time feedback was received from CMS, the submission deadline had passed.A subsequent interview was conducted with the Facility Administrator (Staff #87) on April 10, 2026, at 11:16 a.m. Staff #87 stated that a possible reason for the rejection of the PBJ data was the submission of incorrect codes, although the specific codes involved were not identified. Staff #87 stated that the facility should have submitted the PBJ data at least one week prior to the deadline to allow sufficient time to correct any errors identified by CMS and to ensure timely resubmission. Neither Staff #64 nor Staff #87 identified the date on which feedback from CMS was received; however, both indicated that the rejection was discovered after the submission window had closed. Neither staff member described the facility's current submission process. For Quarter 1 of each fiscal year, the submission deadline for PBJ data to CMS was February 14 annually.A review of the policy titled Reporting Direct Care Staffing Information (Payroll-Based Journal), last revised in August 2022, indicated that staffing information was collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. The policy further stated that complete and accurate direct care staffing information was to be reported electronically to CMS through the Payroll-Based Journal system in a uniform format specified by CMS.

Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident (#8) out of three residents sampled was appropriately screened and referred for a Level II PASSR (Pre-admission Screening and Record Review) evaluation upon identification of a serious mental illness, in accordance with PASSR requirements. The universe was 23. The deficient practice has the potential to result in failure to identify and provide necessary specialized services.Findings include:Resident #8 was admitted to the facility on [DATE] with diagnoses of major depressive disorder; insomnia, post-traumatic stress disorder (PTSD), chronic; and psychotic disorder with hallucinations due to a known physiological condition.An admission PASRR, dated March 10, 2025, indicated that Resident #8 had a Serious Mental Illness (SMI) diagnosis of major depression. It also indicated he had a substance related disorder as well. The PASSR noted that the most recent substance use was 2-3 months prior. The section of the PASSR asking if the resident had a recent psychiatric or behavioral evaluation was left blank. Also, the section of the PASRR asking if the resident was taking any psychotropic medications was left blank. The bottom of the PASRR form noted that a referral for a Level II PASSR was not necessary and was signed by a hospital Social Worker.The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status assessment and scored 15 which indicated he was cognitively intact. The same MDS assessment noted that he had depression, psychotic disorder, and Post Traumatic Stress Disorder (PTSD). It also noted that he was taking antipsychotic and antidepressant medications.A physician's order was observed, in the clinical record, for Trazodone (anti-depressant) 100 mg (milligrams) at bed time. The order had a start date of March 11, 2025 for Resident #8's inability to sleep due to his depression.A second physician's order was observed for Venlafaxine (anti-depressant) 150 mg once a day. The order had a start date of March 11, 2025 for visual and auditory hallucinations related to his PTSD.A third physician's order was observed for Quetiapine (anti-psychotic) 50 mg once a day. The order had a start date of August 17, 2025 for mood changes and insomnia due to his PTSD.A second PASRR, dated March 13, 2026 was located in Resident #8's clinical record. The PASRR indicated he had a SMI diagnosis of major depression and psychotic/delusional disorder. It also indicated he had PTSD. The PASRR revealed Resident #8 was in remission for alcohol abuse. It was noted that he was taking Quetiapine, Trazodone, and Venlafaxine. The form also noted that Resident #8 did not need a referral for Level II and was signed by Social Services (SS/Staff #86).An interview was conducted on April 9, 2026 at 2:09 P.M. with Social Service/Staff #86. He explained that the PASRR was a screening tool related to a resident's mental health. It was to determine if a resident would need a Level II placement versus a Level I placement. He further explained that a resident would typically come in with a PASRR in place already but if they did not have one on file, he would do it. He also updates the PASRR annually and when there is a change in the resident's condition. Staff #86 shared that if a resident has behaviors or is taking medications related to their mental health, he will involve the interdisciplinary team (IDT) to review their case because he is not a clinician. The IDT team then determines if the referral is to be sent for a Level II PASRR. Staff #86 reviewed Resident #8's clinical record and stated that Resident #8 had two PASRRs, one dated March 10, 2025 and one dated March 13, 2026. He further stated that Resident #8's diagnoses listed on his March 10, 2025 PASRR were major depressive disorder and previous marijuana use. The form also stated that the March 13, 2026 PASRR indicated he had major depression, psychotic disorder, PTSD, and alcohol use. Staff #86 explained that even with the listed diagnoses on the PASRR, Resident #8 was not referred for a Level II PASRR because the resident had no behavioral issues and he was stable. He further explained that if a resident has a serious mental illness and is stable, then he didn't see a need for them to be referred for a Level II PASRR. He added that this was a decision made by the IDT team. Staff #86 confirmed that the PASRR policy indicated that if a resident had a mental health diagnosis, they were to be referred for a Level II PASRR. He shared that he used to send a referral in, for a Level II PASRR, for everyone who had a mental illness diagnosis. He shared that he was then told, by the state PASRR representative, that everyone with a diagnosis did not need to be referred for a Level II. However, Staff #86 was not able to provide proof of this correspondence. Staff #86 stated that, depending on the diagnosis, the risk to the residents for not sending in the Level II PASRR, would be them not being treated appropriately.An interview was conducted on April 9, 2026 at 2:57 P.M. with the Director of Nursing (DON/Staff #72). Staff #72 explained that the purpose of the PASRR was to determine what mental health diagnosis, or other diagnosis, a resident has that might require the facility to refer them to a Level II PASRR. She added that this is completed by the hospital social worker prior to a resident's admission to the facility. Staff #72 shared that if a resident were to need Level II services, that is something they were able to provide with their in-house Geriatric Psychiatry services. After reviewing Resident #8's clinical record, Staff # 72 confirmed that, upon admission, he had SMI diagnoses of major depression. She further confirmed that he had used marijuana as well. She also confirmed that Resident #8 was not referred for a Level II PASRR. She explained that they wouldn't need to refer someone for a Level II screening if their needs can be met in the facility and they are stable. Staff #72 added that due to Resident #8 not having an active acute episode, at the time period of the admission, it indicated that he was stable. She shared that if the IDT team felt that a resident's psychological needs would not be able to be met, they would send them out to the hospital. Staff #72 stated that a possible risk to the residents, for not having a Level II PASRR screening completed, is that their psychological needs are not being met, especially if the facility does not have the services available. She added that this facility does have services such as geriatric psychiatry and psychiatry services available.Review of the facility's policy and procedure, titled Behavioral Assessment, Intervention, and Monitoring revealed it was last revised in January 2026. The policy and procedure indicated that if a resident's level I PASRR screening indicated a resident may meet the criteria for a mental disorder, intellectual disability, or related condition, then they were to be referred to the state PASRR representative for the level II screening and evaluation.

Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to coordinate/implement PASRR findings by failing to ensure one resident (#8) out of three residents sampled was appropriately screened and referred for a Level II PASSR (Pre-admission Screening and Record Review) evaluation upon identification of a serious mental illness, in accordance with PASSR requirements. The universe was 23. The deficient practice has the potential to result in failure to identify and provide necessary specialized services.Findings include:Resident #8 was admitted to the facility on [DATE] with diagnoses of major depressive disorder; insomnia, post-traumatic stress disorder (PTSD), chronic; and psychotic disorder with hallucinations due to a known physiological condition.An admission PASRR, dated March 10, 2025, indicated that Resident #8 had a Serious Mental Illness (SMI) diagnosis of major depression. It also indicated he had a substance related disorder as well. The PASSR noted that the most recent substance use was 2-3 months prior. The section of the PASSR asking if the resident had a recent psychiatric or behavioral evaluation was left blank. Also, the section of the PASRR asking if the resident was taking any psychotropic medications was left blank. The bottom of the PASRR form noted that a referral for a Level II PASSR was not necessary and was signed by a hospital Social Worker.The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status assessment and scored 15 which indicated he was cognitively intact. The same MDS assessment noted that he had depression, psychotic disorder, and Post Traumatic Stress Disorder (PTSD). It also noted that he was taking antipsychotic and antidepressant medications.A physician's order was observed, in the clinical record, for Trazodone (anti-depressant) 100 mg (milligrams) at bed time. The order had a start date of March 11, 2025 for Resident #8's inability to sleep due to his depression.A second physician's order was observed for Venlafaxine (anti-depressant) 150 mg once a day. The order had a start date of March 11, 2025 for visual and auditory hallucinations related to his PTSD.A third physician's order was observed for Quetiapine (anti-psychotic) 50 mg once a day. The order had a start date of August 17, 2025 for mood changes and insomnia due to his PTSD.A second PASRR, dated March 13, 2026 was located in Resident #8's clinical record. The PASRR indicated he had a SMI diagnosis of major depression and psychotic/delusional disorder. It also indicated he had PTSD. The PASRR revealed Resident #8 was in remission for alcohol abuse. It was noted that he was taking Quetiapine, Trazodone, and Venlafaxine. The form also noted that Resident #8 did not need a referral for Level II and was signed by Social Services (SS/Staff #86).An interview was conducted on April 9, 2026 at 2:09 P.M. with Social Service/Staff #86. He explained that the PASRR was a screening tool related to a resident's mental health. It was to determine if a resident would need a Level II placement versus a Level I placement. He further explained that a resident would typically come in with a PASRR in place already but if they did not have one on file, he would do it. He also updates the PASRR annually and when there is a change in the resident's condition. Staff #86 shared that if a resident has behaviors or is taking medications related to their mental health, he will involve the interdisciplinary team (IDT) to review their case because he is not a clinician. The IDT team then determines if the referral is to be sent for a Level II PASRR. Staff #86 reviewed Resident #8's clinical record and stated that Resident #8 had two PASRRs, one dated March 10, 2025 and one dated March 13, 2026. He further stated that Resident #8's diagnoses listed on his March 10, 2025 PASRR were major depressive disorder and previous marijuana use. The form also stated that the March 13, 2026 PASRR indicated he had major depression, psychotic disorder, PTSD, and alcohol use. Staff #86 explained that even with the listed diagnoses on the PASRR, Resident #8 was not referred for a Level II PASRR because the resident had no behavioral issues and he was stable. He further explained that if a resident has a serious mental illness and is stable, then he didn't see a need for them to be referred for a Level II PASRR. He added that this was a decision made by the IDT team. Staff #86 confirmed that the PASRR policy indicated that if a resident had a mental health diagnosis, they were to be referred for a Level II PASRR. He shared that he used to send a referral in, for a Level II PASRR, for everyone who had a mental illness diagnosis. He shared that he was then told, by the state PASRR representative, that everyone with a diagnosis did not need to be referred for a Level II. However, Staff #86 was not able to provide proof of this correspondence. Staff #86 stated that, depending on the diagnosis, the risk to the residents for not sending in the Level II PASRR, would be them not being treated appropriately.An interview was conducted on April 9, 2026 at 2:57 P.M. with the Director of Nursing (DON/Staff #72). Staff #72 explained that the purpose of the PASRR was to determine what mental health diagnosis, or other diagnosis, a resident has that might require the facility to refer them to a Level II PASRR. She added that this is completed by the hospital social worker prior to a resident's admission to the facility. Staff #72 shared that if a resident were to need Level II services, that is something they were able to provide with their in-house Geriatric Psychiatry services. After reviewing Resident #8's clinical record, Staff # 72 confirmed that, upon admission, he had SMI diagnoses of major depression. She further confirmed that he had used marijuana as well. She also confirmed that Resident #8 was not referred for a Level II PASRR. She explained that they wouldn't need to refer someone for a Level II screening if their needs can be met in the facility and they are stable. Staff #72 added that due to Resident #8 not having an active acute episode, at the time period of the admission, it indicated that he was stable. She shared that if the IDT team felt that a resident's psychological needs would not be able to be met, they would send them out to the hospital. Staff #72 stated that a possible risk to the residents, for not having a Level II PASRR screening completed, is that their psychological needs are not being met, especially if the facility does not have the services available. She added that this facility does have services such as geriatric psychiatry and psychiatry services available.Review of the facility's policy and procedure, titled Behavioral Assessment, Intervention, and Monitoring revealed it was last revised in January 2026. The policy and procedure indicated that if a resident's level I PASRR screening indicated a resident may meet the criteria for a mental disorder, intellectual disability, or related condition, then they were to be referred to the state PASRR representative for the level II screening and evaluation.

Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident (#1) was free from verbal abuse from visitors. The deficient practice could lead to physical and psychosocial harm to residents.Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, pneumonia, and urinary tract infection (UTI).Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated that a Brief Interview for Mental Status (BIMS) was not able to be completed. However, staff assessed Resident #1's cognitive skills for daily decision making to be severely impaired. The same MDS did not indicate Resident #1 exhibited behaviors of any type.Review of the clinical record revealed Progress Note dated May 23, 2023 at 3:03 P.M. that indicated Resident #1 had a caregiver at bedside. The note further indicated that a CNA (Certified Nursing Assistant) reported the resident had bitten the caregiver on the right 2nd finger during care.Review of additional progress notes revealed an entry dated May 23, 2023 at 5:11 P.M. The entry indicated that a CNA (Certified Nursing Assistant) had reported that Resident #1's caregiver had put soap in his mouth because he was cursing. It also indicated that was the reason Resident #1 had bitten the caregiver. It further indicated that the house supervisor was notified of the incident.An interview was conducted with CNA/Staff #6 on December 26, 2025 at 1:32 P.M. Staff #6 explained that because he works with Veterans, they tend to swear a lot or swear at him. However, he added it did not mean that you can retaliate towards them. When asked if putting soap in a resident's mouth would constitute as abuse, he said yes.A telephonic interview was conducted on December 26, 2025 at 2:25 with the caregiver (alleged perpetrator). The caregiver indicated that she was hired by his wife as a companion caregiver to help with cleaning and feeding Resident #1. However, she stated that she did not really recall the resident but remembered the wife. She further stated that there was some sort of disagreement, but she couldn't recall what, that led to her not working with the family anymore. The caregiver added that she had short-term memory loss so she does not remember a lot of things.An interview was conducted with the Director of Nursing (DON/Staff #49) on December 26, 2025 at 2:34 P.M. Staff #49 explained that the facility self-reported the incident when Resident #1's caregiver had reported to the CNA that they had a verbal altercation and she was not happy with the words he had used. Staff #49 further explained that the caregiver reported telling Resident #1 to be nice and to stop saying vulgar words and if he didn't stop, she told him that people who curse get their mouths washed out with soap. The caregiver had soap on her hands and then Resident #1 lunged forward and bit the soap in the caregiver's hands along with her fingers. Staff #49 shared that after the incident came to light the facility informed the caregiver that she was no longer welcome at the facility. Staff #49 indicated that it was not acceptable for visitors to threaten to put soap into the mouths of residents as it would cause mental anguish to those on the receiving end and they could also feel threatened.An interview was conducted with the Administrator/Staff #12 on December 26, 2025 at 2:53 P.M. He acknowledged that he was the abuse coordinator for the facility. Staff #12 shared that the friend of the family would visit and sit with Resident #1. At one point, the friend had threatened to wash Resident #1's mouth out with soap, however, he was not sure if the friend actually did it or not. He did indicate that Resident #1 did bite the visitor. Staff #12 further indicated that the friend was banned from the facility and the situation was reported to the SA and the local police department. Staff #12 explained that Resident #1 was not able to communicate and he had advanced Parkinson's disease so Staff #12 was not able to get a statement from the resident regarding the incident. When asked if it was acceptable for visitors to threaten putting soap into residents' mouths, Staff #12 shared that it was absolutely not acceptation which is why the friend was banned from the facility. He further shared that he was not comfortable with speculating what harm could come from the residents when they are threatened. However, he pointed out that the facility does not allow that type of behavior and if someone were acting like that, they are not allowed to stay at the facility.Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, indicated the policy was revised in January 2025. The policy indicated that residents have a right to be free from abuse, neglect. It also includes verbal and physical abuse as well.

Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and review of the facility's policies and procedures, the facility failed to protect rights of one resident (resident #10) to be free from misappropriation from staff. The deficient practice could result in further incidents of staff to resident financial abuse. Findings include: -Resident #10 was admitted to the facility on [DATE], with diagnoses that include Bradycardia, atrial fibrillation, bipolar disorder, anxiety, dementia, and peripheral vascular disease. Review of the Significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A review of the SA(state agency) complaint system revealed that on June 18, 2024 at 10:00 a.m. an incident was reported by the facility that resident #10 had reported to her nurse, she had been asked for money by a previous employee (staff #75) that had recently quit the facility. It revealed that the staff #75 picked resident #10 up for lunch and that resident #10 had filled the employee's gas tank for $55, and paid for lunch for $35. It further revealed that after returning to the facility staff #75 asked for $1200, and that resident #10 initially declined but agreed because she felt pressured to give him the money, after which staff #75 had her download the banking app [NAME] on her phone and sent the $1200 to his account. It concluded that resident #10 stated this is not the first instance of giving staff #75 money. An interview was conducted with resident #10 on December 26, 2025 at 1:10 p.m. Resident #10 stated staff #75 started asking for money, for a lot of things. She stated that initially she thought staff #75 didn't make much money and felt sorry for the guy. She stated that she would help the guy as much as she could, and that staff #75 wanted money for rent, but kept buying things like laptops and stuff, and not paying his rent. Resident #10 stated that the icing on the cake was he showed up asking for $1200 to pay his rent and said we can do it through [NAME]. She continued that staff #75 stated he needed the money for his rent. Resident #10 stated that after the [NAME] transaction went through she got a call from the bank to confirm the transaction and she did. She further stated that later she reported the incident and the police got involved, which also involved the administrator who told resident #10 she couldn't give money to employees. Resident #10 stated that she never got the money back, and that the facility never reimbursed any of the money she lost. Resident #10 concluded that she was told by staff #75 that he was going to pay the money back, but never did. Resident #10 concluded that she spoke to staff #75 and he told her that resident #10 got him in trouble with the police, and stated that she did feel abused financially. An attempt to contact the perpetrator staff #75 was attempted on December 26, 2025 at 1:35 p.m., however, the number was no longer valid. An interview with a Certified Nursing Assistant (CNA/staff #150) was conducted on December 29, 2025 at 1:32 p.m. Staff #150 stated that there are multiple kinds of abuse, physical, sexual, and financial. Staff #150 stated she was aware of an incident that had occurred and that they have had training that it wasn't appropriate to ask residents for gifts or to accept them. The CNA stated that it's never ok to ask residents for money or other gifts. Staff #150 concluded that the abuse coordinator is the administrator and that's who she would report abuse to if she saw it. An interview was conducted with the Director of Nursing (RN/staff #90) on December 29, 2026 at 3:20 p.m. The DON stated that she was aware of the incident when it occurred and after investigating it, found it to be substantiated. The DON then confirmed staff #75's name and provided a copy of the facility reported incident (FRI) related to the incident. The DON stated that staff #75 was previously employed by the facility and in the therapy department. The DON further stated that at the time of the incident he was no longer an employee at the time, and that resident #10 had not been reimbursed. The DON further stated that they did training for staff and brought in the ombudsman during a resident council meeting to inform all the residents that they are not to be giving staff money or gratuity. The DON concluded that they did substantiated the complaint and made all the appropriate reports. A review of facility policy titled 'Abuse, Neglect, Exploitation and Misappropriation revised January, 2025 revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, interview, and review of facility policy and procedure, the facility failed to ensure three of three sampled ice machines were cleaned and maintained as needed for sanitary food service. The deficient practice could lead to the spread of foodborne illness for residents.Findings include:The Quarterly Ice Machine Inspection logs for ice machines on 300 A, 300 B, and 300 C common room dining areas revealed that the ice machines were last inspected and cleaned on June 6, 2025, by the maintenance director (Staff #40).An observation was conducted on October 7, 2025, at 11:50 A.M. of the three ice machines on the 300 unit, with one ice machine located in each of the three common room dining areas. Each of the three ice machines had a metallic-appearing housing box, and a clear plastic downspout for dispensing ice. Each of the three ice machine units had white-ish residue build-up on and around the clear plastic downspouts. One unit had brown-ish colored residue on the inside of the clear plastic downspout, and the other two units had multiple black spots of a growth-appearing residue on the inside of the clear plastic downspouts.Another observation was conducted on October 7, 2025, at 12:09 A.M. with the maintenance director (Staff #40), of one of the ice machines on the 300 unit. Staff #40 opened the top of the ice machine to view inside. There was white-ish residue inside the drum of the ice machine.An interview was conducted with Staff #40 at that time, and Staff #40 stated that he deep cleans the ice machines every 6 months, and that he maintains a log of the ice machine cleaning. Staff #40 stated that housekeeping staff clean the outside of the ice machine when they clean the common areas. Staff #40 stated that the white-ish residue was calcium build-up from the local tap water.An additional observation was conducted October 7, 2025, at 1:54 P.M. of all three ice machines on the 300 unit. The ice machines were still observed to have the white residue on and surrounding the clear plastic downspouts. Additionally, the two ice machines with visible black spots inside the clear plastic downspouts were still not cleaned. Photographs of the ice machines were taken at that time.An interview was conducted with a Licensed Practical Nurse (LPN / Staff #29) on October 7, 2025, at 1:56 P.M. One of the ice machines was observed together with Staff #29, and Staff #29 stated that the black spots inside the clear plastic downspout could be mold, but that she did not know what it was. Additionally, Staff #29 stated that the clear plastic downspout was definitely not clean, and that she would not consume ice from that machine after looking at it.An interview was conducted with a housekeeper (Staff #101) on October 7, 2025, at 2:00 P.M. Staff #101 stated that housekeeping staff wipe down the outside housing of the ice machine during cleaning rounds of the common area, and that the housekeeping supervisor deep cleans the ice machine every other week. Staff #101 stated that the housekeeping supervisor cleans the inside of the clear plastic downspout of the ice machine, but that the cleaning brush does not fit inside the downspout very well. One of the ice machines was observed together, and Staff #101 stated that she did not know what the black spots inside the clear plastic downspout were.An interview was conducted with the housekeeping supervisor (Staff #83) on October 7, 2025, at 2:05 P.M. Staff #83 stated that the housekeeping department cleans the outside housing of the ice machines only, and does not clean any of the inside parts. Specifically, Staff #83 stated that the housekeeping department does not clean the clear plastic downspout of the ice machines. One of the ice machines on the 300 unit was observed together, and Staff #83 stated that he did not know what the black spots inside the downspout were.An interview was conducted with the Administrator (Staff #70) on October 7, 2025, at 2:42 P.M. The Administrator stated that his expectation for cleaning and maintaining the ice machines would be for staff to follow the manufacturer's instructions and to keep them as clean as possible in order to prevent spread of infection. The Administrator stated that he would expect if staff noticed residue and build-up in the ice machines, that staff should submit a work order to the maintenance department, and that it should be addressed timely. The Administrator observed photographs of the ice machine clear plastic downspouts with residue and black spots, and the Administrator stated that they would not be considered clean.Review of the manufacturer's instructions for the facility's ice machines on the 300 unit, revised 2022, revealed the maintenance procedure included to descale and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent descaling and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. If required, an extremely dirty ice machine may be taken apart for descaling and sanitizing. Sanitizing for exterior, remedial, and detailed procedures can be performed independently and more frequently than descaling when needed. Weekly: remove grill from scrap ice tray and wipe splash panel, scrap ice tray and grill with sanitizer and water solution, and pour excess solution in scrap ice tray to clear drain. Preventative Maintenance Descaling Procedure included to perform this procedure as required for your water conditions, however recommended monthly to remove mineral deposits from areas or surfaces that are in direct contact with water during the freeze cycle. Additionally, a sanitizing procedure must be performed after all descaling procedures have been completed. A Heavily Scaled Descaling Procedure is to be performed if the water has a high concentration of minerals. The Sanitizing Procedure included that ice machine sanitizer is used to remove algae or slime. It is not used to remove lime scale or other mineral deposits, and to refer to the Descaling Procedure for removal of lime scale or other mineral deposits. Additionally, sanitizing must be performed on adjacent surface areas not contacted by the water distribution system. Always perform Component Disassembly for Descaling/Sanitizing procedure and a Descaling Procedure before sanitizing the ice machine.Review of the facility policy titled Ice Machines and Ice Storage Chests, dated 2002, revealed that ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Ice-making machines, ice storage chests/containers, and ice can all become contaminated by: unsanitary manipulation by employees, residents, and visitors; waterborne microorganisms naturally occurring in the water source; colonization by microorganisms; and/or improper storage or handling of ice. The facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. The infection preventionist (or designee) maintains a copy of these procedures.The facility policy titled Legionella Water Management Program, revised September 2022, revealed that the facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The identification of situations that can lead to Legionella growth included the presence of biofilm, scale or sediment, and inadequate disinfection.Review of the facility policy titled Environmental Services: Common Areas, revised January 1, 2025, revealed common areas may include but not limited to physician lounges, on-call rooms, conference rooms, vending areas, corridors, lobbies, waiting areas, staff lounges and sky bridges. The policy included cleaning and disinfection of surfaces touched by patients, healthcare staff and visitors, and cleaning environmental surfaces and surfaces with visible soil, followed by disinfection in accordance with evidence-based practice guidance. Using a clean microfiber cloth with cleaner/disinfectant solution or a properly saturated cleaner/disinfectant wipe, wipe all surfaces. Wipe any desktops, telephone, arm chairs, door and cabinet handles, light switches, closet handles, and any other high-touch areas in the room, again following a logical pattern to avoid duplication or missing items.

Based on observations, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen and properly store food products. The deficient practice could result in a potential for food borne illness. The resident census was 96. Findings include: During an initial walk-through of the kitchen on January 2, 2024 at 8:23 A.M a cell phone was observed sitting on a food preparation counter. Staff #120 (dining services director) removed the cell phone, once it had been brought to his attention. Additionally, during the initial walk-through staff #120 was observed walking through the kitchen without wearing a hairnet. In the food storage area, 2 dented cans were observed in the 'ready to use' area of the kitchen and not stored separately in the area specified for dented cans. These consisted of one can of marinara and another can of mushroom soup. An interview was conducted on January 4, 2024 at 7:57 A.M. with staff #120 (Dietary services director). Staff #120 stated that the expectation is that phones are not left on food service preparation areas, and that hairnets are worn at all times in the kitchen. He stated that the risk for items such as cell phones on food preparation counters and not wearing a hairnet could include contamination of food. He further stated that the expectation is that dented cans are not utilized and that the risk for having dented cans in the ready to use area could include foodborne illness. An interview was conducted on January 4, 2024 with staff #67 (administrator). Staff #67 stated that the expectation is that everyone in the kitchen and handling food needs to wear a hairnet, as hair could otherwise get in to the food. Staff #67 further stated that there should be no cell phones in the kitchen area as these could convey germs. He stated dented cans should not be utilized and the risk could conceivably include botulism. A review of the facility policy entitled preventing foodborne illness with a revision date of November 2022 revealed that hairnets or caps are to be worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils or linens. The policy further revealed that employees will demonstrate knowledge and competency of safe food handling practice.

