Every finding on record at Brookdale Santa Catalina

Based on record review, staff interviews, facility document and policy review, and observation of the facility's current practice, the facility failed to protect one of one sampled resident's (#48) right to secure confidential information in the electronic medical record. The deficient practice could compromise a resident's protected health information (PHI) leaving it unsecured and accessible to unauthorized individuals.Findings include:Resident #48 was admitted to the facility on [DATE], with diagnoses that included intraspinal abscess, spinal stenosis, and type 2 diabetes mellitus.The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13.0, indicating intact cognition.On August 26, 2026, at 8:56 AM, a medication administration observation was conducted with a Registered Nurse (RN/Staff #50). At 8:59 AM, the RN entered the resident's room, standing by the resident's room doorway, with her back to the back of the medication cart. The resident's medication cards were observed on top of the medication cart. At 8:59 AM, the RN came back to the front of the medication cart. At 9:02 AM, after the medications were dispensed from the blister packs, the RN verified the resident's name and date of birth . At 9:03 AM, the RN entered the resident's room and left her laptop screen open with the resident's profile displayed.The following information was displayed and visible, on the laptop screen, while the RN was inside the resident's room:The resident's photo located in the upper left corner of the screenTo the left side of the resident's photo was the resident's name and in parenthesis a 4-digit number with 5-letters written in upper caseResident's date of birth Physician's nameResident's room numberResident's code status, which was observed to be full codeResident's allergies, which were documented as no known allergiesSpecial instructions, which included Enhanced Barrier Precautions (EBP), PICC (Peripherally Inserted Central Catheter) and location, and surgical woundThe profile also revealed the resident's a list of medications. At 9:04 AM, it was observed that the resident took his medications. The RN exited the room after using the hand sanitizer mounted inside the resident's room.On August 26, 2026, at 9:05 AM, an interview was conducted with the RN (Staff #50). The RN stated that she forgot to lock her laptop, as she entered the resident's room. The RN stated that the laptop has to be locked to protect the resident's information on the screen, due to HIPAA, which the RN defined as the health protection act.According to the National Library of Medicine, last updated on November 24, 2024, the United States Health Insurance Portability And Accountability Act (HIPAA), enacted in 1996, was established to safeguard patient privacy and secure health information. HIPAA sets strict standards for managing, transmitting, and storing protected health information. HIPAA applies to healthcare providers, insurers, and other organizations handling patient data, mandating safeguards to prevent unauthorized access or misuse of sensitive information. HIPAA regulations uphold patients' rights to confidentiality and empower them to control the disclosure of their health information, fostering trust in the healthcare systems. An interview was conducted on August 26, 2026, at 1:35 PM with a Licensed Practical Nurse (LPN/Staff #40). The LPN stated that the medication administration process includes moving her medication cart door to door, logging in the electronic medical record, opening the resident's profile to look at the resident's medication list in the electronic medical record, hand sanitizing and grabbing a medication cup. The LPN also stated that when she looks at the medication card, she would first confirm that it was the right medication, right dose, right route, right resident before dispensing the medication from the card. The LPN also stated that she would check the resident's vital signs if she was to administer a blood pressure medication to the resident. The LPN stated that once she had the resident's medications prepared, she would lock her computer screen and also lock the medication cart. The LPN stated that she would lock her computer screen to be HIPAA compliant. The LPN stated that HIPAA was the Health Care Information Protection Act which ensures the resident's right to privacy to include the resident's profile on the computer screen such as date of birth , what medications they were taking, frequency, and the resident's personal information. The LPN stated that if she also had a paper with the resident's information, she would flip it over to not show the resident's information.An interview was conducted on August 27, 2026, at 8:33 AM with the Interim Director of Nursing (DON/Staff #211). The DON stated that the process and expectation during medication administration was for the nurse to look at the order, and go by what the provider ordered. The DON stated that if the order needed clarification, she expects the nurse to call the provider and then document their interaction in the chart. The DON stated that she expects nurses to follow the medication administration process which includes the right resident, right drug, right route, right time, right dose, right documentation, right reason, right assessment, right education and evaluate the response. The DON stated that the nurse would identify the resident to administer the medication. The DON stated that she expected the electronic medical record to be open with the resident's profile displayed, she would knock on the door, she would verify the resident, she would let the resident know what she was about to do which was to administer their medications. The DON also stated that if vital signs were required, she expects the vital signs to be taken. The DON further stated that she would answer questions regarding the resident's medications.While the DON opened Resident #48's electronic Medication Administration Record (e-MAR) profile, and stated that once the e-MAR was opened, the screen would reveal the resident's photo, date of birth , physician, room number location, code status, any allergies and any special instructions or indication such as enhanced barrier precautions, surgical wound to lumbar area, and squares which indicated the medications that were ordered. The DON stated that if she was going into the resident room to administer medication, she would close her laptop which would automatically lock the screen because she would not want anybody seeing the resident's information such name, date of birth , location, provider, and those were protected information. The DON stated that protected information is part of HIPAA and compliance. The DON stated that HIPAA is an act to safeguard information and determine who has the privilege of viewing the information. The DON stated that she would not leave her laptop screen open even if there was nobody around because of the possibility of something being seen that does not need to be seen by others. The DON stated that she would not know the risk because she would not know the intent of the individual that saw the information on the screen. The DON further stated that she would not leave her laptop open with the resident's profile displayed.The facility policy titled, Electronic Medical records-DOC-3, with a last revision date of March 2026, revealed that electronic records are an acceptable form of medical record management. Only authorized associates who have been issued a unique User ID and password will be permitted access to the electronic medical record system. The electronic medical record system has safeguards to prevent unauthorized access, including HIPPA requirements.

Based on interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure an allegation of neglect was reported to the SA within the timeframes required by the facility's policy and federal regulation. The deficient practice could lead to residents feeling unsafe and/or having their needs unmet while receiving care at the facility.Findings include:A facility self-report was submitted to the SA on April 20, 2026 at 11:51 A.M., which revealed that a Nursing Student had voiced an allegation of neglect to Registered Nurse (RN/Staff #2). The report further revealed that a Certified Nursing Assistant (CNA/Staff #13) neglected the residents in her unit when she failed to provide cares to them.Review of the facility's 5-day report revealed that a Nursing Student had initially made an allegation of neglect on March 27, 2026 to Staff #2. The report indicated that upon receiving the initial allegation, Staff #2 then reported it to the facility's former Administrator (Staff #9). The report further indicated that the facility made initial report of neglect to the SA on April 17, 2026, approximately 21 days after the allegation was made, and then initiated an investigation.Review of the SA's complaint portal found no other facility self-report alleging neglect around the alleged timeframe of March 27, 2026.An interview was conducted on May 29, 2026 at 9:19 A.M. with RN/Staff #2. Staff #2 described neglect as a delay of care, staff isolation of residents, not giving residents their medications, or not implementing resident interventions. Staff #2 explained that suspected neglect is reported to the abuse coordinator, who was formerly the facility Administrator (Staff #9), and is now reported to the Social Services Director (SSD/Staff #41). Staff #2 shared that towards the end of her shift, a Nursing Student approached her and reported that several nursing students were upset because the CNA (Staff #13) had not changed the residents on her unit. Staff #2 stated she then called Staff #9 to notify him of the neglect allegation; however, he did not answer his phone. Staff #2 stated she then instructed the Nursing Student to fill out the complaint/grievance form, took a picture of the completed form, and texted it to Staff #9. Staff #2 stated that she received a call from Staff #9 that same night at 10:45 P.M. and relayed to him what was reported by the Nursing Student. Staff #2 also recalled that Staff #9 had told her that he was in the building earlier that day and had spoken with Staff #13 and had observed her entering and leaving resident rooms. Staff #2 indicated that after speaking with Staff #9, she did not receive status updates on the outcome of the facility's investigation and stated that she does not typically receive that type of information.An interview was conducted on May 29, 2026 at 10:07 A.M. with SSD/Staff #41. Staff #41 stated that suspected cases of neglect are reported to the abuse coordinator which currently is herself. She explained that allegations of neglect are to be reported to the SA within 24 hours. Staff #41 recalled a grievance form being completed in March 2026 alleging neglect; however, upon retrieving the binder, where complaint/grievance forms are maintained, she was unable to locate the specific grievance form. Staff #41 stated that she was aware of the complaint/grievance form because it was sent via text message from Staff #2 to herself, Staff #19, and Staff #9. Staff #41 further stated she was not assigned to investigate the alleged neglect, as Staff #9 had indicated he would conduct the investigation, and that she had the impression that Staff #9 had also reported the incident to the SA. Staff #41 explained that she did not hear anything further regarding the alleged neglect until several weeks later, when corporate office staff arrived at the facility and began interviewing her. It was at that time that she raised the alleged neglect issue, and the incident was subsequently reported to the SA by the corporate office. An interview was conducted on May 29, 2026 at 10:49 A.M. with the DON/Staff #19. Staff #19 acknowledged that a complaint/grievance form was sent via text message from Staff #2 to herself, Staff #41 and Staff #9 in March 2026 indicating that residents were soaking wet all day and remained unchanged. Staff #19 recalled speaking with Staff #9 and informing him that she was unable to follow up with the complaint/grievance due to a personal matter, and that he assumed responsibility for the follow-up. Staff #19 added that upon returning to the facility the following Monday, she did not follow up on the incident.A telephonic interview was conducted on May 29, 2026 at 12:01 P.M. with the facility's former Administrator (ADM/Staff #9). Staff #9 stated that he was not notified of an allegation of neglect in March of 2026 and denied receiving a text message with a picture of the complaint/grievance form. Staff #9 stated that he was traveling at the time the incident allegedly took place; however, he did acknowledge that he was the abuse coordinator even while traveling and was expected to be available if neglect or abuse situations arose. Staff #9 stated there was no alternate abuse coordinator in place at that time. When surveyor read aloud the following statement written on the complaint/grievance form - multiple patients went their whole shift without being changed and properly cared for - Staff #9 stated that it did sound like an allegation of neglect and it would need to be reported to the SA. A telephonic interview was conducted on May 29, 2026 at 12:15 P.M. with the Senior Director of Clinical Services for Skilled Nursing (Staff # 44). Staff #44 stated that on April 16, 2026 the facility received an anonymous complaint via the company's Integrity Phone Line, alleging that facility management staff did not take action regarding allegations of neglect. Staff #44 indicated that management staff were placed on suspension while an investigation was conducted. Staff #44 explained that during an interview with Staff #9, he shared a complaint/grievance made by a Nursing Student alleging that a CNA was not providing cares and services to residents. Staff #44 stated that Staff #9 indicated he had investigated the incident by speaking with residents and staff members, who raised no concerns regarding the cares provided by Staff #13, and therefore concluded that the alleged neglect had not occurred. Staff #44 stated that Staff #9 shared that he did not report the alleged abuse to the SA because he felt that it did not take place. However, Staff #9 did not provide documentation of his investigation. Staff #44 stated that the standard process requires the investigation to be documented. Staff #44 explained that once she became aware of the allegation of neglect, it was reported to the SA on April 17, 2026. Staff #44 also shared that the facility's policy on neglect requires that allegations of suspected neglect must be reported to the SA, and it that this requirement not followed.Review of the facility's policy and procedures titled, Abuse, Neglect, & Exploitation Policy, last revised in October 2022, revealed the policy defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further identifies the alleged neglect is to be made to the SA within 24 hours and the follow-up investigation report is submitted within 5 working days of the initial report.

