Every finding on record at Camelback Post Acute Care and Rehabilitation

Based on interviews, clinical record review, and review of facility policy and procedure, the facility failed to ensure two residents (#31 and #135) were provided written notice of discharge including contact information for the ombudsman prior to the discharge, and that the notice of discharge was sent to the ombudsman prior to the resident's discharge. The deficient practice could result in residents and their representatives being unaware of their appeal and advocacy rights and could prevent the ombudsman from reviewing and advocating for safe and appropriate discharge planning before the discharge occurred. Findings include: - Regarding Resident #135: Resident #135 admitted to the facility December 22, 2025, with diagnoses that included acute kidney failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, encephalopathy, and schizophrenia. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #135 had a Brief Interview for Mental Status (BIMS) assessment score of 12, indicating moderate cognitive impairment. A Notice of Medicare Non-Coverage (NOMNC) signed by Resident #135 and dated January 5, 2026, revealed the resident's insurance coverage of the current stay would end on January 7, 2026. The notice did not include an effective date of discharge, the reason for discharge, the location of discharge, nor contact information for the state ombudsman. The clinical record was reviewed, and revealed no evidence of any other discharge notice provided to the resident. A Discharge summary dated [DATE], revealed the resident was discharging to her home, and that the reason for discharge was that Resident #135's health had improved sufficiently, and the resident no longer needed the services of the facility. The documentation revealed the planned discharge date was that same day, January 8, 2026. The note revealed the phone number and email contact information for the state ombudsman. - Regarding Resident #31: Resident #31was admitted to the facility on [DATE] with diagnoses including sepsis due to streptococcus, group a, cellulitis of left lower limb, unspecified intracranial injury with loss of consciousness, encephalopathy, type 2 diabetes mellitus, anxiety disorder, unspecified dementia, schizophrenia, chronic post-traumatic headache, unsteadiness on feet, altered mental status, cognitive communication deficit, severe sepsis without septic shock, and need for assistance with personal care. An interim payment assessment Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) assessment score of 6, indicating severe cognitive impairment. Review of the clinical record for Resident #31 revealed that Resident #31 was issued a Notice of Medicare Non-Coverage (NOMNC) indicating that Resident #31's last day of coverage for skilled services was July 2, 2026. Under additional information, a handwritten statement revealed Not cognitively able to sign. Under the signature line it was revealed that verbal notification was given to Resident #31's daughter on June 30, 2026. At the bottom of the form, it is written that the document was rescinded. The notice did not include an effective date of discharge, the reason for discharge, the location of discharge, nor contact information for the state ombudsman. Another NOMNC was entered into the clinical record for Resident #31. This NOMNC indicated that Medicare coverage for Resident #31 would end on July 6, 2026. Under the signature line, the document revealed that verbal notification was given to Resident #31's daughter on July 2, 2026. The notice did not include an effective date of discharge, the reason for discharge, the location of discharge, nor contact information for the state ombudsman. The clinical record was reviewed, and revealed no evidence of any other discharge notice provided to the resident or the resident's representative. Review of the Discharge Summary for Resident #31, dated July 7, 2026, revealed he was discharging home with the assistance of a community health provider. The note revealed the phone number and email contact information for the state ombudsman. An interview was conducted with the state ombudsman on July 9, 2026, at 2:09 p.m. The ombudsman stated that the facility typically notified her of resident discharges on the day of discharge or after the resident had already left the facility. The ombudsman stated that advance notification was not routinely provided. The ombudsman stated that timely notification would allow the ombudsman's office the opportunity to review discharge plans, assist residents with concerns regarding the discharge, and advocate for alternative discharge options when appropriate. An interview was conducted on July 10, 2026, at 10:33 a.m., with a case manager (Staff #61), who stated she was responsible for coordinating discharges for residents receiving skilled services. Staff #61 stated her duties included communicating with residents and their representatives, arranging discharge destinations, coordinating home health services, transportation, and durable medical equipment. Staff #61 stated that the Notice of Medicare Non-Coverage (NOMNC) was the only discharge-related notice routinely provided to residents and/or their representatives before discharge. Staff #61 stated no separate written discharge notice was issued. Staff #61 stated that notification to the state ombudsman was typically sent by email after the resident had discharged because discharge plans could change prior to the resident leaving the facility. Staff #61 stated that delaying notification until after discharge could prevent the ombudsman from addressing resident concerns or assisting with discharge planning before the discharge occurred. Staff #61 reviewed the NOMNC and confirmed the document did not contain contact information for the state ombudsman. Staff #61 stated residents received ombudsman contact information on the discharge summary, which was provided on the day of discharge. Staff #61 further stated she became aware in February 2026 that the ombudsman was to receive notification regarding resident discharges. Staff #61 reviewed her email correspondence and confirmed notification regarding Resident #31's discharge was sent to the ombudsman on July 8, 2026 at 3:37 p.m. An interview was conducted with the Director of Nursing (DON / Staff #43) on July 10, 2026, at 2:04 p.m., who stated the case manager (Staff #61) was responsible for notifying residents and resident representatives of planned discharges. The DON stated the process included communicating with the resident and any designated representative, such as a power of attorney or emergency contact, regarding the discharge plan. The DON stated the facility utilized the NOMNC form to document discharge notification and that the form was signed by the resident and/or representative and uploaded into the medical record. The DON stated the NOMNC included information regarding insurance coverage dates and appeal rights. The DON stated she was aware the case manager provided discharge notifications to the state ombudsman but was unsure whether those notifications were required to occur before discharge. The DON stated residents should receive written discharge notice containing ombudsman contact information prior to discharge and stated this process was the responsibility of the case manager. The DON also stated ombudsman contact information was included on the discharge summary provided to residents on the day of discharge.

Based on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure care and services regarding oxygen therapy were provided to meet the needs of one of four sampled residents (Resident #3). The deficient practice could result in a resident not receiving necessary respiratory care, and could result in a worsening medical condition and physical harm.Findings include:Resident #3 was re-admitted on [DATE] with diagnoses of cognitive communication deficit, schizophrenia, abnormalities of gait and mobility, acquired absence of right leg below the knee, acquired absence of left toe(s), fracture of shaft of left fibula, atrial fibrillation, end stage renal disease, dependence on renal dialysis, and chronic obstructive pulmonary disease, need for assistance with personal care, and personal history of other mental and behavioral disorders.Physician orders dated November 23, 2025, included:- PRN (as needed) oxygen, to titrate between 1-5 liters per minute via nasal cannula to maintain oxygen saturation over 90%.-Check oxygen saturation every shift.A care plan focus initiated on November 23, 2025, included that Resident #3 was at risk for impaired cognitive function/dementia, or impaired thought processes due to the new environment. Interventions included engaging in simple, structured activities that avoid overly demanding tasks.A care plan focus initiated on November 24, 2025, revealed the resident had oxygen therapy due to hypoxia, with interventions that included:-Oxygen per the physician's orders-Give medications as ordered by the physician, and monitor and document side effects and effectiveness.-Change the resident's position every 2 hours to facilitate lung secretion movement and drainage.-Monitor for signs and symptoms of respiratory distress and report to the physician as needed: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color.-For residents who should be ambulatory, provide extension tubing or a portable oxygen apparatus.A significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident was cognitively intact. Section GG Functional Abilities revealed that the resident required substantial/maximal assistance with sit-to-stand and transfers, and the resident did not ambulate. Section O revealed the resident received oxygen therapy while a resident, however, the assessment was blank under the specification of whether the resident was on continuous, intermittent, or high concentration oxygen therapy.A physician's order dated January 14, 2026, included an oxygen concentrator, portable oxygen tank, nasal cannula, nebulizer, conserving device, and also included for continuous oxygen at 2 liters per minute (LPM) via nasal cannula.Despite the new order for continuous oxygen at 2 LPM via nasal cannula, the clinical record revealed no evidence that the order for oxygen as needed from 1-5 LPM from November 23, 2025, was cancelled or further clarified.A physician's order dated January 28, 2026, included a prosthetic appointment at an outside clinic on February 11, 2026, at 1:00 p.m. A Nurse Practitioner / Physician Assistant (NP/PA) progress note dated February 2, 2026, revealed Resident #2's chief complaint was chronic respiratory failure with hypoxia, with chronic obstructive pulmonary disease (COPD) on oxygen. The note included that the resident was on 4 LPM of oxygen therapy. The assessment and plan included supplemental oxygen as needed to keep saturation above 89% and to monitor oxygen saturation.An NP/PA progress note dated February 9, 2026, revealed the resident was on oxygen and tolerating 4 LPM. The assessment and plan included supplemental oxygen as needed to keep saturation above 89% and to monitor oxygen saturation.An oxygen saturation vitals log revealed:-February 11, 2026, at 8:23 a.m.: 96.0% on oxygen via nasal cannula-February 11, 2026, at 11:01 a.m.: 96.0% on oxygen via nasal cannulaA Nursing note dated February 11, 2026, revealed that Resident #3 went to a prosthetic appointment, and left the facility around 12:30 p.m., and that the resident was still out, and the nurse called the resident, who stated he was sent to the hospital because his oxygen was low, but that he was planning to return to the facility that day.A clinical visit note from the prosthetic clinic dated February 11, 2026, revealed an incident occurring at 2:00 p.m. The note included that the resident was seen for an initial evaluation at the clinic, and by the end of the appointment, the resident was noticeably struggling to breathe, gasping, and his head was bobbing up and down. 911 was called, and clinic staff requested that the resident receive a refill on his oxygen and to ensure that the resident received the help that he needed to prevent him from running out of oxygen in his tank. The note included that the fire department arrived, provided the resident with more oxygen, and brought the resident to the emergency room.A hospital Emergency Documentation physician note dated February 11, 2026, revealed that Resident #3 arrived at the emergency room via ambulance on February 11, 2026, at 2:23 p.m. The note revealed that Resident #3 was at an appointment, his oxygen tank ran out of oxygen, staff reported the resident was slow to respond, and that his oxygen saturation dropped to 80%. The note included that the resident was placed on a baseline dose of 4 LPM via nasal cannula, and his saturation returned to 94%. Additionally, the note included that the resident was brought to the emergency department for increased oxygen needs and was currently on 6 LPM. The note revealed that his symptoms appeared to be related to the transient loss of his baseline oxygen supply, that the resident did not require hospitalization once his oxygen requirements stabilized back toward his baseline, and that the resident was cleared for discharge.A nursing note dated February 11, 2026, at 10:40 p.m. revealed the resident returned from the emergency room visit to the facility, and arrived at the facility, via stretcher, in stable condition.An NP/PA Progress Note dated February 12, 2026, revealed that the resident apparently went to a prosthetic appointment the day prior, and his oxygen was low, so he was sent to the hospital. The note included that the resident was on 5 LPM today. The assessment and plan included that the resident had a cognitive impairment and COPD, and to provide supplemental oxygen as needed.A written statement submitted to the State Agency (SA) by a local fire department staff on March 17, 2026, revealed that on February 11, 2026, emergency medical services (EMS) were initially called on scene to a clinic for Resident #3's difficulty breathing, and that the resident was normally on 3 LPM of oxygen therapy. The documentation revealed that the clinic staff had noticed that the resident was altered and that his oxygen bottle was empty, and they called 911 for assistance. The documentation revealed that EMS quickly placed the resident on 4 LPM of oxygen and that shortly thereafter, the resident was alert and oriented and answering questions appropriately. The note included that the resident was then transported to the hospital by EMS. A physician's order dated April 30, 2026, included a follow-up appointment at the prosthetic clinic on May 4, 2026, at 1:00 p.m., with transportation pickup time between 11:00 and 11:30 a.m., and return transportation at 2:00 p.m.An oxygen saturation vitals log revealed:-May 4, 2026, at 7:12 a.m.: 96% on oxygen via nasal cannulaA clinical visit note from the prosthetic clinic dated May 4, 2026, revealed that Resident #3 arrived at the appointment as scheduled. The note included that prior to the resident's appointment, the clinic staff requested that the facility staff bring the resident to the appointment with enough oxygen to last the duration of the appointment and travel time. The note revealed that toward the end of the appointment, the resident was noticeably gasping for air and bobbing their head, similarly to the previous incident on February 11, 2026. The note also revealed that 911 was called due to the resident running out of oxygen, and the fire department arrived and provided oxygen to the resident and took him to the emergency room. The note revealed that the fire department had to leave behind the resident's power chair at the clinic due to transportation issues, and that the facility was able to retrieve the power chair.A facility Appointment/Procedure Note dated May 4, 2026, at 1:23 p.m., revealed that the resident's wheelchair would be picked up from the appointment clinic between 3:00 and 3:30 p.m.A hospital Emergency Documentation physician note dated May 4, 2026, revealed that the resident arrived at the emergency department at 1:22 p.m. from an appointment at a clinic and presented with shortness of breath. The note included that the resident was oxygen dependent and on 2 LPM oxygen therapy via nasal cannula at baseline, and that his oxygen tank started running out while he was at the clinic, causing him to experience shortness of breath, so emergency medical services were called. The note included that the resident was brought to the clinic from the facility for an appointment without a full tank of oxygen, and his oxygen tank ran out, causing him to experience an episode of shortness of breath. The note also revealed that the resident was now on his baseline 2 LPM oxygen therapy, was stable, and discharged back to the facility.A Nursing Note dated May 4, 2026, revealed that Resident #3 ran out of oxygen at his appointment, he was sent to the emergency room, and the resident returned to the facility at approximately 5:00 p.m.A physician's order dated May 4, 2026, included a follow-up appointment at the prosthetic clinic on May 13, 2026, at 9:30 a.m., with transportation pickup time between 8:00 and 8:30 a.m., and return transportation at 10:30 a.m.An NP/PA Progress Note dated May 7, 2026, revealed that Resident #3 was on 4 LPM oxygen therapy via nasal cannula and was resting in bed, with oxygen saturations within normal limits. The assessment and plan for COPD included supplemental oxygen as needed to keep oxygen saturation above 89%.A NP/PA Progress Note dated May 7, 2026, revealed the resident was resting in bed on 3 LPM oxygen therapy at baseline. The note included that the resident had a cognitive impairment and COPD, and the plan included providing supplemental oxygen as needed.An NP/PA Progress Note dated May 12, 2026, revealed the resident had COPD on oxygen therapy and was resting in bed on 4 LPM via nasal cannula. The plan included supplemental oxygen as needed to keep saturation above 89%.An oxygen saturation vitals log revealed:-May 13, 2026, at 8:52 a.m.: 94.0% on oxygen via nasal cannulaA clinical visit note from the prosthetic clinic dated May 13, 2026, revealed that when scheduling the appointment with Resident #3's facility, clinic staff requested that Resident #3 be brought with extra oxygen, due to two previous appointments where the resident was not provided enough oxygen and had to be taken to the emergency room. Upon arrival at his appointment on May 13, 2026, the resident arrived with less than half of a full oxygen tank and no extra tanks. The note included that the resident was then sent back to the facility to be able to refill his oxygen tank to ensure that the resident would not have to go to the emergency room. The note revealed that the clinic staff called the facility staff to notify them that the resident would need to return to the facility and reschedule the appointment.A Nursing note dated May 12, 2026, revealed that, per the prosthetic clinic, Resident #3's appointment would need to be rescheduled.An observation was conducted on June 3, 2026, at 11:11 a.m. of Resident #3, who was sitting in a power wheelchair. The resident was wearing a nasal cannula and receiving oxygen therapy. An oxygen tank was attached to the back of the wheelchair, and the oxygen tank gauge was positioned behind the backrest of the wheelchair, which could not have been visible to Resident #3 sitting in the wheelchair.An interview was conducted with a Licensed Practical Nurse (LPN / Staff #9) on June 3, 2026, at 10:50 a.m., who stated that as a floor nurse, she would be aware of a resident's need for oxygen therapy by following the physician's order, which would provide the dose or dose range, and to keep the resident's oxygen saturation above a specified percentage. The LPN stated that certified nursing assistants (CNAs) check the resident's oxygen saturation 3 times a day, once per shift, and as needed. The LPN stated that if a resident who was on oxygen therapy needed to go to an outside appointment, it would be the nurse's and CNA's responsibility to check to make sure the resident had a full tank before leaving for the appointment. The LPN stated she did not know how long an oxygen tank would last if the resident was on 2-3 liters, but estimated the tank would last several hours, and maybe 4-5 hours. The LPN stated the tank would run out faster if the oxygen dose was higher. Regarding Resident #3, the LPN stated that she had heard about an incident where Resident #3 had run out of oxygen in his tank while at an outside appointment and had to go to the hospital. The LPN stated she only heard of that happening once, and that usually, staff would receive educational training from management when something like that happened. The LPN stated that she had not received any education or training after the incident where Resident #3 ran out of oxygen. The LPN stated that there could be a risk of negative impact on a resident's health if the resident on oxygen therapy ran out of oxygen in their tank while at an outside appointment. Additionally, the LPN stated it was the nurse's responsibility to call and follow up as needed to ensure a resident comes back from an appointment on time.A telephonic interview was conducted with the prosthetic clinic manager on June 2, 2026, at 11:57 a.m. who stated that Resident #3 had arrived to the prosthetic clinic on 2 occasions, on February 2, 2026, and May 4, 2026, and ran out of oxygen in his tank during the visits, was noticed by the clinic staff to have altered mental status by the clinic staff, 911 was called, and the resident was transferred to the hospital during both instances. The prosthetic clinic manager stated the resident had another appointment scheduled on May 13, 2026, and that the clinic staff had contacted the facility prior to that appointment, requesting that the resident come with an extra oxygen tank due to the previous two incidents. The manager stated that the resident showed up to the appointment on May 13, 2026, with a partially empty tank and no extra tank, so the clinic staff sent the resident back to the facility to avoid the risk of the resident running out of oxygen again. An interview was conducted with Resident #3 on June 3, 2026, at 11:12 a.m., who stated that he recalled that he went out to appointments, but could not specify when, and that he ran out of oxygen while at the clinic and had to go to the hospital. He stated that after those incidents, he went to the appointment at the clinic another time, and the clinic staff checked his oxygen tank and noticed the tank was low, so the clinic staff sent him back to the facility and rescheduled the appointment. Resident #3 stated that his usual dose of oxygen was 2 to 3 LPM, and that he needs the oxygen, and cannot go without it. Resident #3 stated that the only way for him to run out of oxygen at the appointments was if the oxygen tank was partially empty when he left the facility.An interview was conducted with an LPN (Staff #54) on June 3, 2026, at 11:51 a.m., who stated that floor nurses would know if a resident required oxygen therapy based on a physician's order, and that nurses and CNAs check vital signs every shift and as needed. The LPN stated that nurses and CNAs are responsible for checking a resident's oxygen tank throughout the day, usually every 1-2 hours, to ensure that a resident with a portable oxygen tank did not run out of oxygen. The LPN stated that a full oxygen tank on a low dose of 1-2 LPM would probably last around 4-6 hours; however, a higher dose of 3 LPM would last less than that. The LPN stated that if a resident had an appointment scheduled at an outside clinic, floor staff would need to ensure that the resident had a full oxygen tank before leaving for the appointment, and that staff could always send an extra tank on a rolling carrier if needed. The LPN stated that she was familiar with Resident #3 and had never heard of an instance of the resident running out of oxygen at an appointment.An interview was conducted with a CNA (Staff #26) on June 3, 2026, at 12:59 p.m., who stated that the floor staff was responsible for ensuring a resident had enough oxygen in their tank before leaving for an appointment by making sure the tank was full. The CNA stated that she estimated that a full tank would probably last about 4-6 hours, but would depend on what dose the resident was on. The CNA stated that she was familiar with Resident #3 and that she had cared for him for about a year. The CNA stated that the resident required oxygen, and his normal dose was 3-4 LPM. The CNA stated that the resident did not go without his oxygen, and that she had seen a rare instance where the resident's oxygen nasal cannula had fallen off his face when he was sleeping, and his oxygen saturation was low, and when the CNA helped the resident put the cannula back on and rechecked his oxygen saturation within the same hour, his saturation had returned to normal. The CNA stated she had not heard of any instance where Resident #3 had run out of oxygen while at an outside appointment. The CNA said that if Resident #3 had a full oxygen tank when he left for an appointment, and returned within 4-5 hours, his tank should not have run out for that period of time.An interview was conducted with a medical record staff / appointment scheduler (Staff #31) on June 3, 2026, at 1:05 p.m., who stated that she was the staff member responsible for scheduling appointments. She stated that her process includes checking for physicians' orders to determine if there were any new upcoming appointments, then scheduling transportation for the resident, and preparing an appointment envelope to place at the nurses' station to notify the floor nurse that a resident had an appointment that day. Staff #31 stated that Resident #3 had an appointment in May 2026, where the floor nurse had instructed Staff #31 the day prior to notify the next nurse to make sure Resident #3 had a full tank of oxygen for his appointment the following day. Staff #31 stated that she assumed the resident must have come close to running out of oxygen previously, but had not heard anything about it. Staff #31 stated that she wrote on the appointment envelope for the floor nurse for Resident #3 to have a full tank of oxygen for his appointment, but that she did not verbally tell anyone.An interview was conducted with the Director of Nursing (DON / Staff #89) on June 3, 2026, at 1:25 p.m. who stated that the process for scheduling a resident at an outside clinic appointment was that there would be a physician order for the appointment, and that transportation would be scheduled, and that an appointment envelope would be created that contained the details of the appointment, transportation, and any pertinent medical records, and that the envelope would go with the resident to their appointment. The DON stated that it would be the floor nurse's responsibility to ensure a resident had everything they needed to go to the appointment safely. The DON stated a nurse would know if a resident required oxygen therapy based on looking at the resident's oxygen saturation or by following the physician's orders for continuous or PRN oxygen therapy. The DON stated that it was her expectation that floor staff send a resident to an outside appointment with a full oxygen tank to ensure the tank did not run out. The DON declined to answer directly if there would be any risk to a resident on oxygen therapy who went to an appointment and ran out of oxygen in their tank, however, the DON stated that if the resident was alert and aware, then the resident should be aware of how full or empty their tank was and could request a new tank if it were getting low. The DON stated that at the point the resident would become aware that their tank was low, the resident could ask the outside clinic staff to request a new tank from the facility, or request a new tank from the transportation driver, because sometimes they would have an extra tank in their transport vehicle. The DON then stated that there would be no risk to the resident because the residents who were alert and aware would be able to monitor their own oxygen tank. The DON stated that she was familiar with Resident #3, that the resident was alert and oriented, and that he was able to make decisions for himself. The DON stated that the resident was not able to stand up on his own and walk behind his power wheelchair to look at his oxygen tank gauge positioned behind the backrest of the chair. The DON stated that the resident had a PRN order for oxygen therapy and that he could be off oxygen at times, but that he was on oxygen therapy more often than not. The DON reviewed the clinical record and stated that his usual oxygen dose was 2 LPM. The DON also stated she was aware that the resident had an instance of running out of oxygen at the appointment on February 11, 2026, and that she was not sure exactly how that occurred, but that he ended up getting sent to the hospital. After that instance, the DON stated that she took the action of educating the resident that he needed to make sure he had a full tank of oxygen before going to an appointment. The DON stated that another incident occurred on May 4, 2026, when the resident was at the clinic appointment, and that the clinic staff called the facility and informed the facility that the resident was running out of oxygen and requested the facility either bring more oxygen or for transport to come to the clinic, but that the resident ended up getting sent to the hospital in the meantime. The DON declined to state whether this would meet her expectation for nursing staff to ensure Resident #3 was provided oxygen therapy to meet his needs during an appointment, but rather stated that the nursing staff followed the protocol of sending the resident with an oxygen tank, and it was a situation where the resident needed to be educated to be aware of his oxygen tank status and communicate with the clinic to meet his needs.Review of the facility policy titled, Oxygen Administration (Mask, Cannula, Catheter), revised March 2025, revealed it was the policy of this facility that oxygen therapy was administered as ordered by the physician or as an emergency measure until the order could be obtained. The policy revealed that the purpose of the oxygen therapy was to provide sufficient oxygen to the bloodstream and tissues. The procedure included obtaining appropriate physician's orders, identifying the resident, explaining the procedure, assembling the oxygen unit, making sure all connections were secure, attaching the oxygen delivery device to the oxygen unit, turning the unit on to the desired flow rate, and assessing the equipment for proper functioning.Review of the facility policy titled, Physician Orders, dated August 2023, revealed it was the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's care plan.Review of the facility's policy titled, Appointments, dated April 2023, revealed it was the policy of the facility to coordinate and arrange for appointments as ordered by the physician. The policy revealed that procedures included that the facility would maintain a system to monitor for ordered appointments, the appointments would be scheduled as ordered, if unable to arrange for the ordered appointment, the nurse manager or designee would be notified for further directions / interventions, and the resident or responsible party would be notified of the appointment and of any changes / issues.

