Every finding on record at Az - Rio Vista Post Acute and Rehabilitation

Based on interviews, clinical record review, and review of policy and procedure, the facility failed to ensure one of three sampled residents (#6) was provided written notice of discharge as soon as practicable prior to discharge, that the written notice included date and location of discharge, as well as contact information for the state long term care ombudsman, and that the notice of discharge was also sent to the state long term care ombudsman prior to discharge. The deficient practice could result in residents and their representatives being unaware of their appeal and advocacy rights and could prevent the ombudsman from reviewing and advocating for safe and appropriate discharge planning before the discharge occurred.-Findings include:Resident #6 admitted to the facility August 27, 2025, with diagnoses that included osteomyelitis of right femur, peripheral vascular disease, diabetes mellitus, hyponatremia, hyperlipidemia, and arthritis.A Minimum Data Set (MDS) assessment, dated September 2, 2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating intact cognition.A nurse practitioner (NP)/physician assistant (PA) progress note date October 13, 2025, revealed the resident was seen, was tearful, and did not want to discharge that day. The progress note further documented that the resident was to discharge that day, but elected to private pay for two days pending his state long term care insurance application results.An NP/PA progress note dated October 24, 2025, revealed that the discharge paperwork and prescriptions were completed with a case manager. The note included no evidence that the resident received either verbal or written notification of discharge.A Discharge Summary - nursing note dated October 27, 2026, revealed Resident #6 was to discharge to the homeless shelter on October 28, 2026. The documentation revealed no evidence that this information was provided in writing to the resident.A Required Notification of Interfacility Transfers Infection Control Transfer form dated October 28, 2025, and related discharge documents packet, uploaded into the medical record on October 28, 2025, included a physician order that the resident may discharge to a specified homeless shelter. The documentation revealed no evidence that this information was provided to the resident in writing prior to discharge.A Discharge Summary and Post-Discharge Plan of Care dated October 28, 2025, revealed that the resident was being discharged to a specified homeless shelter on October 28, 2025, and that the resident was provided a donated wheelchair and would receive medications and scripts. The document also included that the resident required ongoing treatment for wound care to bilateral buttocks; to cleanse with wound cleanser or normal saline, pat dry, apply triad paste to wound bed, leave open to air, and to apply every shift and as needed. Lastly, the documentation included the name of the state long term care ombudsman; however, the phone number listed revealed an incorrect phone number for the state long term care ombudsman.An NP/PA note progress note dated October 28, 2025, revealed the resident stated that he was not discharging that day and was waiting on placement. The plan included for discharge, pending placement per case manager.A Functional Abilities Discharge assessment dated [DATE], revealed Resident #6 was dependent on a caregiver for showering/bathing, putting on/taking off footwear, sit to stand, and toilet transfers. Additionally, the resident required substantial/maximal assistance with oral hygiene and lower body dressing. The documentation revealed the resident required partial/moderate assistance with chair/bed to chair transfers and lying to sitting on the side of the bed.A Nursing note dated October 28, 2025, revealed Resident #6 discharged from the facility at 5:10 p.m. with personal belongings and medications.Review of Resident #6's clinical record revealed no evidence of a Notice of Medical Non-Coverage (NOMNC) document.An email from the social services supervisor (Staff #19) sent on October 31, 2025, to the state long term care ombudsman, which was sent three days after the resident's discharge, contained a discharge report that revealed Resident #6 was discharged to a medical shelter on October 28, 2025, and not the previously specified homeless shelter listed in the resident's Discharge Summary.A written statement submitted to the State Agency (SA) on November 24, 2025 by the state long term care ombudsman, revealed that the ombudsman office received a discharge report from the facility on October 31, 2025, which was several days after Resident #6 had already discharged . Additionally, the statement revealed that the information that the ombudsman's office received from the facility was not accurate, as the discharge list informed the ombudsman's office that the resident was discharged to a medical shelter providing medical care, when the resident was instead sent to a homeless shelter that did not provide medical care or assistance. The statement revealed that the facility did not provide the resident written notice of the discharge prior to the discharge, or orient the resident to prepare for the discharge. The statement revealed that Resident #6 was not notified of where he was going until he was placed in the transportation vehicle by facility staff on October 28, 2025. The statement further revealed that Resident #6 arrived at the homeless shelter at dusk and had to wait in a long line for intake, and then was forced to pack up his belongings and leave the shelter early the next morning.An interview was conducted with the Case Manager Assistant (Staff #66) on July 16, 2026, at 12:54 p.m. Staff #66 stated she was responsible for coordinating resident discharges. She explained that when a resident's insurance coverage ended, she issued a Notice of Medicare Non-Coverage (NOMNC) to the resident or responsible party identifying the last covered day, obtained the required signature, arranged necessary durable medical equipment and transportation, and coordinated discharge planning. If a resident was homeless or the planned discharge location was unsafe, she stated she would involve a placement agent. She further stated that residents who wished to remain in the facility after insurance coverage ended could private pay; however, for private-pay residents, no written discharge notice was provided and discharge notification was communicated verbally.Staff #66 stated the State Long-Term Care Ombudsman's contact information was included only on the discharge summary provided to the resident as the resident was leaving the facility. She stated the facility did not notify the Ombudsman before discharge. Instead, she completed a daily discharge list each evening, and another social services staff member emailed the list of discharged residents to the Ombudsman the following morning. Staff #66 acknowledged that delaying notification until after discharge, and not providing the Ombudsman's contact information before discharge, could prevent the Ombudsman from assisting with appropriate discharge placement and aftercare services.Regarding Resident #6, Staff #66 stated she knew the homeless shelter listed on the discharge summary operated only overnight, required individuals to wait in line each evening for bed availability, and provided no medical or caregiving assistance. She also stated the medical shelter identified on the discharge report sent to the Ombudsman required residents to qualify for admission and provided housing, caregiving, and medical services to eligible individuals.Staff #66 stated she worked with a discharge placement agent for Resident #6. She explained the resident had approximately $1,500 borrowed from a friend, which was insufficient to pay for placement in a group home, and the funds were instead used to pay for several days of private-pay stay at the facility while staff attempted to secure placement. Staff #66 stated Resident #6 was not provided written notice identifying the date and location of discharge before leaving the facility. She stated the resident was discharged to the homeless shelter identified on the discharge summary, not the medical shelter listed in the report sent to the Ombudsman.After reviewing the clinical record during the interview, Staff #66 stated she was unaware before discharge that Resident #6 required daily wound care. She further confirmed the resident required caregiver assistance with lower-body dressing and footwear and partial to moderate assistance with wheelchair transfers. Based on those care needs, Staff #66 stated discharge to the homeless shelter was not safe or appropriate and placed the resident at risk for falls. When asked why Resident #6 was discharged , Staff #66 stated management informed her the resident no longer had a payer source and needed to be discharged . She also stated that, at the time of Resident #6's discharge, the facility was not sending discharge notices to the Ombudsman before discharge and that notification occurred several days later.A telephonic interview was conducted with Resident #6's emergency contact / friend on July 16, 2026, at 2:53 p.m., who stated that she was not contacted by the facility prior to Resident #6's discharge, and that she was contacted by Resident #6 after he was discharged to the homeless shelter. The friend stated that Resident #6 told her that while he was in the hospital, his roommate passed away and that he had lost his previous living situation. The friend stated that Resident #6 had told her that while he was at the facility, he was attempting to find discharge placement, and suddenly the facility staff told him he was being discharged and put him on transportation to the homeless shelter at the same time. The friend stated that she picked Resident #6 up from the homeless shelter, and that he could barely stand, could not walk, and needed help with dressing and bathing. The friend stated Resident #6 had to go back to the hospital a short time later.A telephonic interview was conducted with Resident #6 on July 16, 2026, at 3:02 p.m., who stated that he did not receive any prior verbal or written notice regarding the date and location of his discharge from the facility on October 28, 2025. He stated that on the day of his discharge, he had been participating in activities, and was informed by staff that his belongings in his room had been packed up by staff, and that he was being discharged , and they brought him outside in his wheelchair and helped him get into the transportation vehicle, and left him with his prescription medications. Resident #6 stated he had to ask the transportation vehicle driver where he was being transported to find out that he was being discharged to the homeless shelter. Resident #6 stated that he was dropped off in front of the shelter and was left unassisted. Resident #6 stated that he could barely stand but could not walk, and could not dress himself or bathe/shower himself.An interview was conducted with the Administrator (Staff #90) on July 16, 2026, at 3:22 p.m. who stated that the facility did not have a policy for notification of discharge. The Administrator stated that the facility uses the NOMNC document as the written notification of discharge.An interview was conducted with the Director of Nursing (DON / Staff #50) on July 16, 2026, at 3:30 p.m. who stated that the case management staff were responsible for providing notification of discharge and setting up a safe discharge. The DON stated that her expectation for notifying a resident of discharge was that the nurse would review the resident's discharge summary with the resident on the actual day of discharge. The DON stated that some nurses review the discharge summary with the resident earlier in the day, while some nurses review the discharge summary just prior to the resident exiting the facility. The DON stated that not all residents receive prior notice of discharge in writing, as some residents receive NOMNC forms, and others do not, depending on the insurance or payor source. Regarding notification to the state long term care ombudsman, the DON stated that the facility used to email a list of residents who had already discharged , including their discharge date and location, after every month; however, the facility staff have since changed their process to send the notice daily after the residents have discharged . The DON stated that she had received no training that the notification to the ombudsman was required to be sent prior to the residents' discharges.The DON stated that due to the Resident #6's payor source, that her understanding was that no notice of discharge needed to be provided in writing. The DON stated that she believed the notification for Resident #6's discharge was provided in the discharge summary and given to the resident at the time of his discharge. The clinical record was reviewed, and the DON stated that the resident's functional abilities for discharge assessment showed the resident required partial/moderate assistance for transfers from bed to chair, and dependent for toilet transfers. The DON stated that based on reviewing the resident's required assistance, that the resident's discharge to the homeless shelter was not safe. The DON declined to state if there would be any risk to the resident if not provided written notice of discharge including the state long term care ombudsman's contact information prior to discharge, and the DON stated that residents were notified verbally prior to their discharge.A telephonic interview was attempted on July 17, 2026, at 9:46 a.m. with the state long term care ombudsman, using the phone contact information provided on Resident #6's discharge summary. The phone number was an incorrect phone number for a different state agency.A telephonic interview was conducted on July 17, 2026, at 11:00 a.m. with the state long term care ombudsman regional director (RD) who stated that she was familiar with Resident #6's discharge from the facility, and that the ombudsman's office did not receive notice of the resident's discharge until several days after the resident had already discharged . Further, the RD stated that the ombudsman's office received incorrect information, that the resident had been discharged to a medical shelter, when in actuality, the resident had been dropped off at a homeless shelter that did not provide any medical or caregiving assistance. Additionally, the RD stated that the ombudsman's office became involved in the resident's case, and that the resident had stated he had received no written notice of discharge prior to the time he was being escorted out of the facility.Review of facility policy titled Admission, Transfer and Discharge, reviewed May 2025 and May 2026, revealed that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The policy included that the facility shall permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless:(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;(D) The health of individuals in the facility would otherwise be endangered;(E) The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission, the facility may charge a resident only allowable charges under Medicaid; or(F) The facility ceases to operate.The policy included no evidence of information regarding notice of transfer or discharge or notification to the state ombudsman.Review of federal regulation S483.15 revealed that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing. Before a facility transfers or discharges a resident, the facility must also send a copy of the notice to a representative of the state ombudsman. The notice must include: the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident is transferred or discharge, and the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Regarding timing of the notice, the notice must be made as soon as practicable before transfer or discharge when the safety of individuals in the facility would be endangered, the health of individuals in the facility would be endangered, the resident's health improves sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge is required by the resident's urgent medical needs, or a resident has not resided in the facility for 30 days. Excluding the exceptions specified in the regulation, the notice of transfer or discharge must be made by the facility at least 30 days before the resident is transferred or discharged .