1) Based on clinical record review, staff interviews and facility policy, the facility failed to ensure that medication side effects were monitored and documented for 2 residents (#84, #60) Findings include: Resident #84 was admitted with diagnoses of depression A care plan included that veteran displays inappropriate hand gestures and cursing towards staff and peers; 8/30/2023 Psychotropic meeting per wife with history of behaviors (no specific). 12/8/2023 verbal Aggressive Behavior towards peer. This care plan also included that this resident receives antidepressant medication : Sertraline for depression, dated 6/8/23. Sertraline increased 100 mg to 125 mg, 10/5/2023. Then increased to 150 mg. on 12/12/2023. Added Mirtazapine 7.5 mg PO QHS due to poor intake, then increased the Mirtazapine increased to 15 mg on 10/5/2023. This care plan included to monitor and report signs of sedation, hypotension, or anticholinergic symptoms. A physician's order dated 12/12/23 included Mirtazapine tablet 7.5 mg increased to 15 mg for a diagnosis of depression as evidenced by self-isolation, irritability, and reduced appetite at bedtime. A Medication Administration Record (MAR) included that this medication had been given as ordered for December 2023 and January, 2024. However, review of the clinical record did not find documentation that this resident was monitored for side effects of Mirtazapine. A physician's order dated 10/5/23 included Sertraline tablet 100 mg, increased to 150 mg for a diagnosis of depression as evidenced by self-isolation, flat affect, irritability, and sleep disturbance one time a day. A Medication Administration Record (MAR) included that this medication had been given as ordered for October through December 2023 and January 2024. However, review of the clinical record did not find documentation that this resident was monitored for side effects of Mirtazapine or Sertraline. An interview was conducted on 1/4/24 at 11:35 AM with a Licensed Practical Nurse (LPN/staff #9) who said that psychotropic side effect monitoring should be in the order so there is be a place to chart if there are side effects. An interview was conducted on 1/4/24 at 12:20 PM with a LPN (staff #201) who said that monitoring psychotropic side effects is found in an order to follow up on side effects. This staff reviewed the medication orders for resident #84 and said that she did not see monitoring for side effects of this medication. She said that either the nurse entering the order or sometimes the providers will put their own orders in. 47911 2) Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure that medication side effects were monitored and documented for 2 residents (#60, #84). The deficient practice could result in unmonitored adverse side effects. Findings Include: Resident #60 was admitted o June 17, 2023 with diagnosis including vascular dementia, surgical after-care post ORIF of the left hip, chronic obstructive pulmonary disease, systolic congestive heart failure, atherosclerotic heart disease, ischemic cardio-myopathy, atrial fibrillation type II diabetes hypertension, chronic kidney disease, major depressive disorder-recurrent, and post-traumatic stress disorder. A review of the MDS (minimum data set), for resident #60, dated December 8, 2023 revealed a BIMS (brief interview of mental status sore) of 4, indicating severe impact on cognition. A review of the medical record revealed an open-ended physician's order for Fluoxetine 10 mg, 1 tablet per day for depression with an effective date of December 13, 2023. The order noted that the medication was prescribed for depression as evidenced by self-isolation. A review of the MAR (medication administration record) and TAR (treatment administration record) for December 2023 and January 2024 revealed no evidence of side-effect monitoring for resident #60. An interview was conducted on January 4, 2024 at 3:39 PM with staff #103, LPN (licensed practical nurse). Staff #103 stated that nurses monitor and chart the side-effects for residents receiving antidepressants. The LPN stated that a doctor's orders would be in place for the monitoring of medication side-effects; however, no evidence of an order for mediation side-effects was evident in the medical record for resident #60. She further stated that if based on the monitoring an issue was identified that the doctor would be notified immediately. Staff #103 then reviewed the resident electronic health record and stated that she was unable to locate an order for medication side-effect monitoring or charting in the MAR/ TAR for side-effects of the anti-depressant medication for resident #60. An interview was conducted on January 4, 2024 at 3:43 PM with staff #81, RN (registered nurse) and staff #38, ADON (assistant director of nursing). The ADON reviewed with electronic health record for resident #60 and stated that no orders for medication side-effect monitoring were present in the record. She further stated that the record showed no evidence that side effects were being monitored. Staff #38 stated that she would ensure that it is added this date. She further stated that the expectation is that orders are present for monitoring the side-effects of applicable medications and that side-effects are charted by nursing staff. Staff #81 stated that the risk to the resident could include suicidal ideations, lethargy and overall change in behavior. An interview was conducted on January 5, 2024 at 11:03 AM with the Director of Nursing (DON/staff #140). The DON reviewed the medical record for resident #60 and stated that she did not see evidence of medication side-effect monitoring, although she stated that it had been documented in the care plan. She stated that the risk to the resident could include possibly not knowing the effectiveness of the medication and documentation thereof. A review of the facility psychotropic medication use policy, with a July 2022 revise date, revealed that psychotropic medication management includes adequate monitoring for efficacy and adverse consequences; however, there was no evidence in the medical record for Fluoxetine monitoring for efficacy and adverse consequences for resident #60.

Based on interviews and record review, the facility failed to provide documentation of transfer notification for one resident. This had the potential for Residents and/or their representative to be unaware of their rights. Resident #6 was admitted to the facility on [DATE] with diagnoses that included Calculus of the Kidney, hypertension, Chronic Obstructive Pulmonary Disease (COPD), Mood disorder, and obesity. Review of resident #6's Electronic Health Record (EHR) indicated the resident was hospitalized on [DATE], September 20, 2023, November 13, 2023, and December 21, 2023. There was no evidence of a transfer notice being provided to the resident and/or their representative. Review of the discharge Minimum Data Set (MDS), dated [DATE] revealed the resident was not assessed for a Brief Interview for Mental Status (BIMS). The staff assessment indicated the resident's cognitive skills for daily decision making was independent. An interview was conducted with Social Services (staff #137) on January 4, 2024 at 1:50 PM. Staff #137 stated that when a resident is sent to the hospital, a bed hold form is reviewed with the resident or Power of Attorney (POA). If the form is not able to be signed prior to residents leaving, he would go to the hospital to review and have it signed by the resident. Staff #137 indicated that no other form is reviewed with residents during this period. An interview was conducted with medical records staff (staff #143) on January 5, 2024 at 12:00 PM. Staff #143 indicated the documentation of notification of transfer would be done in writing in the form of a progress note indicating the family and the primary provider was notified of the transfer. Staff #143 was not able to locate documentation in the EHR indicating transfer notification was provided for resident #6. An interview was conducted with the Director of Nursing (DON) on January 5, 2024 at 1:23 PM. The DON was asked to locate documentation indicating a notice of transfer was completed in resident #6's EHR. DON stated the documentation was not there and confirmed that this did not meet their expectation. Their expectation was if the resident was their own person, the family would not be notified of the transfer, however in this case the family should have been notified of the transfer. The DON stated that the risk of not notifying the family of the transfer was the family would be unaware of the transfer.

Based on clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 out of 2 residents reviewed (resident #1). The deficient practice could result in increase the risk of harm and injury. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included dementia with other behavioral disturbance, depression and psychotic disorder with hallucinations due to known physiological condition. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status, indicating intact cognition. According to the assessment, the resident displayed no behaviors, including wandering, and required supervision and oversight for most activities of daily living. A behavior symptoms care plan initiated October 4, 2022 related to exit-seeking behavior had a goal for the resident's behavior to be managed and redirected. Interventions included to ensure the resident was wearing a wanderguard and to provide an escort off memory care unit. A nursing progress note dated December 26, 2022 at 5:36 a.m. included that the writer had received a call from house security at about 6:45 p.m. indicating that when the resident returned from a leave of absence he did not set off the alarm. The note included that the writer checked the resident's wanderguard and realized that the resident had covered it with aluminum foil. According to the note, the writer took the foil off and let the resident know that it was not alright to do that. However, review of the resident's clinical record did not provide evidence that nursing administration had been notified of the incident or that the resident's plan of care had been updated to reflect it. A Wandering assessment dated [DATE] included that the resident was not able to leave the building on his own, that he did not exhibit wandering behaviors and that he had made no statements about going home. According to the assessment the resident's conditions included dementia and depression and that interventions included a door alarm band having been applied (e.g. wanderguard). Per the assessment, the resident did not present an elopement risk. Review of a nursing progress note dated April 3, 2023 at 4:31 p.m. included that at 1:21 p.m. the writer received a call from security that the resident was up front and needed to be picked up. The note stated that the writer went to get him and on the way back to the unit discovered that the resident had left the unit on his own and had gone to the mental health clinic trying to be seen, but was unsuccessful. According to the note, the resident was asked how he had gotten off the unit without sounding the alarm, but he said that it was a secret and refused to say. Security was called to check the cameras to see when the resident had left and whether he had been escorted. Security reported that the resident had left unescorted at approximately 12:20 p.m. and that he had returned at 1:15 p.m. to the facility. The note included that the resident later stated that he had covered his wanderguard with foil and was able to get off the unit without sounding the alarm. The writer then detailed they attempted to test this theory of the foil and were able to pass through the door 4 times without sounding any alarms. A mood state care plan dated April 4, 2023 related to a suicidal statement with no self-harm planned and an attempt to get out of the facility/elopement. The goal was for the resident to have no further suicidal ideation statements and no further elopement attempts for the next 90 days. Interventions included frequent wellness checks/rounding. A nursing note dated May 28, 2023 at 3:01 p.m. detailed that resident #1 left the facility with an escort who was a family friend at approximately 6:40 a.m. The facility received a call at approximately 12:00 p.m. alerting that the resident was missing, and that the police were notified. The note further states the resident was found at 1:15 p.m. and returned to the facility. The note further states that the resident was assessed and found the resident had no injuries, and noted that the staff was informed he was a high elopement risk. However, review of the clinical record did not indicate that an updated Wandering Assessment had been completed or that the resident's care plan had been revised to reflect the elopement. On May 29, 2023 at 2:14 a.m. nursing progress note revealed that the resident had been placed on 15 minutes watch for elopement precaution. According to the note, the resident did not want 15 minute checks to continue after 7:15 p.m. and became very upset and verbally aggressive towards staff. The house supervisor was notified and suggested that staff should just monitor that the resident had not left his room during the shift. Per the note, staff was therefore monitoring only the resident's door, as best they could, and assuming that he was there. On June 13, 2023 at 6:25 a.m. the facility notified the State agency that the resident had eloped. The report detailed that during change of shift rounding the resident was not found to be in his room or the adjoining bathroom. A unit search to include all other individual resident rooms and common areas was completed by unit staff and the resident wasn't found. An interview was conducted on June 15, 2023 at 12:05 p.m. with a Licensed Practical Nurse (LPN/staff #60.) The LPN stated that the resident was very alert, and very intelligent. She stated he used to be an engineer. She stated that to get out the resident found a way to remove the stopper on the window and pushed out the screen. She also stated that he hid the screen behind a cabinet. An interview was conducted on June 15, 2023 at 2:48 p.m. with a Certified Nursing Assistant (CNA/staff 23). She stated that they regularly round on the residents for safety, and that if a resident is noted to be missing they notify the nurse and supervisor. She stated that the resident was a very determined guy and detailed a previous instance where he covered his wander guard in foil to escape the unit. An interview was conducted on June 15, 2023 at 3:50 p.m. with the Director of Nursing (DON/staff #67.) The DON stated that residents are determined to be a flight risk upon admission, based on their diagnoses, level of confusion, ambulatory status and mental status. She further stated that if risks were identified they would do an assessment. The DON accessed the resident's medical record and noted the nursing notes detailing prior elopements. However, the last wandering assessment was on March 20, 2023. Review of facility policy titled 'Wandering and Elopements', revised October 2021, included that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy further stated that if a resident was identified as a risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety.