Based on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to protect the rights of one resident, resident (#1) to be free from verbal abuse by staff. The deficient practice could result in further abuse. Findings Include: Resident #1 was admitted on [DATE], with a diagnosis that included spinal stenosis, retention of urine, hypertension, fibromyalgia, obesity, muscle weakness, abnormalities of gait and mobility, need for assistance with personal care, and low back pain. The care plan dated November 26, 2025, had a focused care area for risk of impaired cognitive function/dementia or impaired thought process related to the new environment. Interventions included engaging in simple, structured activities that avoid overly demanding tasks, identifying yourself at each interaction, face when speaking, and making eye contact, reducing any distractions-turn off the TV and radio, and closing the door. Use simple, directive sentences. Provide with necessary cues-stop and return if agitated. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 was cognitively intact. Review of the Progress Notes for Dates December 17, 2026, and December 18, 2026, no evidence was found of the incident. The Daily Skilled notes dated December 17 and 18, 2026, revealed that the Resident #1's skin was warm and dry with no active skin condition or treatments observed. Review of the grievances log for December 2025, there were no grievances filed by Resident #1. Review of the facility's 5-day report dated December 18, 2025, revealed that the witness (Resident #1's roommate) heard the Certified Nursing Assistant (CNA/Staff #5) tell Resident #1, you are okay, your feet are not broken, while they were transferring the resident with the Hoyer lift. The staff member #3, who was a licensed Nursing assistant (LNA), was helping Staff #5 to assist the resident who stated that she, told the resident to be quiet, then she corrected Staff #3 that she can not talk to Resident #1 like that. Employee file for the staff #5 revealed that disciplinary action was taken against her on December 18, 2025, regarding how she told resident #1 to be be quiet during a Hoyer transfer. Staff #3, who was with Staff #5, corrected her on what she said. An interview was conducted on January 13, 2026, at 11:24 AM with a CNA (Staff #5), who stated that she had been working at the facility for 20 years. She stated that if she hears or witnesses abuse, she will ensure the resident's safety and then notify the administrator. She stated that if a resident is screaming in pain, while doing a transfer, she will try to calm the resident first, then if they still do not stop, she will wait until the resident is feeling better, and notify the nurse of the Resident #1's pain. Staff #5 stated that she worked with Resident #1 on November 17, 2025. She stated that she assisted Staff #3 with the transfer of Resident #1. The CNA stated that while they were transferring Resident #1 from bed to chair, Resident #1 began to scream, my legs, my legs. Staff #5 stated that when Resident #1 did not stop screaming, she told Resident #1 to calm down, and please don't scream like that, you already have your muscle relaxant and pain medication. Further, Staff #5 stated she was not trying to diminish her or tell her to shut up, but she could not understand why she had so much pain. She stated she apologized after Staff #3 stated she can not talk like that. This was reported to the nurse who was on the shift. Staff #5 stated that she does not recall stating whether she told her that her feet were broken. An interview was conducted on January 13, 2026, at 12:52 PM with the witness, a LNA (Staff #3), who stated that using the hoyer should be done by two people, because one person puts the sling under the resident and the other holds the resident and checks the sling to ensure it is attached. She stated staff should lift the resident when transferring to the wheelchair or bed. She stated that in the process, they hold the resident's legs so the bar does not hurt the resident or cause any pain. However, if a resident is screaming due to any pain during a staff transfer, should stop and find out where the pain is and what the level of the pain scale of 1 to 10. If the resident refuses the transfer, they will not force them. Staff #3 confirmed working on November 17, 2026. Staff #3 stated she was called by Staff #5 to do a hoyer transfer of Resident #1 from the bed to the wheelchair. She stated that she was behind the wheelchair and while transferring Resident #1's foot was on the Hoyer bar which was when Resident #1 started screaming out that her foot was hurting, due to her foot hitting the Hoyer bar. While the resident was screaming, staff #5 shouted at Resident #1, be quiet, you're behaving as if your foot is broken. Staff #3 stated that she immediately corrected Staff #5, telling her she can not say that. She stated that after putting Resident #1 in the chair, they immediately reported it to the nurse, and Staff #5 went back to apologize to the resident. Staff #3 went back into the room. Resident #1 was crying and stated that Staff #5's words had made her feel like she was abused. An interview was conducted on January 13, 2026, at 2:38 PM with CNA (Staff #1), who stated that she will immediately report to anyone in charge if she is aware of abuse. She stated that it is not appropriate to tell residents to be quiet while they are screaming in pain. She stated that staff members are trained not to talk to others like that; and, to always hear the resident out regarding their concerns and pain. An interview was conducted on January 13, 2026, at 2:45 PM with a Registered Nurse (RN/Staff# 2) who stated that she will immediately notify the administrator and follow up with the resident about who the person if she hears about any abuse. She also stated she would remove that person from further abuse to ensure that the resident was safe. Staff #2 stated that Resident #1, during transfer, will complain about pain in her legs. She stated that it would not be good to tell a resident, be quiet, you are behaving as if your foot is broken, while a resident is in pain, because it is disrespectful. An interview was conducted on January 13, 2026, at 3:01 PM with the Operations Manager (Staff #6), who stated that he is the temporary Administrator until the facility administrator is back from vacation. He further stated that his role as of right now is to take care of financials, keep the facility in line, have a good culture, hire staff, provide good care of the residents, and be the abuse coordinator. He stated that as the abuse coordinator, they make sure the resident is kept safe and start the reporting process. Then stated that if anyone hears about the abuse, he would expect the staff to report it immediately. An interview was conducted on January 13, 2026, at 3:49 PM with the Director of Nursing (DON/staff #10), who stated that the process for abuse is that when someone hears about abuse, they will report it to the administrator, depending on the alleged abuse. The abuse should be reported immediately to the DON or the administrator, and they have two hours to report if it is necessary. She stated that if the abuse is witnessed, they will expect the staff member to separate the alleged abuser. She stated that if the CNA tells the resident to be quiet, it is inappropriate and unprofessional language. Further, Staff #10 stated that when they tried to talk to Resident #1, she did not want to talk. A week later, she stated that the CNA #5 told her to shut up while on the mechanical lift and reported alleged abuse. Staff #10 also stated that Staff #5 was just trying to calm down Resident #1, even though she had made bad choices of words. A Policy titled Abuse Prevention of and Prohibition Against was revised in October 2022, revealing that each resident has the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary inclusion. Verbal abuse is defined in the policy as the use of oral, written, or gestured language that wilfully includes disparaging and derogatory terms to residents or their representatives, or within hearing distance, regardless of their age, ability to comprehend, or disability.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent the spread of infection. The deficient practice could result in the spread of infection to residents. Findings include: On May 28, 2024 at approximately 8:01 a.m., a yellow round bin and one gray square bin full of soiled sheets and other laundry items were observed to be overflowing in the hallway on Hall 200 by the laundry room. There was also a smaller silver container full of dirty towels and the lid was not completely covering the bin. The hallway smelled of urine. On May 28, 2024 at approximately 8:05 a.m. a female staff was observed pushing the yellow round bin and gray square bin full of soiled laundry through the exit door near the laundry room and left them outside. The smaller silver container with dirty towels was left in the hallway. On May 28, 2024 at the Housekeeping Supervisor (staff #76) was observed entering the Hall 200 through the exit door when the soiled sheets and laundry were left outside and went into the laundry room. She did not remove the smaller silver container with dirty towels was left in the hallway. On May 28, 2024 at 9:42 a.m. an interview was conducted with a certified nursing assistant (CNA/staff #53), who stated that soiled sheets, towels, and laundry are suppose to go into a bag, the bag is tied, and taken directly to the soiled utility room. She stated that the purpose of tying the bags is to reduce the smell and prevent contamination. There is a risk of odor and possible contamination to the residents if the binds are left in common areas. She stated that she thinks the night shift is supposed to take the bins of soiled sheets, towels, and laundry outside until the laundry staff arrives between 7:30 a.m. and 8:00 a.m. and then the laundry staff bring in the bins in one at a time. An interview was conducted on May 28, 2024 at 10:03 a.m. with the Housekeeping Supervisor (staff #76), who stated that starts work at 7:00 a.m. She stated that when she arrives to work, she gets the bins of soiled laundry and linens from the soiled utility room to wash them. She stated that the bins of soiled laundry and linens are not supposed to be left in the hallway because they are dirty, smell, and the residents could touch the soiled laundry, which could spread infection. She stated that she saw the bins of soiled laundry and linens in the hallway this morning and doesn't know who left the bins in hallway. She stated that the soiled laundry is left in the hall sometimes. An interview was conducted on May 28, 2024 at approximately 10:40 a.m. with the Director of Nursing (DON/staff #1), who stated that staff are trained on the removal of soiled linens, towels, laundry. It is her expectation that they are bagged up and tied, to prevent odors and the spread of infection. She stated that when the staff are doing rounds, the staff keep the bins in the hallway, so they don't have to walk back and forth and the bins are supposed to have a lid on them to prevent the spread of odors and items from falling out. She stated that there is a risk to residents having access to the soiled items. An interview was conducted on May 28, 2024 at 1:59 p.m. with a licensed practical nurse (LPN/staff #72), she stated that about a month ago, they started putting the soiled linens, towels, laundry, and soiled adult briefs in the bins in the hallway. The bins are supposed to be covered with lids and soiled items are supposed to be in bags that are tied. She stated that the change occurred because there were complaints about the soiled adult briefs. The facility policy, Laundry, Linen, Soiled dated October 2023 states that when collecting soiled linens, keep soiled linen containers properly covered at all times, return soiled linen to the laundry in the designated in the non-permeable containers, and the containers are to be covered at all times, lined with plastic bags and cleaned daily. When the containers are three-fourths full, linen containers should be transported to the laundry sorting room by laundry personnel or nurse assistant.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent odor and ensure a comfortable environment. The deficient practice could impact the residents' safe, sanitary, and homelike environment. Findings include: On May 28, 2024 at approximately 8:01 a.m., a yellow round bin and one gray square bin full of soiled sheets and other laundry items were observed to be overflowing in the hallway on Hall 200 by the laundry room. There was also a smaller silver container full of dirty towels and the lid was not completely covering the bin. The hallway smelled of urine. On May 28, 2024 at approximately 8:05 a.m. a female staff was observed pushing the yellow round bin and gray square bin full of soiled laundry through the exit door near the laundry room and left them outside. The smaller silver container with dirty towels was left in the hallway. On May 28, 2024 at the Housekeeping Supervisor (staff #76) was observed entering the Hall 200 through the exit door when the soiled sheets and laundry were left outside and went into the laundry room. She did not remove the smaller silver container with dirty towels, so it was left in the hallway. On May 28, 2024 at 9:42 a.m. an interview was conducted with a certified nursing assistant (CNA/staff #53), who stated that soiled sheets, towels, and laundry are suppose to go into a bag, the bag is tied, and taken directly to the soiled utility room. She stated that the purpose of tying the bags is to reduce the smell and prevent contaminiation. There is a risk of odor and possible contamination to the residents if the binds are left in common areas. She stated that she thinks the night shift is supposed to take the bins of soiled sheets, towels, and laundry outside until the laundry staff arrives between 7:30 a.m. and 8:00 a.m. and then the laundry staff bring in the bins one at a time. An interview was conducted on May 28, 2024 at 10:03 a.m. with the Housekeeping Supervisor (staff #76), who stated that starts work at 7:00 a.m. She stated that when she arrives to work, she gets the bins of soiled laundry and linens from the soiled utility room to wash them. She stated that the bins of soiled laundry and linens are not supposed to be left in the hallway because they are dirty, smell, and the residents could touch the soiled laundry, which could spread infection. She stated that she saw the bins of soiled laundry and linens in the hallway this morning and doesn't know who left the bins in hallway. She stated that the soiled laundry is left in the hall sometimes. An interview was conducted on May 28, 2024 at 1:59 p.m. with a licensed practical nurse (LPN/staff #72), she stated that about a month ago, they started putting the soiled linens, towels, laundry, and soiled adult briefs in the bins in the hallway. The bins are supposed to be covered with lids and soiled items are supposed to be in bags that are tied. She stated that the change occurred because there were complaints about the smell of the soiled adult briefs. The facility policy, Laundry, Linen, Soiled dated October 2023 states that when collecting soiled linens, keep soiled linen containers properly covered at all times, return soiled linen to the laundry in the designated in the non-permable containers, and the containers are to be covered at all times, lined with plastic bags and cleaned daily. When the containers are three-fourths full, linen containers should be transported to the laundry sorting room by laundry personnel or nurse assistant.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to assess one resident (#35) for pain and take vitals when admitted to the facility in a timely manner, and failed to administer pain medication with pain parameters for one resident (#27). The deficient practice could result in residents' pain not being identified and addressed, residents' being overmedicated or under-medicated. Findings include: Resident #35 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of left tibial tuberosity, subsequent encounter for closed fracture with routine healing, Epilepsy, and type II diabetes. Review of the order summary revealed: -April 27, 2024, monitor level of pain for every shift/using the following scale: 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10=severe pain. -April 27, 2024, Tylenol tablet 325 mg give two tablets by mouth every six hours as needed for pain 1-3. -April 27, 2024, Celecoxib capsule 200 mg give one capsule by mouth every 24 hours as needed for pain 4-7. -April 27, 2024, Norco oral tablet 5-325 mg give one tablet by mouth every six hours as needed for pain 8-10 for three days. Review of the Medication Administration Record (MAR) dated April 2024 did not reveal that the resident was assessed for pain during the day shift. A progress note dated April 27, 2024 at 9:32 p.m. revealed that the resident was alert and oriented times three, and able to make his own decisions. The resident admitted with a diagnosis of a left Tibial fracture after a ground fall. Internal fixation was placed on April 24, 2024. The resident denies pain, nausea, or shortness of breath. A daily skilled progress note dated April 27, 2024 at 10:02 p.m. included vital signs: blood pressure 125/72, temperature 97.4, and pulse 62 at at 7:59 p.m. Heart rate 18, and oxygen 95.0 % at 9:01 p.m. Resident has no pain. At 10:33 p.m. resident had a pain scale of 5. Review of the (MAR) dated April 2024 revealed that the resident was assessed at a pain level of five at 10:33 p.m. and was administered Tylenol tablet 325 mg give two tablets by mouth every six hours as needed for pain 1-3. A progress note dated April 28, 2024 at 12:46 p.m. revealed that the resident was alert and oriented times four. The resident was able to make his needs known and expressed the need for a room change due to the pleasantly confused roommate, but before the room change could be complete, the resident chose to leave against medical advise due to sharing a bathroom and a room. An interview was conducted on May 28, 2024 at approximately 1:04 p.m. with the Director of Nursing (DON/staff #1), who stated that resident #35 was admitted to the facility on [DATE] at approximately 1:25 p.m. She reviewed the resident's clinical record and stated that there was no documention about the resident's pain level being assessed when admitted . She stated that the progress notes indicate that the resident was assessed for pain on April 27, 2024 at 9:32 p.m. An interview was conducted on May 28, 2024 at 1:59 p.m. with a licensed practical nurse (LPN/staff #72), who stated that if the admission nurse is not here, she tries to get orders in place, take vitals, and complete a pain assessment. She stated that it is important to complete the initial assessment during the initial admission, so there is a baseline and changes can be identified. She stated that a pain assessment should be included, so it can be determined if the resident is comfortable. During a second interview conducted on May 28, 2024 at 2:18 p.m. with the (DON/staff #1), she stated that the resident left the facility against medical advise, so the initial assessment and baseline care plan were not completed. The assessment and the baseline care plan was deleted, so there is no record of them being done. She stated that (LPN/staff #72) was supposed to complete the initial assessment when the resident was admitted , which would include a pain assessment. She acknowledged that the resident was not evaluated for pain until 9:30 p.m. on May 27, 2024 and stated that vitals and a pain assessment are recorded when the resident is admitted to determine a baseline, so staff know when there is a change of condition. The facility policy, Pain Management dated September 2023 states that the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by screening to determine if the resident has been or is experiencing pain. The resident will be assessed for pain on admission with a pain-related diagnosis, or if pain is indicated through the nursing admission evaluation. -Resident #27 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified parts of the lumbosacral spine and pelvis, subsequent encounter with routine healing, specified fracture of unspecified pubis, subsequent encounter for routine healing, stable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, and unspecified open wound of abdominal wall. The care plan dated May 3, 2024 revealed that the resident has acute pain related to fractures and wounds. Interventions included to administer analgesia medication as per orders; give half an hour before treatments or care, follow pain scale to medicate as ordered. Review of the order summary revealed: -May 3, 2024, monitor level of pain for every shift/using the following scale: 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10=severe pain. -May 3, 2024, Tylenol tablet 325 mg give two tablets by mouth every six hours as needed for pain 1-3. -May 7, 2024, Oxycodone HCI oral capsule 5 mg give 5 mg by mouth every six hours as needed for pain 4-10. Review of the MAR dated May 2024 revealed: -Oxycodone HCI oral capsule 5 mg give 5 mg by mouth every six hours as needed for pain 4-10 was administered on May 4, 2024 for a pain level of 0, and on May 7, 2024 for a pain level of 1. -Tylenol tablet 325 mg give two tablets by mouth every six hours as needed for pain 1-3 was administered on May 8, 2024 for a pain level of 8. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. An interview was conducted on May 29, 2024 at 12:58 p.m. with (LPN/staff #106), who stated that orders for pain medications administered as needed (PRN), require a pain scale. She documents on the MAR the resident's level of pain prior to administering the pain medication and after administering the medication to determine if it was effective. She stated that there is risk of underdosing or overdosing a resident if the pain medication is given outside of the parameters on the order. Staff #106 reviewed the MAR dated May 2024 and stated that the Oxycodone HCI oral capsule 5 mg give 5 mg by mouth every six hours as needed for pain 4-10 was administered outside of parameters. She also stated that the resident can state that he doesn't want the stronger pain medication and request the Tylenol, but the nurse should document the resident's request in the progress notes and follow up to ensure the Tylenol was effective. She thinks the DON is responsible for monitoring the MAR to ensure that medications are administered as per the orders. An interview was conducted on May 29, 2024 at 1:24 p.m. with (DON/staff #1), who stated that there needs to be a pain scale on the order for PRN pain medications. She stated that there is a risk of the resident being undermedicated or overmedicated if the pain medication is given outside of parameters. She also stated that the resident the Tylenol instead of the Oxycodone even if the pain scale is higher than 1-3, but must document the resident's request and notify the physician. The facility policy, Medication Administration dated February 2024 states that medications must be administered in accordance with the written orders of the attending physician.

Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, food items were not expired, temperature logs were maintained, equipment was sanitized, and food was served under sanitary conditions. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding food labeling and dating: During the initial kitchen observation conducted on [DATE] at 7:17 a.m., two items wrapped in foil was found in the walk-in freezer which was unmarked/not labeled and not dated. Additionally, cereal dispenser for what appears to be Rice Krispies, Raisin Bran, Corn Flakes, and Cheerios did not have an expiration date. A bin containing oatmeal was marked ,d+[DATE] but it is unknown if that is the filled date or the expiration date. A bin containing lentil was marked ,d+[DATE] and did not specify if it was the fill date or expiration date. A container marked bread crumbs was labeled ,d+[DATE] but the same container was also marked Panko with a date of ,d+[DATE]. It is unknown if the item is regular bread crumb or Panko and if the date is the filled date or expiration date. A look at the nutrition fridge located by room [ROOM NUMBER] conducted on [DATE] at 8:00 a.m., revealed what appears to be two peanut butter and jelly sandwiches that was undated/unmarked. During a follow-up kitchen observation conducted on [DATE] at 2:58 p.m., it was observed that 2 shelves of jello cups were undated in the walk-in fridge. Additionally, 5 racks of bread loaves was observed undated. Information regarding the product is normally on the shipping box but was not transcribed/marked on each individual package. The facility's undated kitchen policy titled Food Storage and Date Marking indicated that all containers must be legible and accurately labeled if product is not easily identifiable. An open date is recommended. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated if stored for over 24 hours. TCS (Time and Temperature Control For Safety) foods should be covered, labeled and dated if stored and not for immediate use. All foods will be checked to assure that foods will be consumed by their use by dates, or frozen or discarded at the end of the day. Use by dates for TCS foods are 7 days or less of prep date. Regarding expired items: During the initial kitchen observation conducted on [DATE] at 7:17 a.m., a container of low-fat cottage cheese marked ,d+[DATE] with a best if use by date of [DATE] was found in the walk-in fridge. Review of the facility's undated kitchen policy titled Dry Storage Areas indicated that foods with expiration dates are used prior to the date on the package. Regarding temperature logs: An initial kitchen observation conducted on [DATE] at 7:17 a.m. Review of the temperature log for the both the walk-in fridge and walk-in freezer revealed that the last time the temperature was checked/documented was [DATE] which was three days prior. The facility's undated kitchen policy titled Food Storage and Date Marking indicated that temperature for the refrigerated food should be checked routinely to check for proper functioning of the unit. The policy also noted that freezer temperatures should be checked daily for proper functioning. Regarding sanitary kitchen and conditions: During the initial kitchen observation conducted on [DATE] at 7:17 a.m., it was observed that the ceiling fan facing the dishwasher station was dusty. The fan had dust covering a majority of the cover. The fan was located above 2 wire racks where dishware, cups, drinkware, and baking sheets were stored. Four small plates located on the wire rack under the ceiling fan was observed to be dirty/dusty. Additionally, the hood above the oven was observed to be dusty and grimy. The dust and grime had a brownish/black appearance. Review of the kitchen's cleaning checklist for the aides revealed that it was last completed on Thursday, [DATE] for the a.m. shift and Tuesday, [DATE] for the p.m. shift. The cleaning checklist for cooks for the week of [DATE] was last completed on Thursday, [DATE] for the a.m. shift and on Monday, [DATE] for the p.m. shift. Additionally, the dishwasher cleaning checklist was last completed on Thursday, [DATE]. In a follow-up kitchen observation conducted on [DATE] at 10:29 a.m., the ceiling fan facing the dishwasher station was still observed dusty. Additionally, the pipe by the counter where pureed meals are prepared was observed to to have a clump of dusty strings hanging down from the pipe/ceiling. During the tray line observation conducted on [DATE] at 11:37 a.m., it was observed that the vent over the tray line counter was dusty. Additionally, during the tray line observation conducted on [DATE] at 11:37 a.m., the heating element containing the spinach/greens was observed to have what appears to be a piece of an alcohol prep packet. The staff did not seem to notice that the food contained a foreign object. On [DATE] at 11:44 a.m., the Dietary Supervisor (staff #44) was asked what the foreign object/item was on the spinach/greens. Staff #44 removed the item and scooped around the area where the item was. He indicated that it was probably from when they temperature checked the dish earlier. The batch was still used and served to the residents. During the tray line observation, it was noticed that the vent above the tray line counter was blowing cold air directly down on the food in the tray line. During another follow-up kitchen observation conducted on [DATE] at 2:58 p.m., it was observed that the ceiling fan facing the dishwasher station was still dusty. The vent above the tray line was also noticeably dusty. Furthermore, the pipe located above where pureed meals are prepared still had the dusty clump of string hanging from it. An interview with the Dietary Supervisor (staff #44) conducted on [DATE] at 2:58 p.m., he stated that when the ceiling fan is dusty then dust probably flies to where the dishes are. Potentially, dust can also go over to the tray line. The kitchen is supposed to be clean and sanitary. Staff #44 stated that when a foreign item is found in a dish/food, then the entire batch of that meal item should be thrown away. However, he indicated that he got nervous and that is why it was not done. The purpose of throwing out the entire batch of that meal item is to ensure the safety of residents and ensure they are taken care of. Review of the facility's undated kitchen policy titled General Sanitation of Kitchen, indicated that food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The facility's undated kitchen policy titled Food Storage and Date Marking indicated that Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination.