Based on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure quality of care was provided, including that a physician order for a wheelchair cushion was followed, for one of three sampled residents (#10). The deficient practice could lead to skin breakdown or discomfort to the resident. -Findings include:Resident #10 admitted to the facility on [DATE], with diagnoses that included severe morbid obesity, metabolic encephalopathy, type 2 diabetes mellitus, acute respiratory failure with hypoxia, pneumonitis, malignant neoplasm of pancreas, and age-related physical debility.A Clinical admission note dated July 12, 2026, revealed the Resident #10 was alert and oriented x 3, was able to understand and could be understood when speaking. The documentation included that the resident was bedfast all or most of the time, and was very weak and severely debilitated.A Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated July 12, 2026, revealed Resident #12 had a high risk for pressure ulcer development.A physician's order dated July 12, 2026, included a wheelchair cushion every shift.A care plan focus initiated July 12, 2026, revealed Resident #10 had the potential for pressure ulcer development due to pneumonia, sepsis, pancreatic cancer with metastasis, neuropathy, diabetes, muscle weakness, and debility. Interventions included that the resident needed monitoring, reminding, and assistance with turning and repositioning, and to turn and reposition the resident as tolerated. An additional intervention included for a pressure-reducing device in the wheelchair.A Brief Interview for Mental Status (BIMS) Evaluation dated July 14, 2026, revealed Resident #10 had a BIMS score of 15, indicating cognitively intact.A physical therapy (PT) evaluation dated July 13, 2026, and completed by a physical therapist (Staff #96) revealed that Resident #10 required substantial/maximal assistance for rolling left and right in bed, sit to lying, sit to stand, and bed to chair transfers.A physical therapy treatment encounter note dated July 13, 2026, by Staff #96, revealed Resident #10 performed bed mobility with maximal assistance, and performed a transfer with maximal assistance. The note included no evidence specifying whether the resident performed a sit to stand transfer or a bed to chair transfer or other type of transfer. The note included no evidence whether one or two staff were required to assist with the transfer, or if an assistive device was utilized.A PT treatment encounter note dated July 14, 2026, by Staff #96, revealed Resident #10 performed bed mobility with maximal assistance, and performed a transfer with maximal assistance x 2 person. The note included no evidence specifying if the resident performed a sit to stand transfer or a bed to chair transfer or other type of transfer. The note included no evidence if an assistive device such as a walker was utilized. Additionally, the note included that the resident had increased pain with sitting in the wheelchair, but did not include a pain rating, or the resident's time tolerated sitting in the wheelchair.The clinical record revealed that despite an occupational therapy (OT) evaluation documented on July 13, 2026, there was no evidence of an OT daily treatment encounter note for July 13, 2026, nor any OT minutes logged on that date.An OT treatment encounter note dated July 14, 2026, by an occupational therapist (OT / Staff #33) revealed Resident #10 performed a stand pivot transfer from the edge of the bed to the wheelchair with maximal assistance, and with extra time and verbal cues required for hand placement for safety. The note revealed that a sit to stand transfer was attempted in the parallel bars, and the resident was able to clear his hips from the wheelchair, but could not achieve full upright standing, despite maximal assistance of two staff provided. The note also included that the resident required maximal assistance of 2 staff for a stand pivot transfer from the wheelchair to the bed. The documentation revealed that Resident #10 had poor activity tolerance, requiring multiple rest breaks throughout the session. The note did not include any evidence of the resident's tolerance to sitting in the wheelchair or pain level.A weight log dated July 13, 2026, revealed Resident #10 weighed 278.4 pounds.A vital log for pain revealed that Resident #10 had the following numerical pain values:-July 12, 2026, at 9:34 p.m.: 1-July 13, 2026, at 5:08 a.m.: 0-July 13, 2026, at 9:31 p.m.: 1-July 14, 2026, at 5:08 a.m.: 1-July 14, 2026, at 11:05 a.m.: 5-July 14, 2026, at 8:02 p.m.: 3Review of the Medication Administration Record for July, 2026, revealed Resident #10 was administered Acetaminophen Oral Tablet 325 mg, 2 tablets by mouth for a pain level of 5, on July 14, 2026, at 2:00 p.m.An observation was conducted on July 16, 2026, at 8:56 a.m. of Resident #10 lying in bed in his room. Outside the doorway of his room in the hallway, was a bariatric size wheelchair with no wheelchair cushion. Additionally, the left armrest of the wheelchair was missing the padding piece, and the remaining part of the armrest was a bare metal tube.An interview was conducted on July 16, 2026, at 8:50 a.m., with Resident #10, who stated that he had a horrible experience after his therapy session on July 14, 2026. Resident #10 stated that the day prior, on July 13, 2026, two male therapists, an OT and a PT had come to his room together to complete evaluations. Resident #10 stated that with the two therapists' assistance, he was able to sit on the edge of the bed, and briefly stand with a walker, however was not able to take any steps, nor was he able to transfer to the wheelchair. Resident #10 stated that the next day, on July 14, 2026, an OT (Staff #33) and a PT (Staff #96) had entered his room together at approximately 10:00 a.m., and helped him to stand and shuffle his feet to transfer to the wheelchair. The resident stated that the therapists had not put a wheelchair cushion in the wheelchair, nor was there a hoyer sling in the wheelchair. Resident #10 stated that he went to the therapy gym to complete his session, then the two therapists brought him back to the room at approximately 11:00 a.m. The resident stated that the two therapists had left him sitting in the wheelchair and had informed him that they would return in one hour to assist him with transferring back to bed. The resident also stated that they informed him that they had to go to a therapy staff meeting.The interview with Resident #10 continued, and the resident stated that one hour had passed, and he was uncomfortable in the wheelchair and put his call light on for staff to help him get back in bed. He stated that two certified nursing assistants (CNAs) came to the room, and did not place a gait belt around his waist because they stated they could not find one, and attempted to help him get out of the wheelchair by pulling under his armpit region. Resident #10 stated that the CNAs were unsuccessful in getting him out of the wheelchair. Resident #10 stated he waited in the wheelchair for over another hour for the therapists to come back to the room, at which point he was in 10/10 pain and in tears due to the pain in his bottom, low back, and arm from resting on the bare metal of the wheelchair armrest. The resident stated the pain in his bottom was due to not having a wheelchair cushion in the wheelchair. Resident #10 stated that when the therapists returned to the room, they put a gait belt around his waist and had to use brute force to lift him out of the wheelchair and transfer him back to the bed because he was in so much pain. Resident #10 stated that this painful experience had made him not want to do therapy anymore.An interview was conducted with Resident #10's family member, on July 16, 2026, at 8:54 a.m., who stated that she was at the facility with Resident #10 all day on July 14, 2026, and corroborated Resident #10's statement and stated that she had witnessed the events as he had described, and additionally stated that she took a picture of the wheelchair after Resident #10 finally got out of the wheelchair on the afternoon of July 14, 2026. At that time, Resident #10's family showed a picture of the wheelchair, which revealed the bariatric size wheelchair with no wheelchair cushion, with the left armrest padding missing, and the bare metal tube of the armrest exposed.An interview was conducted with a PT (Staff #96) on July 16, 2026, at 11:01 a.m., who stated that prior to completing a therapy evaluation, he conducts a thorough review of the medical record to become aware of the resident's medical conditions, precautions, and prior level of function. He stated that during the evaluation, he assesses the resident's strength, and how much assistance is required for the resident to complete mobility tasks. Staff #96 stated that if a resident was transferred to a wheelchair, and there was any question of safety for the resident transferring back to bed, he stated that he would give the resident a call light device, and alert nursing staff of the resident's transfer status, and to request help if needed. Staff #96 stated that staff would always use a gait belt when assisting a resident with a transfer, and that placement of the gait belt may change if there was a medical reason such as an incision, however a gait belt would always be used for transfers.The interview with Staff #96 continued, who stated that he completed the physical therapy evaluation along with the occupational therapist who conducted the occupational therapy evaluation at the same time on July 13, 2026. He stated that on July 13, Resident #10 was able to sit on the edge of the bed, and then was able to perform a sit to stand transfer at the side of the bed, with maximal assistance of the two therapists, and using a walker in front of the resident. He stated that the resident could only tolerate standing for 5 seconds, and could not take any steps to get into the wheelchair.The interview continued, and Staff #96 stated that the next day, on July 14, 2026, that the OT (Staff #33) and he went to Resident #10's room for a therapy session. Staff #96 stated that the resident was able to stand and transfer to the wheelchair with maximal assistance from the two therapists. Staff #96 stated that there was not a wheelchair cushion in the wheelchair, nor was there a hoyer lift sling placed in the wheelchair in case the resident could not stand and transfer back out of the wheelchair. The resident was then brought to the therapy gym for the remainder of his treatment session. After the therapy session was over, Staff #96 stated that the two therapists brought Resident #10 back to his room and the therapists requested that the resident try to stay sitting up in the wheelchair, and requested that he use his call light to get assistance to transfer back to bed. Staff #95 stated that after that, the therapists went to a therapy staff meeting that started at 12:00 p.m. Staff #95 stated that during the meeting, a CNA student whom he was not familiar with the student's name, had entered the meeting and informed Staff #96 that Resident #10 wanted to go back to bed. Staff #95 stated that he informed the CNA student that they were in a meeting, and the student left the meeting. Staff #95 stated that the meeting ended at 1:30 p.m., and Staff #96 and Staff #33 went to Resident #10's room after the meeting. Upon entry to the resident's room, Staff #96 stated he observed Resident #10 sitting in his wheelchair and crying. Staff #96 stated that Resident #10 stated that he was in a lot of pain and wanted assistance transferring back to bed, and stated that he wanted a wheelchair cushion, and also stated to Staff #96 that the armrest of the wheelchair was missing the padding piece. Staff #96 stated that he and Staff #33 then assisted Resident #10 with transferring from the wheelchair to the bed with maximal assistance x 2 person, using a gait belt.At the end of the interview, Staff #96 then observed the wheelchair sitting outside Resident #10's room, and stated that it was the same wheelchair that was used for the resident on July 14, 2026, and that it did not have a wheelchair cushion, was missing the left armrest padded piece, and that he had only noticed that the armrest padding was missing when Resident #10 had brought it up to him on July 14. Staff #96 stated that he had not informed anyone that the wheelchair armrest needed repaired. Staff #96 stated that a risk to a resident if padding or cushioning was missing from a wheelchair could be pain, discomfort, or skin breakdown.An interview was conducted with the Director of Nursing (DON / Staff #50) on July 16, 2026, at 3:24 p.m., who stated that the facility staff's process for preventing skin breakdown was to perform an initial skin assessment upon admission, to complete a Braden Scale assessment along with other assessments, and if a resident were determined to be high risk for skin breakdown, then resident-specific interventions would be put in place. The DON stated that the importance of following the interventions was to prevent skin breakdown. The DON stated that it was her expectation that staff follow physician's orders, that the physician's orders were where staff get their guidance, and that it was very important for staff to follow them. Regarding wheelchairs, the DON stated that staff would fit a resident with a wheelchair and offer various equipment to the resident as needed, and that if the wheelchair or equipment were broken or missing parts, that it could still be offered to the resident, as long as it was not harmful to the resident. The DON stated that if there was a physician order for a wheelchair cushion, then she would expect staff to follow the order and provide a wheelchair cushion in the wheelchair. Regarding Resident #10, the DON stated that she had not been made aware of any care concerns from the resident. The clinical record was reviewed and the DON stated that Resident #10 had a physician order for a wheelchair cushion dated July 12, 2026, and that it would not meet her expectations if the order was not followed.Review of the facility policy titled Physician Orders, revised May 2021, revealed it is the policy of the facility to accurately implement physician orders in addition to medication, treatment, and procedure orders, only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.Review of the facility policy titled Specialized Rehabilitative Services, revised May 2021, revealed it is the policy of the facility to provide rehabilitative services to residents as determined by their comprehensive plan of care to assist them to attain, maintain, or restore their highest practicable level of physical, mental, functional and psycho-social well-being.Review of the facility policy titled Comprehensive Person-Centered Care Planning, revised January 2022, revealed it is the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.Review of the facility policy titled Transfers, Types of, revised November 2017, revealed that for a maximal assistance stand pivot transfer, the procedural steps included:1. The resident slides to the edge of bed, placing feet apart, flat on the floor.2. Stand facing the resident, grasping the safety belt with both hands at the resident's side. Block the resident's knee.3. At 1-2-3, stand the resident up by straightening your knees.4. Pivot the resident, then guide him to sitting position in the chair. The resident's strong-arm position is up to your preference and resident's physical ability.5. When the resident is in position in front of wheelchair, the resident reaches back to grasp middle of arm rest and lowers himself into wheelchair.6. Steady the wheelchair as it tends to move even with the brakes locked.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed implement their abuse policy. By failing to report an allegation of misappropriation involving one resident (#5) to the state agency. The deficient practice could result in abuse/neglect and misappropriation, and other policies not being followed and potentially placing residents at harm. Findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses that included Hypertension, and fractures.The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 10 indicating the resident had moderate cognitive impairment.A request was made on June 27, 2025 at 11:04 a.m. for the 5 day reports from April 2024 through May 2024 and revealed no 5 day reports for Resident #5 were completed.A request of grievances was made on June 27, 2025 at 11:04 a.m. for the grievance log from April 2024 through May 2024 which revealed a documented on grievance on the May 2024 grievance log -- Line 2 had a grievance with Resident #5's name. The Summary of Concern and was listed as 'missing money'. The Resolution box listed, 'police called'.An interview was conducted on June 27, 2025 at 2:21 p.m. with Staff #1 LPN (licensed practical nurse) who stated that if staff suspect someone is abusing or stealing from a resident they immediately report to staff #7 (Administrator). Training is done yearly and if you do not report abuse/neglect/misappropriation you could get fired, reported to the state, and fined.An interview was conducted on June 27, 2025 at 2:28 p.m. with Staff #3 CNA (certified nursing assistant) who stated that when a resident tells staff their money is missing, staff should report that to the nurse right away. The training for abuse/neglect/misappropriation happens every month and if staff do not report, they could lose their license.An interview was conducted on June 27, 2025 at 2:35 p.m. with Staff #2 the assistant director of nursing (ADON) who stated that trainings are done for abuse/neglect and misappropriation and if suspected, staff should notify the facility officer right away. The facility officer for abuse/neglect/misappropriation is (Staff #7). An interview was conducted on June 27, 2025 at 2:44 p.m. with Staff #7 who stated that she was not in the building when Resident #5 reported that his wallet with $800-$1200 was missing; and that the admission packet had a statement that if you have over $50, the nurse would strongly suggest to put it in the trust. Staff #7 stated that the admission nurses are trained to encourage the family member to take the money to the bank or put it in the trust (at the facility). Staff # 7 stated that if a grievance is made, it will at least be investigated to find out if it was on the inventory sheet. Staff #7 stated that if it were reported it to the state, it would be within the two hour time frame; and that, if facility does not go through proper investigations and reporting timely, may cause residents to feel it won't be addressed or taken seriously.An interview was conducted on June 27, 2025 at 3:12 p.m. with Staff #4 Social Services Coordinator and Staff #7 who confirmed that the grievance was documented. Staff #4 revealed that Resident #5 had mentioned that he did not have his wallet; and that the police were called. Staff #7 joined in the interview who confirmed yes, that is a reportable. A review of the facility policy entitled Abuse: Prevention of and Prohibition Against, with a revision date 10/2024 revealed that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Section F. Investigation: all allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Section H. Reporting/Response Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State and Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to report an allegation of misappropriation for one resident (#5), within the required timeframe. The sample was 3. The deficient practice could result in resident personal property being misappropriated.Findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses that included Hypertension, and fractures.The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 10 indicating the resident had moderate cognitive impairment.A request was made on June 27, 2025 at 11:04 a.m. for the 5 day reports from April 2024 through May 2024 and revealed no 5 day reports for Resident #5 were completed.A request of grievances was made on June 27, 2025 at 11:04 a.m. for the grievance log from April 2024 through May 2024 which revealed a documented on grievance on the May 2024 grievance log -- Line 2 had a grievance with Resident #5's name. The Summary of Concern and was listed as 'missing money'. The Resolution box listed, 'police called'.An interview was conducted on June 27, 2025 at 2:21 p.m. with Staff #1 LPN (licensed practical nurse) who stated that if staff suspect someone is abusing or stealing from a resident they immediately report to staff #7 (Administrator). Training is done yearly and if you do not report abuse/neglect/misappropriation you could get fired, reported to the state, and fined.An interview was conducted on June 27, 2025 at 2:28 p.m. with Staff #3 CNA (certified nursing assistant) who stated that when a resident tells staff their money is missing, staff should report that to the nurse right away. The training for abuse/neglect/misappropriation happens every month and if staff do not report, they could lose their license.An interview was conducted on June 27, 2025 at 2:35 p.m. with Staff #2 the assistant director of nursing (ADON) who stated that trainings are done for abuse/neglect and misappropriation and if suspected, staff should notify the facility officer right away. The facility officer for abuse/neglect/misappropriation is (Staff #7). An interview was conducted on June 27, 2025 at 2:44 p.m. with Staff #7 who stated that she was not in the building when Resident #5 reported that his wallet with $800-$1200 was missing; and that the admission packet had a statement that if you have over $50, the nurse would strongly suggest to put it in the trust. Staff #7 stated that the admission nurses are trained to encourage the family member to take the money to the bank or put it in the trust (at the facility). Staff # 7 stated that if a grievance is made, it will at least be investigated to find out if it was on the inventory sheet. Staff #7 stated that if it were reported it to the state, it would be within the two hour time frame; and that, if facility does not go through proper investigations and reporting timely, may cause residents to feel it won't be addressed or taken seriously.An interview was conducted on June 27, 2025 at 3:12 p.m. with Staff #4 Social Services Coordinator and Staff #7 who confirmed that the grievance was documented. Staff #4 revealed that Resident #5 had mentioned that he did not have his wallet; and that the police were called. Staff #7 joined in the interview who confirmed yes, that is a reportable. A review of the facility policy entitled Abuse: Prevention of and Prohibition Against, with a revision date 10/2024 revealed in section H. Reporting/Response revealed that allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to complete a thorough investigation regarding misappropriation for one resident (#5), submit the 5 day investigation within the required timeframe, and prevent further potential misappropriation during the investigation. The sample was 3. The deficient practice could result in resident personal property being misappropriated.Findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses that included Hypertension, and fractures.The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 10 indicating the resident had moderate cognitive impairment.A request was made on June 27, 2025 at 11:04 a.m. for the 5 day reports from April 2024 through May 2024 and revealed no 5 day reports for Resident #5 were completed.A request of grievances was made on June 27, 2025 at 11:04 a.m. for the grievance log from April 2024 through May 2024 which revealed a documented on grievance on the May 2024 grievance log -- Line 2 had a grievance with Resident #5's name. The Summary of Concern and was listed as 'missing money'. The Resolution box listed, 'police called'.An interview was conducted on June 27, 2025 at 2:21 p.m. with Staff #1 LPN (licensed practical nurse) who stated that if staff suspect someone is abusing or stealing from a resident they immediately report to staff #7 (Administrator). Training is done yearly and if you do not report abuse/neglect/misappropriation you could get fired, reported to the state, and fined.An interview was conducted on June 27, 2025 at 2:28 p.m. with Staff #3 CNA (certified nursing assistant) who stated that when a resident tells staff their money is missing, staff should report that to the nurse right away. The training for abuse/neglect/misappropriation happens every month and if staff do not report, they could lose their license.An interview was conducted on June 27, 2025 at 2:35 p.m. with Staff #2 the assistant director of nursing (ADON) who stated that trainings are done for abuse/neglect and misappropriation and if suspected, staff should notify the facility officer right away. The facility officer for abuse/neglect/misappropriation is (Staff #7). An interview was conducted on June 27, 2025 at 2:44 p.m. with Staff #7 who stated that she was not in the building when Resident #5 reported that his wallet with $800-$1200 was missing; and that the admission packet had a statement that if you have over $50, the nurse would strongly suggest to put it in the trust. Staff #7 stated that the admission nurses are trained to encourage the family member to take the money to the bank or put it in the trust (at the facility). Staff # 7 stated that if a grievance is made, it will at least be investigated to find out if it was on the inventory sheet. Staff #7 stated that if it were reported it to the state, it would be within the two hour time frame; and that, if facility does not go through proper investigations and reporting timely, may cause residents to feel it won't be addressed or taken seriously.An interview was conducted on June 27, 2025 at 3:12 p.m. with Staff #4 Social Services Coordinator and Staff #7 who confirmed that the grievance was documented. Staff #4 revealed that Resident #5 had mentioned that he did not have his wallet; and that the police were called. Staff #7 joined in the interview who confirmed yes, that is a reportable. A review of the facility policy entitled Abuse: Prevention of and Prohibition Against, with a revision date 10/2024 revealed in section F. Investigation revealed that allegations of abuse, neglect, misappropriation of resident property, or exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Interviews with any witnesses to the incident; An interview with staff members (on all shifts) who may have information regarding the alleged incident. A review of all circumstances surrounding the incident. At the conclusion of the investigation, the Facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred. The investigation, and the results of the investigation, will be documented.

Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one (#4) of three sampled residents was provided respiratory care consistent with professional standards and highest practicability of care. The deficient practice could result in respiratory complications. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, hypertension, and heart failure with preserved ejection fraction. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of the care plan revealed no evidence of oxygen use or needs and no evidence of the resident having a focus related to respiratory issues. Review of the progress notes revealed Physician and nurse practitioner (NP)/physician asssistant (PA) progress notes from November 2, 2024 to November 27, 2022 which recommended supplemental oxygen use to keep oxygen saturation (the amount of oxygen circulating in your blood) percent greater than ninety-two percent. Review of the documented oxygen saturations revealed that all oxygen saturations documented included that the resident was on room air, indicating oxygen was not being administered during the reading. Additionally, the documentation revealed eight oxygen saturation readings that were less than or equal to ninety-two percent: November 27, 2024 14:37 82.0% Room Air November 27, 2024 06:55 91.0% Room Air November 25, 2024 07:26 92.0% Room Air November 21, 2024 07:37 92.0% Room Air November 20, 2024 21:12 82.0% Room Air November 20, 2024 06:50 86.0% Room Air November 18, 2024 08:26 90.0% Room Air November 17, 2024 21:13 80.0% Room Air There was no evidence found that the staff re-checked oxygen saturation following these low oxygen saturation readings, or that oxygen was applied. Further review of the nursing progress notes revealed multiple daily skilled notes (dated November 18, November 19, November 20, November 21, November 25, November 27 of 2024) which included vital signs for Resident #4. In these notes, the recorded oxygen saturation were less than ninety-two percent, and the note indicated that the resident was on room air. There was no evidence found that the provider was notified of these lower readings. Review of provider orders revealed no evidence that oxygen was ordered for Resident #4. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2024 revealed no evidence that oxygen was ordered or administered to Resident #4. A telephone interview was conducted on May 6, 2025 at 8:32AM with Resident #4's family member, who revealed that she had noticed on multiple occasions, during her stay, that Resident #4 had difficulty breathing. The family expressed that she would tell the staff about the respiratory issues the resident was having, but felt that the staff brushed her off. The family member stated that the facility did not provide Resident #4 with oxygen when Resident #4 was experiencing respiratory distress. A interview was conducted on May 6, 2025 at 08:55AM with a Certified Nursing Assistant (CNA/Staff #7) who stated that if she noticed a resident was in respiratory distress, she would sit them upright to help them breathe better. She stated that if the resident had orders for oxygen, she would ensure the oxygen was on and did not fall off. The CNA stated that she would then call the nurse. Interview was conducted on May 7, 2025 at 1:00PM with a Registered Nurse (RN/Staff #24), who stated that if a negative change in a resident's condition was noticed, he should notify the provider and colleagues. The RN further explained that if the change was emergent, such as one that disrupted the resident's vitals, this would require immediate intervention and he would call his supervisor for assistance. A interview was conducted on May 7, 2025 at 4:10PM with the Director of Nursing (DON/Staff #18), who stated that she would expect that during a change of condition, the staff should notify the provider, who would give instruction on what to do next. She stated she would then expect the staff to follow any new orders, notify family, and document the change of condition. The DON also stated that if a resident needs oxygen therapy, the staff should call the provider, obtain an order, and administer oxygen per the order. The DON stated that oxygen should have an order to administer it. The DON also stated that if a resident's oxygen saturation is noted to be abnormally low, she would expect the staff to notify the nurse, who would then assess the patient. She stated she would then expect the nurse to call the provider for orders if the resident showed signs of distress and follow the orders. When reviewing the chart for Resident #4, the DON could not find evidence that the provider was contacted for the low oxygen saturation readings recorded. Additionally, no order was located for oxygen usage. Review of the facility policy titled, Change of Condition Reporting (reviewed June 2024), revealed that all changes in resident condition will be communicated to the physician and resident representative and documented. Review of the facility policy titled, Oxygen Administration (reviewed January 2025), revealed that oxygen therapy should be administered by a licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained.

Based on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one (#5) of three sampled residents' choices regarding personal hygiene care were considered and honored in regard to shower preferences. The deficient practice could result in residents not having their choice in personal preferences that are significant to them. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, urinary tract infection, and end stage renal disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the care plan revealed a problem focus initiated on September 10, 2024, which revealed that the resident could be resistive to care, such as refusing showers. Interventions in place included allowing the resident to make decision about treatment regime to provide a sense of control, providing consistency in care to promote comfort with Activities of Daily Living (ADLs) as much as possible, and providing the resident with opportunities for choice during care provision. Review of the bathing charting in the Electronic Health Record (EHR) revealed that from April 7, 2025 to May 6, 2025, Resident #5 received one shower, two sponge baths, and one full-body bath. At that time period, there were three documented instances of the resident refusing, on April 9, April 16, and April 30 of 2025, which all were on Wednesdays. Review of the provider order dated March 14, 2025 revealed that Resident #5 received dialysis three times a week on Monday, Wednesday, and Friday. Review of the shower sheets for February 2025 through May 4, 2025 revealed that Resident #5 received six showers, nine bed baths, and refused ten showers. Of the ten documented refusals, eight of these were on Wednesdays, which was one of the resident's scheduled dialysis days. Review of the shower sheet dated Wednesday, April 2, 2025, revealed that the staff documented that the resident left before a shower could be completed. There was no evidence found that a shower was completed or attempted again until April 6, 2025. Additionally, review of the shower sheet dated April 9, 2025 revealed a comment from staff that indicated that the resident had refused her shower; and that, stated she did not want to go outside after shower because she was concerned about developing pneumonia. Review of the progress notes revealed psychiatric notes, from December 2024 to the most recent note dated April 22, 2025. These notes revealed that the resident had been documented by staff to occasionally refuse showers. There was no evidence found in the progress notes that the resident had been asked about why she had refused. An interview was conducted on May 6, 2025 at 10:07AM with Resident #5, who stated that she did not like her shower schedule. She explained that one of her scheduled shower days fell on Wednesdays, which was a day she was also scheduled for dialysis outside of the facility. The resident explained that she normally leaves for dialysis between 08:00AM and 9:00AM and she does not return to the facility until 3:00 or 4:00PM. The resident further explained that she does not want to go out to dialysis with wet hair, so she often denies a shower on Wednesday mornings when staff offer her a shower. The resident stated she had told multiple staff that she does not like showering on dialysis days, but claimed that none of the staff have done anything to change her shower schedule. Interview was conducted on May 7, 2025 at 10:50AM with a Certified Nursing Assistant (CNA/Staff #16), who confirmed that Resident #5's shower days were Sundays and Wednesdays during the day shift. The CNA stated that Resident #5 could take showers, but had lately been preferring to do bed baths instead. The CNA also stated that staff attempt to shower Resident #5 before dialysis because she is often tired after dialysis. The CNA stated that Resident #5 will sometimes say that she does not want to shower before going to dialysis because she does not want to get sick with pneumonia again. The CNA then stated that the resident is particular in her wants, as she will often deny her shower before dialysis, but she almost always gets up for her smoke breaks. The CNA stated that she felt there was time to complete Resident #5's showers before dialysis, as her transportation does not arrive until around 0830AM, however Resident #5 often does not want to get up or she gets cold. When asked what is done for a resident that is frequently refusing baths, the CNA explained that the staff will attempt to talk to the resident and offer to do a bed bath instead. The CNA stated that a shower is always offered first, and if the resident refuses, the staff should document on the shower sheets that a shower was offered and the resident chose a bed bath instead. The CNA also explained that each room is assigned a shower date and time, though staff attempt to accommodate if the residents have preferences. She also stated that if a shower is missed due to an appointment, staff would attempt to complete later that day or the following day. An interview was conducted on May 7, 2025 at 11:35AM with a Licensed Practical Nurse (LPN/Staff #33) who stated that Resident #5 decides what she wants to do regarding her care, including showers. The LPN stated that the resident will often be tired the day of and the day after dialysis. The LPN explained that Resident #5's shower times were Sundays and Wednesdays between 6:00AM and 2:00PM. She stated that the resident's transportation normally arrives between 08:30AM and 09:30AM. The LPN explained that staff attempt to provide showers before her dialysis. The LPN also stated that the resident will sometimes refuse, stating that she does not want her hair to be wet when going to dialysis. The LPN stated that she had attempted to tell the resident that she could get a shower without wetting her hair, but the resident did not accept. Interview was conducted on May 7, 2025 with the Director of Nursing (DON/Staff #18) who stated that resident preferences are considered when implementing the facility shower schedule. The DON also stated that some residents may have dialysis or appointments on their shower days, and if this was the case, staff discuss with the resident if they would like their shower moved to another day. The DON stated that if a resident was noted to frequently refuse showers, staff would discuss with the resident to ask for the resident's preferences, and staff would see if the preferences could be accommodated. When asked if she was aware of Resident #5's preference to not have showers on dialysis days, the DON stated she was unsure if the concern had been brought up to any management, but stated that staff did not bring up shower concerns during the weekly interdisciplinary team (IDT) rounds. Review of the facility policy titled, ADL's - hygiene, grooming, toileting, bathing, oral care, dressing, grooming, mobility, transfers, ambulation, etc. (Revised July 2025), revealed that residents should be involved in decision making and given choices related to ADL activities as much as possible.

Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one (#2) of four residents reviewed for pressure ulcers was provided care and services to prevent and safely treat pressure ulcers. The deficient practice could result in the development and worsening of pressure ulcers. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included (cystitis) inflammation of the bladder, Type two diabetes mellitus, and generalized muscle weakness. Review of the nursing progress note dated April 8, 2025 revealed that on admission, the resident was noted to have a wound to the right heel, which had a clean dressing in place. There was no evidence of other wounds noted at this time. Review of the Initial Admission Record revealed that on April 9, 2025, the resident was observed to have a right heel wound. There was no evidence of any other wounds or skin impairments at that time. Review of Resident #2's care plan revealed a problem focus, initiated on April 9, 2025, that revealed that the resident had a pressure ulcer or potential for pressure ulcer development. The goal in place for this focus was that the resident would have intact skin, free of redness, blisters, or discoloration through the review date. Interventions in place for this focus included: weekly head to toe skin assessments; informing the resident, family, and caregivers of any new areas of skin breakdown; and monitoring, documenting, and reporting to the Medical Doctor (MD) any changes in skin status. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of the nursing notes revealed a note dated April 20, 2025, which indicated that Resident #2 was noted to have a superficial popped out blister at the sacral area with redness on surrounding skin. The note revealed that the area was about one and a half inches in diameter. The nurse indicated that they had cleansed the area and applied a healing cream to avoid irritation. There was no evidence found in this note that the medical doctor (MD) had been notified or new orders were ordered to administer treatment. There was no evidence found to indicate what type of cream treatment was applied to the wound. An interview was conducted on May 7, 2025 at 10:50AM with a Certified Nursing Assistant (CNA/Staff #16), who stated that if she noticed a new skin impairment on a resident, she would let the nurse know and contact the wound nurse to determine if it was a new skin impairment. An interview was conducted on May 7, 2025 at 1:00PM with the Registered Nurse (RN/Staff #24) who initially noted the new skin impairment. The RN described that he had noticed on April 20, 2025, that Resident #2 had a sore on his bottom, which he described as a red open area with tearing skin, about a one-inch area. The RN stated that he had never seen a bed sore prior to this, but stated that he knew that they often started with a blister. The RN detailed that he had applied a cream to the wound when he noticed it. The RN could not identify the name of the cream he had used, but knew that the CNAs often used the cream for patients with bedsores. When asked if staff should obtain an order to apply a treatment to a wound, the RN explained that he did not think the treatment would require an order, as he believed this was a treatment he could begin and notify the MD after. The RN stated that he had spoken to his Director of Nursing (DON) about this case this morning, May 7, 2025, and understood that he had failed to follow protocol with this case. An interview was conducted on May 7, 2025 at 2:34PM with the wound care Registered Nurse (RN/Staff #27), who stated that she was not aware of Resident #2's new skin impairment, which was noted on April 20, 2025. The RN explained that she was on vacation at that time, so the DON was covering her job at the time. The RN reviewed the nursing note in which the skin impairment was described, and the RN stated that the wound described could be a potential pressure ulcer or it could be a skin tear. An interview was conducted on May 7, 2025 at 4:10PM with the Director of Nursing (DON/Staff #18), who stated that she would expect that if staff noticed a change of condition, the staff should notify the provider, who would give instruction on what to do next. She stated she would then expect staff to follow any new orders, notify family, and document the change of condition. When asked if she felt that Resident #2's new noted skin impairment on April 20, 2025 would be considered a change of condition, the DON stated it was potentially a change of condition, depending on what type of open area was discovered. When asked if she could determine what type of treatment was applied by the nurse, the DON stated that she would assume the nurse applied a protective barrier cream with zinc. The DON stated that the nurse should have notified the wound care nurse and put in a nursing note upon discovering the skin impairment. When asked if the DON felt this wound could have potentially been a pressure ulcer developing, the DON denied that this was a pressure ulcer, stating that the nurse had the skills to assess and determine the nature of the wound, though the wound nurse should have been notified. Review of the facility policy titled, Wound Management (reviewed June 2024), revealed that once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area per the Physician's order. The policy also indicated that all wound or skin treatments should be documented in the resident's clinical record at the time they are administered. Review of the facility policy titled, Change of Condition Reporting (reviewed June 2024), revealed that all changes in resident condition will be communicated to the physician and resident representative and documented.

Based on observation, staff and resident interviews, and facility policy, the facility failed to ensure medication were not left unsecured at bedside for two sample residents (#105 & #67). The deficientpractice of unattended medications does not align with accepted professional standards of practice and may result in undesirable medication-induced harm. Findings include: -Resident #105 was admitted on [DATE] with diagnoses of alcoholic cirrhosis of liver, depression, opioid abuse, and anxiety disorder. Review of resident #105 medical records revealed a significant change Minimum Data Set (MDS) completed December 08, 2024 when admitted on to hospice. He had a Brief Interview for Mental Status (BIM) score of 15/15 which means he has no cognitive impairment. Review of medical records did not reveal an assessment to allow self-administration nor to allow storage of medications or treatment at bedside. On April 01, 2025 at 10:19 AM, during initial observation, a beige color asthma mist inhaler unit was observed on the bed side cabinet and an uneaten meal tray on the over the bed table. The resident #105 was asleep with a head-set on. A later observation conducted on April 01, 2025, at 1:46 PM revealed the inhaler in the same location. Review of the resident's care plans revealed an intervention: allow to make decisions about treatment regime, to provide sense of control, but did not include a care plan to allow storage of medications or treatments in a secured location at bedside, nor a care plan for self-administration. Review of physician's orders revealed that the resident did not have an order for an inhaler treatment nor include an order for self-administration. An interview was conducted on April 03, 2025, at 1:09 PM, with resident #105 who was lying in bed, awake. Resident #105 stated that he had an inhaler brought in because he believed that his severe edema has traveled from his feet into his chest and been feeling pressure making it difficult to breathe, but the inhaler did not resolve that feeling. - Resident #67 was re-admitted [DATE] with diagnosis myeloma, plasmacytoma, atrial fibrillation, chronic obstructive pulmonary disease, colostomy, depression, and insomnia. His April 02, MDS Quarterly had a BIM score of 15/15 that means he is cognitively intact. Review of care plan revealed that the resident #67 had shortness of breath treatment to, Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. The care plans did not include resident to allow storage of medications or treatments at bedside, nor a related care plan for self-administration of nasal decongestion spray (oxymetazoline). Review of this resident's medical records did not reveal an assessment to allow secured storage of medications or to have treatments at bedside, nor self-administration of nasal spray. Although review physician's orders revealed an order dated February 07, 2025 treatment to have, Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligram/3milliliter) 0.083% (Albuterol Sulfate) 3 milliliter inhale orally via nebulizer every 4 hours as needed for SOB/ wheezing, and a nasal spray order dated February 06, 2025, Narcan Nasal Liquid 4 milligram/0.1milliliter (Naloxone HCI) 1 spray in nostril as needed for Opioid Reversal, may repeat every 2-3 min until patient responds. The physician's orders did not reveal an order for nasal spray treatment nor include an order for self-administration of a nasal spray. On April 01, 2025 at 09:59 AM, during initial observation, resident #67 had an box with the label Afrin sitting on top of his bedside table. On April 02, 20250 at 07:26 AM, a follow-up interview was conducted with resident #67. He stated that he had allergies and used an inhaler and the nasal spray. An interview was conducted on April 04, 2025 at 08:42 AM with a Licensed Nursing Assistant (LNA/Staff #175) who stated that the residents are not supposed to have medications nor vitamins within their rooms; and that, if she sees any type of medication or vitamin container in a resident's room, she would inform the nurse. Staff #175 stated that the residents can keep medications in their room, but has to be locked-up, and mentioned that the nurses will let the nursing assistants know who had medications in their room and that those medication have to be locked up when not in use. Staff #175 stated that having medications out in the open within a resident's rooms creates a risk of an overdosing by a wandering resident. Staff #175 stated that her expectations was that all nursing aides and staff will let the nurse know when they see medications in a resident room area. An interview was conducted on April 04, 2025 at 08:57 AM with Certified Nursing Assistant (CNA/Staff #179) who stated that had the responsibility to let her nurse know when there are medications in a resident's room; and that, there is a risk of wanders taking the item and that medication becomes a risk of of misuse. Staff #179 stated that some of the rooms have lock boxes, and she expects that all new CNAs confirm with the nurse if it is safe for that resident to have those or medications in their room. An interview was conducted on April 04, 2025 at 10:22 AM with (CNA/Staff #81) who stated that medications should not be in a resident's room, and that she would inform the nurse, who would expect a nurse to go into that room with her, and remove the item. Staff #81 stated that the nurse would let the rest of the nursing staff know who can keep their meds within room, but those meds are to be placed in a lock box. An interview was conducted on April 04, 2025 at 09:37 AM with the Licensed Practical Nurse (LPN/Staff #150) who stated whenever a medication is found, first procedure would be to make sure that resident had an order for that medication, and second to assure that the resident had an assessment and had an order to be allowed to have medication at bedside in a secured box. The nurse stated that the risk of unsecured medications could be other patients getting a hold of the medication and overdosing. Staff #150 stated that the expectation is that staff notify her whenever any type of unsecured medication is within a resident's room. An interview was conducted on April 04, 2025 at 10:41 AM with an (LPN/Staff #139) who stated that she will remove the medication or hazard items from the room, after talking to the resident or family on the risks, and call the provider. She confirmed that the nurses keep inhalers inside locked medication carts. Staff #139 stated that she had no residents that can keep medications at bedside, but the policy requires that bedside medications have to have a lock box, have to have an order, and a care plan. Staff #139 stated that the risk of unsecure medication was overdose; and that, the over use of an inhaler could affect the breathing. Staff #139 stated that the expectation would be that staff will check that the patient's lock box is secured and report items to the nurse that are left out. An interview was conducted on April 04, 2025 at 11:20 AM with the Director of Nursing (DON/Staff #1) who stated that the facility's policy and procedures are primarily focused on keeping medications, including over the counter medications, safely locked up in the medication cart, otherwise the process to keep medications in a resident's room are within a locked box. DON stated that residents are assessed to see if they can manage their own treatment, consult with the provider on the situational risks who makes the final decision, and then nursing staff will create a care plan and inform staff. DON stated that the risk of unsecured medication is the potential of someone wandering into the room. The DON stated that she expected staff to inform her of medications including over the counter medications brought in by family, and those items are given to the nurse; and that, the nurse will call and consult with the provider. Review of the facility's policy titled, Nursing Clinical (revised July 2024), revealed should a resident's medications be kept at bedside, it shall be placed in a secure container. Resident's requesting to keep medications at bedside may be assessed for the safety to self-administer medications, if approved by the medical provider. Resident found to have brought in medications from outside of the facility will be asked if the medications can be stored in a secure location. If the resident agrees to have medications removed, they will be removed to a secure area until family can pick up.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line was discontinued when not required prior to, or at time of, discharge for one of three Residents (#1). The deficient practice could result in residents utilizing the PICC line inappropriately or getting infection if not prope. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included sepsis, psychoactive substance abuse, depression, and anxiety. An order was initiated on January 23, 2025 to flush the PICC line right upper extremity (RUE) before and after use of intravenous IV medications. An order was initiated on January 23, 2025 to do PICC line care and dressing changes. An order initiated on January 24, 2025 revealed that Resident #1 ' s opioid risk was high risk. An order initiated on January 24, 2025 revealed that upon discharge, the facility should have removed the negative pressure wound therapy (NPWT) dressing and discarded it, as well as removed the canister from the device and placed the device in a clear plastic bag to be placed in the med room. There was no evidence of an order to remove Resident #1 ' s PICC line in the clinical record. An assessment utilizing the opioid risk tool was conducted on January 24, 2025 which revealed that Resident #1 had a personal history of substance abuse of illegal drugs. A care plan initiated on January 24, 2025 revealed a focus on the potential for an adverse outcome from opioid use because of her history of opioid abuse or other substance abuse. The care plan also revealed a focus on IV antibiotic therapy with an intervention for RUE PICC line care as ordered with no evidence of a revision to that intervention. The care plan revealed focuses on fall risk, pain, dehydration, ADL self care performance deficit, the risk for impaired cognitive function or impaired thought processes, and the potential for a psychosocial well-being problem all due to opioid dependency, psychoactive substance abuse, depression, and homelessness. The care plan also revealed a focus on the resident ' s wish to be discharged to their home. A weekly skin assessment conducted on January 30, 2025 at 6:39 p.m. indicated that the resident had a wound vac on her left foot and a PICC RUE line. A progress note dated January 31, 2025 revealed that the resident was discharged on January 31, 2025 at 2:30 p.m. via wheelchair, and that she left without signing her discharge summary. It was revealed that the resident left with the wound vaccuum in place and that the resident was alert and oriented and could communicate her needs well. The Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview for Mental Status (BIMS) score was 14, which indicated intact cognition. A Discharge summary dated [DATE] and signed by the Director of Nursing (DON/Staff#22) revealed that the resident was discharged to a shelter. The skin assessment portion of the discharge summary remained blank and indicated not available na for the need for ongoing treatment, treatment ordered, and other treatments or skin care. The discharge summary revealed that discharge instructions were given to the resident and her personal belongings were sent with her, the resident needed to follow up with wound care, and that her insurance ended on January 31, 2025. An interview was conducted on February 5, 2025 at 11:54 a.m. with a social worker at the hospital (Hospital Social Worker/Staff#507) who stated that a patient came into the emergency room on February 2, 2025 after being homeless following her discharge from the facility. The social worker stated that the resident was discharged from the facility with a PICC line and a history of substance abuse, including methadone. The social worker stated that when they asked Resident #1 about the PICC line she stated the facility did not remove it, and she still had it in. An interview was conducted on February 5, 2025 at 12:37 p.m. with an emergency room physician (emergency room Physician/Staff#398) who stated that she was the physician working at the hospital at the time the resident came into the emergency room on February 2, 2025 and that she did the initial assessment of Resident #1. The physician stated that Resident #1 claimed she was discharged to a shelter from the facility and that they did not have space for her when she arrived. The physician stated that the nurses witnessed and documented a PICC line in the right upper extremity of Resident #1 upon her admission to the hospital. An interview was conducted on February 5, 2025 at 2:18 p.m. with a Licensed Practical Nurse (LPN/Staff#57) who stated that on the day of discharge, the PICC line would be removed from residents with a PICC line. The LPN further stated that residents would not be discharged with a PICC line in place. An interview was conducted on February 5, 2025 at 2:25 p.m. with the Director of Case Management (DOCM/Staff#77) who stated that when a resident ' s coverage would run out she would try to find a discharge location that works for them, and if a resident had substance abuse problems she would try to get placement. Staff #77 stated that when the facility discharged residents to shelters, they would look at whether or not a resident was alert and oriented because they wouldn't know if there would be a spot at the shelter when they were discharged and there was no way to communicate with the shelter. Staff #77 stated that in Resident #1's case, her coverage was ending on January 31, 2025, the doctor changed the antibiotics from IV antibiotics to PO (by mouth), and that the facility could not send residents with a wound vac if they did not have a place to live. Staff #77 stated that they changed Resident #1 from IV to PO antibiotics because they, would have had to keep her if they did not. Staff #77 stated that it would be dangerous to discharge a resident with a PICC line who had a history of drug abuse. Staff #77 stated that if a resident was discharged with a PICC line left in place, it would indicate an unsafe discharge. An interview was conducted on February 5, 2025 at 2:32 p.m. with a Registered Nurse (RN/Staff#23) who stated that a resident being discharged would need their PICC line removed by a registered nurse before discharging. A telephonic interview was conducted on February 5, 2025 at 3:48 p.m. with a License Practical Nurse (LPN/Staff#66) who stated that his role in the discharge process was to check for wounds, sign the discharge summary, initiate a discharge progress note, document the time the resident left and what they signed, document if the resident took prescriptions, who was taking the resident, and how they left. Staff #66 stated that if he removed a PICC line he would document in the progress note that it was removed. The LPN also stated that there needed to be an order to remove the PICC line. The LPN stated that he had removed a PICC line before, but never at this facility and he stated that it was important to remove a PICC line to avoid problems with infection and to prevent residents from using it for their own purposes like drug abuse. The LPN further stated that he worked with Resident #1 the morning she was to be discharged and he was unsure of why she was moved from IV to PO antibiotics. The LPN relayed that when he got to Resident #1's room to discharge her, she was nowhere to be found, but he did not want to say she was lost. He further stated that at that time he spoke with a staff member at the front desk who stated that they witnessed the resident leaving with the wheelchair and getting into a vehicle. The LPN stated that he does know if the resident left against medical advice because, someone told me (Staff #66) she (the resident) was smoking downstairs by the chapel. Staff #66 further stated that he did not report it to anyone because his, schedule was busy that day, and he did not tell anyone that Resident #1 left without a skin assessment. The LPN stated that he did not remove Resident #1's PICC line prior to her discharge and that he would call it an unsafe discharge if a resident discharged into the community with a PICC line in place and a history of substance abuse. An interview was conducted on February 5, 2025 at approximately 4 p.m. with the Director of Nursing, (DON/Staff#22), who confirmed that the resident was discharged with a PICC line. The DON stated that the nurse let Resident #1 know she would be discharging and that she needed to come back to see him. The DON stated that the facility knew Resident #1 left with the PICC line in place because she was on IV antibiotics at the facility. The DON further stated that the facility did have patients who would leave against medical advice in the past; and that, the process would be to call the police, but the police told the facility they are, no longer taking those calls. DON stated that the discharge for Resident #1 was considered a completed discharge and was not considered an against medical advice (AMA) discharge. The DON stated that the facility called the resident a ride for transportation to the shelter, and that they don't know if Resident #1 got into the vehicle. The DON stated that discharging Resident #1 with a PICC line would be a safe discharge because she was alert and oriented, and could leave if she chose to. The DON then stated that you cannot safely discharge to the community a resident with history of drug abuse with a PICC line.