Based on interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure their Neglect policy was implemented in that an allegation of neglect was not reported to the SA within the required timeframe and the investigation of the alleged neglect was not documented. The deficient practice could lead to residents feeling unsafe and/or having their needs unmet while receiving care at the facility.Findings include:A facility self-report was submitted to the SA on April 20, 2026 at 11:51 A.M., which revealed that a Nursing Student had voiced an allegation of neglect to Registered Nurse (RN/Staff #2). The report further revealed that a Certified Nursing Assistant (CNA/Staff #13) neglected the residents in her unit when she failed to provide cares to them.Review of the facility's 5-day report revealed that a Nursing Student had initially made an allegation of neglect on March 27, 2026 to Staff #2. The report indicated that upon receiving the initial allegation, Staff #2 then reported it to the facility's former Administrator (Staff #9). The report further indicated that the facility made initial report of neglect to the SA on April 17, 2026, approximately 21 days after the allegation was made, and then initiated an investigation.An interview was conducted on May 29, 2026 at 9:19 A.M. with RN/Staff #2. Staff #2 described neglect as a delay of care, staff isolation of residents, not giving residents their medications, or not implementing resident interventions. Staff #2 explained that suspected neglect is reported to the abuse coordinator, who was formerly the facility Administrator (Staff #9), and is now reported to the Social Services Director (SSD/Staff #41). Staff #2 shared that towards the end of her shift, a Nursing Student approached her and reported that several nursing students were upset because the CNA (Staff #13) had not changed the residents on her unit. Staff #2 stated she then called Staff #9 to notify him of the neglect allegation; however, he did not answer his phone. Staff #2 stated she then instructed the Nursing Student to fill out the complaint/grievance form, took a picture of the completed form, and texted it to Staff #9. Staff #2 stated that she received a call from Staff #9 that same night at 10:45 P.M. and relayed to him what was reported by the Nursing Student. Staff #2 also recalled that Staff #9 had told her that he was in the building earlier that day and had spoken with Staff #13 and had observed her entering and leaving resident rooms. Staff #2 indicated that after speaking with Staff #9, she did not receive status updates on the outcome of the facility's investigation and stated that she does not typically receive that type of information.An interview was conducted on May 29, 2026 at 10:07 A.M. with SSD/Staff #41. Staff #41 stated that suspected cases of neglect is reported to the abuse coordinator which currently is herself. She explained that a complaint/grievance form is completed and is assigned to either herself, the Director of Nursing (DON), or the Administrator to investigate depending on the nature allegation. Staff #41 further explained that allegations of neglect are to be reported to the SA within 24 hours. Staff #41 further explained that allegations of neglect are to be reported to the SA within 24 hours. She added that complaint/grievance forms are maintained in a binder in her office and recalled a grievance form being completed in March 2026. Upon retrieving the binder, Staff #41 stated she was unable to locate the specific grievance form alleging neglect. She recalled Staff #2 placing the form under her office door and noted that they only individuals with access to her office were the maintenance person, the former Administrator (Staff #9) and herself. Staff #41 stated that she was aware of the complaint/grievance form because it was sent via text message from Staff # 2 to herself, Staff #19, and Staff #9. Staff #41 further stated that she was not assigned to investigate alleged neglect, as Staff #9 had indicated he would conduct the investigation. Staff #41 explained that she did not hear anything further regarding the alleged neglect until several weeks later, when corporate office staff arrived at the facility and began interviewing her. It was at that time that she raised the alleged neglect issue, and the incident was subsequently reported to the SA by the corporate office. An interview was conducted on May 29, 2026 at 10:49 A.M. with the DON/Staff #19. Staff #19 acknowledged that a complaint/grievance form was sent via text message from Staff #2 to herself, Staff #41 and Staff #9 in March 2026 indicating that residents were soaking wet all day and remained unchanged. Staff #19 recalled speaking with Staff #9 and informing him that she was unable to follow up with the complaint/grievance due to a personal matter, and that he assumed responsibility for the follow-up. When asked to produce the original complaint/grievance form, Staff #19 stated it was located in Staff #41's office and went to retrieve it. Upon returning, Staff #19 reported that the original complaint/grievance form was missing; however, she retained the original text message on her cell phone and shared the image with the surveyor. Staff #19 described the picture as a statement from a Nursing Student indicating that residents were left soaking wet all day. Staff #19 recalled contacting Staff #2 for additional information regarding the complaint/grievance form, at which time Staff #2 had told her that the Nursing Students had provided cares to residents throughout the shift because Staff #13 was on her phone. Staff #19 added that upon returning to the facility the following Monday, she did not follow up on the incident.A telephonic interview was conducted on May 29, 2026 at 12:01 P.M. with the facility's former Administrator (ADM/Staff #9). Staff #9 described neglect as services not being provided to residents and gave the example of not changing them. Staff #9 stated that he was not notified of an allegation of neglect in March of 2026 and denied receiving a text message with a picture of the complaint/grievance form. Staff #9 stated that he was traveling at the time the incident allegedly took place; however, he did acknowledge that he was the abuse coordinator even while traveling and was expected to be available if neglect or abuse situations arose. Staff #9 stated there was no alternate abuse coordinator in place at that time. When surveyor read aloud the following statement written on the complaint/grievance form - multiple patients went their whole shift without being changed and properly cared for - Staff #9 stated that it did sound like an allegation of neglect.A telephonic interview was conducted on May 29, 2026 at 12:15 P.M. with the Senior Director of Clinical Services for Skilled Nursing (Staff # 44). Staff #44 stated that on April 16, 2026 the facility received an anonymous complaint via the company's Integrity Phone Line, alleging that facility management staff were not taking action regarding allegations of neglect. Staff #44 indicated that management staff were placed on suspension while an investigation was conducted. Staff #44 explained that during an interview with Staff #9, he shared a complaint/grievance made by a Nursing Student alleging that a CNA was not providing cares and services to residents. Staff #44 stated that Staff #9 indicated he had investigated the incident by speaking with residents and staff members, who raised no concerns regarding the cares provided by Staff #13, and therefore concluded that the alleged neglect had not occurred. However, Staff #9 did not provide documentation of his investigation. Staff #44 stated that the standard process requires the investigation to be documented. Staff #44 explained that once she became aware of the allegation of neglect, it was reported to the SA on April 17, 2026. Staff #44 also shared that the facility's policy on neglect requires that allegations of suspected neglect must be reported to the SA, and it that this requirement not followed.Review of the facility's policy and procedures titled, Abuse, Neglect, & Exploitation Policy, last revised in October 2022, revealed the policy defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further identifies the Administrator being responsible to ensure the policy is implemented, and describes the following steps to be taken should an allegation of neglect be made:The administrator or supervisor, on duty, are to take necessary steps to ensure residents are protected from continued neglect, suspend the staff member pending the outcome of the investigation.Investigate the potential neglect incident as soon as practicable by interviewing residents and staff members, and maintain a written record of the investigation.Report the alleged neglect incident externally to the SA.

Based on interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure an allegation of neglect was thoroughly investigated and that the investigation was documented. The deficient practice could lead to residents feeling unsafe and/or having their needs unmet while receiving care at the facility.Findings include:A facility self-report was submitted to the SA on April 20, 2026 at 11:51 A.M., which revealed that a Nursing Student had voiced an allegation of neglect to Registered Nurse (RN/Staff #2). The report further revealed that a Certified Nursing Assistant (CNA/Staff #13) neglected the residents in her unit when she failed to provide cares to them.Review of the facility's 5-day report revealed that a Nursing Student had initially made an allegation of neglect on March 27, 2026 to Staff #2. The report indicated that upon receiving the initial allegation, Staff #2 then reported it to the facility's former Administrator (Staff #9). The report further indicated that the facility made initial report of neglect to the SA on April 17, 2026, approximately 21 days after the allegation was made, and then initiated an investigation.Review of the SA's complaint portal found no other facility self-report alleging neglect around the alleged timeframe of March 27, 2026 or a 5-day investigation report.An interview was conducted on May 29, 2026 at 9:19 A.M. with RN/Staff #2. Staff #2 described neglect as a delay of care, staff isolation of residents, not giving residents their medications, or not implementing resident interventions. Staff #2 explained that suspected neglect is reported to the abuse coordinator, who was formerly the facility Administrator (Staff #9), and is now reported to the Social Services Director (SSD/Staff #41). Staff #2 shared that towards the end of her shift, a Nursing Student approached her and reported that several nursing students were upset because the CNA (Staff #13) had not changed the residents on her unit. Staff #2 stated she then called Staff #9 to notify him of the neglect allegation; however, he did not answer his phone. Staff #2 stated she then instructed the Nursing Student to fill out the complaint/grievance form, took a picture of the completed form, and texted it to Staff #9. Staff #2 stated that she received a call from Staff #9 that same night at 10:45 P.M. and relayed to him what was reported by the Nursing Student. Staff #2 also recalled that Staff #9 had told her that he was in the building earlier that day and had spoken with Staff #13 and had observed her entering and leaving resident rooms. Staff #2 indicated that after speaking with Staff #9, she did not receive status updates on the outcome of the facility's investigation and stated that she does not typically receive that type of information.An interview was conducted on May 29, 2026 at 10:07 A.M. with SSD/Staff #41. Staff #41 stated that suspected cases of neglect is reported to the abuse coordinator which currently is herself. She explained that a complaint/grievance form is completed and is assigned to either herself, the Director of Nursing (DON), or the Administrator to investigate depending on the nature allegation. Staff #41 recalled a grievance form being completed in March 2026; however, upon retrieving the binder, Staff #41 stated she was unable to locate the specific grievance form. She recalled Staff #2 placing the form under her office door and noted that they only individuals with access to her office were the maintenance person, the former Administrator (Staff #9) and herself. Staff #41 stated that she was aware of the complaint/grievance form because it was sent via text message from Staff # 2 to herself, Staff #19, and Staff #9. Staff #41 further stated that she was not assigned to investigate alleged neglect, as Staff #9 had indicated he would conduct the investigation. Staff #41 explained that she did not hear anything further regarding the alleged neglect until several weeks later, when corporate office staff arrived at the facility and began interviewing her. An interview was conducted on May 29, 2026 at 10:49 A.M. with the DON/Staff #19. Staff #19 acknowledged that a complaint/grievance form was sent via text message from Staff #2 to herself, Staff #41 and Staff #9 in March 2026 indicating that residents were soaking wet all day and remained unchanged. Staff #19 recalled speaking with Staff #9 and informing him that she was unable to follow up with the complaint/grievance due to a personal matter, and that he assumed responsibility for the follow-up. When asked to produce the original complaint/grievance form, Staff #19 stated it was located in Staff #41's office and went to retrieve it. Upon returning, Staff #19 reported that the original complaint/grievance form was missing; however, she retained the original text message on her cell phone and shared the image with the surveyor. Staff #19 described the picture as a statement from a Nursing Student indicating that residents were left soaking wet all day. Staff #19 recalled contacting Staff #2 for additional information regarding the complaint/grievance form, at which time Staff #2 had told her that the Nursing Students had provided cares to residents throughout the shift because Staff #13 was on her phone. Staff #19 added that upon returning to the facility the following Monday, she did not follow up on the incident.A telephonic interview was conducted on May 29, 2026 at 12:01 P.M. with the facility's former Administrator (ADM/Staff #9). Staff #9 stated that he was not notified of an allegation of neglect in March of 2026 and denied receiving a text message with a picture of the complaint/grievance form. Staff #9 stated that he was traveling at the time the incident allegedly took place; however, he did acknowledge that he was the abuse coordinator even while traveling and was expected to be available if neglect or abuse situations arose. Staff #9 stated there was no alternate abuse coordinator in place at that time. When surveyor read aloud the following statement written on the complaint/grievance form - multiple patients went their whole shift without being changed and properly cared for - Staff #9 stated that it did sound like an allegation of neglect.A telephonic interview was conducted on May 29, 2026 at 12:15 P.M. with the Senior Director of Clinical Services for Skilled Nursing (Staff # 44). Staff #44 stated that on April 16, 2026 the facility received an anonymous complaint via the company's Integrity Phone Line, alleging that facility management staff did not take action regarding allegations of neglect. Staff #44 indicated that management staff were placed on suspension while an investigation was conducted. Staff #44 explained that during an interview with Staff #9, he shared a complaint/grievance made by a Nursing Student alleging that a CNA was not providing cares and services to residents. Staff #44 stated that Staff #9 indicated he had investigated the incident by speaking with residents and staff members, who raised no concerns regarding the cares provided by Staff #13, and therefore concluded that the alleged neglect had not occurred. However, Staff #9 did not provide documentation of his investigation. Staff #44 also shared that the facility's policy on neglect requires that allegations of suspected neglect be thoroughly investigated and documented, and that this requirement was not followed.Review of the facility's policy and procedures titled, Abuse, Neglect, & Exploitation Policy, last revised in October 2022, revealed the policy defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further identifies the alleged neglect is to be investigated as soon as practicable by interviewing residents and staff members, and maintain a written record of the investigation.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that one resident (#2) was properly transferred during a shower. The deficient practice could lead to serious injury. The Facility provided sufficient evidence that noncompliance was identified on March 27, 2026, and April 16.2026 prior to the survey, and was in substantial compliance at the time of the survey for F0684. A QAPI meeting minutes revealed the original date identified was April 16, 2026, and the meeting was conducted on April 19, 2026, education provided by the facility revealed evidence of staff education/training. Past non compliance was identified. Findings include: Resident # 2 was admitted on [DATE] with diagnoses that included wedge compression fracture of 3rd lumbar, surgical aftercare, cauda equina syndrome, spinal stenosis, and need for assistance with personal care. A Care Plan initiated on April 10, 2026 revealed that Resident # 2 required assistance with bathing and showering. Further review of the Care Plan initiated on April 10, 2026 revealed that Resident # 2 has Activity of Daily Living (ADL) self care performance deficit. Interventions initiated on April 20, 2026 revealed that resident requires assistance with transfers with two people. Review of Resident Tasks revised April 14, 2026 revealed that Resident # 2 was 2 person maximum assist for transfer to the wheelchair.A Facility Investigation report dated April 22, 2026, revealed that a Certified Nursing Assistant (CNA/Staff # 79 ) transferred Resident # 2 from the recliner into the wheelchair and from the wheelchair to the shower chair. The report also revealed that after the shower Resident # 2 was transferred from the shower chair back to his wheel chair and that the resident was transferred back into bed. The investigation report revealed that Resident # 2 had a transfer status of 2 person assist and that CNA # 79 transferred the resident on his own. The investigation report also revealed that CNA # 79 confirmed that he had transferred Resident # 2 on his own using a gait belt. The report indicated that the resident's nephew reported to the facility social worker that Resident #2 had been treated poorly by a CNA who was rough with the resident during a shower.An interview was conducted on April 22, 2026 at 11:00 a.m. with Resident # 2 who stated that Staff # 79 came in to take him to get a shower. Resident # 2 stated that Staff # 79 picked him up from his recliner and transferred him to the wheelchair and wheeled him to the shower. Resident # 2 stated he was transferred again to the shower chair and when done was transferred back to wheel chair then taken to his room and transferred again by CNA # 79. Resident # 2 also stated that CNA # 79 was by himself and had no one to help him. Resident # 2 stated he was very rough with these transfers and it was painful. The Resident went on to say that the CNA never said anything to him while he continued with the shower. An interview was conducted on April 22, 2026 at 11:19 a.m. via phone with Licensed Practical Nurse (LPN/ Staff # 96) who stated that she worked with CNA # 79 on the night of April 16, 2026 into the morning of April 17, 2026. She stated that she received a complaint from Resident # 2 who told LPN # 96 that CNA # 79 was not 'caring' during his shower and was very fast with him. LPN # 96 stated that CNA was the only staff member present during the shower. LPN stated she talked to Resident # 2 and listened to his concerns. LPN # 96 stated that Resident # 2 did not want Staff #79 taking care of him and she assured Resident # 2 another CNA would take care of him the rest of the night. An attempt to contact CNA # 79 was made on April 22, 2026 at 11:35 a.m. but was unable to make contact with CNA. An interview with CNA (Staff # 72 ) conducted on April 22, 2026 at 12:13 p.m. who stated that she knows if a resident is a 2 person assist by looking at the Kardex. CNA # 72 also stated that Resident # 2 is a 2 person assist and she usually gets the physical therapist to help transfer him into his wheel chair. CNA #72 also stated that if physical therapist is not available, she would get another person to help with the transfer. CNA # 72 stated that the risk of transferring Resident # 2 alone is that it could cause pain and injure the Resident. An interview with Regional Clinical Specialist (Staff #102), on April 22, 2026 at 12:59 p.m. revealed that it is her expectation that CNAs are to look at the Kardex to know if residents require 2-person assist during transfer. She also stated that if the Kardex says two person assist then her expectation is that two people are utilized to assist with transfers. Staff #102 stated that it was determined in their investigation that CNA #79 had transferred Resident #2 without any assistance. Staff #102 revealed the risk for not transferring Resident #2 with two people is that it could cause harm to the resident and the staff member. Review of the Policy titled, Supporting Activities of Daily Living, effective reviewed March 2026 revealed that residents who are unable to carry out ADLs independently should receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. The Policy also revealed that appropriate care and service should be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with mobility which include transfer and ambulation, including walking.

Based on observation, interviews, and review of policies and procedures, the facility failed to ensure multiple infection control practices were being adhered to in the kitchen. The deficient practices could increase the risk of residents consuming food that is not being prepared in a sanitary manner. The facility ' s census was 27.Findings include:On June 25, 2025 at 12:18 PM, the tray line was observed in the 1st floor kitchen. The Sous Chef/Staff #23 was observed using a red knife to split open a baked potato. He then took a piece of cooked chicken, with tongs, and moved it from the pan on the tray line to a cutting board behind him. He then used the same red knife to chop up the cooked chicken. An interview was conducted with the Executive Chef/Staff #31 on June 25, 2025 at 11:02 AM. He explained that cross contamination of foods is when you ' re touching hot foods and raw foods with the same hands or utensils. He explained that the risk to the residents would be salmonella, bacteria, or possible food allergies. He indicated that he would consider using the same knife, without cleaning between use, to cut up cooked chicken and cooked baked potato to be a form of cross contamination. He also explained that there should be one knife for one food item. An interview was conducted with Staff #23 on June 25, 2025 at 12:46 PM. He explained that cross contamination occurs when raw food is mixed with cooked food. Raw and cooked foods should have two separate cutting boards. He also explained that he cannot use the same utensils for all the foods; cooked meat would have its own utensil and vegetables would have their own. When asked if he used the same knife with the red handle to split open a cooked baked potato and to chop up cooked chicken, Staff #23, let out a big sigh and stated that he did use the same knife for both foods. When asked what the risk to the residents would be, he indicated that the risk would be cross-contamination and that residents could acquire a food borne illness. An interview was conducted with Dietary Manager/Staff #35 on June 26, 2025 at 10:43 AM. He explained that cross contamination occurs when something dirty comes into contact with something clean. He gave an example of raw chicken coming into contact with salad. He indicated that the risk to the residents could include salmonella poisoning. Staff #35 explained that he did not think that cross contamination would be an issue if staff used the same knife to cut cooked chicken and cooked baked potato. On June 25, 2025 at 9:24 AM, Dining Services Supervisor/Staff #38 was observed in the kitchen with her hairnet not covering her bangs. On June 25, 2025 at 12:04 PM, Server/Staff #19 was observed in the kitchen prepping the beverages on the tray line. She was observed to have her front hair hanging loosely outside of her hairnet. Dietary Manager/Staff #35 was informed of this observation and he instructed her to fully cover her hair. An interview was conducted with Staff #19 on June 25, 2025 at 11:14 AM. She shared that she was to wear hairnets anytime she was in the kitchen. When asked if she could have her bangs hanging outside the hairnet, she indicated that she could not and they would have to be covered as well. When asked what would be the risk to the residents if staff did not fully cover their hair, she shared that the hair could fall into the food and residents would eat it.An interview was conducted with Staff #31 on June 25, 2025 at 11:35 AM. He explained that all staff are required to wear hairnets when in the kitchen. The hairnets must fully cover the hair. and if he were to observe hair not being covered, he would let staff know it would need to be fixed. An observation of the kitchen was conducted on June 25, 2025 at 8:49 AM with the Staff #35. The ice machine, located on the 2nd floor kitchen, was observed to have black particles on the white ice guard Staff #35 shared that the ice machines are cleaned on a weekly basis and then an outside vendor comes to sanitize the machine on a monthly basis. Staff #35 stated that the ice machine had recently been cleaned. The black substance on the white guard was revealed when he opened the cover to the ice machine. Staff #35 stated that the machine would be put out of service, emptied and cleaned.An observation of the dish machine was conducted on June 24, 2025 at 4:00 PM. The temperature gauge during the wash cycle was 166 degrees and the gauge during the rinse cycle was 138 degrees. The manual for the dish machine indicated that the minimum operating high temperature for the wash was 160 degrees and the sanitizing rinse was 180 degrees. Dish Machine Temperature logs for the months of March, April, May, and June of 2025 were reviewed. For all of March 2025, the log indicated the wash temperature was at 160 degrees and the rinse temperature was at 185 degrees. The temperature was identical during all three temperature checks which were taken at breakfast, lunch, and dinner, each day. For all of April 2025, the log indicated the wash temperature was at 160 degrees and the rinse temperature was at 185 degrees for the entire month. For all of May 2025, the log indicated the wash temperature was at 160 degrees and the rinse temperature was at 185 degrees for the entire month. For all of June 2025, the log indicated the wash temperature was at 160 degrees and the rinse temperature was at 185 degrees for the entire month. The same log sheets also indicated that the PPM (parts per million) level was at 300 during each check.An interview was conducted on June 26, 2025 at 10:43 AM with Staff #35. He explained that the dish machine was a high temperature machine and the rinse temperature was to be over 180 degrees and the wash temperature was to be over 160 degrees. He also explained that he checks the temperature logs on a regular basis and he makes sure that the temperatures of the dish machine are being logged. When asked he indicated that it was not realistic for the temperatures to be identical 3 times a day for a 4 month time period . He stated that the temperatures would vary by a few degrees and would not be identical each wash and or rinse. He explained that he didn ' t notice and admitted that he should have