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that dirty dishes were not left in a common areas where residents have access, and that common areas were cleaned and disinfected. The deficient practice could result in residents becoming ill or infected. Findings include: On April 21, 2024 at 8:27 a.m. brown liquid in a gray cup with a straw was observed on a mobile tray in the 200 hall just outside a resident's room and it was unattended. Also, a tray was observed in the Northeast dining room with toast, leftover cereal in a bowl that resembled heart shaped Cheerios, one bowl of leftover oatmeal and milk, leftover scrambled eggs on the plate, and orange liquid in a Styrofoam cup with a straw. The tray was unattended and there were three residents sitting in the dining area watching TV. On April 21, 2024 at 8:49 a.m. feces, approximately 1.5 inches, was observed in the middle of the hallway in front of room [ROOM NUMBER]. Staff were observed walking by it. One nurse stopped the surveyor from stepping in it and said that someone will come to clean it up and then walked away. One certified nursing assistant (CNA/staff #4) was observed wearing a glove, and picking the feces up. Then, staff #4 walked away and did not disinfect the floor. Shortly after, a male staff was observed walking and wheeling a cart over the area. On April 23, 2024 at 2:06 p.m., a three tiered black tray was observed in the hallway by the kitchen doors at approximately 1:15 p.m. until approximately 2:00 p.m. There were dirty dishes with leftover rice, carrots, bread, and chicken, a clear glass with 1/4 of a red drink, and opened coffee creamer wrappers. The food was not covered. During an interview conducted on April 21, 2024 at 8:37 a.m. with a certified nursing assistant (CNA/staff #88), she observed the brown liquid in the gray cup sitting on a mobile tray in the hallway just outside the resident's room. She stated that it was leftover coffee. She stated that leftover food and drinks are not supposed to be left in common areas because there is a risk of cross contamination and safety. An interview was conducted on April 23, 2024 at 2:16 p.m. with a registered nurse (RN/staff #11), who stated that dirty dishes should be removed immediately from hallway and dining room to prevent other residents from having access because there is a risk of infection. He stated that if there is feces on the floor, staff should use bleach, something to disinfect the floor, and if the area is not disinfected, there is a risk of spreading infection as people walk through the area and then to other areas. If a resident finds feces on the floor, the CNA blood or anything like a secretion. Should use bleach, something to disinfect the floor, and if not disinfected could spread infection if people walking through and then to other areas. An interview was conducted on April 23, 2024 at 3:12 p.m. with the Director of Nursing (DON/staff #29), who stated that it is her expectation that staff remove dirty dishes from the rooms and place them in a closed cart because the dishes are dirty/contaminated, and residents could become ill. She stated that if there is feces in the hallway, staff should use gloves and pick it up, and the floor should be bleached/sanitized. She stated that if staff are walking through the area or pushing equipment through it, it would track the feces elsewhere and creates the risk of contamination/infection. The facility policy, Infection Prevention and Control Program dated December 2023 states that process surveillance is the review of practices by staff directly related to resident care. Some considerations for this process may include cleaning and disinfection production and procedures for environmental surfaces and equipment. The facility will use effective methods for the safe storage, transport and disposal of garbage, refuse and infectious waste, consistent with all applicable local, state, and federal requirements for such disposal.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident's (#81) clinical record included the required information for transfer/discharge. The deficient practice could result in residents not having a safe and effective transition of care. Findings include: Resident #81 was admitted on [DATE] with diagnosis including an unspecified fracture of the right femur, end stage renal disease, osteomyelitis, encounter for orthopedic aftercare following surgical amputation, complete amputation of left foot, dependence on renal dialysis, type II diabetes mellites with diabetic polyneuropathy, chronic systolic heart failure and aneurysm of iliac artery. It was further noted in the electronic health record that the resident left the facility against medical advice on August 20, 2023. A review of the MDS (minimum data set) revealed no noted score for the BIMS (brief interview of mental status). A review of the electronic medical record, revealed no evidence of documentation that EMS (emergency medical services) arrived at the facility on August 20, 2024. A review of the electronic health record revealed that an AMA (against medical advice) form was completed by staff #121, RN (registered nurse) on August 20, 2023 at 4:17 P.M. A review of the medical record revealed that staff #121, RN (registered nurse) conducted the discharge. Staff #121 is no longer with the facility. An attempt was made to contact staff #121 telephonically on April 24, 2024 at 9:58 A.M.; however, the associated voicemail was full and the surveyor was unable to leave a message. An interview was conducted on April 24, 2024 at 8:40 A.M. with staff #1, CNA (certified nursing assistant). Staff #1 stated that she would notify the nurse if a resident wanted to leave against medical advice. She stated that she would then help collect the resident's belongings in preparation for departure. She stated that discharge documentation is then provided by the nurse. An interview was conducted on April 24, 2024 at 8:43 A.M. with staff #11, RN (registered nurse). Staff #11 stated that when a resident wants to leave against medical advice, the nurse would discuss the consequences with the resident. Staff #11 stated that if the resident wanted to proceed with leaving, he would notify the resident's emergency contact and inform the doctor. Staff #11 stated that he would have the resident sign the AMA form and if EMS was present, provide documentation to the EMS staff to include the face sheet, medical diagnosis, medication orders and recent laboratory progress notes. An interview conducted on April 24, 2024 at 9:05 A.M with staff #21, case manager. The case manager stated that when a resident wants to depart the facility AMA (against medical advice), she would speak with the resident to try to get them to reconsider. If the resident does not wish to reconsider, she stated that she would discuss the issue with the team to see if there is a possibility to change the AMA departure to a possible discharge. She stated that she would notify the resident's nurse if the resident opted to continue with leaving against medical advice. Once the nurse is notified, she stated that the nurse would provide the documentation for discharge. The case manager stated that she would inquire about the need for any DME (durable medical equipment) and inquire if the resident had any concerns. Staff #21 stated that staff would inquire about transport and provide notifications; however, she stated if the resident opted to leave against medical advice and the fire department is called then no one is notified, but documentation would be provided to the fire department. An interview was conducted on April 24, 2024 at 10:17 A.M. with EMS staff #120. Staff #120 stated that he reviewed the documentation of the call on August 20, 2023. He stated that it was noted that EMS staff arrived at the facility at 4:04 P.M. and were not provided any verbal or written report regarding the resident's condition. The electronic health record noted that the AMA form was signed by resident #81 and staff #121 at 4:17 P.M. after EMS arrival at 4:04 P.M. An interview was conducted on April 24, 2024 at 10:32 A.M. with staff#29, DON (director of nursing). Staff # 29 stated that if a resident had chosen to leave the facility against medical advice, she would first ensure that the resident was not confused and if they were she would make sure that a responsible family member was with them, if possible. She stated that the facility would offer home health, medications and transfer to another facility, as applicable. She stated that her expectation would be for staff to document everything regarding the AMA discharge; however, the medical record for resident #81 revealed no documentation of EMS arrival and or report to EMS on August 20, 2024 for AMA discharge. Staff #29 reviewed the medical record and stated that there was no documentation that EMS had arrived at the facility on August 20, 2024. She stated that her expectation is that information would be shared with either EMS and or the resident, but the medical record revealed no evidence that discharge or transfer documentation had been shared. She stated that the risk to resident would include a lack of continuation of care. A review of facility policy in the Continuum of Care section, entitled Discharge against Medical Advice with a revised date on May 6, 2021revealed that appropriate instructions are to be given to the resident and the instructions given are to be documented in the record; however, the record revealed no evidence of documentation of instructions given to either the EMS or the resident. The policy further revealed that the facility is to facilitate the coordination of a safe discharge; however, per EMS interview, no written or verbal report had been provided by the facility on August 20, 2024. Finally, the policy stated that all occurrences and steps throughout the situation are to be documented in nursing notes; however, there is no evidence in the nursing notes that EMS arrived at the facility to remove the resident on August 20, 2023.

Based on clinical record review, staff and resident interviews and policy review, the facility failed to ensure one resident's (#44) representative was able to participate in the care planning process. The deficient practice could result in residents and representatives not participating in and understanding their plan of care. Findings include: Resident #44 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urinary tract infection, atrial fibrillation, aphasia, and cognitive communication deficit. Review of the cognition care plan initiated on November 20, 2023 indicated that the resident is at risk for impaired cognitive function/dementia or impaired thought process. Interventions include to communicate with family/caregivers regarding resident's capabilities and needs, and social services to provide psychosocial support as needed. The resident's admission record indicated that the resident has two emergency contacts. The first emergency contact (primary) is his son and the secondary emergency contact is his wife. Review of the resident's clinical record revealed that the most recent documented contact regarding a care conference was back in December 12, 2023. According to the progress note, the contact was regarding setting up a care conference was not directed to the identified emergency contacts but rather to the resident's other son. There was no documentation on whether or not a care conference was actually completed. Further review of the resident's record did not reveal any recent documentation pertaining to care plan conferences. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2 indicating that the resident has severe cognitive impairment. During an interview with resident #44's son conducted telephonically on April 21, 2024 at 12:26 p.m., he stated that he has not been informed/invited to care plan meeting recently even if he is the primary emergency contact. He stated he has had some concerns regarding his father's care and would like to be part of care conferences so he is aware of what is going on. An initial interview was conducted with the Director of Nursing (DON/staff #29) on April 24, 2024 at 9:38 a.m. The DON stated that care conferences for long term care residents are conducted quarterly by social services and in 1-2 days by the case manager for skilled residents. An interview with the Social Services Director (staff #7) was conducted on April 24, 2024 at 9:42 a.m., she stated that care conferences for long term care residents are usually accomplished quarterly. When asked when resident #44 last had his care conference, she stated that it was December 2023. Staff #7 indicated that the next one will be scheduled April 2024. She noted that they normally give the family a week's notice. When asked if the care conference for resident #44 was schedule, she noted that it has not yet been scheduled but will be scheduled. She stated that they normally notify the wife but not the son. Staff #7 said that normally they invite the family member that is indicated as emergency contact #1 or 2, the wife, and adult child. She said that she does not maintain a tracker to monitor who is due for their care plan conference. Staff #7 stated that she goes by when the MDS is due. However, when asked why resident #44's care conference was not done when his MDS was done in February 20, 2024, she stated that she would like to go by the MDS due date but that is not what they are currently doing. Staff #7 stated that her current process is reviewing the list of her residents weekly and see who is due. She said that the impact of not conducting the care conference and inviting family to the care conferences is that there might be something that is not discussed regarding a resident's care and services that needs to be addressed. A follow-up interview was conducted with the DON (staff #29) on April 24, 2024 at 1:08 p.m., staff #29 stated that her expectation regarding care conferences is that it will be done quarterly and that both the resident and the family are invited. The DON indicated that is a resident has a low BIMS score, she expects for the family or responsible party to be invited to the conference. Staff #29 stated that care conferences should be scheduled based on the family's availability. If are resident was due this month, then they should have already been notified and the conference already scheduled based on family's availability. Review of the facility policy titled Comprehensive Person-Centered Planning reviewed February 2024 indicated that the facility will provide the resident and the resident representative advance notice of care planning conferences to encourage resident and/or resident representative participation.

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a potentially dangerous item was not left in a public area on one resident's (#1) mobile tray where other residents could access it. The deficient practice could result in residents injuring themselves. Findings include: On April 21, 2024 at 8:27 a.m., a mobile tray was observed in the hallway by room [ROOM NUMBER]. There was a blue razor with a clear plastic cover over the blade on the tray and the tray was left unattended. An interview was conducted on April 21, 2024 at 8:37 a.m. with a certified nursing assistant (CNA/staff #88), who stated that they put the mobile tray outside of the resident's room because there is no room for his wheelchair. She stated that the razor is supposed to be thrown away once it has been used and there is a risk of residents cutting themselves on the razor. After the interview, staff #88 began walking away and the surveyor had to intervene and ask her to remove the razor from the tray. During an interview conducted on April 21, 2024 at 10:36 a.m. with resident #1, he stated that the staff put his mobile tray in the hallway, so there is room for the Hoyer lift when he is being assisted with transfers. An interview was conducted on April 23, 2024 at 2:16 p.m. with a registered nurse (RN/staff #11), who stated that a razor should be removed if not being used and put in a sharp container right away, if it are disposable. He stated that if a razor is left out in common area, there is a risk of residents being injured. An interview was conducted on April 4, 2024 at 3:12 p.m. with the Director of Nursing (DON/staff #29), who stated that staff should put razors in the sharps container when done because there is a risk of another resident getting the razor and cutting himself/herself if left in a common area. The facility policy, Elopement/Unsafe Wandering dated December 2023 states that It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment and interventions.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#1) was assessed for the risk of entrapment when using full size bedrails on both sides of the bed and to assess and document the ongoing need for bed rails. The deficient practice could result in residents being physically injured. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, muscle spasm of the back, disorder of the autonomic nervous system and depression. Review of the Assistive Device Consent form dated September 18, 2019 did not reveal a consent for the use of two full size bed rails. The care plan dated September 24, 2019 included that the resident has quadriplegia related to a spinal injury status post a motor vehicle accident in 1991. Interventions included two full side rails up when in bed for unsafe jerky movements related to muscle spasms. The resident's care plan dated September 24, 2019 states the resident is at risk for falls related to quadriplegia, psychoactive drug use, spasms, impaired range of motion. Interventions included full size bed rails for muscle spasms related to quadriplegia. Review of the Fall Risk Evaluation dated May 10, 2021 revealed that the resident had not fallen in the last three months, did not have a decrease in muscular coordination, or jerking movements. The order summary revealed an order dated January 12, 2022 for two full side rails up when in bed for unsafe jerky movements related to muscle spasms every shift. Review of the Assistive Device Consent form dated February 14, 2022 revealed a consent for the use of two full size bed rails for bed mobility/repositioning. Review of the Restraint/Enabling Device/Safety Device Evaluation dated April 21, 2022 The assessment states that the bed rails potentially protect the resident, increases sense of safety/security per the resident's request. The risks include death by strangulation, suffocation, contractures, and accidental injuries. Review of the Assistive Device Consent form dated February 24, 2023 did not reveal a consent for the use of two full size bed rails. Review of the Restraint/Enabling Device/Safety Device Evaluation dated February 24, 2023 did not include an assessment for full size bed rails. Review of the Restraint/Enabling Device/Safety Device Evaluation dated June 2, 2023 did not include an assessment for full size bed rails. Review of the Fall Risk Evaluation dated February 6, 2024 revealed that the resident had not fallen in the last three months, did not have a decrease in muscular coordination, or jerking movements. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated February 2024, March 2024, April 2024 revealed two full side rails up when in bed for unsafe jerky movements related to muscle spasms every shift, but did not reveal that muscle spasms were being tracked. Review of the Restraint/Enabling Device/Safety Device Evaluation dated March 5, 2024 revealed an assessment for grab bars. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident is dependent on staff assistance with rolling from left and right and a bed rail is not used. Review of the Restraint/Enabling Device/Safety Device Evaluation dated April 23, 2024. The assessment states that the bed rails potentially protect the resident, increases sense of safety/security per the resident's request. The risks include death by strangulation, suffocation, contractures, and accidental injuries. Review of the EMAR progress notes from February 2024 through April 2024 did not reveal that the resident had any muscle spasm. On April 23, 2024 at 1:22 p.m. the resident was observed lying in bed and long bed rails on both sides of the bed were in the up position. On April 24, 2024 at 10:14 a.m. the resident's bed was observed up against the left wall and he was lying in bed with full size bed rails up on both sides of the bed, and there were no pads on the rails. An interview was conducted on April 23, 2024 at 1:24 p.m. with a certified nursing assistant (CNA/staff #51), who stated that a resident needs an assessment for bed rails and they are used because a resident may roll from one side of the bed to the other and can fall on the floor. An interview was conducted on April 23, 2024 at 2:16 p.m. with a registered nurse (RN/staff #11), who stated that the resident wanted the bed rails to balance his communication board, to use the remote and call-light. He stated that the resident balances these things up against the bed rail and uses the pointer in his mouth to draw on the board, access the remote, and call-light. He stated that the resident needs an assessment for the bed rails to determine if the resident still needs them. An interview was conducted on April 23, 2024 at 3:12 p.m. with the Director of Nursing (DON/staff #29), who stated that an assessment must be completed for a resident to use bedrails. She reviewed the Restraint/Enabling Device/Safety Device Evaluation dated March 5, 2024 and stated that resident was assessed for grab bars and he is not able to use his hands to use the grab bars. She stated that the resident needs the full size bed rails because he has muscle spasms. She reviewed the resident's MAR and TAR, but was not able to find where the resident's spasms were being tracked and stated that she would need to search for the tracking. The facility policy, Restraints, Physical dated October 2023 states that the use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. Medical symptoms that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments, and care plans.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a registered nurse (RN) provided eight hours of coverage in a 24 hour period. Findings include: Review of the daily staff posting dated December 24, 2023 revealed that the census was 82. There were four licensed practical nurses (LPNs) from 6:00 a.m. to 6:00 p.m. and seven certified nursing assistants (CNAs) from 6:00 am. to 2:00 p.m. for the day shift. There were six CNAs from 2:00 p.m. to 10:00 p.m. There were four LPNs from 6:00 p.m. to 6:00 a.m. and four CNAs from 10:00 p.m. to 6:00 a.m. During an interview conducted on April 23, 2024 at 9:16 a.m. with the Staffing Coordinator (staff #75), the daily staff posting dated December 24, 2023 was reviewed and Staff #75. She stated that the census was 82 and that there were four (LPNs) from 6:00 a.m to 6:00 p.m. and four LPNs from 6:00 p.m. to 6:00 a.m. She stated that the facility is required to for 8 hours daily and she could not find one for December 24, 2023. She stated that she called the Director of Nursing (DON) to tell her that registry did not have a RN available. She stated that the DON can't stand for a RN when the census 82. During an interview conducted on April 23, 2024 at 3:01 p.m. with the (DON/staff #29), she stated that a registered nurse must be scheduled to work 8 consecutive hours daily, and it her responsibility to ensure that a RN is scheduled. The facility policy, Staffing dated January 2024 states that there will be 8 hours of RN coverage on a daily basis.