Based on observations, clinical record reviews, staff interviews and facility policy review, the facility failed to ensure that medications were not left at bedside and readily available for use for one resident (104) and, the facility failed to ensure medications were administered to one resident (#66) as ordered by the physician. This deficient practice could result in residents not receiving medications as ordered by the physician and could result in increased risk of side effects. Findings include. Resident #104 admitted on [DATE] with diagnoses of necrotizing fasciitis, sepsis, acute respiratory failure and type 2 diabetes mellitus with diabetic neuropathy. A review of the clinical record revealed no documentation of a physician order for any eye drops. During an observation of the resident's (#104) room conducted on May 22, 2023, revealed the following eye drop bottles were found at the bedside: Refresh (ocular lubricant), Latanoprost (eye pressure lowering agent) and Brimonidine Tartrate (alpha adrenergic agonist). In another observation conducted on May 25, 2023 at 10:24 a.m., the abovementioned eye drop medication bottles continued to be found at bedside of resident #104. An interview with certified nursing assistant (CNA/staff #114) was conducted on May 25, 2023 at 10:39 a.m. The CNA she had never observed medications in resident rooms; and that, residents are not allowed to keep medications in their rooms. The CNA also said that she had not seen a resident self administer medications; and, had only seen a nurse give medications. The CNA also stated if she finds medications in a resident room, she would remove the medications and give them to the nurse on shift. In an interview with registered nurse (RN/staff #63) conducted May 25, 2023 at 10:32 a.m., the RN stated that residents were not allowed to administer their own medications; and that, if she enters and finds medications in the resident room, she would ask the resident when the last time he/she took the medication, would remove the medications and would check if there was an order for them. The RN also said that she would compare the medication/s with the physician order or MAR (medication administration record) transcribed; and, would notify the provider and follow directive/orders. During the interview, a review of the clinical record with the LPN who stated that resident #104 did not have physician orderd for the eye drops found at bedside in the resident's (#104) room. During an interview conducted with Director of Nursing (DON/staff #27) on May 25, 2023 at 10:44 a.m., the DON stated the residents are allowed to self administer medications, prescribed or OTC (over the counter) if the residents were assessed and approved by the provider. The DON stated that there were no residents in the facility that were assessed and approved to self administer medication. Further, the DON said that residents were not allowed to keep medications in their room unless they were approved for self administration of the medication. She stated that if there was medication in the resident room that was not approved for self administration, it will be removed and the provider orders will be reviewed to see if there was an order for the medication. The DON also said that if there was no order for resident self administration, the nurse will store and administer the medication; and that, if there was no order for the medication, the provider will be notified and obtain an order to continue or discontinue the medication. The DON stated that residents will always be educated regarding medication and facility policy; and that, risk/benefits of the medication will be discussed with the resident as well. 47749 -Resident #66 was admitted on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, aphasia, epilepsy unspecified, type 2 diabetes mellitus, atrial fibrillation, unspecified dementia and anxiety disorder. The care plan initiated on October 21, 2021 included that resident was on anticoagulant therapy related to atrial fibrillation. Interventions included to take/give medication at the same time each day. The current comprehensive care plan included an intervention to administer medications as ordered and to monitor/document for side effects and effectiveness. Review of the physician orders revealed the following morning medications: -Aspirin (nonsteroidal anti-inflammatory) 81 mg (milligrams) give 1 tablet by mouth one time a day for DVT (deep vein thrombosis) prophylaxis; -Tramadol (narcotic analgesic) 50 mg give 1 tablet by mouth every 6 hours as needed for pain 1-10; -Acetaminophen (analgesic) 325 mg give 2 tablets by mouth every 6 hours as needed for generalized discomfort; -Amiodarone (antiarrhythmic) 200 mg give 1 tablet by mouth one time a day for Atrial fibrillation; -Apixaban (anticoagulant) 5 mg give 1 tablet by mouth two times a day for Atrial fibrillation; -Clonidine (anti-hypertensive) 0.1 mg give 1 tablet by mouth every 8 hours for hypertension; -Diltiazem (calcium-channel blocker) 30 mg give 1 tablet by mouth two times a day for hypertension; and, -Famotidine (antacid) 20 mg give 1 tablet by mouth two times a day for GERD (gastro-esophageal reflux disease). These medications were transcribed onto the MAR for August 2022. However, review of the MAR revealed that these medications were neither documented as administered or not administered as ordered on August 26, 2022; and that, the boxes for these medication on this date were blank. The clinical record revealed no evidence why these medications were not administered as ordered; and that, the physician was notified. An interview with licensed practical nurse (LPN/staff #156) was conducted on May 26, 2023 at approximately 10:00 a.m. The LPN stated that staff were supposed to document if the resident took the medication or refused; and, inform the physician if the medication was not given or the resident refused. The LPN also stated that a nurse was expected to document administration/non-administration of medication and/or refusal of medication at time of administration in the clinical record. The LPN stated that she was unable to answer why there was no documentation that medications were administered or not administered to resident #66; or. the resident refused medications on August 26, 2022; and that, nursing staff probably failed to document administration. The LPN also stated that nurses worked 12 hour shifts and it was weird that charting of administration was not present in the electronic clinical record. Further, the LPN said if a nurse fails to document administration could result in a possible or definite medication error because the nurse may be unsure if the medication was given or not. The LPN also said that if a medication was not given it could pose harm to the resident. During an interview with the Director of Nursing (DON/staff #27) on May 26, 2023 at approximately 10:30 a.m., the DON stated that if a resident was administered with a medication, the staff would document the administration on the medication administration record (MAR) and/or if the medication was refused staff would document the refusal in the clinical record (MAR or progress note) and contact the provider. The DON stated that her expectation was for nurses to document in the clinical record whether or not the resident had received the medication. She stated that the risk to a resident could be a complication or change in condition due to the administration or lack of administration; and that, the nurse managing the change in condition would not know if the change in condition was related to the administration or lack of administration of the medication. Further, the DON stated that all resident refusal of medications is passed along in shift report. According to facility policy titled Administration of Drugs revised August 2022, it is their policy that medications shall be administered as prescribed by the attending physician. The policy included the seven rights of medication administration are as follows to ensure safety and accuracy of administration: right resident, right time, right medication, right dose, right route, right documentation and right diagnosis. Further, right documentation was defined as documentation of administration or refusal of medication after the administration or attempt and note any concerns. Further, the policy included that medications must be administered in accordance with the written orders of the attending physician; and that, Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer and record the administration of medications.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that assessments consistently identified and accurately described the skin condition for one resident (#2). The deficient practice could result in resident not receiving the appropriate care and services according to their needs. Findings Include: Resident #2 was readmitted on [DATE] with diagnoses of abscess of bursa to right shoulder, cellulitis of right upper limb, end stage renal disease (ESRD), type 2 diabetes and anemia. The care plan dated February 17, 2023 included the resident had potential for pressure ulcer development related to right shoulder abscess, s/p (status post-surgical debridement, morbid obesity, and had a wound to the right shoulder. Interventions included to follow facility policies/protocol for the prevention/treatment of skin breakdown; to monitor/document/report to physician as needed changes in skin status such as appearance, color, wound healing, signs/symptoms of infection, wound size and stage; and weekly head to toe skin at risk assessment. The physician progress note dated March 6, 2023 revealed the resident was alert and awake, had warm and dry skin with no rash noted. Assessments included chronic issue of shoulder pain; and that, the resident was informed 2 weeks ago that she may have a pus pocket in her shoulder which on examination looked to be at baseline; and that there may be fluid collection or inflammatory reaction palpated in the right shoulder. Plan included checking the area using an ultrasound; and, preventive skin measures per nursing/facility. Despite documentation that the resident had skin issue identified, the shower skin assessment dated [DATE] included shower was provided and there were no old/new skin issues identified and documented. The soft tissue ultrasound result dated March 8, 2023 included 8.5 cm (centimeters) in greatest diameter of hypoechoic vascular area seen on the right shoulder which could represent bony deformity versus soft tissue mass. Impression was an 8.5 cm mass. The shower skin assessment dated [DATE] included that bed/sponge bath was provided and there were no old/new skin issues identified and documented. A nurse practitioner (NP) progress note dated March 15, 2023 included the resident was alert and awake and skin was warm and dry with no rashes noted. Per the documentation, the surface of the shoulder looked to at baseline; and that, there may be a fluid collection or inflammatory reaction palpated in the right shoulder. The daily skilled note dated March 15, 2023 included resident was alert and oriented x 4; and there were no active symptoms affecting the integumentary system observed and no new issues reported. The documentation did not mention description of the right shoulder. The shower skin assessments dated March 14, 16 and 19, 2023 included resident refused shower or bed/sponge bath. The weekly skin evaluations dated March 9 and 21, 2023 revealed the skin was intact, had skin discoloration to buttocks and back of thighs and some scattered bruising to the left arm and to the top of the left foot. However, it did not document description of wound to the right shoulder. The shower skin assessment dated [DATE] included bed/sponge bath was provided; and that, there was nothing new to report related to old/new skin issues. The weekly skin evaluation dated March 29, 2023 included skin was intact, warm to touch and had no areas of concerns noted. It did not include description of wound to the right shoulder. Review of the clinical record revealed that succeeding skin assessments dated April 5, 12 and 19, 2023 revealed skin was intact and there were no issues noted related to the right shoulder. Further, the clinical record revealed no documentation of the wound to the right shoulder from march 7 through April 22, 2023. The skin assessment dated [DATE] revealed an abscess was noted to the front of the right shoulder; and that, there was redness, warmth and tenderness to touch noted. Per the documentation, there was no drainage noted. The nursing note dated April 24, 2023 included resident had abscess, raised, soft, reddened right shoulder. Per the documentation resident was requesting to go to the hospital for evaluation. Another nursing note dated April 24, 2023 revealed that resident was transported to the hospital in stable condition. Further review of the clinical record revealed no documentation that the wound to the right shoulder was monitored; and that, treatment was provided from March 6 through April 24, 2023. Review of hospital physician progress note dated April 27, 2023 included that I&D (incision and drainage) was completed; and that, the resident had a large necrotizing soft tissue infection of the right shoulder. An interview with resident #2 was conducted on May 22, 2023 at 10:30 a.m., she stated the pain on right shoulder was worsening each day and she wanted to be seen by a skin specialist. Resident #2 stated her family came to visit one day and saw how bad her skin looked and had informed the nurses to examine her skin. Resident #2 stated the facility and the nurse at that time did not want to send the resident out to the hospital; however, her family got upset and demanded the facility to send resident #2 out to the nearest hospital. Resident #2 stated she had told the nurses about the bruising, redness and swelling to her right shoulder but the nurses told resident #2 that they will just continue to monitor. In an interview with the Director of Nursing (DON/staff #27) conducted on May 24, 2023 at 12:26 p.m., the DON stated that skin assessments are done on the day it prompts the nurses on the TAR (treatment administration record); and that, skin assessments are done weekly. The DON said that the expectation was for nurses to complete a thorough assessment of the skin and document any area that needs to be treated. She stated that if there were new skin issues and it was not on the day of the skin assessment, the expectation was for the nurse to document it in a progress note. The DON said that the wound nurse would be consulted; and that, the best time to notice any new skin issues is during the resident's shower days. She stated the CNA does not complete the skin assessment but if anything abnormal was noticed and was noted before, then the CNA was to notify the bedside nurse. In another interview with the DON (staff #27) conducted on May 24, 2023 at 3:40 p.m., the DON stated that skin assessment was completed for resident #2; and that, the physician note dated March 6, 2023 documented a pocket of puss to the right shoulder from an appointment the resident went outside of the facility. The DON said that the facility physician reported a mild boggy sensation on the resident arm; and that, she did not know why the skin assessments completed by staff did not mention skin issue regarding the pocket pus identified by the facility physician. Further, the DON said that the facility physician did not say the resident had pocket pus as this was a description documented by a physician who saw the resident during an out-of-facility appointment. An interview with corporate staff and the DON (staff #27) was conducted on May 25, 2023 approximately between 12:00 p.m. and 1:00 p.m. Both the corporate staff and the DON stated that proper interventions were followed for resident #2 and explained that an abscess could be internal and in the case of resident #2, there was not much the nurses could document in their skin assessment. Review of the facility policy on Skin and Wound Monitoring and Management included that a licensed nurse must assess/evaluate a resident's skin on admission and each pressure injury and/or non-pressure injury that exists on the resident. The assessment t/evaluation should align with the scope of practice and include but not limited to: measuring the skin injury; staging the skin injury (when the cause is pressure); describing the nature of the injury (e.g., pressure, stasis, surgical incision), describing the location and characteristics of the skin alteration. A licensed nurse will assess/evaluate a resident's skin at least weekly. Areas of breakdown, excoriation, or discoloration, or other unusual findings (either initially identified at the time of admission or as a new findings) must be documented in the nursing notes or on appropriate weekly assessment form. (Skin Pressure Ulcer Weekly, Skin Ulcer Non-Pressure Weekly, or Skin Evaluation - PRN/Weekly). The policy further included that once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per physician's order. Licensed nurse should document skin evaluations in accordance with this policy and document on the appropriate skin assessment/evaluation weekly/PRN (as needed) form. All residents will have a head to toe skin check performed at least weekly by a licensed nurse who should document the findings. Any skin issues identified as a result of weekly skin check should be documented and responded to.

Based on personnel file review, staff interviews and facility documentation and policy review, the facility failed to ensure that evidence of training to safely and effectively carry out the functions of the food and nutrition services were not expired for two staff members (#92 and #132). The deficient practice could result in dietary not having the appropriate skills to carry out their functions and responsibilities. Findings include: -Regarding the dietary aide (staff #92) The personnel file of dietary aide (staff #92) revealed a hire dated of [DATE]. The file also included a completion of a Food Handler Card Training dated [DATE] and was valid through [DATE]. However, there was no evidence found that the food handler card training was renewed and completed after [DATE]. Review of the punch details for staff #92 revealed that staff #92 worked more than 50% of the time after [DATE]. -Regarding dietary aide/cook (staff #132) The personnel file of dietary aide/cook (staff # 132) revealed a hire date of [DATE]. The file included that staff #132 did not complete food handler card training within 30 days of the hire date. The unsigned and undated job description for staff #132 revealed that education and experience requirement for a job title of a cook included a current food handler's permit as required by State regulation. However, there was no evidence found that staff #132 had food handler card training from [DATE] through [DATE]. The personnel file revealed that food handler card training was issued for staff #132 on [DATE]. During an interview with the Human Resource (HR) Director (staff #46) who stated the onboarding process was done once an offer letter is sent out and signed by the new hire employee; and that, a sit down is done with HR and all the required documents are done in the office. Staff #46 said that orientation is set up for the new hire and they are to complete online training through corporate, and two in-person orientation as well. Further, staff #46 stated training is scheduled through the department head and the staffing coordinator also helps out with onboarding. The HR director said that they use a payroll system call Workday and all the license information is entered into that system. She said she runs a report monthly and will send a detailed email to each department head for any upcoming renewal license or expired license or certifications. Regarding the dietary aide (staff #92), the HR director stated that the food handlers' card for staff #92 expired on [DATE] and there no renewal completed. Regarding the dietary aide/cook (staff #132), the HR director said that staff #132 did not have a food handler card training completed within 30 days of hired date; and, did not have a food handler card training until [DATE].

Based on clinical record review, interviews, and facility policy, the facility failed to ensure that one resident (#1) was able to exercise her rights regarding decisions about her care. The deficient practice could result in residents' not being able to make their own healthcare decisions. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed the resident was documented to be her own financial responsible party. A family member's name was listed as a contact, but no designation was noted for this family member to indicate them as a responsible party. The record did not include any documentation to indicate that the resident had a Medical Power of Attorney (MPOA). An admission Minimum Data Set (MDS) assessment dated [DATE] included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. A social service note dated August 25, 2021 at 2:37 pm included that the resident was alert and oriented times three and was able to make decisions. She was admitted for a skilled nursing stay and had lived in the community prior to her admission. A progress note, dated October 18, 2021, included that the resident was seen and examined in bed. The note included that the the resident stated her boyfriend visited for 4 hours on Saturday and she had a good time. The note included that she is tearful at times and feels family had dumped her at the facility. A social service note, dated December 3, 2021, included that per the resident's request, she did not want her family to have any information pertaining to her or her care. The note included that the resident only wants her family to be notified in the event of a medical emergency. The note included that the resident also informed her health plan case manager that she did not want her family notified. Review of the clinical record revealed that the resident was transferred to a hospital by her request following a fall on May 15, 2022. She was readmitted to the facility on [DATE]. Review of the clinical record revealed multiple documents dated May 20, 2022 that had been discussed verbally with the resident's family member/representative. For some of these documents, the family member/representative provided verbal consent to provide care and services to the resident. The documents included the following: -Consent to treat the resident -Consent for bed mobility bars (a potential restraint) -Consent for [MEDICATION(S)] and trazadone (antidepressant [CONDITION(S)] medications) -Advanced directive information/decisions -Baseline care plan acknowledgement -7-10 day observations for COVID-19 restrictions acknowledgement Further review of the documents revealed the family name provided matched the name entered in the electronic record but did not fully match any of the resident's actual family members. Additionally, the clinical record did not reveal any documentation to show that the resident had a Medical Power of Attorney (MPOA). There was no evidence that the resident was included in the discussion regarding these documents and decisions. Review of the quarterly MDS dated [DATE] revealed the resident scored a 13 on the BIMS, which indicates she was cognitively intact. During an interview conducted on August 17, 2022 at 11:07 am with the resident's family member, they stated that the first name on the consents was correct but the last name is not their name. The family member stated they were never called on May 20, 2022 to consent to anything for the resident and that they have never been a MPOA for the resident. An interview was conducted on August 17, 2022 at 1:15 pm with Social Services (staff #6). She stated that the resident had no designated MPOA and only wanted her family called if there was a medical emergency. She stated that when the resident returned from the hospital on May 20, 2022 she was able to make her own decisions and was alert. She said that sometimes residents don't want to answer questions so they ask the staff to just ask a family member. She stated she does not know for sure if that is what happened or not. During an interview conducted on August 17, 2022 at 1:53 pm with a Certified Nursing Assistant (CNA/staff #13), staff #13 stated that the resident was very alert and made her own choices. Staff #13 stated that the resident would answer every question and never had a time when she wanted her family contacted. An interview was conducted on August 17, 2022 at 2:09 pm with a Licensed Practical Nurse (LPN/staff #20). She stated that the resident would make all her own choices for her care. She stated that the resident would refuse care or treatments sometimes and would get upset if staff tried to encourage her. She stated that one time the resident needed to get up and move and refused and the family was visiting. She stated that the family member wanted the staff to make her do things. She stated that she once heard the family strongly tell the resident to get up and then essentially made the resident get up. During an interview conducted on August 17, 2022 at 2:30 pm with the Director of Nursing (DON/staff #28), the DON stated the expectation of the staff is to get signed consents from residents who are cognitively intact. The DON stated that if a resident states they want the family to complete the admission paperwork the staff need to document that in the clinical record. The DON stated that if the resident is unable to make decisions and has no documented MPOA, the next of kin on file would be notified for change of condition, consents, and care planning. The facility's resident rights policy included that the policy of the facility is that all resident rights will be followed per state and federal guidelines as well as other regulative agencies. The policy noted that the resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. The resident also has the right to be fully informed in advance about care and treatment, and, unless adjudicated incompetent or otherwise found incapacitated under state law, participate in planning medical treatment. The policy included that the resident also has the right to a written directive concerning medical care that is signed by the resident.

Based on clinical record review and interviews, the facility failed to ensure that one resident's (#1) medical record included an accurate family contact and failed to ensure a wound provider note was included in the medical record. The deficient practice could result in additional resident medical records not being maintained accurately. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment dated [DATE] included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Regarding inaccurate family contact information: Review of the clinical record revealed the resident was documented to be her own financial responsible party. A family member's name was listed as a contact, but no designation was noted for this family member to indicate them as a responsible party. The record did not include any documentation to indicate that the resident had a Medical Power of Attorney (MPOA). A social service note dated August 25, 2021 included that the resident was alert and oriented times three and was able to make decisions. Review of the clinical record revealed that the resident was transferred to a hospital by her request following a fall on May 15, 2022. She was readmitted to the facility on [DATE]. Review of the clinical record revealed multiple documents dated May 20, 2022 that had been discussed verbally with the resident's family member/representative. For some of these documents, the family member/representative provided verbal consent to provide care and services to the resident. The documents included the following: -Consent to treat the resident -Consent for bed mobility bars (a potential restraint) -Consent for [MEDICATION(S)] and trazadone (antidepressant [CONDITION(S)] medications) -Advanced directive information/decisions -Baseline care plan acknowledgement -7-10 day observations for COVID-19 restrictions acknowledgement Further review of the documents revealed the family name provided matched the name entered in the electronic record but did not quite match any of the resident's actual family. During an interview conducted on August 17, 2022 at 11:07 am with the resident's family member, they stated that the first name on the consents was correct but the last name is not their name. The family member stated they were never called on May 20, 2022 to consent to anything for the resident and that they have never been a MPOA for the resident. Regarding the missing wound provider note: Review of the clinical record revealed the resident had an upper back abscess that was being treated by the facility. A provider note dated April 30, 2022 included a referral to wound care for evaluation and possible incision and drainage of an upper back abscess. Provider notes dated May 2 and May 4, 2022 included that there was still a request for a wound care consult. A nursing note dated May 4, 2022 included that the resident was receiving antibiotics for an abscess on the upper back that had thick yellow drainage. The note included to follow up with a wound physician. A progress note dated May 5, 2022 at 10:10 am included wound to see today. A progress note dated May 6, 2022 at 9:40 am included that it would be requested that the wound provide evaluate the resident's right upper back abscess. A progress note dated May 13, 2022 at 10:50 am included that the writer had again requested for wound team to evaluate and treat as patient has completed antibiotics and there are no overt signs and/or symptoms of infection or decline of the area at this time. Review of the clinical record did not reveal documentation to show if the wound care provider had assessed the resident's abscess. During an interview conducted on August 17, 2022 at 2:09 pm with a Licensed Practical Nurse (LPN/staff #20), she stated the wound care provider had rounded on the resident but she refused to let the doctor look at it. She stated she did not know if the resident ever let anyone look at the abscess on her back.