paid more attention to the temperature logs. When asked why he thought the numbers were identical on the dish machine temperature log, he shared that he thought staff were not checking the actual temperatures on the gauge and were just writing down what the previous person wrote. When asked how often the solution in the sani-buckets were replaced, he indicated that this was done every 4 hours. An interview was conducted on June 26, 2025 at 10:53 AM with Dishwasher/Staff #43. He indicated that he would take the temperature at 6:00 AM and again after the lunch service. When asked about the temperature log, he indicated that he just carries the previous entry forward. Staff #43 was not able to identify where the 300 PPM information came from and indicated that he also copied that from the previous entry. Staff #43 indicated that he was the person who usually ran the dish machine during the day and recorded the temperatures onto the log sheet and a different staff person would run it after the dinner service and record the temperatures. An interview was conducted on June 26, 2025 at 11:02 AM with staff #31. He explained that the 300 ppm is when staff check the sani-bucket and then record it on the dish machine temperature log. He also added that the solution in the sani-buckets are replaced every 4 hours. He also explained that the dishmachine has a wash temperature of 160 degrees and the rinse should be 180 degrees.An interview was conducted on June 26, 2025 with Executive Director/Staff #74. He explained that the dish machine was a high temperature wash and the rinse temperature needed to be at least 180 degrees and the wash temperature needed to be at least 160 degrees. When asked if it was realistic for the dish machine temperature logs to have identical temperature readings over a period of several months, he indicated that it was not. He was not able to explain why that was the case. When asked how often the cleaning solution in the sani-buckets needed to be changed out, he indicated this was to be done every 4 hours. When asked about the company ' s guideline indicating the solution needing to be changed every 2 hours, he was not able to explain the discrepancy and indicated that he would need to review the guide. When asked about cross contamination, he explained that cooked foods and raw foods would need to be kept separate and different utensils would need to be used when handling the food. When asked if it was acceptable to use the same knife, without cleaning it, to cut up a cooked chicken and a cooked baked potato, he indicated that it was not acceptable. Staff #74 explained that residents could be at risk for salmonella or other food borne illnesses, if they were to eat cross contaminated foods. When asked if staff were supposed to wear hairnets when in the kitchen, staff #74 explained they were. He explained that hairnets must fully cover the hair at all times when in the kitchen. A review of a policy titled, Hair Restraints, last revised in December 2024, indicated that all hair must be kept covered including using a beard restraint if needed. A review of a policy titled, Washing and Sanitizing Dishes, last revised in December 2024, indicated that all dishwear was to be washed and sanitized using commercial machine washing procedures. It also indicated that in a high temperature dish machine the wash water temperature needed to be at a minimum of 150 degrees - 165 degrees and the rinse water needed to reach 180 degrees. The same policy also indicated that the water temperature must be taken and recorded on the temperature log. A review of the Sanitation and Safety guideline, provided by the facility, indicates that the red sani-pails are used for a chemical sanitizing solution to sanitize surfaces and equipment. The same document also indicated that kitchen towels were to be stored in the red bucket when not in use and the sanitizing solution should be tested and changed every 2 hours.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that medications were administered, stored and residents were assessed for self-administration of medication for 3 residents (#1, #7 and #24). The deficient practice could result in medications not being administered according to physician's orders and medications not being stored safely.-Regarding Resident # 7Resident #7 was admitted to the facility on [DATE] with diagnoses that include fracture of the right femur, cognitive communication deficit, weakness, and the need for assistance with personal care. Review of the admission MDS, dated [DATE] revealed a BIMS score of 13 which indicated Resident #7 was cognitively intact. An observation was conducted on June 24, 2025 at 2:31 PM. A bottle of Chloride Nasal Spray was observed on a table next to Resident #7's recliner. A second observation was conducted on June 25, 2025 at 2:17 PM. A bottle of Chloride Nasal Spray was observed in the same location. An interview was conducted on June 25, 2025 at 2:19 PM with Resident #7 and his family member, who was visiting. Resident #7's family member that she had brought the medication to the facility from the hospital and had told the nurse about it. The family member did not recall the nurse's name. Resident #7 indicated that he was using it because his nasal cavity was dry after his recent hospital stay. When asked if he would administer the nasal spray himself, Resident #7 indicated that he did. A third observation was conducted on June 26, 2025 at 8:43 AM and the bottle of Chloride Nasal Spray was not observed. A review of Resident #7's medication orders did not reveal an order for Chloride Nasal Spray. A review of the clinical chart did not reveal an assessment to determine if he was able to safely self-administer medications. -Regarding Resident #24Resident #24 was admitted to the facility on [DATE], with diagnoses that include Nondisplaced Intertrochanteric Fracture of the right Femur, Malignant Neoplasm of the Esophagus, and Major Depressive Disorder.A review of the Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) Summary score of 13, indicating that the resident is cognitively intact.During the initial interview with Resident #24 on June 24, 2025, at 10:45 a.m., the resident was observed to have Remedy Antifungal Ointment on their bedside table. Upon inspection of the Antifungal Ointment container, it was discovered to have the active ingredient Miconazole Nitrate. There were no staff present in the room when the Remedy Antifungal Ointment was discovered. A physician order dated May 27, 2025, was written for: Remedy Antifungal cream for sacral buttocks wound. Then layer Clinical Silicone Barrier Cream. Directions: Every shift for skin care.A care plan report, initiated on May 20, 2025, revealed that Resident #24 has potential/actual impairment to skin integrity: Right Hip surgical site, Sacrum stage IIU ulcer, and decreased mobility following hospitalization, incontinence. Further review of the care plan report revealed no evidence that Resident #24 should self-administer the medication. Upon a second visit to Resident #24 at 12:45 p.m., it was observed that the Remedy Antifungal Ointment was still on the bedside table. A Licensed Practical Nurse (LPN, Staff #87) was then informed that the medication was on the bedside table. The LPN was then observed removing the medication from the room.An interview was conducted on June 24, 2025, at 12:46 PM with a Licensed Practical Nurse (LPN, Staff #87). Staff #87 stated that medications are not supposed to be at bedside. Staff # 87 further stated that there needs to be an order for self-administration of medications. The LPN then stated that there is an entire process for self-administration of medication and that this would include a lot of different things to include oral, topical, and nasal sprays, and includes over-the-counter products as well. The LPN further stated that the expectation would be that there are no medications at bedside and that they do a walk-through once a week to check for meds, but really check the resident rooms each time they go inon a daily basis.When asked what the risk would be for a medication to be left unattended in a resident ' s room, the LPN stated that the risk would be that a different patient could take it and cause a reaction. The LPN also stated that there is more of a risk for dementia patients. When asked if there were any dementia patients in the unit, the LPN stated that she didn ' t think there was anyone with dementia on the unit. The LPN was then asked to check on the diagnosis for Resident # 15 on the unit and stated that he did have dementia. The LPN identified the following medications at bedside, which were removed: zinc oxide paste, antifungal cream with miconazole and sodium chloride. LPN stated that if medication is discovered at bedside it is removed, placed in a bag, and labeled with the resident ' s name and returned to the resident at discharge.An interview was conducted on June 25, 2025, at 11:56 AM with a Certified Nursing Assistant (CNA, Staff #82). The CNA was asked what a medication was. The CNA replied that a medication or drug is a treatment to treat health issues. CNA also stated that it can come in different forms, tablets, liquids, oral, IV, injections, and topicals, and that over the counter can be considered a medication. CNA further stated that medications are not allowed at bedside and that if observed, the staff should notify the nurse immediately. When asked what the risk of an unattended medication would be, the CNA stated that maybe they don't take the medication, or another resident could accidentally take it.An interview was conducted on June 25, 2025, at 1:57PM with the Director of Nursing (DON, Staff #92). The DON was asked what the expectations were regarding meds left at bedside. The DON stated that they do not expect any medications would be left at bedside unless the resident is assessed and competent to take medications independently. The DON then stated that these forms are listed in a med review-form indicating that they were competent to self-administer. The DON was then asked what a medication is. The DON stated that a medication is anything that is prescribed, a treatment, or creams. Anything over the counter, herbals, topicals. The DON stated that their expectations for staff was that they hope they would recognize what's appropriate and to also educate the patient. The DON further stated that they would expect staff to remove medications out of the resident's room and that staff observe what's at bedside when they round. When asked what risks were associated with unattended medications, the DON stated that risks include inhaling something that is not appropriate, missing a medication, or someone else taking the medication/treatment. The DON stated that she was aware that something was taken out of room but not what and from whom. The DON stated that continuation of education is key.Review of facility ' s policy titled, Resident Self-Administration of Medications, last revised on March 2019 revealed that residents who desire to self-administer medications may do so if the review determines the resident is capable. Policy detail: (3) The result of the Interdisciplinary Team (IDT) assessment is documented on the ' Self-Administration of Medications Data Collection form, which is placed in the medical record;(5) obtain health care provider ' s order that the resident may self-administer; and (6) the IDT shall develop and implement a care plan to monitor the resident ' s ongoing ability to self -administer medications.-Regardint Resident #1 Resident #1 was admitted to the facility on [DATE] with a diagnosis that included pneumonia, acute on chronic systolic (congestive) heart failure, hypertension, major depressive disorder, and urinary tract infection (UTI).Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0, cognitively intact.During the survey's initial pool on June 24, 2025 at 10:55 AM, in Resident #1's room at the bedside table was a green covered top container which has Flonase label on it stored in a Ziplock bag and Resident stated that it is there to help him breath, he brought it with him, and it has always been on the table just in case he needed it.On June 24, 2025 at 11:03 AM, a Licensed Practical Nurse (LPN)/Staff #100 came in the room. Staff #100 stated that she did not know anything about the medications at bedside. She informed the resident that he is not supposed to have those in his room. Staff #100 identified the following item inside the ziplock bag as Flonase, lubricant eye drops, and Halls cough drops.Review of physician orders revealed an order for the following medications:- On June 24, 2025 at 11:15 AM, cough drops mouth/Throat lozenge 7.6 mg (milligram) give one drop by mouth every 3 hours as needed for cough and/or dry throat;- On June 24, 2025 at 11:15 AM, Artificial Tears Ophthalmic Solution 0.5-0.6 % (Polyvinyl Alcohol-Povidone (Ophthalmic), Instill 2 drop in both eyes every 4 hours as needed for dry eyes allergies; and - On June 24, 2025 at 11:15 AM, Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (microgram/actuation) (Fluticasone Propionate (Nasal), 1 spray in both nostrils every 12 hours as needed for allergies.Review of care plan and progress notes revealed no self-administration of medication assessment documentation.An interview was conducted on June 25, 2025 at 9:21 AM with a LPN/Staff #60. Staff #60 stated that her role includes medication administration, wound care and catheter care. For medication administration, she compares the medication administration record (MAR) to the medication/bubble pack with the name and dosage of the medication. She verifies the resident's name. She stated that she would not leave medications at bedside because it is not safe, it can mess with the ordered medication time, and the resident can hide or store it and not take the medication. She stated that in some facilities, she is not familiar with this facility's policy, that some residents are allowed medications at bedside if it is specified in the physician's order. An