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that the daily staff posting reflected the correct information. Findings include: An observation of the daily staff posting was conducted on April 21, 2024 at 7:15 a.m. The daily staff posting was posted on the wall behind the receptionist's desk. The date on the posting was April 19, 2024 with a census of 76. The census for April 21, 2024 was 75. An interview was conducted on April 21, 2024 at 7:15 a.m. with a licensed practical nurse (LPN/staff #6, who stated that she thought the charge nurse updates the daily staff posting when she comes in to work at 10:00 a.m. An interview was conducted on April 21, 2023 at 8:57 a.m. with the receptionist (staff #109), who stated that the Staffing Coordinator (staff #75) usually posts the daily staff posting and is usually here by 8:00 a.m. During the interview, it was observed that there was not a daily staff posting on the wall and staff #109 stated that she usually looks at the posting to ensure that the date is correct and didn't know why there wasn't a posting when she arrived to work this morning. An interview was conducted on April 23, 2024 at 9:16 a.m. with the Staffing Coordinator (staff #75), who stated that she is responsible for updating the daily staff posting. She stated that she works Monday through Friday and has not designated another staff to update the posting on the weekend, and when she arrived this morning, there was not a daily staff posting on the wall. An interview was conducted on April 23, 2024 at 2:56 p.m. with the (DON/staff #29), who stated that the daily staff posting is completed by the Staffing Coordinator (staff #75), and it is her expectation that staff #75 will complete the postings for the weekend and put them behind the Friday posting, so the weekend staff can rotate them. She stated that the purpose of daily staff posting is to show residents and visitors what the staffing is for the day and should include the census, date, floor staff, and the number of hours worked for each position. The facility policy, Staffing Numbers, Posting dated May 2022 states that it is the policy of this facility to post staffing numbers. Procedures include to comply with the Benefits Improvement and Protection Act of 2000, the facility must include hours worked by registered nurses, licensed practical/vocational nurses, and nursing assistants for each shift. Post prominently in a public area in readable font on a surface of at least 8.5 x 11 inches. The policy doesn't include the correct date and census.

Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to coordinate one resident's (#4) care/medications with hospital physician to ensure medications were given according to physician instructions. The deficient practice resulted in significant harm to the resident. Findings included: Resident #4 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included epilepsy and traumatic brain injury (TBI). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 which suggested severe cognitive impairment. Review of a discharge paperwork from a hospital with a printed date of 10/19/2023 revealed a physician order for Phenytoin (anti-convulsant) 50 mg (milligram) oral tablet, chewable 3 tab(s) oral twice a day; Clobazam (sedative) 10 mg oral tablet 2 tablets oral twice a day. The hospital discharge order also included an order to continue taking Cenobamate (anti-convulsant) Titration Pack 12.5 mg-25 mg oral tablet. The nursing note dated 10/19/2023 revealed the resident was alert and oriented x 4, with history of multiple TBI and seizures. The care plan initiated on 10/20/2023 revealed the resident had a seizure disorder. The goal was the resident will remain free of seizure activity. Interventions that included giving seizure medication as ordered by doctor and monitoring and documenting side effects and effectiveness. -Regarding Dilantin Review of a physician order dated 10/19/2023 revealed Dilantin (Phenytoin) infatabs tablet chewable 50 mg to give 1 tablet by mouth every 8 hours for seizure disorder with a start date of 10/19/2023. This order was created by an Licensed Practical Nurse Supervisor on 10/19/2023 and was signed by a physician on 10/24/2023. The physician order for Dilantin was transcribed in the Medication Administration Record (MAR) as Dilantin (Phenytoin) infatabs tablet chewable 50 mg to give 1 tablet by mouth every 8 hours for seizure disorder. The documentation in the MAR also included that the resident received Dilantin as ordered from 10:00 p.m. on 10/19/2023 to 6:00 a.m. on 10/22/2023. However, the written physician order and the Dilantin dose administered to the resident by the facility was half the daily dose prescribed at hospital discharge order. Despite discrepancy between the hospital order and the physician order, there was no evidence that the order was clarified with the physician. Further, the physician order with half the daily dose prescribed at the hospital was signed by the facility physician on 10/24/2023 which two days after the resident was discharged from the facility. -Regarding Clobazam The physician order dated 10/19/2023 included for Clobazam tablets at 10mg/tab to give two tablets twice a day for seizure disorder with a start date of 10/19/2023 The physician order for Clobazam was transcribed in the Medication Administration Record which revealed from 10/19/2023 to 10/22/2023; however, Clobazam was not documented as administered; and, documentation in the MAR was coded 7 indicating to see nursing notes. The electronic Medication Administration Record (eMAR) administration note dated 10/19/2023 at 11:16 p.m. revealed the clobazam was on order and pharmacy was notified by phone. Another eMAR note dated 10/20/2023 at 7:22 a.m. revealed the physician order for Clobazam with no notes associated with the order. Another eMAR note dated 10/20/2023 at 7:48 p.m. revealed a note that stated per pharmacy need an updated RX [prescription]. reprinting RX for provider to sign. The eMAR note dated 10/21/2023 at 9:35 a.m. revealed the physician order with no notes associated with the order. Another eMAR note dated 10/21/2023 at 9:51 p.m. revealed a note, called and left a message with the pharmacy answering service to f/u (follow up) on medication delivery. Review of the MAR revealed documentation that resident #4 did not receive Clobazam during his stay in the facility. Despite documentation that Clobazam was not available and was not documented as administered to the resident, the clinical record revealed no evidence that the physician was notified until 10/22/2023 or the order was put on hold priori to 10/22/2023. -Regarding Cenobamate The physician order dated 10/19/2023 revealed for Cenobamate oral tablet therapy pack 14 x 12.5 mg and 25 mg to give 12.5 mg by mouth on time a day for seizure disorder for 2 weeks. The physician order for Cenobamate was transcribed in the MAR; and, documentation in the MAR from 10/20/2023 to 10/22/2023 was coded 7 indicating to see nursing notes. Review of the MAR revealed the Cenobamate was not documented as administered during his stay in the facility. Despite documentation that Cenobamate was not administered, there is no evidence found in the clinical record that the physician was notified. The eMAR administration note dated 10/20/2023 revealed the physician order for Cenobamate but no notes associated with the order. The eMAR note dated 10/21/2023 10:11 a.m. revealed the physician order for Cenobamate but no notes associated with the order. An eMAR note dated 10/22/2023 at 7:41 a.m. included that med not given pending pharmacy delivery. Review of the NP (nurse practitioner) admitting note dated 10/20/2023 revealed that resident #4 had an initial visit by the nurse practitioner on 10/20/2023. The note included that medications were reviewed and to see electronic record for updated list of medications. Assessments included Epilepsy and breakthrough seizure. Plan was to continue Clobazam, Dilantin and Cenobamate. Measures revealed that the NP had utilized all available immediate resources to obtain, update or review the resident's current medications including prescriptions, over-the-counter products, herbals and vitamin/mineral/dietary (nutritional) supplements. Further review of this note revealed that this was not signed until 10/22/2023 at 7:41 p.m. (the date of the resident's discharge). A nursing progress note dated 10/22/2023 at 7:01 a.m. revealed the nurse called the pharmacy and left a message for a call back to follow up on Clobazam order. Per the documentation, after not receiving a call back from pharmacy another call was made requesting emergency call back due to resident's seizure becoming more frequent. Further, the note included that pharmacy were out of medication and have been looking for it from other pharmacies to fill. Further, the documentation included that the on-call provider was notified that resident was having frequent mini seizures and showing signs of confusion; and that, the physician agreed to send the resident to the hospital due to frequent seizures, confusion, and missing anti-seizure medications. However, this is the first progress note found in the clinical record that mentioned the resident having frequent mini seizures and showing signs of confusion. A nursing note dated 10/22/2023 at 8:21 a.m. revealed resident appeared to be oriented x 2 and was transferred to the hospital for management of his epilepsy. Review of the clinical record revealed that the physician order for Dilantin was changed on 10/22/23 at 7:00 p.m. (after the resident was discharged to the hospital) to reflect Dilantin Infatabs tablet chewable 50 mg (Phenytoin) to give 3 tablets by mouth every 12 hours for seizure disorder. This order matched the hospital order dated 10/19/2023. A letter from the neurologist at the hospital where resident #4 was admitted to on 10/22/2023 revealed the resident was admitted for status epilepticus (nonstop or near-stop seizures, a potentially fatal condition) on 10/22/2023. The documentation included that the resident had been receiving the antiseizure medication phenytoin (Dilantin) at a dose of 50 mg three times daily which was less than what the resident was supposed to receive while at the facility. The letter also stated that, giving the wrong dose of an antiseizure medication is dangerous at best and fatal at worst. Further, it stated, to a reasonable degree of medical probablity, he (referring to resident #4) would not have had to be readmitted to [hospital] in status epilepticus had he received the correct dose of Phenytoin. An interview was conducted on 11/8/23 at 3:24 p.m. with admission nurse (staff #22) who stated that when a resident is admitted to the facility from the hospital she receives a packet from the hospital case manager with discharge paperwork where it states the medication orders for the patient. She stated staff then input those orders in the system and the provider will approve them. Further, she stated the medications that the hospital ordered at discharge are the medications the resident will take until the provider sees the resident and changes the orders. In an interview conducted with the Director of Nursing (DON/staff #31) on 11/8/23 at 3:35 p.m., the DON stated that her expectation was for staff to enter the medication orders that the hospital discharge paperwork had listed. Regarding the discrepancy in the resident's (#4) seizure medication, the DON stated there can be a possibility that the provider was on site and changed the order immediately. The DON said that the pharmacy can also give a recommendation whether a medication was appropriate; and that, the order will then be changed. In a later interview on 11/8/2023 at 4:43 p.m. the DON stated that the provider had changed the order for Dilantin because the hospital paperwork was chaotic and needed clarification. In an interview with the pharmacist (staff #5) that filled prescriptions for the facility conducted on 11/8/23 at 4:05 p.m., the pharmacist stated that the only order for Dilantin they received and filled was for chewable tablet of Dilantin 50 mg every 8 hours. He stated the order came from the facility and did not match the order from the hospital. He stated the hospital order was for three 50mg tabs, twice a day. Further, he stated he was unsure when the order was changed. Review of the facility's policy titled, Nursing Services- Physician Orders last reviewed 8/2022, revealed, admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly.

Based on observations, staff interviews, facility policy and procedures, and the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure that hand hygiene was performed during medication administration and that staff were wearing appropriate Personal Protective Equipment (PPE). The deficient practice could result in the spread of infections. Findings include: Regarding hand hygiene: -On August 18, 2021 at 11:10 a.m., a medication administration observation was conducted with a Licensed Practical Nurse (LPN/staff #61). Staff #61 was observed to performed hand hygiene prior to entering a resident's room. He went into the room and asked the resident to rate their level of pain. The resident responded, and the nurse stated that he would be back with a dose of acetaminophen (non-opioid [MEDICATION(S)]). Staff #61 left the room and went to the medication cart. He did not perform hand hygiene. Staff #61 prepared the medication, took it into the resident's room, and administered it. Staff #61 left the room without performing hand hygiene. Staff #61 stated he would then ask a resident in another room what their pain level was. Staff #61 entered the resident's room. He did not perform hand hygiene. He asked the resident to rate their level of pain. After the resident responded, staff #61 stated that he would return with the resident's acetaminophen. Staff #61 left the resident's room and was not observed to perform hand hygiene. The LPN prepared the resident's medication without performing hand hygiene, then returned to the resident's room, and administered the medication. Staff #61 left that resident's room and did not perform hand hygiene. An interview was conducted on August 18, 2021 at 11:16 a.m. with the LPN (staff #61). He stated that he usually performs hand hygiene, but that he did not have hand sanitizer on his medication cart. The LPN stated that there were hand sanitizer dispensers in the hallway, but that the alcohol-based hand rub gave him an allergic reaction on his hands. He stated that the risks of not performing hand hygiene between residents/medication passes included cross-contamination. -On August 19, 2021 at 8:26 a.m., a medication administration observation was conducted with a Registered Nurse (RN/staff #60). Staff #60 did not perform hand hygiene prior to preparing the medication. Staff #60 stated that he would need to go to Central Supply to retrieve a medication that was not found in the medication cart. Staff #60 locked the medication cart and walked to the other side of the facility. He opened the door to Central Supply, took a bottle of medication off the shelf, and read the label. After stating that the medication he needed was unavailable, staff #60 returned to his medication cart. He did not perform hand hygiene. Staff #60 retrieved the previously prepared medication and enter the resident's room. Staff #60 set the medication cup down onto the resident's bedside table. He then obtained a pair of gloves from a box on the wall and donned them. Staff #60 administered the medication. He doffed his gloves prior to exiting the resident's room. He did not perform hand hygiene. An interview was conducted on August 19, 2021 at 8:46 a.m. with the RN (staff #60). He stated that he did not perform hand hygiene before pulling the medication or before donning his gloves. The RN stated that donning gloves did not take the place of hand hygiene. He stated that he was probably nervous. The RN stated that not performing hand hygiene increased the risk for spreading infection. -A medication administration observation was conducted on August 19, 2021 at 9:37 a.m. with an LPN (staff #26). She stated that 2 of the medications she was going to administer were not in the medication cart. She locked the medication cart and went into the medication room to obtain one of the medications. She then walked to Central Supply to obtain the other medication. The LPN returned to the medication cart. She did not perform hand hygiene. Staff #26 removed one medication from the cart and placed it into a medication cup. She stated that 2 additional medications were not available in the cart. The LPN locked the medication cart and stated she was going back to the medication room to obtain those medications from the emergency kit. When staff #26 returned, she performed hand hygiene. On August 19, 2021 at 12:01 p.m., an interview was conducted with the LPN (staff #26). She stated that she thought she had not touched the resident's medications until after she had gone to the medication room for the second time. The LPN stated that it is what it is, and that there was nothing she could do about it now. An interview was conducted on August 19, 2021 at 11:31 a.m. with the Director of Nursing (DON/staff #53). He stated that he expects nursing to perform hand hygiene prior to preparing medications. The DON stated that he would expect nurses to perform hand hygiene after leaving the cart to collect supplies, upon their return. The DON stated that he expects nurses to perform hand hygiene between residents. The facility policy titled Hand Hygiene stated it is the policy of the facility to cleanse hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. Hand washing/hand hygiene is generally considered the most important single procedure for preventing the transmission of infection. Except for situations where hand washing is specifically required, antimicrobial agents such as alcohol-based hand rubs are also appropriate for cleaning hands and can be used for direct care. Regarding staff not wearing appropriate Personal Protective Equipment (PPE): -Observations were conducted of the DON (staff #53) on August 17, 2021 at 1:45 pm and 3:05 pm, and on August 18, 2021 at 7:45 am. The DON was observed on these occasions to be wearing a cloth face mask with no other face mask or covering. The cloth face mask was not well fitting and slid down when the DON was talking, exposing his nose. -An observation of a housekeeping staff was conducted on August 18, 2021 at 7:47 am. The housekeeping staff member was cleaning a room in the COVID-19 unknown unit. The staff member was wearing an N95 face mask, with only one strap secured behind her head. The other strap was hanging down below her chin. The staff member was not wearing any other face mask or covering. -An observation was conducted of an LPN (staff #50) on August 18, 2021 at 2:45 pm. The LPN was standing near the nurses' station talking with a resident. The LPN had a surgical mask on, but he was holding the front of the mask under his chin, exposing the LPN's nose and mouth while he was talking to the resident. An interview was conducted with the DON and the facility's Infection Preventionist (IP/staff #72) on August 19, 2021 at 11:25 am. The IP stated it was the expectation that all staff wear a surgical mask while providing patient care. The IP stated the PPE requirements in the COVID-19 unknown unit included an N95 face mask with a surgical mask over the N95 when in a resident room. Staff #72 stated that a cloth face mask would not satisfy the expectations for PPE in the facility. When asked about his cloth face mask, the DON stated that he wears a surgical mask underneath the cloth mask when providing patient care. The IP and DON both stated all staff members are expected to wear a mask at all times while in the facility, unless eating or drinking, and that the face mask should not be removed to speak to residents. The IP also stated she would expect all staff to wear their masks correctly, with all of the straps appropriately placed and not slipping down to expose the nose or mouth. A facility policy regarding PPE requirements for staff was requested on August 17, 2021 at 2:15 pm. The DON stated on August 18, 2021 at 3:15 pm that the facility did not have a specific policy regarding PPE requirements for staff, but that the facility followed the Centers for Disease Control (CDC) guidelines. The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated on March 29, 2021 stated the fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles. It also included facemasks that conform to the wearer's face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer's exposure to particles in the air.