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure care and services were provided to prevent the development of pressure ulcer for one resident (#262) and failed to ensure the pressure ulcer was thoroughly assessed consistently. The deficient practice could result in residents developing pressure ulcers and has the potential for inadequate or inaccurate or inappropriate treatment and subsequent deterioration of pressure ulcer. Findings include: Resident #262 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin integrity care plan dated December 6, 2021 revealed the resident having potential impairment for skin integrity related to incontinence, limited mobility, sciatica and severe pain. Interventions included weekly skin assessment; following facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure ulcer care plan dated December 6, 2021 included the resident having a potential for pressure ulcer development related to incontinence, limited mobility, back pain and sciatica. Goal was that the pressure ulcer will show signs of healing. Interventions included wound care to be completed by the physician/NP (nurse practitioner); medications/treatment as ordered; weekly head to toes skin at risk assessment; and, to monitor/document/report to the physician as needed changes in skin status such as appearance, color, wound healing, wound size and shape. Review of the Braden Scale dated December 6, 2021 revealed a score of 15 indicating the resident was at low risk for pressure ulcer. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date for the weekly skin evaluation was December 10, 2021. The occupational therapy (OT) note dated December 7, 2021 included the resident required maximum assistance x 2 for sit to supine and repositioning; and maximum encouragement for participation due to pain level. The nutritional care plan dated December 7, 2021 included the resident had a nutritional problem or potential related to alteration in skin integrity as evidenced by PI (pressure injury); and that, the resident had increased nutrient needs related to wound healing. However, the skin/wound note dated December 7, 2021 revealed the resident was seen for initial skin evaluation and there were no pressure ulcers present. Per the documentation, the resident had generalized dry skin, was unable to demonstrate ability to turn side to side, unable to reposition self while in bed and unable to lift each leg off the surface due to severe pain. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The shower sheet for December 9, 2021 revealed the resident was provided with a bed/sponge bath. The documentation did not indicate any old or new skin issues. The daily skilled note dated December 11, 2021 included the resident was alert and oriented x 3, with skin described as warm, dry and intact and with fair turgor. Per the documentation, there were no active symptoms affecting the integumentary system observed; and that skin condition is not a new onset. The documentation did not include whether or not the resident had skin issues or wounds. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. The assessment also included the resident at risk of developing pressure ulcers or injuries, had no pressure ulcer or injury and no skin tears or moisture related skin damage. Skin and ulcer treatments included pressure reducing devices for chair and bed. Further, the MDS revealed the resident was frequently incontinent and required extensive assistance with tasks such as personal hygiene and bathing. The weekly skin evaluation dated December 13, 2021 revealed no new skin issues. However, the documentation did not include whether or not the resident had skin issues or wounds. The shower sheet for December 13, 2021 revealed the resident was asked three times but refused a shower or bed/sponge bath. A late-entry daily skilled note dated December 13, 2021 revealed a normal overall skin description and there were no active symptoms affecting the integumentary system observed; and that, skin condition is not a new onset. The documentation did not include whether or not the resident had skin issues or wounds. The succeeding daily skilled notes from December 14 through 16, 2021 included skin was intact with no active symptoms affecting the integumentary system. The shower sheet for December 16, 2021 revealed the resident was provided with a bed/sponge bath. The weekly skin evaluation dated December 18, 2021 revealed skin was warm, dry and intact; and there were no open areas or [CONDITION(S)] noted. The shower sheet for December 19, 2021 revealed the resident was provided with a bed/sponge bath. The documentation did not indicate any old or new skin issues. The shower sheet dated December 23, 2021 revealed the resident refused a shower or bed/sponge bath. The daily skilled notes from December 18 through 25, 2021 revealed the skin was intact with no active symptoms affecting the integumentary system. The weekly skin evaluation dated December 25, 2021 revealed no new skin issue. However, the documentation did not include whether or not the resident had existing skin issues or wounds. The shower sheet dated December 26, 2021 revealed the resident refused a shower or bed/sponge bath; and that the resident was in too much pain. A review of the certified nursing assistant (CNA) documentation from December 8 through 26, 2021 revealed the resident was turned and repositioned at least two to three times per day; except on December 24 and 25 when it was documented that the resident was repositioned only once in a 24-hour period. Review of the treatment administration record (TAR) for December 2021 revealed that weekly Braden scale assessments and skin evaluations were completed as ordered. It also revealed that barrier cream to the buttocks/peri area was administered from December 8 through 25, 2021. Continued review of the clinical record from December 6 through December 25, 2021 revealed no evidence the resident had any wound or skin issues identified. However, review of the weekly pressure ulcer assessment dated [DATE] revealed an initial evaluation of an unstageable pressure ulcer to the sacrum which was not present on admission. It also included moderate serosanguineous exudate with slight odor, macerated wound edges, and wound bed had black/brown eschar. The skin/wound note dated December 26, 2021 revealed the wound on the resident's sacrum that measured 9.5 centimeters (CM) x 13.6 cm with moderate eschar, minimal pink granulation and moderate serosanguineous drainage. The Braden scale assessment dated [DATE] included a score of 12 indicating the resident was at high risk for pressure sore. The pressure ulcer care plan was revised on December 26, 2021 to include wound to the sacrum. The interdisciplinary team (IDT) review note dated December 26, 2022 revealed the resident's pressure ulcer on the sacrum was unavoidable because the resident had impaired mobility, bowel/bladder incontinence and serum [MEDICATION(S)] below 3.4 grams/deciliter (g/dl) or pre-[MEDICATION(S)] below 15 milligrams/deciliter (mg/dl). Risk factors included weight loss and muscle weakness. The following interventions were put in place: low air loss mattress (LALM), wheelchair cushion, frequent repositioning and dietary support. Recommendations included providing supplements and follow up with the wound team. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was transcribed onto the TAR for December and was documented as administered as ordered. Despite documentation the resident had an unstageable pressure ulcer to the sacrum, the daily skilled notes from December 26 through 28, 2021 documented skin was intact. The skin committee IDT note dated December 30, 2021 included unstageable pressure ulcer to sacrum, with moderate eschar, minimal pink granulation and moderate serosanguineous drainage. The documentation did not include the measurement of the wound. The weekly skin evaluation dated January 1, 2022 revealed skin was warm, dry, fair turgor and with sacral wound noted. The documentation did not include the type and stage, measurement and wound descriptions such as presence/absence of exudate, odor, tunneling, slough or eschar. The daily skilled notes dated January 1 and 2, 2022 revealed the skin was warm, dry with a sacral wound; and, to refer to wound notes. However, the clinical record revealed no evidence of wound notes for January 1 and 2, 2022. The Braden scale assessment dated [DATE] revealed a score of 11 indicating the resident was at high risk for pressure sore. The weekly pressure ulcer assessment dated [DATE] was signed as completed. However, there were no other areas answered except that it was a follow-up assessment. The sections regarding wound location, stage, measurement, exudate, description of wound bed/edges and surrounding tissue were blank. The clinical record revealed no evidence the pressure ulcer to the sacrum was thoroughly assessed to include measurement and status of the wound from December 27, 2021 through January 3, 2022. The daily skilled note dated January 4, 2022 revealed skin was warm to touch with new issues; and, to see wound nurse's notes. However, the clinical record revealed no evidence of a wound note for January 4, 2022. Further review of the clinical record revealed that on January 4, 2022, the resident was admitted to hospice services for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospice nurse's initial assessment dated [DATE] revealed a stage IV pressure ulcer to the coccyx that measured 14 cm x 20 cm x 3 cm, with small serosanguinous drainage, red wound bed, attached wound edges, and intact surrounding tissue. The discharge summary dated January 4, 2022 revealed the reason for discharge was that the resident's health had improved sufficiently and services of the facility were no longer required. The section on skin/wounds was blank. The skin committee IDT note dated January 5, 2022 included unstageable pressure ulcer to sacrum, with loose black eschar loosely attached to wound edges, bone and tendon present, moderate serosanguineous drainage and with strong odor on exam. Per the documentation, the wound was staged by the wound care NP as stage IV sacral decubitus ulcer. However, the documentation did not include the measurement of the wound. However, the discharge MDS assessment dated [DATE] revealed the resident had one unstageable pressure ulcer due to slough and/or eschar. There was no documentation found in the clinical record from January 5 through 7, 2022 that the stage IV pressure ulcer to the sacrum noted on January 5 got worse and/or became an unstageable pressure ulcer. The clinical record also revealed no evidence that a new unstageable pressure ulcer developed from January 5 through 7, 2022. An interview was conducted on March 1, 2022 2:40 p.m., with a registered nurse (RN/staff#104) who stated a head to toe assessment is completed/documented in the electronic record upon resident's admission at the facility and succeeding skin assessments of all residents in the skilled unit are done every week, usually on a Thursdays. The RN stated showers are typically done twice a week by the CNAs who also assess the resident for any skin issues and are expected to advise the nurse of any concerns. She said the nurse would then document the concern and inform the wound nurse. Further, she said a wound doctor visits the facility at least weekly and will make rounds with the wound nurse to address resident skin concerns. On March 2, 2022 at 8:54 a.m., an interview was conducted with a licensed practical nurse (LPN/ staff #127) who stated that skin assessments on all residents are done by nursing staff once a week. She said if there are any issues or concerns, the provider and wound care nurse are notified and the issue is documented in the electronic record. Staff #127 said skin assessments are ongoing and it is a standard of practice to always compare the assessments from current week to the prior week. She said an alert and oriented resident can also tell the nurse if they notice new skin issues. Further, staff #127 said that the weekly skin assessment found in the electronic record was the only document the staff use to document skin findings and/or wounds. During the interview, a review of the clinical record was conducted with staff #127 who said resident #262 did not have a wound when she came in, had no skin issues noted on December 25, 2021; but, revealed a large wound on the coccyx on December 26, 2021. Further, staff #127 stated the progression and the size of the resident #262's wound would not have occurred in 24 hours. She said she does not know how a sudden change in skin condition would happen. An interview was conducted with the wound care nurse (staff #102) on March 2, 2022 at 10:15 AM. Staff #102 stated she sees all new admissions within 24 hours to ensure all residents' skin integrity; follows treatment orders; and conducts rounds with the wound care doctor. Staff #102 also stated she also assesses for any potential risks for the development of pressure ulcers the resident may have and would put the needed interventions in place. Regarding resident #262, the wound nurse said the resident was bed-bound, very thin, in pain and was unable to reposition self because of sciatica. She said that because of these factors, wound or pressure ulcer development was probable. She said upon admission, a low air loss mattress was ordered for the resident to assist with repositioning. Additionally, staff #102 stated she conveyed to staff the importance of turning and repositioning for resident #262. During the interview, a review of the clinical record was conducted with staff #102 who stated skin assessments were done on December 15 and 25, 2021 which revealed no new skin issues. Staff #102 said that according to the documentation on December 26, 2021 that she was notified by a nurse supervisor that the resident had a coccyx wound measuring 9.5 cm. X 13.6 cm. Staff #102 stated that in her opinion, it was impossible for a wound that size to develop within 24 hours. She said that from her experience, the wound probably took approximately 2 weeks to form; and that staff should have noticed skin changes much earlier. The wound nurse said that if resident #262 refused turning and repositioning because of pain, staff should have contacted the provider to address a possible change in pain medications. She said she was new to the role of a wound nurse; and that the previous wound nurse who was present at the time the resident was admitted no longer works at the facility. She further stated it was clear to her that the previous wound nurse was not aware of the resident's skin changes because there were no additional interventions put in place since resident's admission on December 6, 2021 until the time when the wound was discovered on December 26, 2021. In an interview with the Director of Nursing (DON/staff #35) on March 3, 2022 at 1:27 p.m., the DON stated her expectation was for skin assessments to be done completely and in a timely manner. She said the Braden scale and/or skin assessments are done by the nurses weekly and/or pressure ulcer wound assessments are done by the wound care team to determine and see the status/progression of the wound. She said skin should also be checked by the CNAs during showers and bed baths; and, the expectation was for the CNAs and/or shower aides to always fill out a shower sheet and include any skin issues found. The DON said that if a new wound is identified, the nurses should contact the wound nurse, write a progress and change of condition note (COC), and notify the family and provider. She said residents who are identified as at risk for developing pressure ulcers should have the following interventions: application of barrier cream, turning/repositioning, medications, discussing risk factors with the resident for refusal of care, and talking with and asking the family to help ensure resident compliance with the interventions. The DON said if a resident report that it was too painful to be turned and repositioned, the nurse should notify the provider for more pain medications or different medications. Additionally, she said that X-rays might be ordered to determine if any bone changes had occurred. Further, the DON stated the wound care nurse is responsible for completing the weekly pressure ulcer assessments. A review of the clinical record of resident #262 was conducted with the DON who said the follow up weekly pressure ulcer assessment dated [DATE] was not filled out, had no information at all and was signed by the floor nurse and not the wound nurse. She said that perhaps it was an error; however, she could not find in the clinical record a completed document by a wound nurse for January 2, 2022. She stated the resident's pressure ulcer in the sacrum should have been assessed and documented the week after it was found and before discharge on January 7, 2022. The DON stated the clinical record of resident #262 was lacking appropriate documentation; and, there was no evidence of any assessments of the resident's pressure ulcer to include measurements from December 26, 2021 through January 7, 2022. Further, she stated this was a problem because the wound nurses should have been measuring and documenting the wound carefully. She said the facility tracks and trends all wounds to establish progress; and, the lack of weekly wound measurement is a concern. The facility policy Care and Treatment / Wound Management reviewed May, 2021 revealed that it is their policy that a resident does not develop pressure ulcers unless the individuals clinical condition or other factors determine that a pressure ulcer was unavoidable interventions included to stabilize, reduce or remove underlying risks, reposition the resident, use pressure relieving devices such as low air loss mattress, pillows and wedges and if the resident is incontinent provide regular peri care to ensure the residents skin remains clean and dry. The policy further revealed that a weekly head to toe skin assessment with follow up as applicable was to be completed. The facility policy Documentation and Charting (reviewed July, 2020) revealed that it is the facility policy to provide a complete account of the residents' care, treatment, response to care, signs, symptoms etc., as well as the progress of the residents' care. The facility policy Skin Assessment (revised May, 2007) revealed that the facility policy was to assess all residents upon admission, when a comprehensive assessment is required and quarterly thereafter to identify risk of skin breakdown. If skin breakdown is present wound care will be followed and documentation is completed.

Based on observation, staff interviews and review of facility documentation, policies and procedures, the facility failed to ensure that staff were consistently screened for COVID-19 upon entry to the facility and prior to working their shift. The deficient practice could result in the spread of infection to residents and staff. Findings include: During an observation conducted on February 28, 2022 at 8:00 a.m., the receptionist instructed the staff and visitors waiting in the lobby to wear a mask and perform hand hygiene using the alcohol-based hand rub (ABHR) also located in the lobby. At the corner of the lobby, there was an I-Pad which the receptionist directed the staff and visitors to go for COVID-19 screening questions. The electronic screening questions included signs and symptoms of COVID-19, recent travel, COVID-19 exposure, and temperature. A laminated poster with information on handwashing and precautionary measures for symptomatic staff and visitors was also posted on the door as you entered the lobby. Review of the Labor Hours Reports dated February 19, 20 and 21, 2022 revealed the following staff punched in and worked their entire shifts on the following dates: -February 19: registered nurse (RN/#170); laundry staff (#24); dietary aide (#22); -February 20: dietary aide (staff #22); licensed practical nurse (LPN/#38); registered nurse (RN/#149); certified nursing assistant (CNA #147); and, -February 21: laundry staff (#97) and dietary aide (#56) A review of the screening documents dated February 19 through 21, 2022 revealed documentations of COVID-19 screening for staffs #24 and #22 only for February 19. Further review of facility documentation revealed no evidence that staffs #38, #56, #97, #147, #149, and #170 were screened for COVID-19 prior to or at the beginning of their shifts on February 19, 20 and 21, 2022. An interview was conducted on February 28, 2022 at 1:42 p.m. with a certified nursing assistant (CNA/staff #142) who stated that the staff screening area is located at the front lobby or the back of the facility by the time clock. Staff #142 stated that staff performs self-screening prior to working and once completed, staff can clock in and sign-in by the computer. In an interview conducted with the Infection Control Preventionist (ICP/ staff #125) on March 1, 2022 at 1:14 p.m., the ICP stated an in-service training on self-screening prior to entry to resident care areas was provided to all staff; and that, Human Resources (HR) maintained screening completed for all staff. However, during an interview conducted on March 2, 2022 at 9:22 a.m., the Director of Nursing (DON/ staff #150) stated that only two (staff #24 and 22) out of 8 sampled staff completed the screening prior to entering the resident's care area; and that, she could not find any documentation that staffs #38, #56, #97, #147, #149, and #170 were screened prior to their shifts. She stated her expectation was for every staff to complete a COVID-19 screening prior to entering the resident's care area; and that, staff who do not comply with the facility's screening policy will not be allowed to enter the building. The DON further stated moving forward, the employee entrance will have a staff monitor 24/7 to ensure this deficient practice does not occur again. The facility policy on Infection Control and Prevention, stated that it is their policy to include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. The policy included healthcare personnel be screened on a daily basis, and monitored for COVID-19 symptoms and fever.

Based on observation, clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure an ongoing activity was provided based on the comprehensive assessment and preferences for one resident (#462). The deficient practice could result in the not having meaningful activities based on the resident's interest and preferences. Findings Include: Resident #462 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated February 16, 2022 revealed the resident was alert and oriented x 4 and was able to make needs known. An activity admission evaluation dated February 17, 2022 revealed the resident was alert and oriented to person, place and time with adequate communication and cognition skills. Activity interests included card games, computer games, puzzles, exercise groups, music, reading, walking and wheeling outdoors, sewing and watching television (TV). The activities care plan dated February 17, 2022 included the resident was dependent on staff for activities, cognitive stimulation and social interactions related to physical limitations such as left hip fracture. The goal was that the resident will attend and participate in activities of choice. Interventions included preferred activities such as computer games, logic puzzles, classical music, [NAME] King books, sitting outside, TV, sewing, pet visits and current events. Further, the care plan included the resident needed one to one bedside/in-room visits and activities if unable to attend out of room. The NP (nurse practitioner) progress note dated February 18, 2022 included the resident was alert and awake and had multiple complaints about food, room and TV (television). The social service summary note dated February 21, 2022 revealed the resident was alert and oriented x 3 and was able to make needs known. Review of the Activities log from February 17, 2022 through March 1, 2022 revealed the resident was documented as active in independent activity of watching TV and meal/food/or snack. According to the documentation, there was no one on one activity provided. The log also revealed the resident was marked as not available for the following activities: -Creative activity in February 20 and 27; -Mental activity on February 24; and, -Social activity on February 26. An observation was conducted on February 28, 2022 at 11:43 a.m., revealed resident #462 was in her room, lying in bed and the activity calendar was posted on the wall to the left of the resident. An interview was conducted immediately following the observation. Resident #462 stated that when she got admitted at the facility, the activity calendar was posted on a different side of the wall where she could not see it; and that, she had to ask for it to be posted closer to her so she could read it. Resident #462 stated she would have gone to activities and she would like to do activities but she did not know how. She stated that there was no posting of activity for February available in her room and the calendar posted at the time of interview was already for the month of March. Further, resident #462 stated that no one from activities had spoken with her to discuss any activity options. An interview was conducted on March 1, 2022 at 12:57 p.m. with the activity director (staff #99) who stated she had been the activity director for a year. She stated each resident is interviewed regarding their activity preferences within three days of admission. Staff #99 said each resident is provided with their preferred activities; and that, all activities provided are documented in the clinical record and in the progress notes. She stated that for residents on transmission-based precautions, activities will be provided in the resident's rooms. Regarding resident #462, she stated she was familiar with the resident and was not aware the resident refused to participate in activities at any time. When asked about resident's preferred activities, staff #99 said she would have to check the resident's record. An interview was conducted on March 3, 2022 at 12:48 p.m. with the Director of Nursing (DON/staff #35) who stated residents were restricted to activities in their rooms due to COVID-19 precautions in the building. The DON stated activity staff put a special focus on residents in the observation unit since they are not able to leave their rooms for activities. She stated the activity staff completes an assessment and provide resident activities according to their preferences. The DON stated the activity director and associates should be going into each resident's room to provide activities. Regarding resident #462, the DON said the resident was admitted in the observation unit and was placed on transmission-based precautions. Further, the DON stated she was not aware of any issues regarding the activity program. The facility policy on Activities revealed that it is their policy to ensure that residents have the right to choose the types of activities and social events in which they wish to participate. Residents are encouraged to choose the types of activities and social events in which they prefer to participate. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations.