Based on resident and staff interviews, and grievances, the facility failed to ensure residents received food that accommodated the residents' preferences. The deficient practice could result in complications related to residents not eating and/or being disinterested in dining. Findings include: During interviews conducted with residents on September 27, 2022, a resident stated the facility does not serve what is on the menu and they are out of everything. Another resident stated the kitchen served the same meals all the time. Another resident stated the staff cannot get the 4-year standing order correct, that the kitchen either does not have it or they do not do as requested. An interview with the Dining Services Director (staff #105) was conducted on September 29, 2022 at 10:45 a.m. He stated that they provide residents with an alternate menu they can choose from if they do not want the item indicated on the scheduled menu. He stated he has only been on the job for a month. Staff #105 stated the menu is set by corporate so it is not changeable. He stated he informed the residents about the alternate meals, and that the kitchen can accommodate changing name brands of items but that the menu cannot be changed. The Social Services Supervisor (staff #39) was interviewed on September 29, 2022 at 12:41 p.m. Staff #39 stated that food is the most common grievance he receives. He stated that he addresses the grievances and informs the administrator of what is going on. Grievances regarding food were reviewed with staff #39. The grievances revealed one resident stated cold tea was served instead of hot tea as requested, and did not receive the tater tots. Another resident would like egg and tuna sandwiches offered as an alternative. Another resident was not served what was on the morning menu per the resident's grievance. Another resident stated au gratin potatoes were served instead of the ordered baked potato, no salad was - kitchen stated no salad, and that no notification was given until the meal was served. Another resident stated chips were served instead of the ordered French fries and that there was no notification until the meal was served. Another resident stated for the last 2 weeks no fruit had been available. Another resident stated the items listed on the menu were chosen and that the meal delivered did not contain the chosen items, and there was no notification that the items were unavailable prior to ordering the items.

Based on resident and staff interviews, a food test tray, facility documents, and policy review, the facility failed to ensure residents consistently received food that was palatable. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: During interviews conducted with residents on September 27, 2022, one resident stated the kitchen cannot cook anything, the fries are frozen, and the meat is tough like shoe leather. Another resident stated the food is terrible. A third resident stated the food is horrible. Another resident stated since the change in food service, the food had been getting worse. A lunch test tray was ordered on September 29, 2022 and arrived at the unit at 11:15 a.m. The test tray consisted of pizza, green beans, and peach cobbler. The test tray was sampled by the survey team. The pizza had an overly crispy crust with toppings that had a rubbery texture. The green beans were mushy, and flavorless. Additionally, the green beans appeared to be teal-green in color and did not look appealing. The peach crisp was also flavorless and was not appetizing. The fruit part of the peach crisp was soppy as though the fruit was overly ripe or overcooked. The food was not hot. The survey team deemed the food not palatable. An interview with the Dining Services Director (staff # 105) was conducted on September 29, 2022 at 10:45 a.m. He stated he has only been on the job for a month but have not heard any complaints about food temperature. He did admit that he had heard of complaints about the food's taste. In an interview conducted with the Social Services Supervisor (staff #39) on September 29, 2022 at 12:41 p.m., staff #39 stated food is the most common grievance he receives. He stated that residents complained about palatability, and the way the food is presented and seasoned. He stated that he addresses grievances and informs the administrator of what is going on. Grievances regarding food were reviewed with staff #39. The grievances revealed one resident stated a cold grilled sandwich was served, another resident stated an open-faced turkey sandwich was served and the turkey meat was too hard to chew. Another resident stated two very hard pieces of chicken parmigiana were served and the chicken pieces were hard and impossible to cut and eat, there was no marinara sauce for the noodles, that the food was unacceptable and not fit for consumption. Review of the undated facility policy titled Food: Quality and Palatability stated that food will be prepared using methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. The cook(s) prepare food in accordance with the recipes, and season for region and/or ethic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention.

Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, food items were not expired or moldy, and stored kitchenware was clean and dry. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding food labeling and dating: During the follow-up kitchen observation conducted on [DATE] at 10:36 a.m., an opened sausage bag was observed not labeled with a use by or expiration date in the walk-in freezer. The Dining Services Director (staff #105) and the District Manager (staff #106) were present during the follow-up observation. The District Manager stated that there are different rules for frozen items and they can be kept longer. He stated that if it is unopened that it goes by the expiration date but it should have been marked with an opened date so that a use by date could be determined. The facility kitchen's policy titled Food Storage: Cold Foods revised [DATE] included that all foods will be stored wrapped or in a covered container, labeled, and dated. Regarding moldy food: During the follow-up kitchen observation conducted on [DATE] at 10:36 a.m., a box marked with a delivery/received date of ,d+[DATE] was observed to contain 7 rotten and moldy cucumbers. One of which was so grossly rotten and moldy that it was wet and appeared to have melted with its juice leaking into the box and the rest of the cucumbers. The box also contained cucumbers that were still fresh. The box was located in the walk-in refrigerator. The Dining Services Director (staff #105) and the District Manager (staff #106) were present during the follow-up observation. The District Manager stated that food items are checked daily and that the items were just delivered as indicated on the box but that it could have gone bad overnight. Staff #106 further stated that they check the items prior to use. The facility kitchen's policy titled Food Storage: Cold Foods revised [DATE] revealed all perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below. Additionally, all food will be stored wrapped or in a covered container, labeled and dated, and arranged in a manner to prevent cross contamination. Regarding expired items: During the follow-up kitchen observation conducted on [DATE] at 10:36 a.m., two big containers of Silk Almond with a best by date of [DATE] were observed stored in the walk-in refrigerator. The Dining Services Director (staff #105) and the District Manager (staff #106) were present during the follow-up observation. When asked how long after the best by date they store and use items, staff #106 stated that they do not keep items past the use by date and that it should have been taken out. The facility kitchen's policy titled Food Storage: Cold Foods revised [DATE] indicated that all perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below. Additionally, all food will be stored wrapped or in a covered container, labeled and dated, and arranged in a manner to prevent cross contamination. Regarding clean and dry kitchenware: During a follow-up kitchen observation conducted on [DATE] at 10:36 a.m., two large metal pans were observed stored wet with the clean stack. They were stored in the ready to use shelf. The Dining Services Director (staff #105) and the District Manager (staff #106) were present during the observation. They removed the items to be rewashed. The kitchen's policy titled Warewashing revised [DATE] stated all dishware will be air dried and properly stored. The facility kitchen's policy titled Manual Warewashing revised [DATE] indicated that all serviceware and cookware will be air dried prior to storage.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure an advanced directive was accurately documented for one sampled resident (#18). The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Advance Directive/Medical Treatment Decision form in resident #18's clinical record revealed the resident's power of attorney (POA) signed the form and indicated that the resident had not chosen to formulate an advance directive. The form was signed by the resident's POA and the facility representative on March 24, 2022. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review of the clinical record revealed the MatrixCare dashboard indicated the resident's code status was DNR (Do Not Resuscitate). Additionally, the advance directive portion of the resident's profile on MatrixCare indicated the resident as Do Not Resuscitate (DNR) and included a note which stated that it was per the legal guardian on July 8, 2022. The orange Prehospital Medical Care Directive/DNR form was not found in the resident's clinical record. Review of the DNR binder located at the nurse's station revealed the resident did not have an orange DNR form on file. An interview was conducted with a Licensed Practical Nurse (LPN/staff #58) on September 28, 2022 at 9:52 a.m. She stated that to determine a resident's code status, staff can look at the DNR binder at the nurses' station or log into MatrixCare. Staff #58 stated that the nurse practitioner (NP) usually reviews a resident's information after admission and inputs the data into the system. The LPN stated in the event there is a question of what is the appropriate status or conflicting information regarding a resident's status then she would follow the full code protocols. After reviewing resident #18's advance directive documents, staff #58 stated the resident's record had conflicting information. She verified that the DNR binder did not contain information for resident #18 which meant the resident was a full code. The LPN stated that since the resident's record indicated the resident was a DNR, she would need to call somebody to verify the resident's actual code status. She said until then, she would have to treat the resident as a full code. An interview was conducted with the Director of Nursing (DON/staff #57) on September 29, 2022 at 1:26 pm. She stated it is her expectation that the resident and the responsible party exercise their right to choose regarding advance directive and that an order is obtained to reflect their wishes. Staff #57 said with regards to resident #18, it could be the individual that made the request did not have the proper documentation to be the responsible party or there might have been a change in who the responsible party was. She stated it could have been a transition between responsible parties and the rightful party might not have had the legal ability to make decisions at the time. Staff #57 stated that annotating the responsible party decided DNR is not enough. The DON stated the record should contain all the appropriate required documentation. The facility policy titled Advance Directives revised August 2021 revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Additionally, the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. In the event a resident or representative refuses treatment, the facility and care providers will document specifically what the resident/representative is refusing.