interview was conducted on June 25, 2025 at 2:10 PM with the Director of Nursing (DON)/Staff #92. The DON stated that her staff administers medications and should never leave the medications at the bedside unless authorized. She stated that there is self-administration of medication that their residents can do. She stated that the process for self-administration of medication is they complete an assessment. If the resident is cognitively able to do so, the medications are safe at the bedside. She stated that residents should not have medications at bedside if the residents did not have self-administration assessment. Furthermore, the DON stated that if the resident or his or her family brought in the medication, and the resident or his or her family did not disclose of the medication to staff, the resident and his or her representatives will receive an education related to bringing medications from home, the staff will store the medication, and the staff will notify the provider to get an order for the medication. The DON stated that she was made aware of the medications left at bedside for Resident #1. The DON stated that the provider was notified of the medications, and that there was no self-administration of medication assessment completed because the resident did not disclose the medications to the staff. The DON stated that the risk of medications being left at bedside could interfere with other medications if taken inappropriately.Review of facility's policy titled, Resident Self-Administration of Medications, last revised on March 2019 revealed that residents who desire to self-administer medications may do so if the review determines the resident is capable. Policy detail: (3) The result of the Interdisciplinary Team (IDT) assessment is documented on the 'Self-Administration of Medications Data Collection form, which is placed in the medical record;(5) obtain health care provider's order that the resident may self-administer; and (6) the IDT shall develop and implement a care plan to monitor the resident's ongoing ability to self -administer medications.Review of facility's policy titled, Storage and Expiration Dating of Medications and Biologicals, last revised on August 1, 2024 revealed Procedure: (14) Facility should ensure resident medication and biological storage areas are locked and do not contain non-medication/biological items.Review of facility's policy titled, Medication Orders, 2001 Med-Pass, Inc. revealed Supervision by a Physician: (2) a current list of orders must be maintained in the clinical record of each resident.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that medications were administered, stored and residents were assessed for self-administration of medication for one residents (#1). The deficient practice could result in medications not being administered according to physician's orders and medications not being stored safely.Findings include:Resident #1 was admitted to the facility on [DATE] with a diagnosis that included pneumonia, acute on chronic systolic (congestive) heart failure, hypertension, major depressive disorder, and urinary tract infection (UTI).Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0, cognitively intact.During the survey's initial pool on June 24, 2025 at 10:55 AM, in Resident #1's room at the bedside table was a green covered top container which has Flonase label on it stored in a Ziplock bag and Resident stated that it is there to help him breath, he brought it with him, and it has always been on the table just in case he needed it.On June 24, 2025 at 11:03 AM, a Licensed Practical Nurse (LPN)/Staff #100 came in the room. Staff #100 stated that she did not know anything about the medications at bedside. She informed the resident that he is not supposed to have those in his room. Staff #100 identified the following item inside the ziplock bag as Flonase, lubricant eye drops, and Halls cough drops.Review of physician orders revealed an order for the following medications:- On June 24, 2025 at 11:15 AM, cough drops mouth/Throat lozenge 7.6 mg (milligram) give one drop by mouth every 3 hours as needed for cough and/or dry throat;- On June 24, 2025 at 11:15 AM, Artificial Tears Ophthalmic Solution 0.5-0.6 % (Polyvinyl Alcohol-Povidone (Ophthalmic), Instill 2 drop in both eyes every 4 hours as needed for dry eyes allergies; and - On June 24, 2025 at 11:15 AM, Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (microgram/actuation) (Fluticasone Propionate (Nasal), 1 spray in both nostrils every 12 hours as needed for allergies.Review of care plan and progress notes revealed no self-administration of medication assessment documentation.An interview was conducted on June 25, 2025 at 9:21 AM with a LPN/Staff #60. Staff #60 stated that her role includes medication administration, wound care and catheter care. For medication administration, she compares the medication administration record (MAR) to the medication/bubble pack with the name and dosage of the medication. She verifies the resident's name. She stated that she would not leave medications at bedside because it is not safe, it can mess with the ordered medication time, and the resident can hide or store it and not take the medication. She stated that in some facilities, she is not familiar with this facility's policy, that some residents are allowed medications at bedside if it is specified in the physician's order. An interview was conducted on June 25, 2025 at 2:10 PM with the Director of Nursing (DON)/Staff #92. The DON stated that her staff administers medications and should never leave the medications at the bedside unless authorized. She stated that there is self-administration of medication that their residents can do. She stated that the process for self-administration of medication is they complete an assessment. If the resident is cognitively able to do so, the medications are safe at the bedside. She stated that residents should not have medications at bedside if the residents did not have self-administration assessment. Furthermore, the DON stated that if the resident or his or her family brought in the medication, and the resident or his or her family did not disclose of the medication to staff, the resident and his or her representatives will receive an education related to bringing medications from home, the staff will store the medication, and the staff will notify the provider to get an order for the medication. The DON stated that she was made aware of the medications left at bedside for Resident #1. The DON stated that the provider was notified of the medications, and that there was no self-administration of medication assessment completed because the resident did not disclose the medications to the staff. The DON stated that the risk of medications being left at bedside could interfere with other medications if taken inappropriately.Review of facility's policy titled, Resident Self-Administration of Medications, last revised on March 2019 revealed that residents who desire to self-administer medications may do so if the review determines the resident is capable. Policy detail: (3) The result of the Interdisciplinary Team (IDT) assessment is documented on the 'Self-Administration of Medications Data Collection form, which is placed in the medical record;(5) obtain health care provider's order that the resident may self-administer; and (6) the IDT shall develop and implement a care plan to monitor the resident's ongoing ability to self -administer medications.Review of facility's policy titled, Storage and Expiration Dating of Medications and Biologicals, last revised on August 1, 2024 revealed Procedure: (14) Facility should ensure resident medication and biological storage areas are locked and do not contain non-medication/biological items.Review of facility's policy titled, Medication Orders, 2001 Med-Pass, Inc. revealed Supervision by a Physician: (2) a current list of orders must be maintained in the clinical record of each resident.

Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident (#332) was free from preventable accidents including oral administration of Dakins solution. The sample size was 13. This deficient practice could result in an adverse event for the resident.Findings include:Resident #332 was admitted on [DATE] with diagnosis including acute and chronic respiratory failure with hypoxia, atrial fibrillation, hypertension, acute pulmonary edema, asthma, and dysphagia. A review of the 5-day MDS (minimum data set) dated April 14, 2025 revealed a BIMS (brief interview of mental status) score of 13, indicating that the resident was cognitively intact. A review of the progress notes revealed that on April 12, 2025 at 7:08 P.M. there was a noted in change in condition. It was documented that vitals taken April 11, 2025 between 9 and 10 P.M. showed an elevated systolic pressure reading of 147 while lying down, pulse, respirations and body temperature were noted to be in the normal range, blood sugars were elevated at 386. Additional documentation revealed that the resident stated that from now on she will drink from her pitcher instead of a cup. Primary care provider feedback noted to encourage the resident to drink plenty of water. It was further documented that the resident had no signs or symptoms of a swallowing disorder and no observed changes in mental of functional status.A progress note dated April 13 2025 revealed that the resident was alert and oriented. No noted pain or discomfort with chewing and swallowing and documentation indicating that the resident denied any gastro-intestinal symptoms.An order summary dated April 14/2025 revealed that the resident is to be monitored and that the physician is to be notified should the resident present with chest pain or tightness, lack of responsiveness, delirium (agitation and confusion), pain in the mouth or through burning, tearing and red eyes, burns to the esophagus-blistering, drooling or gagging sensation and low blood pressure.A review of the facility investigative report revealed that on April 12, 2025 at 2:30 P.M. licensed practical nurse (LPN/ Staff #61) had gathered all her supplies for treatment which included 1/2 strength Dakin's solution, utilized for wound treatment for another resident. It was documented that prior to doing treatment for the other resident, the LPN went into the room of resident #332 to administer her medications. It was noted that the supplies were placed on the medication cart and that the Dakin's solution was placed in a disposable drinking cup which the resident was handed instead of water. It was noted that the resident drank approximately 30 ml of the Dakin's solutions and reported to the LPN that it tasted weird. Staff #61 smelled it and realized that instead of water it was the Dakin's solution. It was noted that the LPN immediately gave the resident more water to drink. It was noted that the resident did not have any complaints of discomfort when swallowing. The provider was notified and staff were ordered to encourage more fluids. Both DON (director of nursing) and ED (executive director) were notified.Dakin's solution, per the NIH (National Institute of Health), National Library of Medicine, is a dilute solution of sodium hypochlorite, which is commonly known as household bleach. It further notes that when properly applied, it can kill pathogenic microorganisms with minimum cytotoxity.No observed evidence in the electronic health record that poison control had been contacted.An interview was conducted on June 25, 2025 at 10:56 A.M. with assistant director of nursing (ADON/ Staff #91) and the nurse practitioner, Staff #210. The ADON stated that nurses who pass meds also conduct the wound care.An interview was conducted June 25, 2025 at 12:14 P.M. with LPN, staff #87. Staff #87 stated that if a resident was administered an incorrect medication or substance, the first step would to identify the error and immediately report it to the DON (director of nursing) or the ADON and then the provider. Staff #87 stated that based on what was administered or ingested, the provider would render guidance on nest steps. The LPN stated that Dakin's solution is a topical used to treat wounds. Staff #87 stated that steps to avoid errors in adminstering medications and or other substances include double checking and taking care with what is provided to the resident.A telephone call was placed on June 25, 2025 at 12:30 P.M. to LPN/ Staff #61. A message was left on the voicemail requesting a call back. A secondary call was placed on June 25, 2025 at 12:50 P.M., the call again went to voicemail and another message was left. No return call received from staff #.A telephone call was placed to resident #332, the call was observed to go to voicemail. A message was left and no return call was received.An interview was conducted on June 25, 2025 at 2:03 P.M. with the DON/ Staff #92. Staff #92 stated that her expectation is for staff to only take those items into the resident rooms that are immediately needed and then to take out any items that were brought into the room after care had been completed. The DON stated that Dakin's solution should not be ingested. Staff #92 stated that she was familiar with the incident and stated that post incident, she would have called poison control; however, review of the electronic health record revealed no evidence that poison control had been contacted. Staff #92 stated that the risk to the resident could include toxicity, diarrhea and nausea. She stated that staff were re-educated on the existing policy regarding hazardous substances and the ADON conducted a full facility sweep to ensure that all hazard substances were locked up.A review of the policy entitled Poison Control with an effective date of October 2015 revealed that if a resident was suspected of taking poison, the charge nurse should notify the healthcare provider and director of clinical services immediately. The policy further stated treatment should be administered as ordered by the healthcare provider, based on poison control recommendations.