Based on observations, clinical record review, resident and staff interviews and facility policy and procedure review, the facility failed to ensure care and assistance with the use of hearing aids was provided to one resident (#65). The deficient practice could lead to the resident not able to hear and maintain hearing abilities resulting in difficulty in communication. Findings include: Resident #65 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated August 11, 2020 revealed the resident was at risk for communication problem related to hearing deficit and had bilateral hearing aids. The goal was that the resident will be able to make needs known on a daily basis. Interventions included to anticipate and meet needs, and use of adaptive communication equipment, hearing aid. A nursing progress note dated January 28, 2022 revealed the resident's hearing aids were delivered. The hearing aid service note dated January 28, 2022 revealed that new rechargeable hearing aids were delivered with charging and cleaning instructions. The NP (nurse practitioner) progress note dated February 3, 2022 included the resident reported getting her hearing aids. The social service summary dated February 3, 2022 revealed the resident was alert and oriented with some forgetfulness and was hard of hearing. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Per the assessment, the resident had adequate hearing with hearing aids. A physician order dated February 9, 2022 revealed for hearing aids to be placed on the charger prior to the resident going to bed every night shift. A psychiatric note dated February 15, 2022 revealed the resident was alert and oriented x 3 and can verbalize needs. Review of the treatment administration records (TAR) and revealed that the hearing aids were placed on the charger every night as ordered from February 10, 2022 through March 1, 2022. However, in an interview conducted on February 28, 2022 at 1:37 p.m., resident #65 stated she was having difficulty with hearing because she does not have her hearing aids on. She said that she received new hearing aids last month but no one has helped her to get them to work yet. She stated that without her hearing aids she cannot hear; and that, she needed staff assistance in putting them on. During the interview, an observation was conducted and revealed there were two hearing aids next to the charger on the bedside table. An interview was conducted with a licensed practical nurse (LPN/staff #25) on March 2, 2022 at 11:58 a.m. The LPN stated she had worked on this unit for several years and the residents' hearing aids are locked in the cart at night. She stated the expectation was the nurse or CNA would help the residents in putting their hearing aids on in the morning. Regarding resident #65, the LPN stated the resident does not have any hearing aids; and that, the resident hears her without a problem. Further, the LPN stated that she was not aware that resident #65 has hearing aids; and that, there are no hearing aids in the medication cart for that unit. During an interview with certified nursing assistant (CNA/staff #59). conducted on March 2, 2022 at 12:05 p.m., the CNA stated she works on the day shift and she assists the residents to get ready for the day. She said the process for residents with hearing aids included for the nurse to take them from the cart, give the hearing aid to the CNA and instruct the CNA to put them on the resident every day in the morning. Regarding resident #65, the CNA said she does not think the resident has hearing aids and was hard of hearing. In another observation conducted on March 2, 2022 at 12:40 p.m., the hearing aids of resident #65 was next to the charger on the bedside table. Immediately following the observation an interview was conducted with the resident who stated she still has not had her hearing aid on because none of the staff has helped her put them on. She also said that in the past, there were two staff members who would always help her with her hearing aids. However, the resident said she does not see them anymore and no one helps her with her hearing aids even when she asks for help. Review of the facility policy on Care of Hearing Aid with review date of May 2007 revealed that it is their policy to maintain the residents hearing aids in good order. The policy included a primary purpose of caring for a hearing aid is to maintain resident's hearing aid in good order. The facility policy on Documentation and Charting reviewed on July 2020 revealed that it was their policy to provide a complete account of the residents' care, treatment, response to care, signs, symptoms etc. as well as the progress of the residents' care. In their policy on Services to Carry Out Activities of Daily Living with review date of July 2020, it revealed that residents are to be given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with a written plan of care.

Based on observations, facility documentation, staff interviews, review of the Center for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure that infection control standards were maintained. The deficient practice could result in the spread of infection to residents and staff, including COVID-19. Findings include: An entrance conference was conducted on September 2, 2020 at 3:15 p.m. with the Administrator (staff #43) and the Director of Nursing (DON/staff 79). During the conference it was revealed there were no COVID-19 positive residents in the facility. It was also revealed that there were residents on observation for symptoms of COVID-19, including [MEDICAL TREATMENT] residents. While on a tour of the facility with the DON and the Assistant Director of Nursing (ADON/staff #16) on September 2, 2020 at 3:40 p.m., the ADON pointed out a linen closet next to the nurses' station and stated that staff are supposed to get a clean gown out of the linen closet and don the gown before entering a resident's room on observation for symptoms of COVID-19. The ADON stated that staff are to doff the gown prior to leaving the resident's room and hang the gown on a hook in the resident's room. She also stated that at the end of the staff shift, the CNAs are to place the gowns in a plastic bag and take them to the laundry. Observation of the hooks revealed CNA labels were posted, however, there was no indication of what gown belonged to what CNA. The ADON and DON were unable to explain how it would be determined which gown belonged to which staff. An interview was conducted on September 3, 2020 at 12:30 p.m. with a Certified Nursing Assistant (CNA/staff #33) in training working on the hall where [MEDICAL TREATMENT] residents were being observed for symptoms of COVID-19. The CNA stated clean gowns are hung by someone in the rooms of the residents on observation for the CNAs and the nurses to don and use for their shift. Observations conducted of 5 residents' rooms with staff #33 revealed one room had two hooks and one label for a nurse between the hooks, one room had a label for a CNA but not for a second CNA, and one room with two gowns hanging on a hook labeled therapy. Staff #33 stated that she always tries to hang her gown on the hook labeled CNA that is closest to the door, so she knows which gown is hers. She also said that she and the other CNA try to let each other know where they are hanging their gowns. Regarding one of the resident's rooms, the CNA stated the room was assigned to the other CNA and that she had been in room earlier to help the resident. She pointed to the gown hanging closest to the door and identified it as her gown. Staff #33 was unable to explain how the other CNA would know that she had assisted the resident or used the gown hanging on the hook closest to the door. Staff #33 checked the two gowns that were observed hanging on a hook labeled therapy for names, however, there were no names. The CNA stated she did not know how staff would know which gown belong to which staff. A nurse within close proximity, stated that staff #33 was right about gowns already hanging in the residents' rooms and that she also uses the gowns that are already hanging in the rooms. An interview was conducted on September 3, 2020 at 1:50 p.m. with the Infection Control Preventionist (ICP/staff #150) and the ADON (staff #16). Staff #150 stated that staff are to get a clean gown from the linen closet before staff enters the resident's room on observation. She stated that when the staff is done assisting the resident, the staff is supposed to hang the gown on a hook in the resident's room. The ICP said there should be hooks labeled for the nurses and the CNAs. She also stated that staff are to use the same gown for the entire shift. She said at the end of their shift, the CNAs are to remove the gowns from the rooms and send them to the laundry to be washed to avoid transmission of [MEDICAL CONDITION] to staff. Staff #16 agreed with staff #150 and acknowledged that this was the process that she had explained during the interview conducted with her on September 2, 2020 at 3:40 p.m. During the interview with staff #150, the DON (staff #79) joined the interview and instructed staff #16 to begin re-training staff on the use of gowns immediately. Review of the facility's Infection Prevention and Control Program policy reviewed January 2020 revealed goals included decreasing the risk of infection to residents and personnel and ensuring compliance with state and federal regulations relating to infection control. The facility's Emerging Infectious Disease (EID): Coronavirus Disease 2019 (COVID-19) policy revised May 4, 2020 states the goal is to implement recommended appropriate infection control strategies, guidance and standards from the local, State and Federal agencies for an EID event. CDC's optimization strategies for PPE offer options for use when PPE supplies are stressed, running low, or absent. As PPE availability returns to normal, healthcare facilities should promptly resume standard practices. The policy included putting on an isolation gown upon entry into the patient room or area and that cloth gowns should be laundered after each use. The CDC Strategies for Optimizing the Supply of Isolation Gowns updated March 17, 2020 regarding the extended use of isolation gowns revealed that for the care of patients with suspected or confirmed COVID-19, HCP (healthcare personnel) risk from re-use of cloth isolation gowns without laundering among multiple HCP sharing one gown is unclear. The goal of this strategy is to minimize exposures to HCP and not necessarily prevent transmission between patients. The guidance included care should be taken to ensure that HCP do not touch outer surfaces of cloth gown during care. Cloth isolation gowns could potentially be untied and retied and could be considered for re-use without laundering in between.

Based on clinical record review, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure one of four sampled residents (#1) was free from neglect. The deficient practice could place residents at risk for further neglect. Findings include: -Regarding the incident on (MONTH) 30, 2019: Resident #1 was readmitted to the facility on (MONTH) 3, 2014 with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 6, 2019 included the resident was blind and required assistance with all activities of daily living (ADL). An intervention included to encourage the resident to use bell to call for assistance. A care plan dated (MONTH) 9, 2019 revealed the resident was at risk for falls related to deconditioning. The goal was the resident would not sustain serious injury. Interventions were to anticipate and meet needs, be sure the call light is within reach and encourage to use it to call for assistance as needed, and to offer toileting every two hours. Review of a care plan dated (MONTH) 20, 2019 revealed a focus area of bowel and bladder incontinence related to impaired mobility, dementia and a history of urinary tract infections [MEDICAL CONDITION]. The goals included that the risk for [MEDICAL CONDITION] would be minimized/prevented via prompt recognition and treatment of [REDACTED]. Interventions included to use briefs and change briefs as needed and check as required for incontinence. A care plan dated (MONTH) 20, 2019 revealed the resident was at risk for impaired visual function related to [MEDICAL CONDITION]. The goal included to maintain an optimal quality of life. A care plan for impaired cognitive function/dementia dated (MONTH) 20, 2019 included an intervention for staff to identify themselves at each interaction. Review of a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 6, 2019 revealed a brief interview for mental status score was 12, which indicated the resident had mild cognitive impairment. Also included was the resident had clear speech, could make herself understood, could understand others, and had severe impaired vision. Per the MDS, the resident required the assistance of one staff with transfers from the wheelchair and required extensive assistance of one staff for toilet use. The MDS also noted that the resident was frequently incontinent of bowel and bladder. Review of the facility's incident investigation documentation dated (MONTH) 1, 2019 revealed an incident was reported on (MONTH) 31, 2019 by a family member of the resident. The investigative note stated that the resident told a family member the following: a CNA (identified by the facility as staff #21) came into the resident's room to get her ready for bed and was rough with her and had refused to identify herself, and had put the resident in the bathroom and did not return for her in a timely manner (no time frame was included), and then sent another CNA (staff #4) to finish her p.m. care. Per the investigation, staff #21 was moved from the unit where resident #1 resided on (MONTH) 1, 2019. Further review of the incident investigation revealed that staff #21 was interviewed on (MONTH) 5, 2019. Staff #21 reported that the resident appeared anxious and repeatedly asked her what her name was, and that she had identified herself to the resident. Staff #21 reported that she had placed the resident in the bathroom, but did not finish her p.m. care. The investigation also included an interview conducted on (MONTH) 5, 2019, with a CNA (staff #4). Staff #4 reported that staff #21 asked her to finish the evening care for resident #1, as she was working with another resident. Staff #4 reported the resident asked her what the other aids name was and she told the resident that she did not know her name. The investigation further included that staff #38 (CNA) had not provided care to the resident on this shift. The specific shift was not was included. (However, in an interview with staff #38, she stated that she had worked with the resident during the time of this incident on (MONTH) 30). Continued review of the incident investigation revealed the best course of action was to re-assign staff #21 to a different floor to avoid further potential for conflict. The facility's investigation did not address the allegation of rough treatment or if staff #21 had returned to the resident in a timely manner. The documentation also did not include the date or time that the incident had occurred, only the date it was reported. An interview was conducted on (MONTH) 3, 2019 at 11:31 a.m., with a corporate Registered Nurse (RN/staff #40). Staff #40 stated there was no further documentation or investigation conducted for this incident, because the facility staff did not believe it happened. An interview was conducted on (MONTH) 3, 2019 at 12:43 p.m., with the administrator (staff #29), who stated that she was the author of the incident investigation. An interview was conducted with a CNA (staff #21) on (MONTH) 4, 2019 at 9:09 a.m. Staff #21 stated she was the staff who found the resident in the bathroom on (MONTH) 30, 2019, and that the resident was screaming and yelling for help. Staff #21 stated the resident is blind and told her that another CNA would not give her their name even though the resident asked her many times. She said the resident stated that she had been left in the bathroom for a very long time and had to scream, so she could get help from staff. Staff #21 stated she tried to calm the resident and then helped her get into bed. Staff #21 stated she was not the staff who left the resident in the bathroom for a long time and to do so would be neglect. Staff #21 said that she told her supervisor of this incident during her shift. Staff #21 also denied that she had physically abused or was rough with the resident and denied that she had been neglectful by leaving the resident in the bathroom for a long time. An interview was conducted with a CNA (staff #38) on (MONTH) 4, 2019 at 10:14 a.m. She stated that she had worked with staff #21 for a portion of the shift on (MONTH) 30, 2019. Staff #38 said that staff #21 told her the resident was being difficult again. Staff #38 said the resident told her earlier that on (MONTH) 30, 2019, a CNA had treated her roughly. An interview was conducted with resident #1 and a family member on (MONTH) 4, 2019 at 12:25 p.m. During the interview, the resident was able to correctly answer questions regarding the year, the date, the day and the name of facility. The resident stated if she talked about the incident from (MONTH) 30, 2019, she would probably cry and be sad. The resident stated she was willing to answer questions and would do her best. The resident stated she could remember the incident and that she had been left in the bathroom for too long of a time. She said that she was scared and called out for help and no one came. She said that she wears an incontinence brief and she had soiled and wet herself and felt very bad. She also said that she had been treated roughly by a staff person and could not identify the staff by name, because the staff do not always tell her their name even though she asks. The resident then became tearful and said that she could no longer talk of the incident. An interview was conducted with the Assistant Director of Nursing (Licensed Practical Nurse/staff #70) on (MONTH) 5, 2019 at 12:25 p.m. She stated that she was aware of the incident on (MONTH) 30, 2019 regarding resident #1, but had not been very involved. She stated the incident was only treated as a customer service incident, because the resident stated that a CNA would not tell the resident her name. Staff #70 stated if she had been aware that the resident reported rough treatment, she would have identified it as an allegation of abuse. Staff #70 stated that leaving a resident in the bathroom for a long period of time and not providing timely care would be considered neglect. Staff #70 stated she had not been called, texted or notified regarding the incident. Staff #70 stated that all allegations of abuse and neglect have to be reported, fully investigated and there needs to be protection of residents during the investigation, so residents can be safe. Staff #70 stated that none of these steps had been implemented regarding this incident. An interview was conducted with the Administrator (staff #29) on (MONTH) 5, 2019 at 1:21 p.m. She stated that she was aware of the incident regarding resident #1, which had occurred on (MONTH) 30, 2019. Staff #29 stated even though she has been fully trained on identification of abuse and neglect, mandatory reporting requirements to various agencies and timeframes, investigation protocols and the protection of residents, this incident was not identified as abuse and/or neglect and therefore, the mandatory steps were not implemented. -Regarding the incident on (MONTH) 16, 2019: Review of an incident note dated (MONTH) 17, 2019 revealed the resident was alert, oriented, and able to state her needs and is legally blind. Per the note, the nurse (RN/staff #23) was making rounds and found the resident in her wheelchair in the bathroom. The bathroom door and the main door to her room were both closed. The resident reported that one of the CNA's put her in the bathroom and never showed up. The resident was reassured and was put back to bed and no change in condition was noted. Review of the facility's investigation dated (MONTH) 28, 2019 revealed that on (MONTH) 17, 2019, staff #23 reported to the Administrator (staff #29) that she found resident #1 in the bathroom of her room around 2:00 a.m., with the door closed. Staff #23 reported the resident said that she was left in the bathroom in her wheelchair for an extended period of time. The investigation included an interview with the resident, however, it was not conducted until (MONTH) 19, 2019 at 11:45 a.m. The resident reported that she had been assisted to the bathroom by a CNA (identified as staff #106) to brush her dentures but she could not remember the CNA's name, however, the resident reported that this CNA was with another CNA (identified as staff #38). The resident reported the CNA (staff #106) told her that she would be back to get her, but no one came back. The resident stated she called for help and no one came. The resident stated she did not know how long she was in the bathroom, but said that she fell asleep for a period of time, while waiting for staff to come back. The investigation included an interview with a RN (staff #23), however, the date of the interview was not documented. Staff #23 reported that she had been the nurse on duty from 10:00 p.m. on (MONTH) 16 until 6:00 a.m. on (MONTH) 17, 2019. Staff #23 stated she found resident #1 in her wheelchair in the middle of the night, but did not recall the time. The report included an interview with a CNA (staff #106) who worked the 2-10 p.m. shift on (MONTH) 16, 2019. There was no date to indicate when this interview was conducted. Staff #106 stated she was the CNA who assisted resident #1 to the bathroom around 9:30 p.m. (on (MONTH) 16) to brush her teeth and complete her evening care. Staff #106 reported that she thought she had put the resident to bed. Staff #106 stated she forgot to go back and check on the resident, prior to leaving for the night. Per the investigation, an interview with a CNA (staff #38) was conducted, however, there was no date to indicate when the interview occurred. Staff #38 worked on (MONTH) 16, 2019 from 10:00 p.m. until 6:00 a.m. on (MONTH) 17, 2019. Staff #38 reported that the CNA's do not have individual assignments and they take full responsibility for the entire floor. Staff #38 reported that she had been made aware of the resident being found in the bathroom by the nurse. Staff #38 stated she had not been in the room of resident #1, because the resident was typically already in bed and will use the call light if she needs anything. The investigation also included an interview with a CNA (staff #102) who worked the 10pm-6am shift on Augsut 16-17. She reported that she worked with staff #38 that night. She said they did not have set assignments and that both of them were responsible for all of the residents together. She said that she did not go into the resident's room during that shift. She said the resident is always already in bed when she gets on shift, and if she needs anything she uses her call light. Further review of the facility's investigative documentation revealed the following conclusions: 1. It was determined that the resident was left in a wheelchair in the bathroom but it is unknown how long. 2. Nursing staff are not assigned to specific residents on any shift and they just work together. 3. Two hour rounds are not conducted on the night shift on every resident, just on those residents that are incontinent or have dementia, and other residents are attended to as they call for help using the call light. 4. The resident's call light cord was sufficient in length to reach, but could not be clipped to the resident. An interview was conducted with resident #1 and a family member on (MONTH) 4, 2019 at 12:25 p.m. The resident stated if she talked about the incident on (MONTH) 16, 2019, she would probably cry and be sad. The resident stated she was willing to answer questions and would do her best. The resident stated she could remember the incident and that she had been left in the bathroom for too long of a time. She said that she was scared and called out for help, but no one came. She said that she wears an incontinence brief and she had soiled and wet herself, and felt very bad. The resident stated there had been a similar incident in (MONTH) 2019 of her being left in the bathroom for a long time and the incident in (MONTH) 2019 was not nearly as bad as the second incident that occurred on (MONTH) 16. The resident stated she had been left in the bathroom for many hours and she knew this because of her talking watch, which she uses due to her [MEDICAL CONDITION]. The resident stated she could not reach the call light and she was scared. The resident stated the two incidents were very difficult for her and that she relives them in her mind. The resident then became tearful and stopped talking. An interview was conducted with a RN (staff #23) on (MONTH) 4, 2019 at 1:32 p.m. Staff #23 stated she can recall the incident on (MONTH) 16, 2019 with resident #1. Staff #23 stated the resident is alert and oriented x 4, can communicate her needs, needs one person assist for much of her care and is legally blind. Staff #23 stated she gave the resident her evening medications about 9:00 p.m. (on (MONTH) 16) and entered the resident's room again around 4:00 a.m. Staff #23 stated the door to the resident's room and the bathroom door were both closed and the entire room was dark. Staff #23 stated she opened the bathroom door and the resident was sleeping in her wheelchair. Staff #23 stated she went to find the CNA's, so the resident's brief could be changed and she could be put to bed. Staff #23 stated she asked the CNA's who was responsible for leaving the resident in the bathroom and for not checking on her every 2 hours, and there was not one CNA who accepted responsibility. Staff #23 stated she identified this incident as neglect. She said that she informed the Administrator (staff #29) the following day. Staff #23 stated she also notified the ADON (staff #70) by text the following day. She said that staff #70 did not contact her about this incident until days later. Staff #23 stated that neither staff #70 or staff #29 told her this was an incident of neglect. An interview was conducted with a CNA (staff #38) on (MONTH) 4, 2019 at 3:25 p.m. She stated that she worked on (MONTH) 16 from 6:00 p.m. until 6:00 a.m. on (MONTH) 17, 2019. Staff #38 stated that she knows the resident well and cares for her on a routine basis, and that the resident is blind. Staff #38 stated the resident uses her call light when she needs help from staff. Staff #38 said that during the night shift (on (MONTH) 16-17), she worked with another CNA and neither of them had specific residents or room assignments. Staff #38 said they were both responsible for the care of all of the residents on the floor. She said resident #1 always used her call light if she needed anything, so they did not check on resident #1 from 10:00 p.m. on (August 16), until approximately 4:00 a.m. (on (MONTH) 17). Staff #38 stated the shift had been very busy and chaotic. She said that she had noticed the door to the resident's room had been closed which was not normal, but it did not register with her why the door would be closed. Staff #38 stated it was wrong that resident #1 had been stuck and left in the bathroom for such a long time. Staff #38 stated about 4:00 a.m., staff #23 came and got her and they went to the room of resident #1 and the resident was sitting in her wheelchair. She said the resident was very upset and was crying. She said because the resident knew her when she started talking to her, she grabbed onto her tightly and just kept on crying and crying. Staff #38 stated the resident told her she had been hollering and hollering for someone to come and help her and no one came for a very long time. Staff #38 stated the call light cord was too short for the resident to reach when the resident was by the sink, so the resident did not have a way to call for staff. Staff #38 said she then went to get another CNA to help her to give extra support to the resident. Staff #38 stated the Administrator talked with the resident about the incident the following day. She said that she did not immediately report the incident, however she did identify the incident as neglect. She said that she had been educated and trained on identification and timely reporting of incidents of neglect. Staff #38 stated that she took full responsibility for the lack of care for resident #1 and the long time that the resident had been left in the bathroom and knew the resident had been very afraid. During the survey, staff #102 was unable to be reached by telephone. An interview was conducted with a CNA (staff #106) on (MONTH) 5, 2019 at 9:03 a.m. Staff #106 stated she knows the resident well and cares for her on a routine basis. Staff #106 stated the resident is alert, oriented, can communicate her needs and is blind. Staff #106 stated she can recall the incident from (MONTH) 16-17. She said the resident's routine is to be placed by the sink in her bathroom while sitting in the wheelchair. Staff #106 stated she left the resident in the bathroom about 9:00 p.m., so she could finish her bedtime routine. Staff #106 stated she learned the next day that the resident had been left in the bathroom a really long time from the evening on (MONTH) 16 through the early morning on (MONTH) 17. Staff #106 stated she was in shock, because in her mind she had helped the resident get into bed and did not mean to leave her in the bathroom. Staff #106 stated at that time, the CNA's did not do actual rounds like every 2 hours to check on the residents and make sure they were okay. Staff #106 also stated there were no specific room assignments and the CNA's were responsible for all of the residents on the entire floor. She said that she accepted full responsibility for her actions and for not checking that the resident was alright before she left her shift. She said the resident's call light was not within reach and it was a very long time, way too long for her to be in there without anyone checking on her. She said the resident was probably afraid as she could not call for help. Staff #106 stated that she now identifies the incident as neglect. Staff #106 stated about 3-5 days later she was called by management and was told there was going to be an investigation of the incident. An interview was conducted with the ADON (staff #70) on (MONTH) 5, 2019 at 9:25 a.m. Staff #70 stated she had been aware of the incident with resident #1, which occurred on (MONTH) 16, 2019. Staff #70 stated she interviewed resident #1 and the resident reported that she had been left in the bathroom until about 9 a.m. the next morning (on (MONTH) 17). Staff #70 stated the resident told her that she had been placed in her wheelchair in the bathroom by the sink, so she could do her usual denture and mouth care. Staff #70 stated the resident told her no staff came back for her and it was such a long time that she fell asleep in the wheelchair and that the call light was not within reach. She said that during the course of her envolvement with the (MONTH) 16 incident, she identified that the CNA's routine was to not be given assignments on their shifts and that the CNA's were not completing 2 hour checks on all residents. Staff #70 stated this was an allegation of neglect and she now realizes the mandated identification, reporting, investigating and protection of residents was not completed per policy and regulation. An interview was conducted with the Administrator (staff #29) on (MONTH) 5, 2019 at 1:21 p.m. Staff #29 stated the incident from (MONTH) 16-17 regarding resident #1 being left in the bathroom for an extended period of time had not been accurately identified as neglect. Review of the facility's policies and procedures regarding Abuse and Neglect revealed that each resident has the right to be free from abuse and neglect. Residents must not be subjected to abuse by anyone, including but not limited to facility staff. The facility will provide oversight and monitoring to ensure that staff who are agents of the facility, deliver care and services in a way that promotes and respects the rights of residents to be free from abuse and neglect. The Abuse and Neglect polices further included that neglect is the failure of the facility and employees to provide goods and services to a resident to avoid physical harm, pain, mental anguish or emotional distress. The definition of abuse included the following: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This included the deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well being. Instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish.