Based on clinical record review, observations, resident and staff interviews, and policy review, the facility failed to ensure one resident (#56) who was admitted with limited ROM (Range of Motion) was provided treatment and services to prevent further decrease in ROM/mobility. The sample size was 2. The deficient practice could result in residents experiencing decrease in ROM and functioning. Findings include: Resident #56 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set assessment dated [DATE] revealed the resident long-term memory was ok, had short-term memory problems, could recall location of own room and staff names and faces, and had moderately impaired cognitive skills for daily decision making. The assessment also revealed the resident had impairment on one side of the upper extremity and lower extremity. A care plan initiated on August 18, 2022 for ADL (Activity of Daily Living)/Rehabilitation potential stated resident #56 had an ADL and mobility deficit related to right [CONDITION(S)]. The interventions included CNAs (Certified Nursing Assistants) providing washcloth roll/carrot in the right hand to tolerance for contracture management. An observation was conducted on September 27, 2022 at 9:29 a.m. Resident #56 was observed lying in bed with no shirt, partially covered with a sheet. Resident #56 right upper extremity (RUE) was exposed. It was observed the RUE was flaccid, and the right hand was completely closed. The resident was observed rubbing the right arm and hand, and occasionally attempted to open the right fist. It was observed that resident #56's right hand was contracted and completely closed in a fist-like position. No washcloth roll/carrot was observed in the resident's right hand. An interview was conducted on September 29, 2022 at 9:51 a.m. with resident #56 who was able to verbally answer yes or no questions. Resident #56 stated yes, he wanted to stay in bed today. The resident stated yes, he wanted a washcloth in his right hand. The resident stated no, the staff did not offer the washcloth yesterday or today. Resident #56 stated yes, the washcloth would help the right-hand pain. An observation was conducted on September 30, 2022 at 9:42 a.m. Resident #56 was lying in bed watching television, and was partially covered with a sheet. The resident's upper extremities were exposed, and the resident was observed rubbing the right fisted hand continuously. Resident #56 fingernails were short, and the right hand was clean and odor free. However, there was no washcloth roll/carrot in the resident's right contracted hand. An immediate follow up interview was conducted with resident #56 who stated no, the nurse never offered a washcloth to be placed in the right hand. Resident #56 stated yes, the hand would probably feel better if the washcloth was in it. An interview was conducted on September 30, 2022 at 9:27 a.m. with a CNA (staff #75), who stated if a resident has a contracted hand, the therapy would bring a soft toy to place in the hand. She stated she will keep the resident's hand clean and keep the fingernails short to prevent odors and injuries. Staff #75 stated if there is no soft animal, she would use a rolled washcloth. The CNA stated if the resident refused, she would report it to the charge nurse. An interview was conducted on September 30, 2022 at 10:22 a.m. with the DON (Director of Nursing/ staff #57). Staff #57 stated her expectation related to the prevention of contractures included if a washcloth or carrot is on the care plan, it must be followed. Staff #57 stated if the care plan to prevent contractures was not followed, the resident could be at risk to have further contractures. A facility policy, Resident Mobility and Range of Motion, stated a resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#24). The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident #24 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The social services portion of a care plan conference report dated October 7, 2021, indicated the resident had no teeth and did not want dentures. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Oral Cavity assessment dated [DATE] revealed the resident had no natural teeth or tooth fragments (edentulous). It also noted the resident had mouth or facial pain, discomfort or difficulty with chewing. The assessment also revealed the resident did not have dentures and should be referred to a dentist. A nursing progress note dated April 4, 2022 indicated the resident was asked about dentures but could not provide a vivid account of it. The note revealed the resident stated that he would like to have dentures because he was beginning to have difficulty chewing food. The note indicated the social worker would be notified to assist the resident and schedule a dental appointment for dentures. However, further review of the resident's record did not reveal any notes concerning a dental evaluation for the identified dental/oral concern. A quarterly nutrition assessment dated [DATE] included the resident is edentulous. Review of the physician diet order dated April 15, 2022 indicated the resident may have dysphagia advanced (chopped or pre-cut) or pre-cut at the resident's preference, the resident is edentulous but tolerates a regular diet. A significant change in status Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. The assessment also indicated the resident's oral/dental status as edentulous. Review of the care plan pertaining to dental care edited on July 5, 2022, indicated that the resident is edentulous and had a potential for chewing problems as a result. It also indicated the resident declined to obtain dentures. An oral cavity assessment dated [DATE] did not indicate the resident was edentulous but included the resident does not have dentures. Further review of the resident's record did not reveal documentation which stated the resident was offered dental care and declined. Additionally, there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with resident #24 conducted on September 27, 2022 at 9:29 a.m., the resident stated he does not have dentures and has a hard time chewing/swallowing. The resident stated that he would like to get dentures. During an interview with a Licensed Practical Nurse (LPN/staff #58) conducted on September 28, 2022 at 9:26 a.m., she stated that coordinating dental care for residents depends on whether they are covered by the insurance or not. Staff #58 stated if a resident reported having chewing issues, they would set up an appointment to get dentures or the appropriate dental care. The LPN stated there is an alternative means to get care if the resident is not covered by the insurance. She stated that once the appointment is scheduled, the scheduler sets up transport for the resident to attend the appointment. She stated staff #31 (LPN) would most likely have information specific to resident #24. An interview with an LPN (staff #31) was conducted on September 28, 2022 at 2:17 p.m. Staff #31 stated that resident #24 told her that he had dentures and that the dentures broke prior to being admitted to the facility. Staff #31 stated that to her recollection, approximately a year ago (sometime last year) the resident was informed that he would have a copay and he refused to pay it. She stated to her knowledge, the resident is able to eat. An interview with the Social Worker (staff #39) was conducted on September 29, 2022 at 12:27 p.m. He stated that getting dental care for residents depends on whether they have coverage for dental or not. He stated if they do not, then they are referred to an outside provider. Staff #39 stated resident #24 is not covered by the insurance. Staff #39 stated that since he is new, he does not know what happened previously with the resident's dental care. Staff #39 stated that he was made aware yesterday that resident #24 needs dentures. He said he is now trying to get the resident an appointment. During an interview conducted on September 29, 2022 at 1:26 pm with the Director of Nursing (DON/staff #57), the DON stated her expectation is that progress notes should be written by social services, nursing, or the provider that explains the resident refusing treatment. In the case of resident #24, she stated that to her knowledge the resident refused due to having to pay a copayment. The DON stated she understands there is a lack of documentation explaining what transpired between the time the resident was identified as needing a dental referral and the present time. An undated facility policy titled Dental Examination/Assessment revealed residents shall be offered dental services as needed. Records of dental care provided shall be made a part of the resident's medical record.