Based on clinical record review, staff interviews, observations, and facility documentation, staff interviews and policy review, the facility failed to ensure professional standards of quality were met regarding accurate documentation for one sampled resident (#15). The deficient practice could result in resident records not being accurate and complete.Findings include: Resident #15 was admitted to the facility on [DATE], with diagnoses including: fracture of left patella, difficulty in walking, need for assistance with personal care, dementia, and major depressive disorder.An admission Minimum Data Sheet (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated severe cognitive impairment.An interview with resident #15 was conducted on June 24, 2025, at 10:27 a.m. Resident #15 stated that he had a beard-trimming kit that had gone missing since he arrived at the facility, and believed that other personal items had gone missing as well. Review of resident #15's electronic records revealed no record of resident #15's personal property.On June 25, 2025, at 11:48 a.m., an interview was conducted with Certified Nursing Assistant (CNA/staff #65). CNA #65 stated that when residents are admitted , a property form is filled out, even if a resident is arriving without personal property. This form is then given to a nurse for signature and to be placed into the resident's records. An interview with licensed practical nurse (LPN/staff #60) at 12:06 p.m. revealed that after the CNA assists the resident and family with inventorying personal property, a nurse will sign off on the property inventory, upload the document into the electronic records, and place the original form into the resident's charts. LPN #60 was unable to locate resident #15's property inventory in the electronic record or in the resident's chart. Several other resident charts were examined, and property forms were examined for each resident. Property forms listed clothing and personal items, and if residents arrived without property, the forms noted that the resident had no personal property. The Director of Nursing (DON/staff #92) stated in an interview on June 26, 2025, at 9:07 a.m. that resident records should be complete and accurate. She further stated that property of value should be logged immediately, and property brought in after admission should be added to the inventory sheet. DON #92 then stated that property records should be kept on all residents for the security of valuable property , although the value of property is subjective. A policy titled Personal Property, revised August 2022, revealed that Residents are permitted to retain and use personal possessions as space permits, and inventory of high-value personal property should be documented as indicated.

Based on facility record review, review of the National Council of State Boards of Nursing (NCSBN) Licensing verification system and interviews, the facility failed to ensure one Licensed Practical Nurse (LPN/Staff #29) had a valid license to practice in the State of Arizona. The deficient practice could lead to care provided to residents not meeting their needs safely and in a manner that promotes residents' rights, physical, mental, and social well-being. Findings include: Based on personnel record review, Staff #29 was hired by the facility on [DATE]. Review of the facility's records indicate Staff #29's Practical Nurse (PN) license was valid on [DATE] and the license originated in Texas. Review of the NCSBN licensing portal revealed that staff #29's PN license was revoked on [DATE]. Review of the facility's investigative report indicated that staff #29 informed the facility, on [DATE], that her license was revoked. The report further indicated that staff #29 was immediately removed from the schedule and placed on suspension. Review of staff #29's time punch details reveal that she worked 24 shifts between [DATE] and [DATE]. An interview was conducted with the Director of Nursing (DON/staff #22) on February 13, 2025 at 3:45 PM. Staff #22 explained that prior to hire, all clinical staff have their professional licensed verified by her. However, staff #22 was not sure how the facility ensures those professional licenses continue to be valid ongoing. Staff #22 indicated that she thinks the Human Resources department does monthly license checks but she was not sure. When asked what the risks to the residents would be when a staff is not licensed to provide care, staff #22 indicated that the staff would not be able to do procedures and there would be poor client outcomes as a result, they also wouldn't be able to administer medications or might provide inappropriate treatments. An interview was conducted with the Director of Human Resources (staff #49) on February 13, 2025 at 4:10 PM. Staff #49 explained that prior to bringing in nurses for interviews, they verify the nurses have a valid professional license. She indicated that she had a spreadsheet that tracks everyone's licenses, CPR, Tuberculosis, and fingerprint dates. Staff #49 explained that because staff #29's original PN license was in Texas, the facility was not notified of the license revocation right away. Staff #49 further explained that the HR department does random audits of staff license expiration dates and remind staff of upcoming renewal dates. The audits also included random checks to ensure nursing licenses are valid. Staff #49 was not aware of possible risks to the residents should they receive care from a nurse that has an invalid nursing license. However, she did indicate that she wants residents to receive good care. On February 13, 2025 at 9:45 AM a policy on employee licenses and qualifications was requested. The facility provided a policy titled, Associate File which was last revised in [DATE]. The policy indicated that the agency-maintained personnel file for employees will contain the certifications/licenses. It also stated It is the responsibility of the Human Resources Department and agency manager to ensure all files are compliant and complete.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to develop a complete baseline care plan that included the instructions needed to provide effective and person-centered care for one resident (#3). The deficient practice could result in resident care needs not being met. Findings include: Resident #3 was admitted on [DATE] with diagnosis including a displaced fracture of the left femur, pain in the left hip, hypertension, Alzheimer's disease, major depressive disorder, fibromyalgia, dementia, and heart disease. A review of the MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 11, indicating the resident had moderate cognitive impairment. A review of the baseline care plan initiated on June 17, 2024 revealed that resident #3 was noted to be a high fall risk and that the call light should be in reach, and that resident needs prompt responses to all requests for assistance, resident encouraged to wear appropriate footwear, occupational and physical therapy evaluations and treatment, cuing and supervision, bed lowered, mats on the floor by the bedside and initiation into the facilities falling star program for fall prevention and management. The care plan further noted that resident #3 had bladder incontinence; however, the care plan revealed no evidence of any interventions. An interview was conducted on June 24, 2024 at 1:46 P.M. with Social Services Director (SSD/staff #40). Staff #40 stated that the baseline care plan is generated from the nurse admission data collection. She stated that expectation, even for a baseline care plan, would be that interventions for each area of concern are noted. Staff #40 pulled up the care plan and stated that there were no interventions noted for bladder incontinence. She stated that the risk would include, not having the full picture of what the resident's needs are and if the needs and interventions are not properly identified, then staff would not know how to address them. An interview was conducted on June 24, 2024 at 2:18 P.M. with staff #35 LPN (licensed practical nurse). Staff #35 stated that the baseline care plan is conducted by nursing and does need to include the identified needs of the resident as well as the response or intervention to that need. An interview was conducted on June 24, 2024 at 2:19 P.M. with staff #2 (ADON/Assistant director of nursing). Staff #2 reviewed the care plan and observed that area for bladder incontinence, he stated that this did not meet his expectations and that an intervention should have been noted for bladder incontinence. Staff #2 stated that the risk could include lack of oversight when it comes to falls, as well as a potential for skin related issues. He further stated that that it could be catastrophic for the resident if they are not being appropriately monitored due to lack of information in the care plan. A review of the facility policy entitled Interim Care Plan Policy with a revision date of February 2023 revealed that within 48 hours of admission a baseline care plan should be developed to include minimum healthcare information necessary to care for the resident's immediate health and safety needs.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a resident was appropriately monitored post fall. The deficient practice could result in residents being injured. Findings include: Resident #3 was admitted on [DATE] with diagnosis including a displaced fracture of the left femur, pain in the left hip, hypertension, Alzheimer's disease, major depressive disorder, fibromyalgia, dementia, and heart disease. A review of the MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 11, suggesting moderate cognitive impairment. A review of the baseline care plan initiated on June 17, 2024 revealed that resident #3 was noted to be a high fall risk and that the call light should be in reach, and that resident needs prompt responses to all requests for assistance, resident encouraged to wear appropriate footwear, occupational and physical therapy evaluations and treatment, cuing and supervision, bed lowered, mats on the floor by the bedside and initiation into the facilities falling star program for fall prevention and management. The care plan further noted that resident #3 has bladder incontinence; however, the care plan revealed no evidence of any interventions for bladder incontinence. A review of the IDT (interdisciplinary team) note, entered by staff #12 RN (registered nurse) revealed an entry for June 19, 2024 noting that staff had responded to noise from the room of resident #3 and found the resident lying on the floor. The entry further noted that staff from the previous shift had reported that the resident had been attempting to transfer and ambulate on her own. It was further noted that as a result, staff were conducting frequent observations, redirecting the resident and were toileting the resident every 2-hours. It was documented that the resident was impulsive and had poor safety awareness. An interview was conducted on June 24, 2024 at 12:01 P.M. with the daughter (individual #41) of resident #3. Individual #41 stated that on June 19, 2024 at about 6:15 P.M. she had gone to visit her mother. She stated that she had gone to her mother's room and the door to her room was open about 1.5 feet. She stated that a woman came from behind, entered the room and shut the door in the daughter's face. Individual #41 stated that she heard her mother crying and then opened the door and saw that her mother was on the floor. She stated that she asked staff if her mother had fallen and that she was told that she had. She stated that she had observed her mother lying on her side where she just had surgery and that she already had a pillow under her neck. The daughter stated that her mother shared she had to pee and that no one would come to help her. The daughter stated that a CNA (certified nursing assistant) had told her that she had taken resident #3 to the bathroom [ROOM NUMBER] to 13 minutes ago and that she observed her to be fine at that time. The daughter stated that all staff then left the room. She stated that no one was in the resident's room except for her, her husband and mother for about 5 minutes. Daughter stated that she was given no directions by staff, when they left the room. Daughter stated that she had a broken foot and was not able to provide much assistance, but did ask her mother if she would like another pillow. The daughter stated that resident #3 wanted the pillow. Once the pillow was provided, resident #3 pushed herself on her back. The daughter stated that once her mother was taken by the paramedics, none of the staff came back to the room to speak with her. She stated that she had to collect all of her mother's belongings on her own and then exited the building. The daughter came to the facility on [DATE] and showed this surveyor a video recording during the date and time of the incident. The observation of the video recording, revealed that the daughter and son-in-law were left alone with resident #3. Per the video recording, no observation was made that the resident or family members were instructed not to move the resident post fall. An interview was conducted on June 24, 2024 at 2:18 P.M. with staff #35 LPN (licensed practical nurse). Staff #35 stated that she was alerted by staff that resident #3 had fallen at about 6:15 P.M. She stated that she called the doctor while one staff member ensured that the resident was okay. Once the resident was assessed, she stated that one staff member called 911 and another was filling out the bed hold paperwork. She stated that the daughter was in the room with the resident, while staff were making the necessary calls and completing paperwork. She stated that when emergency medical services arrived the resident was still on the floor and that the resident had been left on the floor for a short amount of time without supervision. An interview was conducted on June24, 2024 at 1:30 with staff #15 (LPN). Staff #15 stated that the protocol for an unwitnessed fall includes assessing the resident for injuries, initiating neurological checks, calling the provider and conducting the applicable notifications. She stated that first staff have to ensure that the resident is safe, stay in the room with the resident until the resident can be safely moved or until emergency medical personnel arrive. She stated that she was not present when resident #3 fell . An interview was conducted on June 24, 2024 at 2:19 P.M. with staff #2 (ADON/Assistant director of nursing). Staff #2 stated that post fall, his expectation is that a staff member needs to be with the resident in the room as long as the resident is still on the floor. Staff #2 stated that the risk for not staying in the room with resident could include a worsening of condition, if the resident were to be moved. A telephonic interview was conducted on June 24, 2024 at 4:29 P.M. with staff #28 (LPN). Staff #28 stated that the resident was left alone in the room but only briefly as staff were going back and forth into the room. She stated that someone should have stayed in the room with her at all times. She stated that the fall had occurred in the middle of report/ shift change and that it was a very hectic time. She stated that the resident's initial neurological checks were fine. She further stated that there was a risk for leaving the resident on the floor without staff present, but did not indicate what the risk was. She further stated that she could not recall if anyone had informed the resident or family that the resident should not be moved. A review of the facility policy entitled Incident/ Accident Reporting with a revision date of October 2016 revealed that when a resident sustains a fall, that the extent and injury should be evaluated, health care provider notified and if an unwitnessed head trauma., the resident should be observed for neurological abnormalities. Neither Incident reporting or Falls Management Policy with a revision date of January 2024, provided instructions regarding direct observation and resident movement after a fall had occurred.