Based on staff interviews, review of the clinical record, and policy and procedure, the facility failed to ensure one of two sampled residents (#22) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan initiated on January 30, 2020 revealed the resident used [CONDITION(S)] medications related to mood disorder as evidenced by verbal aggression. The goals included the resident would have fewer episodes of verbal aggression. Interventions included to administer medications as ordered and to monitor/document for side effects. A Pre-admission Screening and Resident Review (PASRR) Level I screening completed on February 21, 2020 included that the resident had no serious mental illnesses or mental disorders. No answers were provided as to whether or not the resident had substance-related disorders, symptoms, or issues related to adaptation to change. There was no documentation/indication indicating whether or not a Level II referral was necessary. There was no signature of the resident/representative. The document was signed by a Registered Nurse Case Manager (RNCM). After a brief admission to the hospital, the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record did not reveal for a psychiatric consultation to address the resident's behaviors. A risk for impaired cognitive function/dementia or impaired thought processes dated February 26, 2020 related to dementia, history of [CONDITION(S)], and included a history of polysubstance abuse and the use of [CONDITION(S)] medication had a goal to remain oriented to person, place, situation, and time. Interventions included social services to provide psychosocial support as needed. A nursing progress note dated March 25, 2020 at 8:04 a.m. included that the resident was exhibiting increased agitation and yelling out towards the roommate, stating, I think the devil in you .don't worry about me. Attempts to redirect were unsuccessful. The PASRR Level I screening dated March 25, 2020 revealed the resident had a non-primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document indicated the resident had no symptoms related to interpersonal behaviors, concentration, or adaptation to change. [CONDITION(S)] medications received by the resident included [MEDICATION(S)] (antipsychotic) 5 milligrams (mg) daily; [MEDICATION(S)] (anxiolytic) 10 mg, 2 tablets twice daily; and [MEDICATION(S)] (antidepressant) 15 mg nightly. The document stated that the resident did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The referral determination stated that no Level II referral was necessary. A nursing progress note dated April 11, 2020 at 4:30 a.m. included that the resident had refused activities of daily living (ADL) care at that time despite education and encouragement. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Social Service Summary dated June 9, 2020 at 9:18 a.m. revealed the resident was admitted for therapy and that she was PASRR Level 1. The note included that the resident was taking [MEDICATION(S)] for anxiety, [MEDICATION(S)] (anticonvulsant/decreased manic episodes) for mood disorder, [MEDICATION(S)] (antidepressant) for depression, and [MEDICATION(S)] (antidepressant) for depression. Staff will monitor for changes in mood and behavior and for signs or symptoms of medication side effects. The note stated that the resident would stay for long-term care in the facility. The resident was using a wheelchair prior to admission and stated the resident did not have a history of trauma that was currently affecting the resident life. Mood and behavior were appropriate at that time. The note was signed by social services (staff #20). Review of the resident's Face Sheet and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status assessment, indicating intact cognition. The resident required extensive 1-2 persons physical assistance with most activities of daily living. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment included the resident received antipsychotic, antianxiety, and antidepressant medications for 7 out of the 7-day in the lookback period. Additionally, the assessment stated the resident had not received psychological therapy by any licensed health professional. However, further review of the clinical record did not reveal documentation to reflect that the resident, who had been diagnosed with a newly evident serious mental disorder, was referred to the state-designated authority for Level II evaluation and determination or a reason why the resident was not referred. An interview was conducted on August 19, 2021 at 12:05 p.m. with social services (staff #20). She stated that if a resident developed a serious mental illness during their residence in the facility she would submit for a Level II PASRR screening. She stated that this is the expectation. She stated that since the resident had dementia she did not refer the resident to the state authority for evaluation. She said that according to her understanding, because the resident had dementia she would not qualify for Level II services. On August 19, 2021 at 1:38 p.m., an interview was conducted with the Director of Nursing (DON/staff #53). He stated he was aware that a Level II PASRR should be submitted for a resident with newly identified serious mental illness as long as the resident did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The AHCCCS Pre-admission and Resident Review policy included that if an individual's mental health condition changes, or new medical records become available that indicate the need for a Level II PASRR, a new Level I screening must be completed as soon as possible and a referral made.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASRR) was completed prior to or upon admission and a PASRR Level I screening was updated when required for one of two sampled residents (#22). The deficient practice increases the risk that individuals who have a mental disorder or intellectual disability may be inappropriately placed in nursing homes and/or they may not receive appropriate treatment or services. Findings include: -Regarding the initial PASRR Level I screening: Resident #22 was admitted to the facility on [DATE]. However, admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the clinical record revealed a PASRR Level I screening completed on October 16, 2018. However, further review of the clinical record did not reveal that a PASRR Level I screening had been completed prior to or upon the resident's admission to the facility on [DATE]. On August 18, 2021 at 1:40 p.m., an interview was conducted with a member of social services (staff #20). She stated that the Level I PASRR should be completed in the hospital before the resident is admitted to the facility. Staff #20 stated that if the PASRR had been done a couple of years prior to their admission, then another one would need to be completed. Staff #20 stated that the resident's initial PASRR should have been updated upon admission in January 2020. She stated that it did not meet her expectation. An interview was conducted on August 19, 2021 at 1:38 p.m. with the Director of Nursing (DON/staff #53). The DON stated that a Level I PASRR screening should be completed in the hospital. Staff #53 stated that he did not really know the timeframe requirement for sure. The DON stated that he would consider a PASRR Level I screening that had been completed 2 years before admission to be outdated. The facility policy titled Resident Assessment PASRR included that it is the policy of the facility to ensure that each resident is properly screened using the PASRR specified by the State. The purpose statement included that mental disorder as defined in the State Operations Manual (SOM) unless the State mental health authority has determined, based on independent physical and mental evaluation performed by a person or entity other that the State mental health authority prior to admission. In addition, the policy stated the facility will refer to the State's AHCCCS PASRR policy. The AHCCCS PASRR policy included that all AHCCCS registered nursing facilities (NF) must complete a Level I PASRR screening, or verify that a screening has been conducted, in order to identify mental illness and/or an intellectual disability prior to initial admission of individuals to a NF bed that is Medicaid certified or dually certified for Medicaid/Medicare. -Regarding the Level I PASRR completed on March 24, 2021: Resident #22 was admitted to the facility on [DATE], discharged to the hospital on February 17, 2020, and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level I PASRR screening dated March 24, 2021 revealed the resident was admitted from the hospital and met the criteria for 30-day convalescent care. The PASRR included a statement that the nursing facility must update the Level I PASRR at such time that it appears the individual's stay will exceed 30 days. Further review of the clinical record revealed the resident continued to reside in the facility until a discharge date of [DATE]. On August 18, 2021 at 1:40 p.m., an interview was conducted with a member of social services (staff #20). She stated residents who are there for a short-stay should have a PASRR screening completed. Staff #20 stated that she always does a PASRR no matter what; that she does a preadmission and a 30-day PASRR screening. She stated it is basically the same thing. Staff #20 further stated that residents that have any kind of dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on August 19, 2021 at 1:38 p.m. with the DON (staff #53). He stated that he did not really know the timeframe requirement for sure. He stated that a PASRR for short-stay convalescent care needs to be completed even if the resident will only be in the facility for 30 days or less. The DON did not provide a response as to whether or not the PASRR screening conducted on March 24, 2021 met his expectations. The AHCCCS Pre-admission and Resident Review policy included that if the individual is to be admitted to the NF for a convalescent period, or respite care, not to exceed 30 consecutive days, a PASRR Level I screening is not required. If it is later determined that the admission will last longer than 30 consecutive days, a Level I PASRR screening must be completed as soon as possible or within 40 calendar days of the admitted .

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of three sampled residents (#267) received the necessary services to maintain good grooming and hygiene. The deficient practice could result in grooming and hygiene needs of residents not being met. Findings include: Resident #267 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #267's care plan was reviewed and included a care plan focus that was initiated on December 16, 2020 which stated the resident had an Activity of Daily Living (ADL) self-care performance deficit and required staff participation with personal hygiene and oral care. The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 11 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate impaired cognition. The MDS assessment included the resident needed extensive assistance with personal hygiene and required the physical assistance of one person. The assessment also included bathing had not occurred the entire lookback period. The Point of Care (POC) Certified Nursing Assistant (CNA) bathing documentation included three parts to be documented: 1. what type of bathing activity was completed? 2. bathing self-performance 3. bathing support provided Review of the POC bathing documentation for resident #267 from December 16, 2020 through January 8, 2021 revealed multiple dates when the first question was answered indicating the resident had a shower or sponge bath. However, the answers to the second and third question for all dates was that the activity did not occur. The POC documentation for resident #267 also included the resident had a sponge bath on January 9, 2021 and was totally dependent on the physical assistance of one staff member to bathe. An interview was conducted on August 19, 2021 at 10:30 am with a Restorative Nursing Assistant (RNA/staff #78), who stated she does assist residents with showers and personal hygiene. Staff #78 stated residents are supposed to get a shower twice a week. She stated there is a schedule and any staff member can look in the shower book to see which residents are scheduled for a shower. Staff #78 stated she will fill out a shower sheet and put it in the shower book, as well as entering shower documentation into the POC system. Staff #78 stated if bathing was provided to a resident, the POC documentation would include answers to all three questions. The RNA stated that if the answer to one of the questions is that the activity did not occur, it would mean the resident was not assisted with bathing on that date. An interview was conducted on August 19, 2021 at 11:10 am with the Director of Nursing (DON/staff #53), who stated all residents shoulder be offered showers twice a week. He stated the showers are documented on shower sheets and in the POC documentation. The DON stated the shower sheets are not kept for long and that resident #267's shower sheets are not likely available. The DON reviewed the POC documentation for bathing for resident #267 and stated it appeared the resident did not receive a shower or bed bath from the time of admission on December 15, 2020 until the resident received a sponge bath on the day of discharge, January 9, 2021. The facility's policy titled ADLs, Services to Carry out was most recently revised in July of 2015 and included bathing will be offered at least twice weekly, and PRN (as needed) per resident request. The policy also included that if a resident is not able to carry out activities of daily living, the necessary services to maintain good grooming and personal oral hygiene will be provided by qualified staff.