Based on observations, staff interviews, policy review, and manufacturer's guidelines, the facility failed to ensure that expired medications and biologicals were not available for resident use. The deficient practice could result in residents receiving medications that are less potent, decreasing effectiveness. Findings include: Regarding hall 400 During an observation conducted of the medication room on hall 400 on July 29, 2021 at 2:32 PM with the Assistant Director of Nursing (ADON/staff #83), the following were observed: -2 ZR [MEDICATION(S)] flush 5ml (milliliters) syringes with an expiration date of June 1, 2021; -an intravenous administration set with an expiration date of March 29, 2021; and -a [MEDICATION(S)] solution that was delivered on July 3, 2021 with no open date on it. Following this observation, the ADON stated that he would take care of the expired items. Regarding hall 500 During an observation conducted of the medication room on hall 500 on July 29, 2021 at 2:42 PM with the ADON (staff #83), the following were observed: -an extension tube with connector with an expiration date of March 2018; -2 boxes of BD eclipse vacutainer blood collection needles with an expiration date of April 30, 2021; -3 individual 3ml 0.9 [MEDICATION(S)] solution vials dated February 28, 2021; -1 staple removal kit with an expiration date of June 1, 2021; -1 open vial of [MEDICATION(S)] with no open date on it; -2 boxes of individually packed [MEDICATION(S)] 3 stick pouches with an expiration date of March 2021; and -an individually packaged antiseptic towel with an expiration date of March 2021. Following this observation, the ADON stated that he would take care of the expired items. Regarding hall 300 During an observation conducted of a medication cart on hall 300 on July 29, 2021 at 3:27 PM with a Registered Nurse (RN/staff #47), the glucometer solutions were observed without open dates on them. An interview was conducted immediately with this RN (staff #47), who stated that there was no open date on the glucometer solution because they never put the date on glucometer solutions. On July 29, 2021 at 2:55 PM, another interview was conducted with the ADON who stated the nurses are responsible for removing expired medications from the medication room. He stated the night shift nurses usually have the time to check for and remove expired medications. The ADON stated it is the nurse's responsibility to check the expiration date on medications before stocking the medication carts. An interview was conducted on July 29, 2021 at 4:48 PM with the Director of Nursing (DON/staff #101), who stated she expected medications and biologicals to be stored according to manufactures recommendations. She stated that if a medication or biological does not have an opened date, they go off of the date that it was filled. She stated that the staff who is going to be utilizing the medications, checks them at the point of utilization. This DON stated the medication room is used for storage but it is not their point of delivery. Staff #101 stated the staff in charge of checking and removing expired medications from the medication rooms would be the house supervisor. The DON further stated the house supervisor may or may not be the staff stocking the medication and treatment carts. She stated it is usually the nurse that stocks the carts. In an interview conducted with the Administrator (staff #40) on August 3, 2021 at 2:39 PM, the Administrator stated they did not have a policy for labeling glucometer solution once they are opened and that they go by manufacturers guidelines. A Blood Glucose Control Solution insert provided by the facility for the glucometer solution that they use revealed that when opening a new vial of Control Solution, write the opening date on the label. The Control Solution is good for 3 months after opening the vial or until the expiration date printed on the label. A facility policy titled Storage of Medications revealed the facility stores all drugs and biologicals in a safe, secure and orderly manner and that all discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on clinical record review and staff interviews, the facility failed to provide evidence that the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was issued to one of three sampled residents (#33). The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Notice of Medicare Non-Coverage (NOMNC) revealed the resident last day of coverage was June 12, 2021 and that the resident signed the form on June 10, 2021. Review of the clinical record revealed the resident remained at the facility. However, continued review of the clinical record revealed no evidence the resident was issued an SNFABN. An interview was conducted on July 28, 2021 at 9:13 AM with the Business Office Manager (staff #138), who stated that this resident's SNFABN was not completed because the social worker did not know she had to complete it. Staff #138 stated that she went online and printed a blank one and the instructions so that the social worker would know what she needed to do. On July 28, 2021 at 9:22 AM, an interview was conducted with the Social Services Supervisor (staff #147). Staff #147 stated the NOMNC is given to a resident two days before the last day of coverage because it gives the resident an opportunity to appeal. Staff #147 stated that she was told to give the NOMNC notice to resident #33 and that she did not give the resident the SNFABN. She stated the SNFABN is a question for the business office. An interview was conducted with the Administrator (staff #40) on July 29, 2021 at 8:40 AM, who stated it was his understanding a SNFABN would be provided to a resident who was issued a NOMNC and continued to stay in the facility. Staff #40 stated resident #33 did not receive a SNFABN because the facility does not have a lot of Medicare insured residents and Social Services usually does the discharge forms. In another interview conducted with the Administrator on August 3, 2021 at 12:49 PM, the Administrator stated they did not have a policy regarding the NOMNC and SNFABN.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure infection control standards were maintained during [CONDITION(S)] care provided to one sampled resident (#7). The deficient practice could result in staff not performing hand hygiene when indicated. Findings include: Resident #7 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed the resident received [CONDITION(S)] care while a resident within the last 14 days. On August 2, 2021 at 3:24 p.m., an observation of [CONDITION(S)] care was conducted with a Licensed Practical Nurse (LPN/staff #31). Staff #31 washed his hands and donned clean gloves. He opened the [CONDITION(S)] cleaning kit, removed the sterile field, and placed it on top of the resident's bed. Staff #31 placed the [CONDITION(S)] cleaning kit on the sterile field and then opened the remaining supplies onto the field. He opened a packet of antibiotic ointment and squeezed a small amount onto the field, and he opened the sterile cotton-tipped applicators. He poured sterile water into the two sides of the [CONDITION(S)] kit and added wound cleanser into one side. He removed the resident's nasal cannula and then removed the soiled split gauze dressing at the [CONDITION(S)] site. Staff #31 doffed his gloves and put the gloves and the soiled gauze into the resident's trash can. He then donned the sterile gloves contained in the [CONDITION(S)] cleaning kit. The LPN was not observed to perform hand hygiene before donning the sterile gloves. He placed one cotton-tipped swab into the cleansing solution, one into the sterile water, and one into the antibiotic ointment. He set the sterile split gauze dressing and the other sterile gauze onto the sterile field. Using a cotton-tipped swab, he cleansed the stoma and the outer cannula working from the inside to the outside, and then cleansed the flange. He stated there was no inner cannula. Staff #31 then rinsed the stoma, outer cannula, and flange with a swab wet with sterile water in the same manner. Using a gauze wet with cleansing solution, he cleansed the stoma, the outer cannula, and flange. He rinsed the area using another gauze wet with sterile water. He patted the stoma, cannula, and flange dry with dry gauze. Using a swab, he applied antibiotic ointment to the stoma. He applied the split gauze to the insertion site. The LPN assisted the resident with reapplying the nasal cannula. He collected the supplies and placed them into the trash can. He doffed his gloves into the trash and took the bag of trash out of the room. After several minutes, staff #31 returned to the resident's room and washed his hands at the sink. At 3:40 p.m. on August 2, 2021, an interview was conducted with the LPN (staff #31). The LPN stated that the protocol for providing [CONDITION(S)] care should have included hand hygiene after doffing the dirty gloves and before donning the sterile gloves. He stated that he forgot to wash his hands. An interview was conducted with the Director of Nursing (DON/staff #101) on August 2, 2021 at 4:20 p.m. The DON stated her expectation would include hand hygiene be performed prior to the beginning of the procedure and after the procedure has been completed. She stated that she would expect the [CONDITION(S)] care to be different depending on the type of [CONDITION(S)] the resident had, whether the nurse was suctioning, or whether they were just cleaning the outside of the stoma. The DON stated that the risks of not performing hand hygiene might increase the risk for infection. The facility's policy titled [CONDITION(S)] Care stated the purpose of the procedure was to guide [CONDITION(S)] care and the cleaning of reusable [CONDITION(S)] cannulas. The general guidelines included that aseptic technique must be used during cleaning and sterilization of reusable [CONDITION(S)] tubes. The procedure guidelines included to wash hands and to don exam gloves, to remove the old dressing, pull the soiled glove over the dressing and discard into the appropriate receptacle. Wash hands. Open the [CONDITION(S)] cleaning kit and set up supplies on the sterile field. Apply clean gloves. Clean the stoma, rinse the stoma, and wipe the stoma with dry gauze. Apply a fenestrated gauze pad around the insertion site. Remove gloves and discard into the appropriate receptacle, and wash hands.

Based on clinical record review, facility document, staff interviews, and policy review, the facility failed to ensure a current written agreement with hospice was in place prior to hospice care being furnished to residents including one sampled resident (#74). Findings include: Resident #74 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospice Election form revealed the resident elected to begin hospice care with a hospice provider as of [DATE]. The document was signed by hospice and by the resident's spouse on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was receiving hospice care. However, review of the facility's current contract and amendments with the hospice provider providing care for resident #74 revealed it was signed on [DATE] and had expired on [DATE]. An interview was conducted on [DATE] at 1:33 p.m. with the administrator (staff # 40). He stated that he was aware that the contract with the hospice provider was being renegotiated but was not aware that it had expired so long ago. Staff #40 stated that it was a concern that hospice was providing services and the contract had been expired for so long. He stated that he would look into the issue and relay any further information. No further information was provided. An interview was conducted on [DATE] at 10:28 a.m. with the director of nursing (DON/staff #101). She stated that the administrator reviews all contracts and makes sure they are valid and signed. The DON stated the hospice contract was expired and that was an administrative issue, not really a clinical issue. An additional interview was conducted at 4:49 p.m. on [DATE] with the administrator (staff #40). He stated that a provider without a valid contract working in the facility was an issue. The administrator stated liability could be increased and they were also out of compliance. Staff #40 stated that he would continue to work with the procurement department to get the contract updated and into compliance. Review of the facility policy titled Hospice Program revised [DATE] revealed that hospice providers who contract with the facility must have a written agreement and it shall be signed by a facility representative and a representative from the hospice agency before hospice services are furnished to any resident.