Based on clinical record review and interviews, the facility failed to ensure two residents (#26 and #79) and their representatives were notified, in writing, of the reason for a transfer to the hospital. The deficient practice could result in residents being inappropriately transferred or discharged and not having a continuity of care once leaving the facility. Findings included: Regarding Resident #26 Resident #26 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, acute respiratory failure, and unsteadiness on their feet. A review of the admission Minimum Data Set (MDS), assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. A progress note by social services dated February 14, 2024 at 11:01 A.M. revealed the resident's wife was contacted regarding the resident's behavior from the previous night. Review of physician order with a revision date of February 16, 2024 revealed an order to send resident #26 to the emergency room for an evaluation of hypotension and hypoxia. A progress notes dated February 16, 2024 indicated the resident was taken to the hospital due to a change of condition, hypoxia and hypotension. Further review of record revealed no evidence that the resident and/or the resident's representative was notified of the transfer to the hospital. An interview was conducted on May 1, 2024 at 11:52 A.M. with the Director of Social Services (SSD/staff #45). Staff #45 indicated the facility called the hospital to inform the resident about the bed hold but found the resident had passed away on February 18th in the hospital. Regarding Resident #79 Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia and fracture of the right femur. A review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of 08 indicating moderate cognitive impaired. A progress note dated April 14, 2024 indicated resident #79 was sent to the hospital. The same note indicated the resident's son was made aware of the transfer. It did not indicate how the son was made aware. An interview was conducted with the Licensed Practical Nurse (LPN/Staff #28) on May 1, 2024 at 9:36 A.M. Staff #28 indicated that she will provide the resident with a copy of their care plan and print out any orders once they are discharged . Staff #28 also indicated that when there is a transfer, a floor nurse will notify the family of the transfer, verbally. It is then documented in a progress note in the resident's chart. An interview was conducted with the SSD (staff#45) on May 1, 2024 at 10:55 A.M. When asked how the facility notifies the resident and their representative of a transfer or a discharge to a hospital, staff #45 indicated the floor nurse will inform both of them verbally. An interview was conducted on the administrator (ADM/Staff #33) on May 1, 2024 at 1:30 P.M. Staff #33 indicated that facility staff will call the resident and their representative and inform them verbally of their transfers. Staff indicated that in most cases, they are notifying their power of attorney.

Based on observations, staff interviews, and record review, the facility failed to ensure infection control protocols were followed during medication administration for two residents (#179 and #6). The deficient practice could result in the development and transmission of infections. Findings included: An observation of a medication administration was conducted on April 30, 2024 at 7:30 A.M. with licensed practical nurse (LPN)/staff #35). Staff #35 dispensed resident #179's medications that included an aspirin 81 milligrams (mg) tablet, calcium with vitamin D tablet, colace 100 mg capsule, folic acid tablet, multivitamin with minerals tablet, omega-3 capsule (fish oil) 500 mg capsules, vitamin C 500 mg give tablets, bupropion tablet, duloxetine hydrochloride 60 mg capsule, hydrochloroquine sulfate tablet, isosorbide extended release half a tablet (15 mg), meclizine hydrochloride 25 mg tablet, and pregabalin 100 mg capsule into a medication cup. After dispensing the medications, staff #35 locked the medications cart and signed out of the computer. At approximately 7:50 A.M. staff #35 entered resident #179's room without performing hand hygiene. Staff #179 administered the resident's medications without performing hand hygiene. After administering the resident's medications staff #179 exited the resident's room without performing hand hygiene and proceeded to move the medication cart outside of resident #6's room. On April 30, 2024 at approximately 7:53 A.M. staff #35 began dispensing resident #6's medications without performing hand hygiene. Staff #35 opened a pro-stat medication container and poured 30 milliliter (ml) in a graduated medicine cup for resident #6. Additional medications were dispensed in a medication cup to include amiodarone 200 mg tablet, eliquis 5 mg tablet, lisinopril 40 mg tablet, metformin 500 mg tablet, pantoprazole sodium 20 mg tablet, tamsulosin 0.4 mg tablet, vitamin C 500 mg tablet, among others. Staff #35 locked her screen and cart and proceeded to administer medications to resident #6 without performing hand hygiene. Staff #35 did not perform hand hygiene before and after administering medications to resident #6. An interview was conducted on April 30, 2024 at 8:16 A.M. with LPN (staff #35) regarding hand hygiene. Staff #35 stated that hand hygiene are performed in between residents and in the resident room. Staff #35 added that she has a sanitizer on top of her medication cart that can be used to perform hand hygiene. An interview was conducted with the Director of Nursing (DON/staff #12) on May 1, 2024 at 2:23 P.M. The DON stated that staff should be sanitizing their hands, and unless visibly soiled then soap and water were used. The DON stated her expectation was that staff sanitized their hands before and after patient care, during medication administration, and in between rooms and medication administrations. The DON added that there were sanitizers on the medication carts that staff can use. The DON stated that the risk for not performing hand hygiene was the potential for infection, and that hand hygiene minimized the spread of infection and cross contamination. A review of the facility's policy, Bloodborne Pathogens Exposure Control Plan effective May 2001, and last revised on September 2019 revealed, All associates should practice handwashing using the following guidelines. Associates should wash their hands between care of residents. Review of the policy titled, Handwashing/Hand Hygiene effective October 2015, last revised January 2021, revealed that all associates shall follow handwashing/hand hygiene procedures to help prevent the spread of infections to other associates, residents, and visitors. Centers for Disease Control and Prevention (CDC) recommends using alcohol based hand sanitizer with 60-95% alcohol in healthcare settings before and after direct contact with residents, and before preparing or handling medications.

Based on observations, interviews, and record review, the facility failed to ensure kitchen equipment was in proper working order. Findings include: A review of the facility's Food Safety Inspection Report, dated January 13, 2024, indicated that the electric meat slicer plastic food contact plate was cracked. An observation was conducted on April 29, 2024 at 10:45 A.M. of the facility's kitchen and observed that the same plastic food contact plate was still cracked, the meat slicer was not covered, and did not have an out of order sign posted. A second observation was conducted on April 30, 2024 and the meat slicer was in the same condition as observed yesterday on April 29, 2024. On May 1, 2024 at 9:00 A.M. a copy of the work order was requested from the facility to determine what was being done to fix the machine. On May 1, 2024, the facility Administrator (staff #33) provided a copy of the work order dated May 1, 2024 at 9:15 A.M. An interview was conducted with the Administrator (staff #33) on May 1, 2024 at 10:10 A.M. The Administrator provided a purchase order, dated May 1, 2024 at 9:58 AM, for a new food contact plate. He also provided a picture of the meat slicer with a sign stating Out of Order on a plastic bag covering the meat slicer. The Administrator did not know whether the meat slicer was being used to prepare food for residents after the Food Safety Inspection identified the cracked contact plate or before the Out of Order sign was displayed. When asked why the replacement part was not ordered prior to May 1, 2024 and not when the county food inspection report came in, he indicated that he was not aware it was broken until today. An interview was conducted with the Head Chef (staff #46) on May 1, 2024 at 10:24 AM. He indicated the meat slicer part was still on order. He also indicated that he had adjusted his food ordering process to have sliced meats and cheese delivered due to not having a functioning meat slicer. When asked why the meat slicer was not repaired during the time in between the county food inspection in January until now, staff #46 indicated that he did not know why it was not fixed and he was not surprised it was taking this long. He indicated that sometimes he has a tough time getting facility maintenance to fix things. An interview was conducted with the Maintenance Director (staff #13) on May 1, 2024 at 12:59 P.M. Staff #13 indicated that when an equipment broke down, staff are to inform the department manager and to put the order in. The Maintenance Department will either do the repair in-house or contract out the work. When asked if he received a work order for the meat slicer in the kitchen, he indicated it was probably overlooked as they had several issues around that time. Staff #13 indicated that he was verbally informed of the issue this morning so he went online to look for a replacement part. A second interview was conducted with Administrator on May 1, 2024 at 1:30 P.M. The Administrator's expectation was that staff inform him and the Maintenance Director of any equipment failure in the kitchen immediately so they can get fixed. Staff #33 indicated that he had changed the process moving forward and that all issues will going to him directly. A review of the facility policy titled, Maintenance Service which was last revised in December of 2009, indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on record review and interviews, the facility failed to ensure one resident (#79) was given a bed-hold policy before a transfer to the hospital. The deficient practice may result in the resident and resident representative not being aware of the bed-hold policy and their right to return to the facility immediately after hospital discharge. Findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture of the right femur, and heart disease. Review of a bed hold agreement signed by the resident on admitted d April 4, 2024 revealed the resident agreed with bed hold in the event the resident was admitted to the hospital. A review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. A progress note dated April 14, 2024 revealed resident #79 was sent to the hospital due to a surgical site assessed as red and hot. The note also indicated that the resident's son was made aware of the transfer. There was no evidence that the bed-hold policy was provided to the resident and/or their representative upon transfer. An interview was conducted on May 1, 2024 at 9:36 A.M. with Licensed Practical Nurse (LPN/Staff #28). Staff #28 indicated that the bed-hold policy was provided to the resident or their family at the time of discharge if possible. Staff #28 reviewed resident #79's records and could not confirm if resident received the bed-hold policy as the staff was not able to locate it in the record. An interview was conducted with the Director of Social Services (SSD/Staff #45) on May 1, 2024 at 10:55 A.M. When asked when are bed-hold notices provided to residents and/or their representative when they transfer to a hospital, staff #45 indicated that the nursing and admission team will talk with the resident and ask them if they want their bed held. Staff #45 also indicated that the business office will coordinate bed-holds with residents that are private-pay. An interview was conducted with the Administrator (staff #33) on May 1, 2024 at 1:30 P.M. The Administrator indicated that the bed-hold policy is in the admission packet which they review and sign upon admission. Staff #33 also indicated the bed-hold policy was reviewed with residents or their representatives when they are transferred to the hospital. A training document titled Bed Hold Policy was provided by the facility. The document was dated May 1, 2024 at 2:30 P.M. The document revealed that training was conducted by staff #45 and five administrative staff members were in attendance. The training revealed that the bed-hold policy was reviewed at admission and at the time of transfer to the hospital. A review of the facility policy titled Bed-Hold Policy revised on December 2016, indicated a resident and their representative should be informed of the bed hold policy at admission and at time of transfer to the hospitalization or therapeutic leave.