Based on clinical record review, staff interviews, hospital and facility documentation and policies and procedures, the facility failed to complete ongoing neurological assessments for one resident (#135), who sustained a significant head injury following a fall. Findings include: Resident #135 was admitted to the facility on (MONTH) 22, (YEAR), and discharged to the community on (MONTH) 9, (YEAR). The resident was readmitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. The MDS included the resident required limited assistance with ambulation and extensive assistance with bed mobility and transfers. The MDS also included the resident had a fall in the last month prior to admission, but had not had any falls since admission. Review of a Daily Skilled Note dated (MONTH) 10, (YEAR) at 7:20 p.m. revealed the resident was alert and oriented x 3, with periods of forgetfulness and was able to make needs known. A falls care plan dated (MONTH) 11, (YEAR) included the resident had a history of [REDACTED]. Interventions included educating the resident to not bend over to pick up dropped items and encourage the use of grabber or ask for assistance, and ensure the resident is wearing appropriate footwear. Review of an Incident Report revealed that on (MONTH) 15, (YEAR) at 7:40 p.m., the nurse heard a loud yell and found the resident in her room near the bed. The resident reported that she was trying to put on her pants, but her pants were on the footboard. Resident stated that she hit her head and hip on the floor. The report also included the following: vital signs and neuro assessment was done and all stable; resident is alert and oriented x 2; big contusion on occipital area of head; bruising on lateral aspect of left thigh; pain upon movement of left leg; and brought back to bed using Hoyer lift with two staff. Review of the clinical record including the nursing notes revealed there was no documentation of the results of any neurological assessments which were done on (MONTH) 15 from 7:40 p.m. to 9:24 p.m., following the fall. The first neurological assessment which was documented in the clinical record was at 9:25 p.m. on (MONTH) 15, which was almost 2 hours after the resident had fallen. The neurological assessment included the resident was .Alert and oriented x 3 with some confusion, pupils ERRLA (equal, round, reactive to light and accommodation) hand grasps are strong, legs are weak. High risk for falls . A Daily Skilled Note dated (MONTH) 15, (YEAR) at 9:36 p.m. by a registered nurse (resident's nurse at the time of the incident/staff #130) revealed the following: Patient found on floor by nurse on duty. Patient said she was trying to put on her pants and tripped on it, assessments done, alert and oriented x 2, bruise on left hip, contusion on occipital area of head. Complains of pain on hip with bruising. Range of motion done with no difficulty. Lifted back to bed by Hoyer lift with 2 person assist. Dr .notified with new orders made and carried out. Ice on contusion on head and stat (immediate) X-ray of left hip done. Increase [MEDICATION NAME] to 50 milligrams tablet every 6 hours for pain. [MEDICATION NAME] 50 milligram tablet given as ordered . The note further included that the resident had increased confusion, restlessness and hallucinations/delusions. Despite documentation that the resident experienced increased confusion, restlessness and hallucinations/delusions, the next full neurological assessment was not completed until 5:25 a.m. on (MONTH) 16, which was approximately 8 hours later. The neurological assessment included the resident was alert and oriented to person and time with some confusion, follows commands and complains of pain on hip and head . According to a Communication/Visit with Physician note dated (MONTH) 16, (YEAR) at 6:42 a.m., the physician was notified about patient's increased confusion, restlessness and agitation. Dr .then ordered to send her out to hospital for evaluation of increased confusion and to do CT (computerized axial tomography) scan of head. However, there was no clinical record documentation that ongoing assessments of the resident's condition were completed related to having increased confusion, restlessness, and agitation. A Communication Note dated (MONTH) 16, (YEAR) at 7:08 a.m. included the hospital was called to inform them that the resident will be coming to them non-emergent for increased confusion, emesis, and pain in head after fall last night . Review of a Health Status Note dated (MONTH) 16, (YEAR) at 7:15 a.m. revealed Patient continues to say she needs to throw up, has basin at her side. Patient stuck index finger down throat and forced herself to vomit. Patient did it again when EMT's (emergency medical technician) arrived. Small amount of bile vomited both times. A Health Status Note dated (MONTH) 16, (YEAR) at 7:25 a.m. revealed the resident left the facility in an ambulance for the hospital. A physician's orders [REDACTED]. The facility provided a handwritten, undated note which was written by staff #130, and was not part of the resident's clinical record. The note included the following: .was in the middle of passing medications then suddenly heard patient yelling. Run to room .and found patient sitting on floor. 'Help me get up as I tried to put on my pants and tripped' as stated by the patient. Patient has some confusion. Nurse assessed patient for injuries. Contusion on head and bruising on left hip .All appropriate parties notified. Patient was put on close watch every hour. Patient alert to self, place and time. Hour later she complained of pain on hip, pain medication given as ordered and stat x-ray of hip done revealed no fracture. Monitoring continued until end of shift, patient started to get more confused, called Dr .and ordered to send her out for revaluation of increased confusion and do a CT scan. Review of the hospital documentation dated (MONTH) 16, (YEAR) at 8:02 a.m. revealed the patient presents to the emergency department with an unwitnessed ground level fall. Per EMS, she is in and out of consciousness . Review of the hospital CT Head/Brain scan results dated (MONTH) 16, (YEAR) at 8:58 a.m. included the following: [MEDICATION NAME] head injury and contusion-interval mixed acute and subacute right frontoparietal and temporal contusion and subdural hematoma .There is a marked right to left midline shift of up to 15 millimeters .There is a large right posterior scalp contusion and hematoma .Recommend emergent neurosurgical consultation Further review of the hospital documentation dated (MONTH) 16, (YEAR) at 9:07 a.m. revealed Informed by nurse that patient had a change in condition. Re-evaluated patient, she is unresponsive to painful stimuli with labored breathing .I did speak with neurosurgery .based on CT scan finding and her exam she would not have a good outcome from a operative standpoint. Patient currently awaiting hospice and comfort care at this time . Continued review of the clinical record revealed the resident was discharged from the hospital and was readmitted back to the facility on (MONTH) 16, (YEAR). Review of the Admission/Readmission Note dated (MONTH) 16, (YEAR) at 5:55 p.m. revealed the resident was readmitted to the facility under hospice. The note included Resident arrived to the unit via stretcher. No response to verbal or painful stimuli . Review of a Death Note dated (MONTH) 16, (YEAR) revealed the following: Date and time vital signs ceased: (MONTH) 16, (YEAR) at 6:05 p.m . An interview was conducted with a LPN (licensed practical nurse/staff #2) on (MONTH) 28, (YEAR) at 12:23 p.m. The LPN stated that if a resident fell and hit their head, neurological checks should be initiated immediately and done every thirty minutes for two hours, and then every shift for 72 hours. Staff #2 stated that neurological checks should be documented in the electronic clinical record. Staff #2 said that if a licensed staff documented correctly in the risk assessment, neurological checks would auto populate in the electronic clinical record, reminding the nurse when the next neurological check was to be done. After reviewing the resident's electronic clinical record, staff #2 stated that she did not see that the neurological checks were done every thirty minutes for the first two hours and was not sure what happened. An interview was conducted with another LPN (staff #89) on (MONTH) 28, (YEAR) at 12:39 p.m. Staff #89 stated that neuro checks should be done every 15 minutes for 5 times after a head injury, then every 30 minutes for 4 times, then every 8 hours for 3 days. Staff #89 stated that after a resident has a fall, a fall incident report is completed in the electronic clinical record and then neurological checks will auto populate in the computer, reminding licensed staff when the next assessment is due. During the survey, multiple phone calls were made to staff #130; however, staff #130 was unable to be reached. An interview was conducted with the Director of Nursing (DON/staff #13) on (MONTH) 29, (YEAR) at 9:56 a.m. The DON stated that if a resident has a fall and hits their head, or if it is an unwitnessed fall, the facility's policy is to do neuro checks every 30 minutes for 4 times and then every 8 hours for 3 days. The DON stated that neurological assessments auto populates in the electronic clinical record, so the oncoming nurse will know when the next neurological check is due. After reviewing the resident's clinical record, the DON stated that the resident fell at 7:40 p.m. on (MONTH) 15, (YEAR), and that the first neurological assessment was not done until 9:35 p.m. on (MONTH) 15. She said that she was unable to find any evidence that additional neurological assessments were done as required. She stated that the next assessment was done at 5:25 a.m. on (MONTH) 16, (YEAR). The DON further stated that these were the only two neurological assessments that she was able to locate in the resident's clinical record. Review of the facility's Neurological Evaluation policy revealed the purpose was to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. The policy included that neurological evaluations should be used following a witnessed fall when a resident has hit his/her head; following an unwitnessed fall; and following an event that results in a known or suspected head injury. Under the procedure section, it included the following: initiate and document a baseline neurological evaluation on the Neuro Check UDA; notify the physician of the event, obtain orders for subsequent neurological evaluations as indicated; after the completion of initial neurological evaluation with vital signs, continue with evaluations every 30 minutes x 4, then every 8 hours x 3 days or as directed by the provider. Subsequent neurological evaluations should be compared to baseline and previous neurological evaluations. All items on the Neuro Check UDS should be completed with each evaluation. Notify physician of any neurological evaluation findings which are a change from the baseline or previous evaluations. Document all physician notifications. Communicate information to subsequent shifts using the computer shift report. Review of the Fall Prevention and Management policy revealed that if a fall was not witnessed; neurological checks are required and must be documented in the medical record. Continue to monitor the resident's condition and notify the physician.

Based on observations, clinical record reviews, staff interviews, and policies and procedures, the facility failed to ensure that one male resident (#106) with known sexually inappropriate behaviors had interventions in place, in order to protect one resident (#112) from abuse/neglect and failed to ensure additional interventions were in place, in order to protect other residents from the potential for further abuse. As a result, the Condition of Immediate Jeopardy and Substandard Quality of Care was identified. Findings include: On June 14, 2016 at 11:07 a.m., a Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care were identified. The Administrator (staff #33) was informed that the Condition of IJ was identified, due to the facility's failure to implement interventions to prevent a male resident (#106) with known inappropriate sexual behaviors, from abusing a female resident (#112) and for failing to prevent the potential for abusing other female residents on the facility's secured dementia unit. The Administrator presented a plan of correction on June 14, 2016 at 12:05 p.m. The plan of correction was unacceptable, due to a lack of procedures for monitoring resident #106 and the need for staff in-services. A second plan of correction was submitted by the Administrator at 1:30 p.m. and was unacceptable, due to a lack of information regarding how or who was to ensure the implementation of the monitoring procedures. A third plan of correction was received at 2:05 p.m., and was accepted at 3:02 p.m. Multiple observations were conducted of the facility implementing their plan of correction, which included that resident #106 was receiving 1:1 supervision, staff in-services were being conducted regarding the new processes and staff interviewed were knowledgeable of the new procedures. As a result of the facility implementing their plan of correction, the Condition of Immediate Jeopardy was abated at 2:30 p.m. on June 15, 2016. -Resident #112 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the secured dementia unit. A review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment. -Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #106 resided on the secured memory unit. The unit consisted of 23 residents. The resident demographics included 7 male and 16 females. Of the 16 females, 12 were able to self-propel in wheelchairs or ambulate on the unit. A physician's monthly note dated May 10, 2016 from an assisted living facility indicated the resident had inappropriate sexual behaviors. A care plan initiated on May 20, 2016, identified that the resident displayed inappropriate sexual advances toward staff when providing care, which included grabbing. Interventions included to continue hormonal therapy and utilize a consistent staff approach. No other interventions were included. According to a social services assessment dated [DATE], the resident was alert and oriented to person, place and time, and short term memory was impaired, but long term memory was intact. The assessment also indicated the resident had inappropriate sexual behaviors. Review of physicians' and nurse practitioners' notes dated May 17, 2016 and May 23, 2016 revealed the resident had sexualized behaviors and the plan was to obtain a psychiatric consult and to continue with medications for behaviors. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Under the behavioral section, the MDS indicated the resident had physical behaviors directed toward others on 1-3 days during the 7-day look back period. In Section V., behavioral symptoms triggered for inclusion on the care plan with objectives to minimize risks and avoid complications. Under functional status, the resident did not require physical help from staff for locomotion on the unit and did not require any mobility devices. A progress note dated June 6, 2016 included that yesterday a CNA (staff #90) heard resident #112 saying no, no, no and as the CNA entered the room, the CNA observed resident #106 slap resident #112 in the face. The note further included that resident #112 was also observed to have bruising to both breasts. Revision of a care plan dated June 6, 2016 indicated a problem of behavioral symptoms related to Alzheimer's dementia. The care plan included that resident #106 slapped resident #112. Interventions included to intervene as necessary to protect others, divert attention, and for supervised visits with resident #112. A progress note dated June 11, 2016 included documentation that resident #106 was observed by a LPN (staff #114) touching another resident and the two were separated. Additional progress notes between May 16, 2016 and June 15, 2016 revealed documentation of 11 incidents of sexual behaviors involving resident #106 and staff. Further review of the care plan interventions revealed they did not identify the potential risks to other residents on the secured unit, nor did the interventions include the need for any increased supervision of resident #106, nor any additional interventions to prevent further incidents. An interview with a Licensed Practical Nurse (LPN/staff #6) was conducted on June 14, 2016 at 9:26 a.m. The LPN stated that after the incident where resident #106 slapped resident #112, resident #112 was supervised at all times, but there was no additional supervision provided to the resident (#106). She further stated that they should have provided supervision to the resident (#106). In an interview conducted on June 14, 2016 at 9:29 a.m. with a Certified Nursing Assistant (CNA/staff #90), the CNA stated that resident #106 likes to touch a lot and he likes to make sexual comments as well. She stated he is very strong and can be aggressive at times. She further stated that when caring for resident #106, he rubs her breasts or grabs her legs and he doesn't listen when they say he can't do that. The CNA stated she saw resident #106 slap resident #112, after she had said that she wanted to go to bed. The CNA stated resident #106 is monitored for safety, but there was no additional monitoring which was done to make sure he is not sexual with other residents. She also stated two CNAs have to shower him, because of his sexual behaviors. In an interview conducted on June 15, 2016 with the Director of Social Services (staff #74), the Director stated resident #106 came from an assisted living facility and they did not know of the extent of his behaviors. She stated she was aware of his behaviors, but thought they were directed only at staff. She further stated that she was aware the resident slapped resident #112 and that he most likely bruised her breasts, so resident #112 was supervised. She said that when these events were discussed at the morning meetings, it was not considered that the resident could potentially touch or injure another resident. She stated the resident behaviors were discussed at the May 31, 2016 Behavioral Health Interdisciplinary Team Meeting and at that time there had been three episodes of inappropriate sexual touching with staff. She stated that in the discussion, it did not come up regarding any precautions to be taken. In an interview conducted on June 15, 2016 at 12:35 p.m., the Registered Nurse/Unit Manager (RN/staff #20) stated that she and the Director of Nursing (DON) assessed the resident for admission to the facility and were aware that he had touched a lady at the assisted living facility, but they thought it was his wife. The RN said that he did not demonstrate any behaviors during the time he was assessed. The RN stated that it did not come up in our daily meetings to provide supervision to resident #106. She said the resident had medication adjustments for his behaviors. In a telephone interview with a LPN (staff #114) on June 15, 2016 at 1:02 p.m., the LPN stated resident #106 came out of his room on June 11, 2016, and as he went by a female resident, he touched her back and shoulder and then sat next to her at the table. She stated the female resident was moved to the TV room, because of his history and she didn't want his behavior to progress further. An interview was conducted with the DON (staff #9) on June 16, 2016 at 8:44 a.m. The DON stated she and the RN unit manager assessed the resident prior to admission to see how the resident would interact with them and others. The DON said they reviewed his medications and assessed his cognitive status. She stated that his history of sexual behaviors was part of the reason they went to assess him. She stated there were reports of staff interactions, but he was on drug therapy and there were no reports of any sexual behaviors in the two weeks prior to him coming to this facility, and that he was not supervised at the assisted living facility. After admission, the DON stated that she was made aware of an incident where he came up behind one of the CNAs and pressed himself against her. She stated our considerations were to protect resident #112 from him, because she seemed to be a target for him. Review of the facility policy regarding Abuse and Neglect revealed the following: Purpose: To define terminology related to abuse. Note: Willful means that the individual intended the action itself that he or she knew, or should have known, could cause physical harm, pain, or mental anguish. Even though a resident may have cognitive impairment, he or she still could commit a willful act. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well being. Physical abuse: Includes hitting, slapping, pinching, kicking, etc. The policy further stated that the definition of neglect was failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The policy also included that the purpose was to ensure that residents are not subjected to abuse by anyone, including other residents. The policy stated that to prevent such occurrences, all reasonable measures within the control of the facility will be taken. In addition, the abuse/neglect policies and procedures included that the facility cannot and does not guarantee that abuse will never occur.