Based on observations, clinical record reviews, resident and staff interviews, and review of policy and procedure, the facility failed to ensure two residents received treatment and care in accordance with professional standards of practice related to a peripheral intravenous (IV) catheter for one resident (#267) and related to treatment orders for a knee immobilizer for one resident (#59). The sample size was 19. The deficient practice could lead to residents not receiving appropriate care and treatment. Findings include: -Resident #267 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 11 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate impaired cognition. Physician orders dated January 4, 2021 included the resident was to receive 50 cc (cubic centimeters) of [MEDICATION(S)]-NaCl Solution 5-0.45% ([MEDICATION(S)]-[MEDICATION(S)]) intravenously for one day for hydration and that the resident was to be monitored for a change in condition for IV fluids every shift for three days. The IV Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #267's right wrist as ordered on January 4, 2021. A nurse's note dated January 4, 2021 included the resident continued to have a poor appetite and that fluids and foods were encouraged. The note included the resident was on IV fluids. The MAR for January 2021 included resident #267 was monitored for a change in condition as ordered on January 4, 5, and 6, 2021. Review of resident #267's clinical record did not reveal any additional orders or notes regarding the peripheral IV. The clinical record did not include an order to remove the IV, or a note to indicate the IV had been removed. The discharge summary and post discharge plan of care for resident #267 was completed on January 8, 2021 and did not include the peripheral IV. An interview was conducted on August 19, 2021 at 10:40 am with a Registered Nurse (RN/staff #60). Staff #60 stated the care for a resident with peripheral IV access is to monitor the site for any changes or signs of infection, change the dressing when it becomes soiled, and to follow the physician's orders regarding the IV. Staff #60 stated orders for placing and removing an IV are confirmed by the physician. Staff #60 stated he would call the physician if he had concerns about a resident IV. Staff #60 stated a resident should not have a peripheral IV that is not in use, and he would call the physician if he was aware of a resident who did have an IV placed that was not being used. Staff #60 stated a resident should never be discharged with IV access and that if he was aware of that occurring, he would have to contact the resident and file an incident report. Staff #60 stated a resident who is discharged with a peripheral IV would be at risk for infection and that there would be concerns of substance abuse as well. An interview was conducted with the Director of Nursing (DON/staff #53) on August 19, 2021 at 11:10 am. The DON stated he was familiar with resident #267 and the care the resident had received at the facility. The DON stated he was aware of resident #267's peripheral IV, and that the resident had been discharged with the IV in place. The DON stated it would not be unusual for a resident to be discharged with peripheral IV access. He also stated the physician would document in the resident's clinical record the reason the IV should not be removed prior to discharge. Resident #267's record was reviewed and the DON stated there was no documentation regarding the resident's discharge with the IV still in place. A policy request was made for any policies regarding IV management on August 18, 2021 at 1:05 pm. The DON stated on August 18, 2021 at 3:15 pm that the facility did not have any policies specific to IV management except for IV medication administration. -Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall risk assessment evaluation dated July 30, 2021 revealed that resident #59 had a balance problem while standing and walking, and a change in gait pattern when walking. A physician's order dated July 31, 2021 included for a knee immobilizer to the right leg at all times, ok to remove for showers and daily skin checks. The order was discontinued on August 19, 2021. Another physician's order dated July 31, 2021 stated to apply a dry dressing to the surgical incision to the right knee, mesh to remain clean, dry, and intact every day shift. This order was discontinued on August 19, 2021 A physician's order dated July 31, 2021 stated check skin integrity under knee immobilizer to the right leg every shift. The order was discontinued on August 19, 2021. Review of the care plan initiated on July 31, 2021 revealed the resident had activities of daily living (ADL) self-care performance deficits related to weakness, multiple rib fractures, right patella fracture, antipsychotic use, and opioid use for pain. The goal was for the resident to safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. Interventions included to explain all procedures/tasks before starting, and for Physical therapy (PT) and Occupational Therapy (OT) evaluation and treatment per physician orders. Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated the resident was cognitively intact. The assessment included the resident required supervision with one-person assistance for bed mobility, one-person limited assistance for transfers, and one-person limited assistance for walking in the room. A PT note dated August 10, 2021 stated resident #59 refused to ambulate for increased distances due to right knee immobilizer discomfort. Review of the care plan initiated on August 12, 2021 revealed the resident had alteration in musculoskeletal status related to left knee, right knee, and left rib fractures. The goal was for the resident to remain free from pain or at a level of discomfort acceptable to the resident. Interventions included to encourage the use of supportive devices (knee immobilizer) as recommended, to follow physician's orders for weight bearing status, give analgesics as ordered by the physician, plan activities during optimal times when pain and stiffness is abated, monitor for fatigue, and to educate the resident, family and caregivers on safety measures that need to be taken in order to reduce risk of falls. A PT note dated August 13, 2021 stated that the resident continued to demonstrate non-compliance with applying a knee immobilizer prior to walking, the resident was educated on the importance of putting on the immobilizer but reported an increased right knee discomfort. A PT note dated August 16, 2021 stated resident #59 was non-compliant with wearing the right knee immobilizer. The Treatment Administration Record (TAR) for August 2021 revealed documentation that the dressing change to the right knee surgical incision was done August 15-19, 2021. At a later point in the review of the TAR for August 19, 2021, documentation from the nurse was changed to indicate that the order was resolved. Further review of the TAR revealed the knee immobilizer to the right leg at all times, ok to remove for showers and daily skin checks was marked as completed August 15-19, 2021. On August 16, 2021 at 12:33 PM, the resident was observed in the bed and a knee immobilizer was observed on the bedside table. While interviewing the resident, the resident exited the room half way through the interview to ask a nurse for a sandwich. The resident was not observed to wear any splinting device and no dressing was observed to the knee. An observation was conducted of the resident on August 16, 2021 at 3:03 PM. The resident was observed with a healed scar to the right knee, no dressing in place to the right knee, and no knee immobilizer device in place. During an observation conducted of the resident on August 17, 2021 at 8:50 AM, the resident was observed in bed sleeping with no knee immobilizer in place and no dressing applied to the right knee. Another observation was conducted of the resident on August 18, 2021 at 8:47 AM. The resident was observed in bed with no immobilizer or dressing to the right knee. An interview was conducted with a Licensed Practical Nurse (LPN/staff#61) on August 18, 2021 at 9:12 AM. He stated that if a resident is non-compliant with cares or is refusing care, he would notify the charge nurse. Staff #61 stated non-compliance should be added to the resident care plan. The LPN stated it is expected for the nurses to follow physician orders and document a task was completed. Additionally, the nurse stated that he was not aware of any residents in his care that have orders for splinting devices or immobilizers. The LPN also stated that he was responsible for resident #59 care on the day shift for August 16 to 19, 2021. During an interview on August 18,2021 at 10:03 AM with Certified nursing assistant (CNA/staff#36), the CNA stated that she was responsible for the care of resident #59. The CNA stated that if a resident refused any cares or treatments, she would notify the nurse immediately. Staff #36 stated that if a resident is ordered to wear an immobilizer and does not wear it, there is a risk the resident would be unsteady when walking or sitting and could hurt themselves. The CNA stated resident #59 does not have any dressings on the legs or hips that she is aware of. The CNA further stated the resident has a brace but he never uses it. Staff #36 stated resident #59 has never really worn the immobilizer and is always refusing to wear the immobilizer. Another interview was conducted with the LPN (staff #61) on August 19, 2021 at 10:56 AM, who stated that if there is a check mark on the TAR, one could assume the care was given. Further, he explained that if a resident refused the care then the TAR would indicate that the resident refused instead of a check mark. The LPN viewed resident #59 TAR and stated that he signed the dressing to the right knee and immobilizer as complete on August 17, 18, and 19, 2021 because he provided the care on all three days. The LPN also stated that the resident had not refused care because it would have been documented. In an interview conducted with resident #59 on August 19, 2021 at 11:02 AM, the resident stated no one had done any dressing treatments that day. The resident further stated staff had not done a dressing treatment to the knee in week. The resident stated that he only wears the knee immobilizer when therapy reminds him that he should. The resident stated that he does not wear it all the time because it is not comfortable. The resident further stated that he might wear the immobilizer 20-30 minutes a day if that. Later that day at 11:10 AM, staff #61 stated he had forgotten to discontinue the order and that maybe he had documented inaccurately. An interview was conducted on August 19, 2021 at 11:55 AM with the Director of Nursing (DON/staff#53). The DON stated that if there is a check mark on the TAR that would indicate the treatment was provided. The DON stated that if a resident refused treatment, it should be documented and the physician notified. The DON stated that the risk factor for not putting on an ordered immobilizer would be the resident's joint could become unstable and affect the joint. After reviewing the TAR, the DON stated the documentation did not indicate the resident refused the treatments. Review of the facility policy regarding professional standards revised November 2007 stated it is the policy of this facility that services provided by the facility meet professional standards of quality and be provided by qualified person in accordance with each resident's care plan. The policy also stated direct care givers will have information regarding the services and care provided to the resident and that care will be given by qualified persons in accordance with the resident's care plan. The facility policy regarding physician orders revised May 2021 stated it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident plan of care. The policy included medication, treatment or related procedure orders are transcribed in the TAR accordingly.

Based on observation, clinical record reviews, staff interviews and policy review, the facility failed to ensure that pressure ulcer care and services were provided for two residents (#'s 236 and 251). Findings include: -Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The initial admission assessment documentation dated January 10, 2017 indicated the resident had a Stage 1 pressure ulcer on/off to the sacrum. No measurements or a description of the area was documented. There was no documentation of any other pressure ulcers present on admission. The initial Braden Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at moderate risk for the development of pressure ulcers. Review of the clinical record revealed there were no treatment orders for the Stage 1 pressure ulcer to the sacrum at this time. A pressure ulcer care plan developed on January 11, 2017 included the resident had pressure ulcers, due to immobility. Interventions included to administer medications as ordered and to monitor for side effects and effectiveness, and to administer treatments as ordered and monitor for effectiveness. However, the care plan did not include any interventions related to the prevention of pressure ulcer development. A physician's order was obtained on January 13, 2017, which was three days after admission. The order included to cleanse the resident's bilateral buttocks area with soap and water each shift and as needed and apply barrier cream, as a preventative measure. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS included that the resident required extensive assistance of one person for all activities of daily living, except eating for which she required supervision. The MDS further included that the resident had only one Stage 1 pressure ulcer and was receiving pressure ulcer care. A physician's order dated January 17, 2017 included for a Braden Scale risk assessment to be completed weekly for 4 weeks. A Braden Pressure Ulcer Risk assessment completed on January 17, 2017 identified the resident was at low risk for the development of pressure ulcers. A wound physician's note dated January 17, 2017 indicated that in addition to wounds #1, #2, and #3 which were surgical wounds, the resident had a wound to the left ischial area (wound #4). The wound was described as a Stage 3 pressure ulcer which measured 2.5 cm x 1.5 cm x 0.2 cm, with a scant amount of drainage. The wound was identified as having 1-25% [MEDICATION NAME], 51-75% pink granulation and was improving. The note further included the resident had a medial sacral Stage 3 pressure ulcer (wound #5), which measured 7.5 cm x 3 cm x 0.2 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a small amount of serosanguinous drainage The plan included to apply calcium alginate to wounds #4 and #5 and cover with a dry protective dressing daily, to reposition the resident per facility protocol, and for an offloading mattress. The note included that the plan of care was discussed with the nursing staff and resident. However, further review of the clinical record revealed there was no physician's order for the calcium alginate to be applied to wounds #4 and #5, as per the physician's note. Review of the initial Skin Pressure Ulcer Weekly documentation dated January 19, 2017 revealed the resident had two pressure ulcers. One wound was noted to be on the left gluteal fold (wound #4) and was identified as a Stage 3 which was present on admission, with an unknown date of onset and measured 2.5 cm x 1.5 cm x 0.2 cm. The wound was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with scant serosanguinous drainage. The second wound was described as a Stage 3 pressure ulcer to the sacrum (wound #5) which was present on admission, with an unknown date of onset and measured 7.5 cm x 3 cm. The wound was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with a small amount of serosanguinous drainage. However, per the initial admission assessment and the MDS dated [DATE], the resident only had one Stage 1 pressure ulcer present upon admission. A physician's treatment order was obtained on January 19, 2017, which was two days after the resident was identified to have two Stage 3 pressure ulcers. The order included to cleanse the sacrum and ischial wounds with wound cleanser or normal saline, pat dry, apply calcium alginate, cover with a dressing daily and as needed for soilage or dislodgment. Further review of the pressure ulcer care plan revealed it had not been revised to include the physician's recommendations (from the January 17 physician's note) for an off-loading mattress and to reposition the resident per facility protocol. A wound physician's note dated January 24, 2017 indicated wound #4 was described as a left ischial Stage 3 pressure ulcer which measured 2.2 cm x 0.8 cm x 0.1 cm, with a small amount of drainage. The wound was identified as having 1-25% [MEDICATION NAME], 51-75% pink granulation tissue and was described as improving. Wound #5 was described as a medial sacral Stage 3 pressure ulcer which measured 4.2 cm x 3 cm x 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME], 51-75% pink granulation tissue, with a small amount of serosanguinous drainage and was improving. The plan included the following: apply calcium alginate to wounds #4 and #5 and cover with a dry protective dressing daily; reposition the resident per facility protocol; and use an offloading mattress. The note further included that the plan of care was discussed with the nursing staff and resident. A Braden Pressure Ulcer Risk assessment completed on January 25, 2017 identified the resident was at low risk for the development of pressure ulcers. A physician's order dated January 25, 2017 included to cleanse the sacral wound and the left ischial wound, pat dry and apply calcium alginate and cover with a dressing every Tuesday, Thursday and Saturday and as needed. Review of a wound physician's note dated January 26, 2017 revealed that wound #4 to the left ischial area was a Stage 3 pressure ulcer which measured 7 cm x 1.7 cm x 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a small amount of drainage and was improving. Wound #5 was described as a Stage 3 pressure ulcer to the medial sacral area, which measured 4.5 cm x 3.5 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a small amount of serosanguinous drainage. The plan included to reposition the resident per facility protocol and use an offloading mattress. No change was noted and the plan remained unchanged. A Braden Pressure Ulcer Risk assessment completed on January 31, 2017 identified the resident was at low risk for the development of pressure ulcers. A wound physician's note dated January 31, 2017 indicated wound #4 to the left ischial area was a Stage 3 pressure ulcer which measured 0.6 cm x 1.5 cm x 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME], 51-75% pink granulation tissue, with a small amount of drainage and was improving. Wound #5 was described as a Stage 3 pressure ulcer to the medial sacral area which measured 4.7 cm x 4 cm 0.1 cm. The wound was described as having 1-25% [MEDICATION NAME] and 51-75% pink granulation tissue, with a moderate amount of serosanguinous drainage. The plan included to reposition the resident per facility protocol and use an offloading mattress. No change was noted and the plan remained unchanged. Review of the Skin Pressure Ulcer Weekly documentation dated February 1, 2017 revealed the Stage 3 pressure ulcer to the left gluteal fold (wound #4) measured 0.6 cm x 1.5 cm x 0.3 cm and was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with a small amount of serosanguinous drainage. The pressure ulcer to the sacrum area (wound #5) was described as a Stage 3 and measured 4.7 cm x 4 cm x 0.1 cm and had 25% [MEDICATION NAME] and 75% granulation tissue, with a moderate amount of serous drainage. A physician's order dated February 2, 2017 included to cleanse the bilateral buttocks with warm, soapy water and pat dry, and apply barrier cream for prevention measures and after incontinent episodes. A physician's order dated February 3, 2017 included to cleanse the sacral wound and the left ischial wound, pat dry, apply calcium alginate and a dressing every day and as needed. A Braden Pressure Ulcer Risk assessment completed on February 7, 2017 identified the resident was at low risk for the development of pressure ulcers. Review of the Skin Pressure Ulcer Weekly documentation dated February 7, 2017 revealed the left gluteal fold Stage 3 pressure ulcer (wound #4) measured 0.7 cm x 1.2 cm x 0.3 cm. The wound was described as having 25% [MEDICATION NAME] and 75% granulation tissue, with a small amount of serous drainage. The Stage 3 pressure ulcer to the sacrum (wound #5) measured 5.0 cm x 5.3 cm and was described as having 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. A Braden Pressure Ulcer Risk assessment completed on February 14, 2017 identified the resident was at low risk for the development of pressure ulcers. Review of the Skin Pressure Ulcer Weekly documentation dated February 14, 2017 indicated the left gluteal fold wound (#4) was resolved. The Stage 3 pressure ulcer to the sacrum (wound #5) measured 3.6 cm x 4.2 cm and had 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. Review of the Skin Pressure Ulcer Weekly documentation dated February 21, 2017 revealed the Stage 3 pressure ulcer to the sacrum (wound #5) measured 2 cm x 3.1 cm x 0.1 cm and had 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. Review of the Skin Pressure Ulcer Weekly documentation dated February 28, 2017 revealed the sacrum pressure ulcer (wound #5) was a Stage 3 and measured 2 cm x 3.1 cm x 0.1 cm. The wound was described as having 50% [MEDICATION NAME] and 50% granulation tissue, with a small amount of serous drainage. Continued review of the pressure ulcer care plan revealed it was not revised to reflect the ongoing recommendations from the wound physician notes regarding the need for an off-loading mattress and repositioning the resident per facility protocol. The care plan was also not revised to reflect any additional interventions related to the resident having two Stage 3 pressure ulcers. In an interview with a Certified Nursing Assistant (CNA/staff #36) on March 10, 2016 at 9:21 a.m., the CNA stated that the information about a resident's positioning needs and how to transfer a resident, are included on the Kardex and the care plan. Staff #36 stated that they also receive this information in report during shift change. An interview was conducted on March 10, 2017 at 10:59 a.m., with the Licensed Practical Nurse (previous wound nurse during resident #236's stay and who is currently in another position/staff #78). Staff #78 stated when a resident is admitted to the facility with a wound, the wound nurse will see the resident within 72 hours. However, staff #78 further stated that they did not see this resident on admission so she cannot speak to what the resident's wounds were like on admission. Staff #78 stated she did not know if the policy included how frequently a wound should be assessed. Staff #78 stated that wound care and preventive interventions needed are to be added to the care plan and if there are changes or new interventions, the care plan should be revised. An interview was conducted on March 10, 2017 at 11:03 a.m., with a Corporate Resource Nurse/Registered Nurse (RN/staff #111) and the Director of Nursing (staff #113). The Corporate Nurse stated that the care plan should include all interventions for the prevention of pressure ulcers, but there was nothing added to this one. The Corporate Nurse also stated that the care plan should have been revised when the resident pressure ulcers worsened and the new one developed. She also stated that all the mattresses in the facility are off-loading mattresses. -Resident #251 was admitted on [DATE], with [DIAGNOSES REDACTED]. The initial admission record documentation dated February 10, 2017, included the resident had a stage 1 pressure ulcer on the left heel, which measured 1 by 1 cm (centimeter). This record did not include any documentation of a pressure ulcer on the resident's right buttocks. Review of a Skin Pressure Ulcer Weekly report dated February 10, 2017 revealed the resident had a SDTI (Suspected Deep Tissue Injury) on the right buttock, which measured 5 by 3 cm (centimeters). Per the report, the wound bed was beefy red, edges were well defined and had no exudate or odor. However, the comment section of this report included that the SDTI was on the left buttock. The documentation also included that a treatment had been completed. The assessment did not include any documentation regarding the stage 1 pressure ulcer on the resident's left heel. A pressure ulcer care plan was developed on February 13, 2017, which identified that a SDTI was present on the resident's right buttock. The care plan included as an intervention to administer treatments as ordered. The care plan did not include the resident had a pressure ulcer to the left heel. Review of the clinical record revealed there were no wound treatment orders upon admission for the stage 1 pressure ulcer to the left heel, nor for the SDTI to the buttocks. The initial Braden Risk assessment dated [DATE], identified the resident was at moderate risk for the development of pressure ulcers. The admission MDS (Minimum Data Set) assessment dated [DATE], included the resident had a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment. The MDS included that the resident required extensive assistance for activities of daily living, except for eating, for which he only required supervision. The MDS also included that a stage 2 pressure ulcer was present. Review of the Skin Pressure Ulcer Weekly report dated February 17, 2017, revealed the resident had a SDTI to the right buttocks, which measured 5 by 3 cm, no odor or exudate was present, and the wound edges were well defined. The assessment did not include any documentation regarding the status of the wound bed. The documentation also included that a treatment was completed. However, further review of the clinical record revealed there were no physician ordered treatments for the buttocks pressure ulcer at this time. Another Skin Pressure Ulcer Weekly report dated February 20, 2017, included the right buttocks was a stage 2, which measured 3.5 by 1 by 0.1 cm. The wound was described as having 100% granulation tissue with well defined edges, and a scant amount of serous exudate with no odor. The comment section of this report included that the resident had a SDTI upon admission, which had opened and was now a stage 2 pressure ulcer. The documentation further included that a treatment was completed. There was no documentation regarding the condition of the resident's left heel. Continued review of the clinical record revealed that a treatment order was not obtained until February 23, 2017, which was 13 days after the SDTI was first identified upon admission. The prescribed treatment included to cleanse the bilateral buttocks with warm, soapy water, pat dry and apply Barrier cream every shift. The orders also included for a low air mattress. According to the March 2017 TAR (Treatment Administration Record), there was no documentation that the treatment to the buttock area had been administered on March 3. Review of the Skin Pressure Ulcer Weekly report dated March 3, 2017, revealed a stage 2 on the resident's right buttock. A pressure ulcer treatment observation was conducted on March 8, 2017 at 12:58 p.m., with the wound nurse (staff #74). At this time, a stage 2 pressure ulcer was observed on the resident's right buttock. The wound measured 0.7 by 0.4 cm, with a small scab in the center, with no odor or drainage present. An interview was conducted on March 8, 2017 at 10:58 a.m., with Corporate Resource staff (staff #115), who stated that the stage 1 pressure ulcer on the left heel may have been resolved and therefore, no treatment would have been required. Staff #115 acknowledged that the clinical record lacked documentation regarding the stage 1 pressure ulcer on the resident's left heel. Staff #115 also stated the documentation that the treatment was completed could refer to the CNA's (Certified Nursing Assistant) having applied Barrier cream after an incontinent episode, but the documentation was not clear or specific as to what treatment had been administered. Staff #111 further stated that pressure ulcer treatment orders should have been obtained and that there was a delay in treatment. Staff #111 stated that prescribed treatments should have been administered and documented. An interview was conducted on March 9, 2017 at 11:35 a.m., with the DON (Director of Nursing/staff #113). She stated the facility did not utilize standing orders for pressure ulcers and that resident specific physician orders needed to be obtained. Staff #113 stated that based on the documentation, the physician was not promptly notified of a change in the resident's pressure ulcer status from a SDTI to a stage 2 pressure ulcer. Staff #113 stated that treatments should have been implemented and documented. She also acknowledged that there had been a delay in treatment. Review of the Wound Management policy revealed that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable and that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new, avoidable sores from developing. The policy included to promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present and prevent the development of additional pressure ulcers. The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: complete the comprehensive admission assessment and Braden Scale to identify risk and to identify any alterations in skin integrity noted at that time; develop a comprehensive care plan following the assessment, and that care plans must be individualized and designed to meet the needs of the resident. The policy further noted that once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the physician's order; and that all wound treatments should be documented in the resident's clinical record at the time they are administered. The policy further included that in order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's plan of care: stabilize, reduce or remove any existing underlying risks, monitor impact of interventions and modify interventions as appropriate based on changes in condition; reposition the resident; use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows etc.); and use transfer techniques which minimize friction and skin tears. The policy also stated to Review and/or re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after a given time or any time a wound is worsening. Review of the Care Planning policy revealed that the resident's plan of care - focus, goals, and interventions are communicated and implemented. The resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.