Based on clinical record review, physician and staff interviews, hospital documentation, and policy review, the facility failed to provide appropriate care and treatment for one resident (#59) with an indwelling urinary catheter, who developed a urinary tract infection [MEDICAL CONDITIONS]. Findings include: Resident #59 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to an admission Minimum Data Set (MDS) assessment dated [DATE], the resident was admitted with an indwelling urinary catheter. Review of a urinary catheter care plan revealed a goal to have catheter care managed appropriately, as evidenced by not exhibiting signs of infection. Approaches included to assess drainage, record the amount, color, odor, observe for leakage, provide catheter care every shift and as needed, and change the catheter as ordered. A nursing note dated September 1, 2013, revealed the resident's Foley catheter was changed and yielded yellow urine. On September 5, 2013, a nursing note included the resident's catheter was leaking and a second catheter was inserted, with a return of dark yellow urine. A nursing note dated September 7, 2013, included the resident had cloudy urine and that there was foul smelling pus-like discharge coming from his penis. The physician was notified. A physician's orders [REDACTED]. A nursing note dated September 8, 2013, included that the urine specimen was obtained and picked up by the lab around 1:30 a.m. Review of the resident's clinical record revealed a preliminary urinalysis laboratory report dated September 9, 2013, that identified nonfermenter species gram negative bacilli (bacteria). There was no documentation that the physician was notified of the preliminary results at this time. A nursing note dated September 10, 2013, included that the resident's catheter was leaking large amounts of urine and the catheter was changed. Output consisted of 700 cc of foul smelling urine. A nursing note dated September 11, 2013 at 10:56 a.m., documented the resident had a temperature last night of a 101.7, but was now 97.3., blood pressure was 81/51, later was up to 103/64, and that the UA culture was still pending. The note continued that the "provider was notified of these. No new orders, said to wait for UA culture." Review of the final C&S laboratory report completed on September 12, 2013, revealed the resident had a UTI. There was no clinical record documentation that the physician was notified of the final lab results at this time. On September 15, at 5:42 p.m., a nursing entry noted that the resident was grimacing in pain, but was unable to say where it hurt. The catheter was draining slowly with an output of 250 cc of tea colored urine. The catheter was changed with a return of 2000 cc of foul smelling cloudy urine. Review of the nursing note dated September 16, 2013 at 11:20 a.m., revealed that the UA results were requested from the lab this a.m., and indicated a UTI was present. The note also included that the catheter was not draining well and was flushed at 7:50 a.m., but "still seems to be no drainage." The physician was notified and at 10:41 a.m., ordered to replace the catheter, which was done at 11:15 a.m., with 200 cc of cloudy yellow urine after 10 minutes. Per the note, the physician ordered an antibiotic and a urology consult. A physician's orders [REDACTED]. Review of a nursing note dated September 16 at 6:32 p.m., revealed that at 5:30 p.m., it was noticed that the catheter bag still had no urine in it. The physician was notified and 911 was called and the resident was transported to the hospital at 6 p.m. A physician's orders [REDACTED]. According to the hospital emergency room notes dated September 16, 2013, the Foley catheter was not draining, so the balloon was deflated and advanced deeper and then started to drain. The urine was described as smelly and cloudy. Review of the hospital urinalysis completed on September 16, 2013, revealed the following: white blood count was 376 (normal value 0-4), red blood cell count was 106 (normal value 0-3) and creatinine (represents kidney function) 3.0 (normal value 0.6-1.2). Review of the hospital CBC (complete blood count) results dated September 16, 2013, revealed a white blood count of 19.9 (normal value 4.5-11). According to the emergency room assessment and treatment plan dated September 17, 2013, medical problems for the resident included the following: 1.[MEDICAL CONDITION] due to UTI; 2. uremic [MEDICAL CONDITION] (an [MEDICAL CONDITION] developed in patients with acute kidney failure); 3. acute kidney injury - due to dehydration. Per the hospital records, the resident was admitted to the intensive care unit, where he continued to receive intravenous antibiotic therapy and IV fluids. During an interview conducted on August 13, 2014 at 12:30 p.m., a licensed practical nurse (LPN) stated if she had telephoned the physician to report the final laboratory report, it would be documented in the nursing notes. She stated if it isn't documented, then it was not done. During a telephone interview conducted on August 13, 2014 at 1:40 p.m., the physician for the resident stated he was not aware of the final laboratory report, until the nurse telephoned him on September 16, 2013. During an interview conducted on August 14, 2014 at 2:15 p.m., the Director of Nursing (DON) stated she would expect the nurses to look for laboratory reports in the computer and that it is critical for nursing staff to provide the residents' physician of all laboratory reports, as soon as they are available. Review of the facility's policy titled, Urinary Tract Infections included that the physician will help identify individuals who have a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling Foley catheter, urinary outflow obstruction) for UTIs. The staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI. The physician will help nursing staff interpret the significance of signs, symptoms, and lab test results. The physician will order appropriate treatment for verified or suspected UTIs based on a pertinent assessment. The physician will help the staff identify cases of suspected [MEDICAL CONDITION] (sepsis) related to a UTI and identify whether hospitalization may be warranted.

Based on clinical record review, a registry staff interview and staff interviews, hospital and facility documentation and policy review, the facility failed to provide the necessary care and services to maintain the residents highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one resident (#59) with a significant change of condition, and failed to ensure one resident (#53) was administered pain medication in a timely manner. Findings include: -Resident #59 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. The orders also noted for catheter care at catheter site to be done every shift, with soap and water. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the resident was assessed with [REDACTED]. The assessment also noted the use of an indwelling catheter upon admission. A care plan for skin breakdown related to immobility included a goal that the resident's skin will remain intact. Approaches were to keep skin clean and dry, minimize skin exposure to moisture, and report any signs of skin breakdown (sore, tender, red, or broken areas). Review of a urinary catheter care plan revealed a goal to have catheter care managed appropriately, as evidenced by not exhibiting signs of infection or urethral trauma. Approaches included to assess for drainage, observe for leakage, provide catheter care every shift and as needed, and change the catheter as ordered. A nursing note dated September 7, 2013, included the resident had cloudy urine and that there was foul smelling pus-like discharge coming from his penis. The physician was notified. A physician's orders [REDACTED]. Review of the clinical record revealed no documentation that assessments had been conducted on September 8 or 9 of the resident's penis/peri area, despite documentation of pus-like drainage previously. According to a nursing note dated September 10, the catheter was leaking large amounts of urine and the catheter was changed. Output consisted of 700 cc of foul smelling urine. The note also included that the weekly skin check was completed and there was no redness or open areas noted. On September 11, a nursing entry noted that the resident had a temperature last night of 101.7, and that a weekly skin check was completed, with skin intact. On September 15, a nursing entry noted that the resident was grimacing in pain, but was unable to say where it hurt. The catheter was changed with 2000 cc of foul smelling cloudy urine in return. Again, there were no assessments regarding the resident's penis/peri area from September 10 through 15. According to a nursing note dated September 16, 2013, at 11:20 a.m., a certified nursing assistant (CNA) notified the nurse that the resident's scrotum was red and swollen, with an open area, which was painful to touch and measured 2 centimeters (cm) x 1 cm. Per the note, the UA was requested from the lab this a.m., and indicated the resident had a UTI. The note included that the catheter was not draining well and was flushed, but still had no drainage. The physician was notified and at 10:41 a.m., he ordered to replace the catheter which was done at 11:15 a.m. After 10 min, the urine output was 200 cc of cloudy yellow urine. The resident was also started on an antibiotic. A physician's orders [REDACTED]. The next nursing note was later this same day at 6:32 p.m., which included that at 5:30 p.m., the Foley bag still had no urine in it. The physician was notified and the resident was transferred to the hospital at 6 p.m. A physician's orders [REDACTED]. Review of the emergency room progress notes dated September 16, 2013, the reident's scrotum was red and excoriated, with unstageable breakdown. Review of the results of the hospital computerized tomography (CT) scan of the resident's abdomen and pelvis dated September 16, 2013 revealed the following: soft tissue air was noted in the scrotum bilaterally, right more than left. Findings are consistent with gangrene. Fluid was also noted around the urethra at the base of the penis, suggesting abscess. Review of the hospital documentation dated September 16, 2013, revealed a urinalysis which showed white blood cells of 376 (normal values 0-4), red blood cells of 106 (normal values 0-3) and creatinine (represents kidney functioning) 3.0 (normal values 0.6-1.2). According to a urologist note dated September 17, 2013, the resident was critically ill with probable gangrene and had an emergent exploration of the scrotum. A pathology report dated September 17, 2013, included that a 23 cm x 17 cm x 9 cm scrotum was received with multiple areas of gangrene, with the largest measuring 5 cm by 3 cm by 0.1 cm. The resident's suprapubic fat pad was excised as well, with a [DIAGNOSES REDACTED]. During an interview conducted on August 13, 2014 at 2:40 p.m., a licensed practical nurse (LPN) stated that if a resident had symptoms of a change in condition, such as pus-like discharge, that would warrant continuing monitoring of those symptoms and the nurse should complete an Event Report on the computer, which serves as a tracking form for a change in condition. During an interview conducted on August 14, 2014 at 2:15 p.m., the Director of Nursing (DON) stated it is very important for nurses to continue to monitor any symptom that represents a change in the resident's condition and to keep the physician updated as needed. Review of the facility's policy titled, Acute Condition Changes included that the staff will monitor and document the resident's progress and the physician will adjust treatment accordingly. The policy also included that the physician will help staff monitor a resident with a recent acute change of condition, until the condition has resolved or stabilized. -Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a facility's investigative report revealed that on May 13, 2014 at 4 a.m., the resident told the CNA to tell his nurse (RN registry staff) that he needed [MEDICATION NAME] for his lower back pain. At 4:30 a.m., the CNA returned to assist the resident and the resident asked about the pain medication. The CNA said he would remind the nurse. At 5 a.m., the resident was still in pain and had not received the [MEDICATION NAME]. The RN had told the resident that he would give the medication after giving two more medications and that he had to wait. Nursing staff reported that the medication was given at 5:40 a.m., however, in a statement from the resident, the pain medication was not given until 6 a.m. In addition, the report included that there was no documentation on the May 2014 MAR, that the resident received the [MEDICATION NAME] on May 13. The report concluded that the medication was given, but was not administered timely. Review of the MAR for May 13, 2014, revealed there was no documentation that the [MEDICATION NAME] was administered to the resident. During a telephone interview conducted on August 14, 2014 at 1:00 p.m., the certified nursing assistant (CNA) involved in the above incident stated he informed the resident's nurse (RN) at 4:00 a.m. on May 13, 2014, that the resident needed pain ointment for his back. The CNA stated the RN replied that he would do it on his rounds. The CNA stated that at 5:00 a.m., the resident still did not have his pain ointment and he again reminded the RN of the resident's pain. The CNA stated that the ointment was applied at 5:40 a.m. During a phone interview conducted on August 14, 2014 at 1:20 p.m., the RN stated that the CNA told him the resident needed pain medication and that he would "get to it" as soon as he finished with 2 or 3 other residents' medications first. The RN stated that it took 30 to 40 minutes to finish med pass and that's when he gave the pain medication to the resident. The resident was interviewed on August 14, 2014 at 1:30 p.m., at which time he stated that he did not recall receiving any pain ointment for his back. During an interview conducted on August 14, 2014 at 2:00 p.m., the Director of Nursing (DON) stated any resident that requests pain medication should not have to wait any longer than 10 minutes to receive it.