Based on observation, clinical record reviews, resident and staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#112) was free from physical abuse from resident (#106). Findings include: -Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the secured memory unit. A physician's monthly note dated May 10, 2016 from an assisted living facility indicated that the resident had inappropriate sexual behaviors. Review of the admission nursing data form dated May 16, 2016 revealed the resident's skin was normal in color and had normal turgor. The documentation included the resident had bruising to both hands, however, there was no documentation that the resident had any bruising to the breast area. According to a social services assessment dated [DATE], the resident was alert and oriented to person, place and time, and that his short term memory was impaired, but long term memory was intact. The assessment also indicated the resident had inappropriate sexual behaviors. A care plan initiated on May 20, 2016 identified that the resident displayed inappropriate sexual advances toward staff when providing care, which included grabbing. Interventions included to continue hormonal therapy and utilize a consistent staff approach. No other interventions were included. Review of the physicians' and nurse practitioners' notes dated May 17, 2016 and May 23, 2016 revealed the resident had sexualized behaviors and the plan was to obtain a psychiatric consult and to continue with medications for behaviors. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS also assessed the resident to be oriented to the day, month and year. Under the behavioral section, the MDS indicated the resident had physical behaviors directed toward others on 1-3 days during the 7-day look back period. In Section V. behavioral symptoms triggered for inclusion on the care plan, with objectives to minimize risks and avoid complications. Under functional status, the resident did not require any physical help from staff for locomotion on the unit and did not require any mobility devices. -Resident #112 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the secured dementia unit. A review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment. A nursing note dated June 5, 2016 included that resident #112 was pushed in the wheelchair to her room by resident #106. A Certified Nursing Assistant (CNA) overheard resident #112 state No, I am tired and then went into the room of resident #112. When the CNA entered the room to see what was happening, she observed resident #106 strike resident #112 in the face with an open hand. Resident #106 was escorted out of the room. Resident #112 became anxious and agitated and was unable to describe what had happened. The resident denied pain or discomfort. An additional nursing note also dated June 5, 2016, documented the following: This Licensed Practical Nurse (LPN) was told that the resident's breasts were bruised. The resident was then examined and on the top of the right breast there was an old bruise; purple in color without [MEDICAL CONDITION] or [DIAGNOSES REDACTED] present. Old and new bruises were found on the left breast. Below the nipple the breast is purple and yellow in color, top of breast is bluish-purple in color. Resident is alert and oriented to self only and she is not able to tell how her breasts got bruised. An interview was conducted with the Administrator (staff #34) on June 14, 2016 at 9:15 a.m. After reviewing the nursing notes for resident #112 dated June 5, 2016, the Administrator stated that staff were highly suspicious that the bruising on the resident's breasts were from resident #106. An interview was conducted with a LPN (staff #6) on June 14, 2016 at 9:26 a.m. She stated that she was the nurse on duty on June 5, when a CNA observed resident #106 slap the face of resident #112. She stated that although the slap was witnessed by the CNA, resident #112 denied she was slapped by resident #106. The LPN also stated that on that same day (June 5, 2016), a CNA noted that resident #112 had bruising to both breast areas. The LPN stated she did examine the resident's breast area and noticed different ages of bruising. She said the coloring of the bruising ranged from yellow to purple to blue and that the bruises did not appear super fresh. The LPN stated she had asked the resident what had happened and the resident told her she had [MEDICAL CONDITION] and that caused the bruising. The LPN further stated that in one area of the breast, there was an imprint, which appeared as if someone had grabbed the resident. An interview was conducted with a CNA (staff #90) on June 15, 2016 at 2:10 p.m. She stated she was walking past the room of resident #112 on June 5, as resident #106 was pushing resident #112 in the wheelchair into her room. The CNA stated she heard resident #112 say that she wanted to take a nap and within seconds resident #106 was heard to say, No in a loud voice. The CNA then entered the room and saw resident #106 slap resident #112 on the cheek. The CNA stated that by the sound of the slap it would have been painful, however, the resident denied she had been slapped and denied any pain to her face. An observation was conducted on June 15, 2016 at 3:06 p.m., with a Registered Nurse (RN/staff #20) of the resident's breast area. The resident was observed to have multiple bruises to the breast area. Observations revealed that there was a bruise to the right upper breast, which was described by the RN as purple-brown in color and was the size of a quarter. There was a bruise under the left nipple and the RN stated that this area was a much larger area and was greenish-gray in color. There was also a bruise to the left anterior breast area and the RN stated that this bruise was approximately 31/2 by 3 inches and was reddish brown in color and looked like it was starting to heal. There was also a bruise to the left lateral breast area and the RN stated that this bruise was purplish in color and the size of a fifty cent piece. The RN further stated that she was unable to determine the age of the bruising, however, she said that some of the bruises appeared old and healing, while others appeared to be a few days old. During an interview with resident #112 during the above observation, the resident stated that resident #106 had done this (caused the bruising in the breast areas). She stated it did not hurt and that it occurred in the past several weeks. The resident also stated that resident #106 told her that he had slapped her in the face and then told her the slap did not hurt her. Following the observation, a nursing note dated June 16, 2016 included the following: Bruise above left breast 6 centimeters (cm) x 3.2 cm and was purple in color. Bruise continues around left nipple, with fading light green color. Bruise above right breast 2.4 cm x 1.8 cm and was light red in color. An interview was conducted with the Administrator (staff #34), the DON (staff #9), and the Director of Social Services (staff #24) on June 16, 2016 at 1:05 p.m. The Administrator stated that staff had identified the slap as abuse, but took no further action except to provide more supervision for resident #112. She stated that the bruising on the breast area of resident #112 was not initially identified as suspicious, because she and the other staff believed it had been caused by resident #106. She stated that because the bruising was believed to have been caused by resident #106, no further action was taken. Review of the facility policy regarding Abuse and Neglect revealed the following: Purpose: To define terminology related to abuse. Note: Willful means that the individual intended the action itself that he or she knew, or should have known, could cause physical harm, pain, or mental anguish. Even though a resident may have cognitive impairment, he or she still could commit a willful act. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well being. Physical abuse: Includes hitting, slapping, pinching, kicking, etc. The policy further included that the purpose was to ensure that residents are not subjected to abuse by anyone, including other residents. The policy stated that to prevent such occurrences, all reasonable measures within the control of the facility will be taken.

Based on clinical record review, facility documentation, staff interviews, and review of policies and procedures, the facility failed to provide the necessary care and services to prevent neglect, by failing to identify that one resident (#1) had not returned timely from a scheduled [MEDICAL TREATMENT] appointment. Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. According to the clinical record documentation, the resident was going out to [MEDICAL TREATMENT] three times a week. An admission MDS (Minimum Data Set) assessment dated [DATE], assessed the resident with a BIMS (brief interview for mental status) score of 7, which indicated severe cognitive impairment. The resident was also assessed to require extensive two person assistance with transfers and was totally dependent on one person for locomotion assistance off the unit. The assessment also noted that the resident was frequently incontinent of bowel and bladder, used a wheelchair for ambulation, and was receiving [MEDICAL TREATMENT] treatments. Review of the daily skilled notes revealed the following: [DATE]-resident was alert and oriented to person and place; [DATE]-resident was alert to person, place, and time; [DATE] and 17-resident was alert to person and place. A daily skilled note dated [DATE], included documentation that the resident's vital signs were recorded between 6:24 a.m. and 6:27 a.m., and that the resident was going to [MEDICAL TREATMENT]. A Pre/Post Data Collection and Assessment completed by the [MEDICAL TREATMENT] provider dated [DATE], included that the resident began treatment at 8:51 a.m. and completed the treatment at 11:56 a.m., and was transported out of [MEDICAL TREATMENT] at 12:49 p.m A progress note dated [DATE] documented that on [DATE] at approximately 8:00 a.m., the resident left the facility via a medical transport provider for a [MEDICAL TREATMENT] appointment. At 11:30 p.m. on [DATE], the facility was notified that the resident would not be returning to the facility, as the resident had expired. According to the facility's investigative documentation, the resident had gone to a [MEDICAL TREATMENT] appointment at 7:40 a.m. on [DATE], via an outside transport provider and at 12:22 p.m., the resident was picked up at the [MEDICAL TREATMENT] center (this time conflicts with documentation from the [MEDICAL TREATMENT] provider that the treatment ended at 11:56 a.m.) and was taken to his home address at 12:49 p.m., instead of being brought back to the facility. The report included that the resident was found unresponsive, by a family member at approximately 11:30 p.m. on [DATE] at his home residence, after a search effort was initiated. The resident was transported via 911 to the hospital and was pronounced deceased at the hospital. The report noted that the resident had previously been transported from the facility to [MEDICAL TREATMENT] and back to the facility seven times, without incident. Per the report, the resident usually returned from [MEDICAL TREATMENT] between 1:00 p.m. to 3:00 p.m. The facility suspended the RN (day shift registered nurse/staff #2), with a final warning for failing to verify the status of an assigned resident who had not returned from a medical appointment by the end of her shift. The evening shift LPN (licensed practical nurse/staff #1) was terminated for failing to initiate a search to ascertain the whereabouts of a missing resident in a timely manner. A review of the facility census for [DATE], revealed the number of resident's on the Desert Gardens unit where resident #1 resided was 11 residents. Review of the pre/post [MEDICAL TREATMENT] data collection sheets from the [MEDICAL TREATMENT] provider and the facility's post [MEDICAL TREATMENT] assessments revealed the following times when [MEDICAL TREATMENT] had ended and when the resident was back in the facility for a post [MEDICAL TREATMENT] assessment: [DATE]-start time for [MEDICAL TREATMENT] was 10:27 a.m. and stop time was 2:09 p.m. and a facility nurse conducted a post [MEDICAL TREATMENT] assessment at 4:20 p.m.; [DATE]-start time for [MEDICAL TREATMENT] was 10:38 a.m. and stop time was 2:44 p.m. and a facility nurse conducted a post [MEDICAL TREATMENT] at 3:58 p.m.; [DATE]-start time for [MEDICAL TREATMENT] was 8:53 a.m. and stop time was 12:00 p.m. and a facility nurse conducted a post [MEDICAL TREATMENT] assessment at 12:58 p.m.; [DATE]-start time for [MEDICAL TREATMENT] was 8:54 a.m. and stop time was 12: 49 p.m. and a facility nurse conducted a post [MEDICAL TREATMENT] assessment at 3:31 p.m. The above documentation showed that the resident was usually back in the facility approximately 1 to 2 ,[DATE] hours after [MEDICAL TREATMENT] treatments ended. A review of the the facility medication pass times included that medications were to be passed on the Desert Garden unit between 7:00 a.m. to 10:00 a.m. and 4:00 p.m. to 8:00 p.m. According to the resident's MAR (Medication Administration Record) for [DATE], the resident was due for multiple medications in the p.m. (med times were documented as a.m. or p.m., and did not include a specific time for administration). However, there was no documentation that the medications were administered. In addition, meal time documentation for the Desert Garden unit showed that the dinner meal time was served at 5:00 p.m. for the main dining room and 5:25 p.m. for room trays. However, there was no clinical record documentation that the resident was missed during the dinner meal. During an interview with the DON (Director of Nursing) on [DATE] at 10:30 a.m., the DON stated that resident #1 went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday and that his transportation was provided through his health plan. The DON stated that the resident usually left the facility around 7:00 a.m. and returned in the afternoon. The DON stated that she received a telephone call at 11:00 p.m. on [DATE], from staff #5 (RN unit manager) who reported that the resident was found at his home and had expired. The DON stated that the number for the transportation provider was available on the nursing unit and that staff had called the provider regarding on previous appointments. On [DATE] at 9:30 a.m., an interview was conducted with staff #3/CNA (certified nursing assistant), who provided care to the resident on the day shift on [DATE]. Staff #3 stated that the resident left for his appointment around 7:00 a.m. and that she told the on-coming CNA (staff #4) at approximately 2:00 p.m. that the resident was still out at his [MEDICAL TREATMENT] appointment. She stated that she did not remember if she told the on-coming CNA an expected return time, but said that the resident didn't usually return on her shift. On [DATE] at 11:45 a.m., a telephone interview was conducted with staff #1, the LPN (licensed practical nurse) assigned to the resident on the Desert Gardens unit for the 2:00 p.m. to 10:00 p.m. shift on [DATE]. Staff #1 stated that when she started her shift, staff #2 the RN on the day shift, informed her that resident #1 was out at a [MEDICAL TREATMENT] appointment and had not returned. Staff #1 stated that she had not worked this unit before and that she had call lights going off, and only had one CNA, and a new admission to process, which she had not done before. Staff #1 stated she told her supervisor, (staff #5/RN unit manager) that she needed to be relieved and that resident #1 had not returned from [MEDICAL TREATMENT]. Staff #1 stated she got no response from staff #5 and she got busy and forgot about the resident at [MEDICAL TREATMENT]. Staff #1 stated there were telephone numbers on the unit that she could have called, such as the DON and the unit manager on call, but she did not call and ask for assistance. A telephone interview was conducted on [DATE] at 1:24 p.m. with staff #5, the RN unit manager on the day shift on the Desert Gardens unit. Staff #5 stated that she was in the facility on [DATE], but did not recall any interactions with staff #1 regarding this resident and did not know the resident had not returned to the building, until she received a telephone call at 10:40 p.m. on [DATE]. A telephone interview was conducted at 1:39 p.m. on [DATE], with staff #4/CNA who worked the 2:00 p.m. to 10:00 p.m. shift on the Desert Gardens unit on [DATE]. Staff #4 stated she was told by staff #3 that the resident was at [MEDICAL TREATMENT], but she did not know his expected return time. Staff #3 stated it was the only shift she had worked on this unit and was not familiar with the residents. An interview was conducted on [DATE] at 8:36 a.m. with staff #2, the RN on the 6:00 a.m. to 2:00 p.m. shift on [DATE]. Staff #2 stated she had assessed the resident prior to his [MEDICAL TREATMENT] appointment on [DATE], and then left the building around 7:30 a.m. She said his vital signs were at baseline and he was alert and oriented times ,[DATE]. Staff #2 stated that staff #1 came onto the unit at 2:00 p.m. and she gave her report and told her that resident #1 was out of the building at a [MEDICAL TREATMENT] appointment and explained the assessments which needed to be completed upon the residents return. Staff #2 stated she did not report an expected time for resident #1 to return, but she pointed out to staff #1 where the telephone numbers for the resident's [MEDICAL TREATMENT] provider and transportation provider were located. Staff #2 stated other administrative staff numbers were readily accessible for staff #1, and there were other nurses in the building if she needed assistance. Staff #2 stated that the residents should be checked at meal times, during medication pass, and at various times during the shift. Review of a facility's Abuse policy revealed to ensure that there is an effective system in place to prevent mistreatment, neglect, and abuse of residents. The policy included that residents have the right to be free from abuse and neglect. Per the job description for the Charge Nurse/LPN included that the nurse would provide care to assigned residents in a caring, safe, and efficient manner, to observe and document care given to residents, and to receive and share information and observe and report residents' conditions.

Based on clinical record review, staff interviews, and review of hospital records, the facility failed to ensure adequate monitoring and sufficient fluids were provided to one resident (#128) to maintain proper hydration. Findings include: Resident #128 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed the resident was receiving antibiotics upon admission for a urinary tract infection and pneumonia. admission orders [REDACTED]. Review of the resident's potential for weight loss care plan from February 14, 2013, revealed that staff were to encourage intake of food and fluids, and also to monitor and record intake daily. According to the nutrition assessment dated [DATE], the resident's estimated daily fluid needs were 2,010 milliliters (ml). Review of the resident's bowel movement (BM) record revealed that from admission through February 28, 2013, the resident had a total of eight episodes of loose stools. According to the BM record from March 1 through March 7, 2013, the resident had multiple episodes of loose stool. There was no documentation in the nurse's notes regarding the loose stools. Review of the Medication Administration Record [REDACTED]. Review of the dining intake record for March 2013, which included food, fluids, nourishments, and supplements, revealed the following daily grand total fluid intake amounts: March 1 = 780 ml, March 2 = 560 ml, March 3 = 240 ml, March 4 = 240 ml, March 5 = 360 ml and March 6 = 120 ml. According to the nurse's note dated March 7, 2013 at 10:00 a.m., the resident's color was very pale and was she was very weak. At that time, the resident was encouraged to drink water and drank 480 ml. For this same date, the dining intake record showed that the resident received an additional amount of 360 ml of fluid. Review of the BM record from March 7, 2013, revealed that the resident had four episodes of loose stool on the day shift and three episodes of a large amount of loose stool on the evening shift. Per the BM record for March 8, the resident had multiple episodes of loose stool. A nurse's note dated March 8 at 9:00 p.m., documented the resident complained of being very tired. Review of the dining intake record documented that the resident's total fluid intake was 240 ml on March 8. Further review of the clinical record revealed there was no documentation that the physician was notified of the on going loose stools or the resident's poor fluid intake. Review of the March 2013 MAR indicated [REDACTED] A nurse's note from March 9, 2013 at 10:00 a.m., documented the resident complained of not feeling good. The nurse's note from the same day at 8:20 p.m., revealed a Certified Nursing Assistant (CNA) reported that the resident was having loose stools. It was documented that the resident had four episodes of diarrhea. A call out to the Nurse Practitioner was made at that time. An order was received to collect a specimen to test for a [MEDICAL CONDITIONS] infection and to hold the Senna four tabs every morning for loose stool. According to the BM record dated March 9, the resident had two episodes of a medium amount of loose stool during the day, and four episodes of a large amount of loose stool during the evening shift. Review of the dining intake record revealed the resident's total fluid intake was 500 ml on March 9. Physician orders [REDACTED]. IV fluids were also ordered at 60 ml an hour. Nurse's notes from March 10, 2013, documented the resident had increased weakness, and poor food and fluid intake during the past three days. The resident was sent to the hospital at 10:45 p.m., for evaluation of debility, dehydration, and diarrhea. According to the Emergency Report dated March 10, 2013, the resident presented with generalized weakness, fatigue, diarrhea and was positive for [MEDICAL CONDITION]. Per the hospital discharge summary, the resident was found to have severe dehydration upon admission to the emergency room , and had "acute [MEDICAL CONDITION] that was possibly secondary to dehydration." A CNA was interviewed on January 29, 2014 at 9:12 a.m. She stated that if a resident had loose stools she would report it to the nurse and document the loose stools. She further reported that she would make sure the nurse was aware, because she knows there are certain medications that may be given to help with the loose stools. During an interview conducted on January 29, 2014 at 9:18 a.m., a Licensed Practical Nurse (LPN) was asked about what their process was when a resident has loose stools. She stated that it depends on the resident's orders and some residents have orders for [MEDICATION NAME] (anti-diarrhea medication). If the resident does not have an order for [REDACTED]. An interview was conducted with another LPN on January 29, 2014 at 11:00 a.m. She reported that CNAs let her know when a resident has loose stools and the CNAs also chart the loose stools. She reported that it is nursing judgment to hold stool softeners, if a resident is having loose stools. During an interview conducted on January 29, 2014 at 3:15 p.m., a Registered Nurse (RN) stated that for residents with loose stools, CNAs monitor the intake amounts and document in the computer. During an interview conducted on January 29, 2014 at 3:25 p.m., the Director of Nursing (DON) was asked about monitoring intakes for residents experiencing loose stools. He stated that they do not routinely monitor intakes and outputs (I & O) and that it depends on the resident and the doctor's orders. He reported that unless seen in the nursing notes, there was no other fluid monitoring being done besides the dietary intakes from meals. The DON was not aware of any other intake monitoring being done for the resident. The facility's procedure on bowel assessment did not include the protocol staff are to follow when a resident has loose stools.