Based on interviews and record review, the facility failed to ensure one resident (#20) and their representative were provided with a summary of the baseline care plan. The deficient practice could result in residents and their representative not receiving a summary of their baseline care plan. Findings included: Resident #20 was admitted to the facility on [DATE] with diagnoses that included noninfective gastroenteritis and colitis, neurocognitive disorder with lewy bodies, and type 2 diabetes mellitus. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS also noted that the resident participated in goal setting. Review of records revealed a comprehensive care plan was developed on April 4, 2024 and a collaborative care review was conducted with the Interdisciplinary Team (IDT) on April 8, 2024. During an interview on 4/30/24 at 3:40p, with the social services director, she stated the interim care plan is created using nursing admission data collection. When asked if residents sign the care plan or an attestation, she stated all residents ae given a copy of their care plan and the RAI (Resident Assessment Instrument) Coordinator goes over it with the resident. Further review of records revealed no evidence that the baseline care plan was provided to the resident and/or to their representative. An interview was conducted with the RAI Coordinator (staff #8) on April 30, 2024 at 3:45 P.M. She stated that she was responsible for completing resident's baseline care plan and that it was generated from initial interviews on admission. In addition, staff #8 stated baseline care plans were signed by the residents, scanned into their electronic health record, and a copy was provided to the residents and/or their representative. Staff #8 said that she was new in the position and was informed today, April 30, 2024, that she would be responsible for reviewing interim care plans and having the residents sign them. She said that currently residents were not provided a copy of their baseline care plan. Staff #8 stated that she will review the last four and a half months of admissions and have residents or their representatives sign their basic care plan and provide them with a copy. Regarding resident #20, staff #8 was unsure whether he was provided with a copy of his care plan and that she would provide him with one. An interview was conducted on May 1, 2024 at 3:02 P.M. with the Director of Nursing (DON) and she stated that her expectation was for resident to get a copy of their baseline care plan prior to their comprehensive care plan. The DON stated that interim care plans were signed and a copy were given to residents along with a copy of their prescribed medication list. She also stated that it was then scanned into the resident's electronic chart. Review of the facility policy titled, Interim Care Plan Policy, reviewed on February 2024 revealed, The resident and/or legal representative should be informed of the interim care plan; the resident and/or legal representative should be provided a summary of the Interim Care Plan; notification of the resident and/or legal representative of the Interim Care Plan should be noted in the resident record.

Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to implement a surveillance plan for identifying, tracking, monitoring of infection and failed to ensure an ongoing analysis of surveillance data and documentation of follow-up activity response. The deficient practice could result in the spread of infections in the facility. Findings include: During the entrance conference on January 3, 2023 at 8:09 a.m., the Administrator (staff #61) stated the facility currently had no COVID-19, and that the last COVID-19 outbreak was on November 7, 2022. Staff #61 stated that the facility does have a staff member assigned to be the infection preventionist (IP)and that this person is Licensed Practical Nurse (LPN/staff #6). Staff # 61 stated the IP is responsible for the facility's vaccination efforts, infection surveillance, and antibiotic stewardship. Record review of the facility's infection surveillance was conducted on January 4, 2022 at 1:57 p.m. with an infection preventionist/licensed practical nurse (LPN/ staff #6). During the record review, staff #6 provided a facility map and a form titled, Infection Control Log, indicating a reporting period of November 1 to November 30, 2022. However, the onset date column included two entries with no dates, 5 entries for October, and 16 entries for November 2022, in no chronological order. The form contained columns for residents' names, name of antibiotics, isolation status, and HAI (healthcare acquired infection). Additional columns on the form was marked for culture date, x-ray date, organism, recultured date, and date resolved. However, the columns were not completely filled out with the required information. During the record review, additional documents related to infection control surveillance for September and October, 2022 were requested from staff #6. She accessed a filing cabinet and binders and searched for the records. However, staff #6 was not able to provide additional evidence of infection control surveillance documentation. Continued review of the infection control surveillance log provided by staff #6 included a facility map titled, Monthly Tracking December 2022. A facility report titled, Order Listing, dated December 13, 2022 that contained the name of the residents with antibiotic orders attached to the facility map. However, the facility failed to provide evidence of completed infection control surveillance log for December 2022. An interview was conducted with staff #6 on January 4, 2023 at 2:13 p.m. Staff #6 stated regarding the infection control surveillance, as off mid December 2022 to today, she has not maintained an infection control surveillance due to lack of training and lack of staff. Staff #6 stated she has been working the floor as a nurse. The staff stated she has not been consistent with maintaining the infection control surveillance and antibiotic stewardship because of lack of training and she was always pulled to work on the floor since December 14, 2022. Staff #6 stated, there was no ICP since December 14, 2022 and that she had resigned, but she was asked to hold the title until they find a replacement. She stated she was not able to do her job as infection control nurse because she was working on the floor and that she notified the administrator of the areas that were not being done related to infection control, including surveillance and antibiotic stewardship. A joint interview was conducted on January 5, 2023 at 3:39 p.m., with regional nurse consultant (staff #81) and social services director (staff #62). Staff #81 stated as far as she knew the facility had an infection control nurse and that she was not made aware of the infection control issues. Staff #62 stated the facility are monitoring and tracking during change of condition. The facility policy, Infection Prevention and Surveillance, revised on January 2020, stated the nurse leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infection. The policy detail included the nurse leader designee shall apply scientific principles and methods to determine if the infection meets the criteria, and shall enter data into the infection trend tracker. Further, the policy detail stated the nurse leader designee shall provide updates in the infection trend tracker including changes and resolution.

Based on personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staffs #35 and #8) were able to demonstrate competencies and skills necessary to provide care for residents. The census was 31. The deficient practice could result in inadequate care for residents. Findings include: Review of a personnel file for a Certified Nursing Assistant (CNA/staff #35) revealed a hire date of 04/17/19, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2020, 2021 or 2022. The personnel file for a CNA (staff #8) revealed a hire date of 06/17/20, for hourly employment. Review of the personnel file revealed no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. An interview with the Human Resources Director (staff #84) was conducted on 01/05/23 at 10:33 a.m. She stated that the CNA skills sheets she had were dated 2021 and that she would ask the administrator if they had anything more current. She stated that the department heads were responsible to ensure their employees complete the training. An interview was conducted on 01/05/23 at 3:23 p.m. with the Regional Director of Clinical Operations (staff #81). She stated that the assistant director of clinical services is responsible to ensure training is complete. She stated that recertification for training and skills was expected to be done annually and that it should contain all the required elements. The Clinical Services Orientation and Skill Checklist policy, updated 03/2020, included clinical service associates who require a license or certification to perform resident care or treatment shall complete the Orientation Checklist upon hire. Clinical Services associates who require a license or certification to perform resident care or treatment shall complete the Orientation and Skills Checklist within the first 90 days of employment. The Clinical Skills Checklist shall be completed annually thereafter. The designated associate who is observing and/or explaining the skill shall document on the associate's checklist. If a concern is noted on the associates skills checklist, the corrective action is also documented. Additional associate training shall be provided as indicated.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to provide adequate supervision for one resident (#8) to prevent a fall which resulted in injury. The sample size was seven. Findings include: Resident #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's clinical record revealed a RAP (Resident Assessment Protocol) dated [DATE], which documented "...has a long history of impaired mobility related to a past CVA (cerebral vascular accident)...is non-ambulatory and uses a wheelchair for locomotion, he is able to propel self in his room and in the hallways of the unit...is assisted outdoors at the front entrance as he enjoys to sit in his wheelchair and enjoy the outdoor environment. Nursing staff applies sun block for protection to skin and monitors his length of time for his outdoor stay." The resident's clinical record revealed a Care Plan Report dated [DATE], which documented "...exhibits cognitive deficits as evidenced by STM/LTM (short term memory/long term memory) deficits. Moderately impaired decision making abilities. Cognition is complicated by CVA with aphasia..." as a problem. A further review of the resident's clinical record revealed a Care Plan Report dated [DATE], which documented "...is at an increased risk for falls due to decreased mobility and weakness...wanderguard alert to monitor whereabouts of res (resident). History of going upstairs to visit wife (now deceased ) or sits outside of front door getting sun" as a problem. Goals documented for the problem were "...will be free from injury times 90 days...If resident attempts to go upstairs he is usually redirected successfully. When res wants to go outside, he is checked on freq (frequently)." There was no documentation on the Care Plan Report as to how often resident should be checked on when he was outside. The resident's clinical record revealed a Resident Summary dated [DATE], which documented "Alert...oriented times three, person, place, and time...lacks awareness of own needs...Wheelchair: propels self...long distances." The resident's clinical record revealed a Fall Risk assessment dated [DATE], which revealed the resident's total score was a 14, or high risk. The resident's clinical record revealed a Resident Summary dated [DATE], which documented "Alert...confused...orientation fluctuates...history of episodic confusion...lacks awareness of own needs...Wheelchair: propels self...long distances...." The resident's Care Plan Report was not updated to reflect the resident's change in mental status from the [DATE], Resident Summary. A review of the resident's quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had short and long term memory problems and cognitive skills for daily decision making were moderately impaired. The resident's clinical record revealed Nurse's Notes dated [DATE], which documented "...At approx. (approximately) 0840 res pointed toward lobby door. Nurse took res outside by front door. Approx 5 mins (minutes) later res brought back into facility. Wander alert system sounded approx 5 mins later with res going back into lobby to go outside. Alarm reset and res again outside front door. Almost immediately came back into facility. Approx 10 mins later a staff member came into facility and reported that someone fell out w/c (wheelchair) by driveway entrance to the unit...Res at side of road laying on his left side. He was on dirt and brushlike plants with apparent cactus spines in chin and both hands...911 immediately called...transferred to (name of hospital)..." A review of hospital documentation dated [DATE], revealed a History and Physical which documented "...male with a past medical history of [REDACTED]. He was found on the ground next to his wheelchair outside of the nursing home. He was found to have fallen into some cactuses. Apparently the patient may have exited the nursing home while in his wheelchair and went down an incline on the sidewalk. While going down the incline, he fell off his wheelchair and fell into the cactuses although the fall was not witnessed. At that point in time the faculty and staff were notified at the nursing home and an ambulance was called for the patient...Right distal femur fracture." An observation of the area where the resident used to sit outdoors was made on [DATE]. The front lobby and the patio where the resident sat was not visible from the nurse's station. The door to the front lobby was alarmed with a wanderguard system. The door to the front lobby must be opened and a staff member must leave the hallway of the facility to the front lobby in order to visualize the patio area outside the front door. The area where the resident fell in the cacti is across the street from the nursing home, approximately 100 yards through the parking lot from the front entrance of the facility. An interview was conducted with a CNA (certified nursing assistant) on [DATE]. The CNA stated that CNA's needed permission first from the ADON (assistant director of nursing) before they were allowed to assist the resident outdoors. The CNA stated that it was the responsibility of whoever was assigned to the resident to monitor the resident while he was outdoors, but that everyone looked out for the resident. The CNA stated the resident was very restless and confused the morning of [DATE]. An interview was conducted with another CNA on [DATE]. The CNA stated that the resident had a wanderguard on so that staff knew when the resident went out the front entrance. The CNA stated that most of the time the resident would go outdoors after lunch at 1:00 p.m. so she would check on the resident at 1:30 p.m. and 2:00 p.m. The CNA stated that the resident was usually outside at shift change so staff coming to work would check on the resident. The CNA stated "He was real agitated that day ([DATE])." An interview was conducted with the ADON on [DATE]. The ADON stated that the resident used the wanderguard to alert staff when he went outside. The ADON stated that she never considered that the resident would be unsafe if he sat outdoors by himself. The ADON stated that if she assisted the resident outdoors, she would alert a licensed staff member and the CNA assigned to the resident and, between the three of them, someone would check on the resident every five minutes. The ADON further stated that there was not a direct assignment as to which staff member checked on the resident every five minutes and it was not documented. She stated that the five minute monitoring of the resident was very informal. She stated that the whole problem with the situation was that nothing was documented. An interview was conducted with the administrator on [DATE]. The administrator stated that the resident was never considered to be at risk for elopement. A review of the facility's policy Elopement Risk documented "Residents who are at risk for elopement should be identified. Elopement occurs when a cognitively impaired resident leaves the community undetected and unsupervised."