Based on a review of the closed and current clinical records, the facility's investigative report, the police reports, staff interviews, and review of facility policies, the facility failed to ensure that adequate supervision was provided to two residents (#s 204 and 25). Both residents sustained actual harm. The sample size was four. Findings include: -Resident #204 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed that the resident was alert and oriented and able to make needs known. A review of [DATE], recapitulation of physician's orders [REDACTED]. -Celexa and Amitriptyline (a tricyclic) for depression. -Lorazepam for anxiety. -Morphine Sulfate (an opiate) for pain. -Oxycodone with Acetaminophen (an opiate) for pain as needed. In addition, the resident was prescribed and administered IV (intravenous) antibiotic therapy via a PICC (Peripherally Inserted Central Catheter) for the osteo[DIAGNOSES REDACTED]. A nursing note entry dated [DATE], included that a syringe full of a liquid with a blue substance in it, was found in the resident's bed. Per the documentation, the resident denied any knowledge of what it was. According to the documentation, the physician was notified, orders were obtained for a urine drug test, and that the urine specimen was sent to the laboratory for testing. The entry also included that the physician would be in to see the resident. The nursing note entry did not include any documented evidence that increased supervision had been provided at this time. A physician's progress note entry dated [DATE], included that the resident was found to have a needle in her room and that a drug screen had been ordered. The urine specimen was obtained and sent to the laboratory on [DATE]. According to the documentation, the test results were reported to the facility on the same date. The drug screen test results were reviewed and included documentation that the opiate and tricyclic screens were positive. A mental health assessment was conducted on [DATE], by an outside resource. Although the documentation included that the resident had no suicidal ideation, it did include that the resident was currently depressed and anxious, and that she had struggled with depression for several years. The assessment also included that although the resident denied illegal drug use, the facility nursing staff had reported that the resident was found with a syringe in her PICC line. According to the documentation, this was an indication that the resident may have been using illegal drugs and self administering them. A continued review of the closed clinical record revealed that the resident had been last administered the following oral medications on [DATE]: -Celexa at 8:00 a.m. -Morphine Sulfate at 4:00 p.m. -Oxycodone with Acetaminophen at 4:30 p.m. -Lorazepam at 6:00 p.m. -Amitriptyline at 8:00 p.m. In addition, the following antibiotic medications were also administered via IV: -Vancomycin at 8:00 a.m. -Meropenem at 4:00 p.m. A nursing note entry dated [DATE] at 12:15 a.m., included that the resident was found not breathing and without a pulse or blood pressure. The entry also included that a syringe, which contained a white, pearlscent and viscous fluid, was found in the resident's right hand. According to the documentation, CPR (Cardio-Pulmonary Resuscitation) was initiated, and 911 was called. However, according to the documentation, CPR was futile, as rigormortis had already set in. The resident's body was subsequently released to the Office of the Medical Examiner. A review of the facility's self report included that two incidents had actually occurred prior to the final incident on [DATE], and the resident's death. The report included that a second incident had occurred on [DATE], and that it had not been reflected in the clinical record documentation. Per the report documentation, on [DATE], (time not included in the report) a room change was in progress, when a syringe was found in the resident's belongings. According to the documentation, this syringe was like the one found on [DATE], and was not consistent with the medical supplies used by the facility. The report included that the syringe contained a milky white substance, and that it was confiscated and given to the DON (Director of Nursing). The documentation again, included that the resident denied any knowledge of it. Per the report documentation, the DON intended to meet with the resident and her physician to discuss the situation. However, the clinical record did not include any documented evidence that a meeting with the resident, the DON, or the physician, had actually occurred on [DATE], or up until the resident's death on [DATE], at 12:15 a.m. The facility's report included numerous staff's accounts of the above incidents. The following is a time line from [DATE], to the resident's death on [DATE] at 12:15 a.m., and was derived from those interviews: -At approximately 4:00 p.m. an IV and oral medications (Ativan, Morphine, and Percocet) were administered. -The resident had five visitors in the late afternoon. -The resident's dinner tray was retrieved between 6:15 and 6:30 p.m. -At approximately 7:00 p.m. staff inquired if resident needed anything and the resident asked about her pain medications. -At approximately 8:00 p.m., the resident's blood sugar level was tested (within normal range) and oral medications were administered (Ativan, Morphine, and Percocet). -At 8:30 p.m. staff responded to the resident's call light (inadvertently put on by the resident). -At approximately 9:00 p.m., the resident appeared to be in asleep in bed. -At approximately ,[DATE]:15 p.m. the resident appeared to be asleep in bed. -At midnight, the resident was found in bed unresponsive. -CPR was imitated, 911, police, and Office of the Medical Examiner arrived on site. -The syringes found on [DATE], and 8, 2012, were given to the police department. A review of the police report documentation revealed that on [DATE], at the time of their response to the facility, a plastic cup with two tablespoons of what appeared to be a crushed pill or pills with a clear liquid on top, was also found in the resident's bedside cabinet drawer. The police report also included that there were no obvious signs of injury or foul play to the body. A supplemental police report dated [DATE], included that the Medical Examiner's Office had not made a determination of cause and manner of death, until the completion of further testing. An interview was conducted on [DATE] at 2:30 p.m., with the DON, who was able to recall the incidents on [DATE], and 8, 2012. Following a review of the clinical record, the DON agreed that a care plan to address the initial incident on [DATE], had not been developed, and therefore, no subsequent interventions, inclusive of increased supervision, had been implemented. The DON did state that on [DATE], after the second syringe was found with the resident, the staff were instructed to check on the resident frequently. At this time, she acknowledged that the staff had not been instructed to provide one on one direct supervision. The DON was unable to state the frequency of those resident observations and was unable to provide any corresponding documented evidence of those resident observations. In addition, the DON acknowledged that the clinical record did not include any documented evidence of this incident on [DATE], and was unable provide an incident or investigative report regarding the two unusual occurrences on [DATE] and 7, 2012, of syringes being found with the resident. A second interview was conducted [DATE], with the LPN (Licensed Practical Nurse), who was on duty on [DATE], and 7, 2012. The LPN stated that on [DATE] at approximately 8:30 a.m., an unmarked syringe, which contained a milky white substance with a small area of blue material at the end of the syringe, was found in the resident's bed. She stated that she removed the syringe, gave it the syringe to the DON, and notified the physician. She also stated that a drug screen was ordered but that no additional instructions were provided. The LPN further stated that on [DATE] at approximately ,[DATE]:30 a.m., she was involved in changing the resident's room. Per the LPN, while assisting the resident with the move, the resident handed her a rolled up towel and told her to take care of her baby. She stated that she layed the rolled up towel on the bedside table, however, the towel unraveled and a syringe was exposed, which contained a white substance. The LPN stated that the syringe was given to the DON, who then instructed her to keep an eye on the resident. Per the LPN, no instructions were given from administrative staff to provide direct one to one supervision, or to conduct a thorough room search. At this time, the LPN acknowledged that she failed to document the [DATE], incident in the resident's clinical record or develop a plan of care for either of the two incidents. A third interview was conducted on [DATE] at 7:00 a.m., with the RN (Registered Nurse) on duty on [DATE]. He stated that he had been advised on the two earlier incidents but had not been given any special instructions and that only routine monitoring had been implemented. Per the RN, at approximately 10:30 to 11:30 p.m., he checked in on the resident and had not observed any distress. He stated that he was later notified by the CNA (Certified Nursing Assistant) that the resident had no vital signs. He stated that he responded to the resident's room and that emergency procedures were implemented but that it was obvious that the resident had expired because she was stiff. The RN further stated that since this incident, all PICC lines now have caps on them to prevent tampering. On [DATE], a second interview was conducted with the DON. Again, she confirmed that no incident/investigative reports had been generated for the incidents on [DATE] and 7, 2012. She stated that she did not think much of the incidents but now stated that incident reports and investigations should have been initiated. At this time, she confirmed that one to one direct supervision was not provided because it was thought that visual checks were enough. The DON also stated that a nursing note entry should have been written on [DATE], when the second syringe was found, and that a care plan and interventions, to address the two incidents should have been initiated and implemented. During this interview, the DON confirmed that neither the Administrative staff or the resident's physician had met with the resident on [DATE], after the second syringe was found at approximately ,[DATE]:30 a.m. until the time of the resident's death on [DATE] at 12:15 a.m. A facility policy titled, IV Administration of Drugs, revised [DATE], included, "...IV lines will be secured using clave covers to prevent unauthorized manipulation..." Another facility policy titled, Incidents-Investigation and Reporting, included, "It is the policy of this facility that all incidents/accidents occurring on our premised must be investigated and reported to the administrator." The policy also include the following, "...Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor, and an Incident Report Form must be completed on the shift that the accident or incident occurred...The charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident...An Investigative Report Form must be submitted to the Director of Nursing Services no later that twelve hours after the occurrence of the accident or incident...The charge nurse and/or department director or supervisor shall complete and Accident and Incident Report Form and submit it to the director of nursing services along with the Investigation Report Form..." A Change of Condition policy, revised [DATE], included, "It is the policy of this facility that all changes in resident condition will be communicated to the physician." The policy also included the following: -All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes. -Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. -Document resident change of condition and response in nursing progress notes and update resident Care Plan, as indicated. -The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two hours or until condition has stabled. -Resident #25 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed that the resident had been identified to be a high fall risk and that she had a history of [REDACTED]. A care plan identified that the resident was at risk for falls related to weakness, decreased safety awareness, and confusion. The care plan included the following fall precautions: -a tab alarm in wheelchair. -a bed sensor alarm -bed in lowest position with floor mats. A nursing note entry dated [DATE], included that the CNA found the resident in the bathroom on the floor, holding her right wrist and complaining of pain. Per the documentation, the physician was notified and an order for [REDACTED]. The result of the right wrist x-ray was positive for a fracture. According to the documentation, the resident was subsequently transferred to the emergency room for treatment and returned to the facility with a splint on the right wrist. A review of the facility's report regarding the fall on [DATE], included that the CNA had transferred the resident to the toilet, gave her the call light and left the resident to answer another resident's call light. Per the documentation, it was during that time that the resident stood up and fell to the floor and injured her right wrist. The report also included that the resident was impulsive, had a history of [REDACTED]. According to the report documentation, the CNA was suspended pending the facility's investigation of this incident, and that all staff, including this CNA, were in-serviced regarding resident safety. Another nursing note entry dated [DATE] included a clarification regarding the circumstances of the fall with injury on [DATE]. This entry included that the CNA, who had found the resident on the bathroom floor, had previously stated that the resident had been in bed prior to the fall on [DATE], and had not disclosed to the licensed staff that the resident had actually been assisted onto the toilet and left alone. An interview was attempted with this resident, however, she was unable to answer any questions regarding the fall on [DATE]. An interview was conducted on [DATE], with the CNA involved in this incident (who had been reinstated). At this time, the CNA confirmed that she had left the resident unattended in the bathroom. She also stated that although she knew not to leave this resident unattended, she left the resident in the bathroom, to answer another resident's call light. She further stated that she had misunderstood the licensed staff questions regarding the resident's location prior to the fall. An interview was conducted on [DATE], with the DON, who acknowledged that the resident had been left unattended in the bathroom resulting in a fall with injury. Another interview was conducted on [DATE] at 12:30 p.m., with the DON, and Administrator. At this, they stated that neither incident had been identified as a Quality Assurance item. The facility was unable to provide a policy regarding leaving residents unattended.